Every finding on record at Sumner Place

Licensure Reference Number 175 NAC 12-006.11(E)Based on observations, interviews, and record reviews, the facility failed to ensure all food was resealed and dated after opening. This had the potential to affect all 83 residents who ate from the kitchen. Census at the time of the survey was 83.Findings are:Record review of the FDA Food Code 2022 (Food Code), a science-based guideline published by the Food and Drug Administration to regulate food service facilities and to create uniform safety rules, revealed in the section 3-501.17 titled Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking that all food establishments must clearly mark the date that the original container is opened.Record review of the Food Code in section 3-202.15 titled Package Integrity revealed that food packages should be in good condition so that the food is not exposed and to protect the food from potential contaminates.Observation on 08/12/2026 at 7:19 AM of the walk-in-refrigerator revealed:A bag of parmesan cheese opened, not resealed, and there was no date to indicate when the package was originally opened.A bag of mozzarella cheese opened and not dated.A package of celery with brown ends, opened, not resealed, and not dated.Observation on 08/12/2026 at 7:25 AM of the walk-in freezer revealed:A package of breaded chicken patties opened and not dated.A package of chopped bacon bits opened and not dated.Observation on 08/12/2026 at 7:28 AM of the dry storage area revealed:2 packages of dry, spiral-macaroni noodles opened and not dated.A package of dry penne pasta opened and not dated. A package of Risotto, opened, not resealed, and not dated.Observation on 08/12/2026 at 7:33 AM of the prep area in the kitchen revealed a large container of cooking oil opened and not dated and to the right of the oil, a large brown paper bag of breadcrumbs opened and not dated.An interview on 08/12/2026 at 8:40AM with the Culinary Lead (cook) confirmed all items that were opened and not resealed and all the items that were opened and not dated. The cook confirmed that all food products should be labeled with a date once opened and then resealed. An interview on 08/13/2026 at 7:31AM with the Culinary Manager (CM) confirmed that it is the facility's expectation that all food be resealed after opening and marked with the date the food was opened.An interview on 08/13/2026 at 2:06PM with the Administrator (ADM) revealed that the facility does not have a policy related to dating and resealing food products but follows the Food Code. The ADM confirmed that it is the expectation that the Food Code is followed and that all food is resealed after opening and marked with the date opened.An interview on 08/18/2026 at 8:54AM with the ADM confirmed all 83 residents who reside at the facility eat from the kitchen.

Licensure Reference Number 175 12-006.18 (D) Based on observations, interviews, and record review, the facility failed to perform hand hygiene between glove changes during resident cares on two residents (Resident 6 and Resident 63) out of five residents sampled. The facility census was 83 at the time of the survey.Findings are: A. A record review of the facility's Hand Hygiene Competency with a revision date of 12/2019 revealed: Wash hands before and after utilizing gloves. Perform hand hygiene after removing gloves or between glove changes. Hand hygiene will occur before/after direct contact with a resident. A record review of the facility's Injectable Medication Administration policy dated 5/2021 revealed: Prior to the injection, wash hands with soap and water. Prepare injection. Perform hand hygiene again. Put on gloves. Remove and discard gloves. Clean hands by hand sanitizing or washing. An observation on 8/12/2026 at 9:26 AM of Licensed Practical Nurse (LPN)-A revealed LPN-A entered the room of Resident 63 to administer an insulin injection. LPN-A donned gloves, administered the insulin, removed the gloves and applied another pair of gloves without performing hand hygiene. LPN-A proceeded to unwrap Resident 63's right foot wound dressing, reapplied the wound dressing, removed the gloves, and left the resident room without performing hand hygiene. An interview on 8/12/2026 at 9:35 AM with LPN-A confirmed hand hygiene was not performed prior to administering Resident 63's insulin, between gloves changes, and before leaving Resident 63's room following cares. LPN-A confirmed hand hygiene should have been performed before providing resident care, between glove changes, and prior to leaving the resident room. An interview on 8/13/2026 at 11:00 AM with the Assistant Director of Nursing/Infection Prevention (ADON/IP) confirmed expectations that staff perform hand hygiene when entering and leaving a resident's room, and between glove changes. B. Continuous observation was completed on 8/17/2026 from 10:53 AM – 11:00 AM of Nurse Aide (NA)-C and NA-D with the Assistant Director of Nursing (ADON) present to observe. NA-C and NA-D donned (put on) gloves and assisted Resident 6 to roll in the bed to remove their pants and soiled brief. NA-D touched the dresser drawer with gloves still on, then doffed (removed) the gloves. Without the benefit of hand hygiene, NA-D donned new gloves. Both NA-C and NA-D performed perineal care for Resident 6. NA-C doffed gloves and performed hand hygiene and donned new gloves. NA-D doffed gloves, and without the benefit of hand hygiene, donned new gloves. NA-C and NA-D assisted to re-dress Resident 6 after applying a clean brief, doffed their gloves, performed hand hygiene, and proceeded to transfer Resident 6 in the recliner. An Interview on 08/17/2026 at 11:00AM with the ADON following the observation witnessed and confirmed that no hand hygiene was completed during glove changes by NA-D. The ADON confirmed that the expectation was to complete hand hygiene between all glove changes during resident cares. An interview on 08/18/2026 at 9:05 AM with the Administrator confirmed there was no facility policy on hand hygiene. They confirmed that all hand hygiene practice expectations were referred to in the Hand Hygiene Competency.

Licensure Reference Number 175 NAC 12.006.11(E) Licensure Reference Number 175 NAC 12.006.11(D) Based on observation, interview, and record review, the facility failed to ensure handwashing was completed for at least 20 seconds during food preparation (prep) to prevent potential cross contamination (transfer of bacteria from one surface to another) and failed to ensure the chicken used in the Sesame Chicken was cooked to an internal temperature of 165 degrees Fahrenheit (F) to prevent the potential for foodborne illness (disease caused by food contaminaton). This had the potential to affect 77 of 78 residents that resided at the facility. The total facility census was 78. Findings are: A. A record review of the facility's Hand Hygiene Competency dated 12/2019 revealed the staff should have wet hands, applied soap, and rubbed hands together for full 20 seconds before rinsing. Handwashing was to be completed after touching contaminated items, before and after gloving, and whenever indicated. A record review of Section 2-301.12(A) of the Nebraska Food Code dated 07/21/2016 revealed that food employees shall clean their hands and exposed portions of their arms for at least 20 seconds, using a cleaning compound. An observation using the second hand of an Apple iWatch (a smart digital watch) on 05/08/2025 at 10:10 AM - 10:50 AM revealed Cook-A pureed (blended to pudding like consistency) beets. Cook-A then removed gloves and washed hands for 11 seconds. [NAME] -A then gloved, removed the blade from the blender and put the blade back in the blender, grabbed beef patties with the gloved hands, and placed in the blender. Cook-A then put the lid on the blender, pressed the start button to the blender, then reached in with the right gloved hand and tested the consistency of the mechanical soft (chopped to reduce the amount of chewing needed) beef patties. Cook-A went to the drawer and got a rubber spatula, scooped the blended beef patties into a small steam pan. Cook-A then adjusted the blade in the blender again with the same gloved hand, then grabbed more beef patties with the same gloved hand, tore them up, placed them into the blender, and pressed the start button on the blender again. When the beef patties' puree process was completed, Cook-A removed gloves, sanitized (cleaned with chemicals) the prep table and blenders, then washed hands for 10 seconds. Cook-A then prepped gravy on the stove and touched the butter with Cook-A's ungloved hands before adding it to the pot. The gravy splashed and Cook-A grabbed a towel and dried hands and wiped Cook-A's face and added milk to the mixture as Cook-A whisked into the pot of gravy ingredients on the stove. Cook-A then took dishes to the dish room, took a drink from a personal cup, performed handwashing for 12 seconds, returned to the stove, whisked in the remaining milk, and placed the whisk in the pot with the handle touching the gravy 5 different times in the gravy prep process. Cook-A then scratched Cook-A's nose with the left hand, went to the serving table, back to the pot of gravy and stirred, got 2 steam pans while touching the inside with the left hand, sprayed with non-stick spray and dumped the gravy in. An observation using the second hand of an Apple iWatch on 05/08/2025 at 11:10 AM - 12:13 PM revealed Cook-A touched face with the left hand, checked food temperatures, got steam pans and sprayed with non-stick spray, placed food in steam pans on steam table, got scissors, gloved, got knife, cut open potatoes bags, dumped in steam pan, touched trash can, removed gloves, and continued to check food temperatures. Cook-A got a large steam pan, wiped pants with right hand, adjusted glasses right hand, took probe out of beef patties with the right hand, adjusted glasses with the right hand and used tongs to put beef in a steam pan with the right hand. Cook-A put an oven mitt on the right hand, moved the steam pan lid, placed temp probe in beef patties in the steam pan. Cook-A then pulled Cook-A's shirt down over Cook-A's bottom, then placed hands on hips. Cook-A then got oven mitts, took cart to oven put mitts on, put potatoes on cart, got a whisk, whisked the gravy with right hand, let whisk handle fall in gravy, got the whisk out with the right hand, and used the whisk to dump the gravy in a small steam. Cook-A then checked the temperature of the remaining food and recorded on the log sheet. Cook-A then put vegetables in the steamer, scratched face with the right hand. At 11:40 AM Cook-A put the potatoes and gravy on steam table, went to dry storage, stopped and scratched head with the right hand, then went into the walk-in refrigerator to get 2 each gallon jugs of Ken's Asian Sesame Sauce and opened and put in a pot on the stove. Cook-A then grabbed the trash can and discarded an empty jug of the Ken's Asian Sesame Sauce, and washed hands for 6 seconds. Cook-A then got a plastic container and dumped the heated sauce in, got a medium steam pan, touched the inside with right hand, sprayed with non-stick spray, and continued with food prep. In an interview on 05/12/2025 at 7:51 AM, the facility's Administrator confirmed the facility did not have a policy for handwashing for the kitchen. The staff was to follow the food code. In an interview on 05/08/2025 at 2:16 PM, the Dietary Manager (DM) confirmed all but 1 of the 78 residents in the facility eat food from the kitchen. In an interview on 05/08/2025 at 12:13 PM, Cook-A confirmed Cook-A washed hands just long enough to get the soap off and it did not wash hands for 20 seconds and should have. In an interview on 05/08/2025 at 12:56 PM, the facility's Dietary manager confirmed Cook-A should have washed hands for at least 20 seconds. B. A record review of Section 3-401.11(3) of the Nebraska Food Code dated 07/21/2016 revealed that poultry (domesticated birds raised for meat, eggs, or feathers) shall be cooked to heat all parts of the food to 165 degrees F or above for 15 seconds. A record review of the facility's Week At a Glance Week 1 menu dated 2025 revealed that on Thursday for lunch the facility was to serve Sesame Chicken and that was the only chicken dish served that day. A record review of the facility's Sesame Chicken recipe dated 2025 revealed the frozen tempura chicken should be cooked to a final internal temperature of 165 degrees F for less than (<) 1 second. A record review of the facility's Quality Assureance: Food Temperatures log dated 05/08/2025 revealed that the Alternate Entree of Orange Chicken beginning temp was 144.1 degrees F. Beginning temps must reach 165 degrees F. An observation on 05/08/2025 at 11:40 AM - 12:24 PM revealed Cook-A got the tempura chicken from the oven and checked the temperature with a thermometer, and it was 144 degrees F. Cook-A then used a metal spatula and transferred the tempura chicken chunks from the cookie sheet to a steam pan on the steam table. Cook-A then added the heated Ken's Asian Sesame Sauce. Cook-A and the DM started plating food without re-temping the Sesame Chicken. Residents 6, 39, 2, 4, and 61 were served the Sesame Chicken prior to the end of the observation. In an interview on 05/12/2025 at 7:51 AM, the facility's Administrator confirmed the facility did not have a policy for checking food temperatures or following the recipes for the kitchen. The staff was to follow the food code. In an interview on 05/08/2025 at 12:56 PM, the facility's DM confirmed Cook-A should not have served the Sesame Chicken at 144 degrees F, it should have been at least 165 degrees, and the Orange Chicken listed on the Quality Assureance: Food Temperatures log was Sesame Chicken.

Licensure Reference Number 175 NAC 12.006.18(B) Licensure Reference Number 175 NAC 12.006.18(D) Based on observation, interview, and record review, the facility failed to implement interventions to heal pressure ulcers (wound on a bony structure on the body caused by pressure to the area) for 1 (Resident 54) of 1 sampled resident. The total facility census was 78. Findings are: A record review of the facility's Skin and Wound Management Standard with a revised date of 04/2019 revealed that a resident that had a pressure ulcer received treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. Dressing changes would be done using good infection control technique. Covering the wound is required for Stage III (3)(full thickness tissue loss) and IV (4)( full thickness tissue loss with exposed bone, tendon, or muscle) ulcers. A record review of Resident 54's Clinical Census dated 05/13/2025 revealed the resident was admitted to the facility on [DATE] and was admitted to Hospice (end of life care) 10/02/2024. A record review of Resident 54's Medical Diagnosis dated 05/13/2025 revealed the resident had diagnoses of Moderate Protein-Calorie Malnutrition (nutrition intake does not meet nutritional needs), Dementia (confused), Cerebral Infarction (stroke), and Parkinson's Disease (movement disorder of the nervous system). A record review of Resident 54's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 04/03/2025 did not reveal the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) which indicated the resident was rarely/never understood. The resident was dependent on staff for all Activities of Daily Living (ADLs) and mobility. The MDS revealed the resident was at risk for developing pressure ulcers/injuries, the resident had unhealed pressure ulcers, and had one Stage 1, three Stage 2, and two Stage 3 ulcers and was receiving pressure ulcer/injury care. A record review of Resident 54's Care Plan with an admitted [DATE] revealed the resident had Stage 3 pressure ulcers on the left 5th finger and the right 5th finger. Interventions included an Abdominal (ABD)(a dry, absorbent dressing) pad wrapped with InterDry (a moisture wicking fabric with an antimicrobial agent), weave (in and out) between fingers on bilateral (both) hands, keep skin clean and dry, and Wound Care Plus nurse practitioner as needed. A record review of Resident 54's Pressure Ulcer Records dated 03/26/2025 - 5/7/2025 revealed on 5/7/2025, the resident had a right and left 5th finger pressure ulcer. The right was 0.2 centimeter (cm) long by (x) 0.2 cm wide x 0.1 cm deep wound, treatment (tx) change skin prep and Mepilex was crossed off. The left was 0.3 cm long x 0.2 cm wide with no depth, tx change skin prep, Mepilex. A record review of Resident 54's Progress Notes dated 04/03/2025 with the author of Licensed Practical Nurse (LPN)-C revealed dictation per the Advanced Practice Registered Nurse (APRN)-D Continue with ABD pad wrapped in InterDry weaved between all fingers. Discussed hard palm/finger splints cause pain and DermaSavers may have been trapping moisture. A record review of Resident 54's Progress Notes dated 05/07/2025 with the author of LPN-C revealed Advanced Practice Registered Nurse (APRN)-D dictated pressure ulcer to bilateral 5th fingers improved treatment changed to skin prep and Mepilex. A record review of Resident 54's Order Summary Report dated 05/12/2025 revealed the following orders: ABD wrapped with InterDry in between fingers bilateral hands every shift check placement every (Q) shift. Wound care pressure ulcer Stage 3 to right 5th finger skin prep. Do not wash skin prep off between application. Every day shift for wound care. Wound care pressure ulcer to left 5th finger skin prep. Do not wash skin prep off between application. Cover with Mepilex (foam dressing used in wound care). Every day shift for wound care. A record review of Resident 54's Wound Care Plus Progress Note dated 05/07/2025 revealed that APRN-D saw the resident and noted both finger wounds were looking pretty good and improving. Patient did complain of a little pain while we were looking at the areas. The ARRN-D would change both wound orders to be skin prep daily and let them dry, then they can put border gauze for protection. The assessment for the left little finger was completed and the Wound Recommendations/Orders and Certified Plan of Care revealed to wipe skin protectant (Skin Prep) to stable eschar (crust of dead tissue that forms over a wound). Ensure edges and surrounding skin are painted. Do not wash off skin protectant between applications. Product is designed to layer and thicken up to ensure eschar is kept intact. Cover with bordered gauze. Change dressing daily and as needed for soiling, saturation, or unscheduled removal. All orders would remain in effect until discontinued, revised, or replaced with additional orders. The assessment for the right little finger was completed and the Wound Recommendations/Orders and Certified Plan of Care revealed to wipe skin protectant (Skin Prep) to stable eschar. Ensure edges and surrounding skin are painted. Do not wash off skin protectant between applications. Product is designed to layer and thicken up to ensure eschar is kept intact. Cover with bordered gauze. Change dressing daily and as needed for soiling, saturation, or unscheduled removal. All orders would remain in effect until discontinued, revised, or replaced with additional orders. A record review of Resident 54's Physician Visit/Communication Form (v6) - V 2 dated 5/12/25 revealed: Right 5th finger area is macerated. May we have a Mepitel (a wound dressing) to the area until wound care nurse can see resident this week? An observation on 05/08/2025 at 9:51 AM revealed Resident 54 had DermaSaver Finger Separators in right hand and did not reveal a dressing on the 5th digit wound or ABD pad wrapped with InterDry between fingers on either hand. An observation on 05/12/2025 at 6:50 AM revealed Resident 54 had DermaSaver Finger Separators in both the left and right hands and did not reveal a dressing on the right-hand 5th digit wound or ABD pad wrapped with InterDry between fingers on either hand. An observation on 05/12/2025 at 9:02 AM with LPN-C revealed Resident 54 was sitting in the wheelchair in the resident's room following a bath. The resident had DermaSaver Finger Separators in both the left and right hands and no dressings in either hand. The DermaSaver Finger Separators fabric was directly against the resident's untreated, uncovered wounds on both hands. LPN-C performed hand hygiene (cleaning), donned (put on) a gown and gloves. LPN-C removed the DermaSaver Finger Separators from the right hand and placed it on the overbed table. LPN-C then opened and applied skin prep to the right-hand 5th digit and allowed it to air dry. LPN-C then took a pre-cut ABD pad and wrapped with InterDry and weaved through the fingers. The observation did not reveal LPN-C changed gloves or performed hand hygiene after touching the contaminated DermaSaver Finger Separators and before doing wound care on the right-hand 5th digit. LPN-C doffed (took off) gloves, performed hand hygiene, and re-gloved. LPN-C removed the DermaSaver Finger Separators from the resident's left hand and placed it on the overbed table, then opened and applied skin prep to the left-hand 5th digit wound and allowed it to air dry. LPN-C opened and applied a border dressing to the wound. LPN-C then took a pre-cut ABD pad and wrapped with InterDry and weaved through the fingers. The observation did not reveal LPN-C changed gloves or performed hand hygiene after touching the contaminated DermaSaver Finger Separators and before doing wound care on the left-hand 5th digit. In an interview on 05/12/2025 at 6:55 AM, LPN-C confirmed Resident 54 was using DermaSavers and they weren't working as they hoped due to excessive moisture, so they are now using an ABD pad and a wicking material to help keep the area between the fingers dry. In an interview on 05/12/2025 at 11:12 AM, LPN-C confirmed that the staff should not have applied the DermaSaver Finger Separators to Resident 54 bilateral hands following the resident's bath and before the treatments were completed, and the resident was not supposed to have them on. LPN-C was going to remove the DermaSaver Finger Seperators from the room. In an interview on 05/13/2025 at 8:34 AM, LPN-C confirmed that Resident 54 had a border dressing applied to the left-hand 5th digit wound, but not the right-hand 5th digit wound. Wound care APRN writes the orders for wound care. In an interview on 05/13/2025 at 8:34 AM, the Assistant Director of Nursing (ADON)-B confirmed that ADON-B used APRN-D's Wound Care Plus Progress Note dated 05/07/2025 Wound Recommendations/Orders and Certified Plan of Care as the wound care orders for Resident 54. ADON-B confirmed the Wound Care Plus Progress Note Wound Recommendations/Orders and Certified Plan of Care contained the following orders for both the left and right hands 5th digit wounds: Wipe skin protectant to stable eschar. Ensure edges and surrounding skin are painted. Do not wash off skin protectant between applications. Product is designed to layer and thicken up to ensure eschar is kept intact. Cover with bordered gauze. Change dressing daily and as needed for soiling, saturation, or unscheduled removal. All orders would remain in effect until discontinued, revised, or replaced with additional orders. ADON-B would not confirm that Resident 54 should have had bordered gauze on the right hand 5th finger wound because APRN-D said in the Visit specific information on the Wound Care Plus Progress Note dated 05/07/2025 that: they can put the border gauze on for protection. In a telephone interview on 05/13/2025 at 8:48 AM, APRN-D confirmed that what APRN-D put in the Wound Care Plus Progress Note dated 05/07/2025 Wound Recommendations/Orders and Certified Plan of Care would be APRN-D's wound care orders for Resident 54 and APRN-D ordered border dressings for both the left and right hands 5th digits for protection. In an interview on 05/13/2025 at 10:49 AM, the Director of Nursing (DON) confirmed there should have been a border dressing applied to the right-hand 5th digit per APRN-D's order.

Licensure Reference Number 175 NAC 12.006.18(B) Licensure Reference Number 175 NAC 12.006.18(D) Based on observation, interview, and record review, The facility failed to ensure 1 (Resident 54) of 1 sampled resident's DermaSaver Finger Separators (cushioning palm pillows with fabric placed between each finger) were not in contact with untreated wounds on the resident's bilateral (both) hand's 5th digit (pinky finger) and ensure glove changes and hand hygiene was completed following touching a contaminated object and before completing wound care to prevent the potential for cross contamination (transfer of bacteria from one surface to another). The total facility census was 78. Findings are: A record review of the facility's Skin and Wound Management Standard with a revised date of 04/2019 revealed that a resident that had a pressure ulcer received treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. Dressing changes would be done using good infection control technique. Covering the wound is required for Stage III (3)(full thickness tissue loss) and IV (4)( full thickness tissue loss with exposed bone, tendon, or muscle) ulcers. A record review of Resident 54's Clinical Census dated 05/13/2025 revealed the resident was admitted to the facility on [DATE] and was admitted to Hospice (end of life care) 10/02/2024. A record review of Resident 54's Medical Diagnosis dated 05/13/2025 revealed the resident had diagnoses of Moderate Protein-Calorie Malnutrition (nutrition intake does not meet nutritional needs), Dementia (confused), Cerebral Infarction (stroke), and Parkinson's Disease (movement disorder of the nervous system). A record review of Resident 54's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 04/03/2025 did not reveal the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) which indicated the resident was rarely/never understood. The resident was dependent on staff for all Activities of Daily Living (ADLs) and mobility. The MDS revealed the resident was at risk for developing pressure ulcers/injuries, the resident had unhealed pressure ulcers, and had one Stage 1, three Stage 2, and two Stage 3 ulcers and was receiving pressure ulcer/injury care. A record review of Resident 54's Care Plan with an admitted [DATE] revealed the resident had Stage 3 pressure ulcers on the left 5th finger and the right 5th finger. Interventions included an Abdominal (ABD)(a dry, absorbent dressing) pad wrapped with InterDry (a moisture wicking fabric with an antimicrobial agent), weave (in and out) between fingers on bilateral (both) hands, keep skin clean and dry, and Wound Care Plus nurse practitioner as needed. A record review of Resident 54's Pressure Ulcer Records dated 03/26/2025 - 5/7/2025 revealed on 5/7/2025, the resident had a right and left 5th finger pressure ulcer. The right was 0.2 centimeter (cm) long by (x) 0.2 cm wide x 0.1 cm deep wound. The left was 0.3 cm long x 0.2 cm wide with no depth. An observation on 05/08/2025 at 9:51 AM revealed Resident 54 had DermaSaver Finger Separators in right hand and did not reveal a dressing on the 5th digit wound. An observation on 05/12/2025 at 6:50 AM revealed Resident 54 had DermaSaver Finger Separators in both the left and right hands and did not reveal a dressing on the right-hand 5th digit wound. An observation on 05/12/2025 at 9:02 AM with Licensed Practical Nurse (LPN)-C revealed Resident 54 was sitting in the wheelchair in the resident's room following a bath. The resident had DermaSaver Finger Separators in both the left and right hands and no dressings in either hand. The DermaSaver Finger Separators fabric was directly against the resident's untreated, uncovered wounds on both hands. LPN-C performed hand hygiene (cleaning), donned (put on) a gown and gloves. LPN-C removed the DermaSaver Finger Separators from the right hand and placed it on the overbed table. LPN-C then opened and applied skin prep to the right-hand 5th digit and allowed it to air dry. LPN-C then took a pre-cut ABD pad and wrapped with InterDry and weaved through the fingers. The observation did not reveal LPN-C changed gloves or performed hand hygiene after touching the contaminated DermaSaver Finger Separators and before doing wound care on the right-hand 5th digit. LPN-C doffed (took off) gloves, performed hand hygiene, and re-gloved. LPN-C removed the DermaSaver Finger Separators from the resident's left hand and placed it on the overbed table, then opened and applied skin prep to the left-hand 5th digit wound and allowed it to air dry. LPN-C opened and applied a border dressing to the wound. LPN-C then took a pre-cut ABD pad and wrapped with InterDry and weaved through the fingers. The observation did not reveal LPN-C changed gloves or performed hand hygiene after touching the contaminated DermaSaver Finger Separators and before doing wound care on the left-hand 5th digit. In an interview on 05/12/2025 at 7:51 AM, the facility's Administrator confirmed the facility did not have a policy for handwashing, but they do facility-wide handwashing competencies. In an interview on 05/12/2025 at 9:15 AM, LPN-C confirmed LPN-C should have done hand hygiene and glove changes between removing the DermaSaver Finger Separators and completing wound care on Resident 54's bilateral hands 5th digits. In an interview on 05/12/2025 at 11:12 AM, LPN-C confirmed that the staff should not have applied the DermaSaver Finger Separators to Resident 54 bilateral hands following the resident's bath and before the treatments were completed. LPN-C confirmed that it could be an infection control concern with the contaminated DermaSaver Finger Separators touching the wounds prior to the treatment being completed. LPN-C confirmed the right-hand 5th digit wound was macerated (breakdown of skin due to excess moisture) and the left-hand 5th digit was not completely covered with new tissue. In an interview on 05/12/2025 at 1:05 PM, the Assistant Director of Nursing (ADON)-B confirmed LPN-C should have changed gloves after removing the DermaSaver Finger Separators and before wiping Resident 54's wounds with skin prep on both hands. ADON-B confirmed the DermaSaver Finger Separators should not have been placed in the residents hands with wounds prior to wound care.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D6(1) Based on interview and record review the facility failed to provide enteral feedings as ordered for Resident 35 related to giving bolus feedings when eating greater than 50% of meals. The sample size was 1. The facility identified a census of 95. Findings Are; A record review of the demographic information for Resident 35 revealed an admitted [DATE]. A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 6/1/23, Section C, indicated Resident 35 had short and long term memory problems and was not cognitively intact. An interview conducted on 07/19/23 at 9:19 AM with Resident 35's representative revealed that Resident 35 did eat orally and was supplemented with bolus feedings (a method of enteral tube feeding given in smaller volumes several times throughout the day for residents that may not consume enough nutritionally by eating orally) via the G-tube (a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) if (gender) eats less than 50% of the meal. A record review conducted on 07/19/23 of the History & Physical exam for Resident 35 dated 7/22/20 revealed a diagnosis of a Traumatic Brain Injury (usually results from a violent blow or jolt to the head or body) and Dysphagia (difficulty swallowing, taking more time and effort to move food or liquid from your mouth to your stomach). A record review of the Speech Therapy (ST) evaluation dated 8/3/22 revealed the following Speech Therapy notes; -Bedside Swallow Evaluation completed at noon meal. Pt (patient) currently on a diet consisting of pureed (foods you don't need to chew) solids and honey thick liquids. Pt has a G-tube for nutrition as well as medications when needed. Pt presents with head lean to the right. Pt referred to ST to document functional decline with meal intakes. Pt presenting with increased pocketing (holding food in the mouth for an extended amount of time without swallowing) refusals to open mouth for PO (by mouth) intake and oral cares at times and increased anterior spillage. Pt consumed ~50% of pureed solids this date with total assist for feeding. SLP (Speech Language Pathology) provided staff education including alternating consistencies and temperatures to sustain attention to meal as well as verbal and tactile cues to initiate swallow when needed. SLP provided education to stop feeding Pt when (gender) is pocketing/spitting food out as this could be a sign of refusal. Staff able to utilize g-tube for nutrition and medications when needed. Standardized Tests. Pt unable to follow directions, Pt unable to communicate, Pt with increased pocketing and denying oral cares. A record review completed on 07/19/23 at 03:12 revealed Resident 35 had the following order; -Jevity 1.2 (calorically dense, fiber-fortified therapeutic nutrition) Bolus 237ml per g-tube if meal intake is less than 50%. Document percentage of meal intakes dated 4/15/2021. The record review revealed that the bolus feedings had been documented as OP (outside of parameters) indicating that the bolus feeding had not been given or as a check mark indicating the bolus tube feeding had been given. A record review of the meal intakes dated 4/21/23 through present revealed the following; -5/26/23 it was documented that Resident 35 had eaten 75% of breakfast and a bolus tube feeding had been given -5/23/23 it was documented that Resident 35 had eaten 75% of lunch and a bolus tube feeding had been given -5/16/23 it was documented that Resident 35 had eaten 75% of dinner (evening meal) and a bolus tube feeding had been given -5/14/23 it was documented that Resident 35 had eaten 75% of lunch and a bolus tube feeding had been given -5/14/23 it was documented that Resident 35 had eaten 75% of dinner and a bolus tube feeding had been given -5/08/23 it was documented that Resident 35 had eaten 75% of breakfast and a bolus tube feeding had been given -5/07/23 no intake had been documented for dinner intake for Resident 35 and a bolus tube feeding had been given An interview on 07/20/23 at 03:27 PM with the ADON (Assistant Director of Nursing) after review of the meal intakes for Resident 35 and the bolus tube feeding documentation covering the last 90 days confirmed that the bolus tube feedings had been given on 7 occasions when it should not have been given.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on interview and record review, the facility failed to attempt non-pharmacological interventions prior to giving anti-anxiety medications for 1(Resident 90) of 2 sampled residents. The facility census was 95. Findings Are: A record review of the demographic information for Resident 90 revealed an admitted [DATE]. A record review of the diagnosis list ran on 7/19/23 revealed Resident 90 had a diagnosis of Vascular Dementia with Anxiety and Depression dated 2/13/23. A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 5/3/23, Section C, indicated Resident 90 had a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 15, indicating Resident 90 was alert and oriented with no confusion at the time of the assessment. A record review conducted on 07/19/23 at 12:46 PM of the Order Summary ran today revealed Resident 90 was receiving an antidepressant and a PRN (as needed) Xanax (a benzodiazepine medication used to treat anxiety and panic disorders). During an interview on 07/19/23 at 2:19 PM Resident 90 voiced experiencing some normal depression upon admission and now (gender) is just angry about not being able to live at home. A record review of the MAR (Medication Administration Record) dated July 2023 revealed Resident 90 had been given the PRN (as needed) Xanax on 7/4/23, 7/11/23, 7/13/23 x2 and 7/15/23. A record review of the Progress Notes dated 4/6/23 through 7/25/23 revealed no documentation of non-pharmacological (any non-chemical intervention performed on and benefitting the patient) interventions provided and no documentation of the Xanax being given on 7/11/23, 7/13/23 and 7/15/23. The record review revealed that on 7/4/23 the Progress Notes did indicate that the PRN Xanax had been given but non-pharmacological interventions had been documented. A record review of the mood and behavior charting completed by the NA's (Nurse Aides) and dated July 2023, revealed target behaviors for Resident 90 consisted of restlessness and tearfulness/crying. The record review of the July 2023 behavior charting indicated no behaviors had occurred on 7/4/23, 7/11/23, 7/13/23 or 7/15/23. An interview on 07/25/23 at 08:22 AM with the ADON (Assistant Director of Nursing), after review of the Progress Notes and Task mood/behavior charting related to the dates of the PRN Xanax had been given to Resident 90, confirmed that non-pharmacological interventions had not been documented and behaviors being exhibited had not been documented. A record review of the facility policy titled Out of Character Response Prevention and Medication Management with a revision dated of 1/2017 revealed the following facility guidelines; Documentation for Antipsychotic Medication: Every target behavior occurrence should have a corresponding entry in the Interdisciplinary Notes (Progress Notes) to provide a thorough description of the factors leading to the behavior, interventions (Non-Pharmacological) attempted, the effectiveness of the attempted interventions, physician/responsible party notifications as appropriate and any identified side effects.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B Based on observation, interview and record review, the facility failed to ensure respiratory equipment was cleaned and stored in a manner to prevent potential cross contamination for 1( Resident's 40) of 2 sampled residents. Findings Are: A. A record review of the demographic information for Resident 40 revealed an admitted [DATE] with a diagnosis of COPD (Chronic obstructive pulmonary disease is a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and Acute on Chronic Respiratory Failure with Hypoxia (a sudden or repetitive condition where there's not enough oxygen or too much carbon dioxide in your body). A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 6/9/23, Section C, indicated Resident 40 had a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 14, indicating Resident 40 was alert and oriented at the time of the assessment. An observation conducted on 07/19/23 at 1:40 PM revealed Resident 40 to have a CPAP (a treatment that uses mild air pressure to keep your breathing airways open while sleeping) mask resting on the bedside stand and not covered. An observation conducted on 07/20/23 at 8:40 AM revealed Resident 40's CPAP mask to be resting on the nightstand with the mask touching other items on the nightstand. An observation conducted on 07/24/23 at 09:40 AM revealed Resident 40's CPAP mask to be resting on the nightstand with the mask touching other items on the nightstand. An interview on 07/24/23 at 9:45 AM with Registered Nurse (RN)-H confirmed the CPAP mask for Resident 40 should be stored in the black IP (infection prevention) bag and was not.

Licensure Reference Number 175 NAC 12-006.18A Based on observation, interview, and record review; the facility staff failed to maintain the cleanliness of ventilation covers in 4 (Room 214, 215, 300 and 304) of 97 occupied resident bathrooms as evidenced by the ventilation covers had a coating of dust on the interior and exterior of the ventilation cover. The facility census was 125. Findings are: Observation on 4/13/22 at 10:00 AM of the resident bathrooms in Rooms 214, 215, 300 and 304 revealed the ventilation covers were coated with dust on the interior and exterior of the ventilation cover. Observation on 4/19/22 at 11:30 AM with the facility Administrator revealed ventilation covers were coated with dust in Rooms 214, 215, 300 and 304. Interview on 4/19/22 at 11:35 AM with the facility Administrator revealed the expectation of the ventilation covers would be clean and without dust, and confirmed that the ventilation covers were coated with dust and the housekeeping department were responsible for cleaning this area. Record review of a daily cleaning log called Housekeeping Daily Checklist for housekeeping revealed that bathroom interior ventilation covers were to be cleaned on a daily basis.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on record review and interview, the facility failed to ensure behavior monitoring was completed to support the use of non-pharmacological interventions and the use of [CONDITION(S)] medications for Resident 47, 80, and 84, and failed to ensure a 14 day or less duration for a PRN (as needed) anti-psychotic medication for Resident 50. The sample size was 5. The facility census was 87. FINDINGS ARE: A. During an observation of dining on the 400 unit, which included Resident 47, Resident 47 began to walk around, staff intervened and stated we don't want (gender) spitting on you. A record review of the document titled Behavior/Intervention Monthly Flow Record and dated 4/2022 revealed target behaviors for Resident 47 to include Statements of sadness and Self Isolation, spitting was not a listed target behavior. A record review of the Order Summary Report dated 4/14/22 revealed Resident 47 had the following medication orders which affected mood and behaviors: -[MEDICATION(S)] Tablet 20 MG (milligram) Give 1 tablet by mouth in the morning for anxiety, agitation -[MEDICATION(S)] Capsule 100 MG Give 1 capsule by mouth three times a day for Anxiety -[MEDICATION(S)] Tablet 25 MG ([MEDICATION(S)]) Give 0.5 tablet by mouth one time a day for Anxiety related to UNSPECIFIED DEMENTIA WITH BEHAVIORAL DISTURBANCE (F03.91) give 12.5 mg TID -[MEDICATION(S)] Tablet 25 MG ([MEDICATION(S)]) Give 1 tablet by mouth two times a day related to UNSPECIFIED DEMENTIA WITH BEHAVIORAL DISTURBANCE (F03.91) -[MEDICATION(S)] Tablet 0.5 MG ([MEDICATION(S)]) Give 1 tablet by mouth in the morning every Mon, Thu for anxiety A record review of the document titled Behavior/Intervention Monthly Flow Record and dated 4/2022 for Resident 47 revealed no occurrences of target behaviors being exhibited 4/1/22 through 4/18/22. A record review of the Progress Notes dated 4/1/22 through 4/15/22 revealed no negative or target behaviors occurring for Resident 47. An interview with the DON (Director of Nursing) on 04/18/22 at 09:45 AM after review of the Behavior/Intervention Monthly Flow Record and dated 4/2022 for Resident 47 and the Progress Notes dated 4/1/22 through 4/15/22 confirmed it did not contain information supporting the use of [CONDITION(S)] medications. B. A record review of the demographic information for Resident 80 titled Admission Record revealed an admitted [DATE] A record review of the Order Summary Report dated 4/14/22 revealed Resident 80 had the following orders which affected mood and behaviors: -[MEDICATION(S)] Tablet 10 MG ([MEDICATION(S)]) Give 1 tablet by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED (F33.9) -[MEDICATION(S)] Tablet 0.5 MG ([MEDICATION(S)]) Give 1 tablet by mouth as needed for anxiety related to ANXIETY DISORDER, UNSPECIFIED (F41.9) until 04/21/2022 23:59 HS -[MEDICATION(S)] Tablet 25 MG ([MEDICATION(S)]) Give 1 tablet by mouth at bedtime for anxiety/depression -[MEDICATION(S)] Tablet 5 MG ([MEDICATION(S)]) Give 1 tablet by mouth two times a day related to VASCULAR DEMENTIA WITH BEHAVIORAL DISTURBANCE (F01.51) A record review of the Behavior/Intervention Monthly Flow Record and dated 4/2022 for Resident 80 revealed target behaviors of Exit Seeking and Restlessness. A record review of the undated Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) contained the following information related to target behaviors for Resident 80: See behavior/intervention monthly flow record for targeted behavior and potential side effects Date Initiated: 03/22/2022 Created on: 03/22/2022 A record review of the MAR (Medication Administration Record) dated 4/1/22-4/30/22 for Resident 80 revealed that the PRN (as needed) [MEDICATION(S)] (an anti-anxiety medication) had been given 7 times between 4/1/22 and 4/14/22. A record review of the Progress Notes dated 4/1/22 through 4/14/22 revealed that non-pharmacological intervention attempts had not been documented for 4 of the 7 occurrences. A record review of the facility policy titled Out of Character Response Prevention and Medication Management with a review date of 1/2017, read as follows: -Best practice is to have one licensed nurse oversee this process in each facility. The [NAME] Health Service expectation is to review this form during the weekly Risk meeting, in conjunction with the care planning process and prn. -When complete the Behavior/Intervention Monthly Flow Record, use a separate form for each psychoactive medication. -Every target behavior occurrence that is documented on the above mention form should have a corresponding entry in the Interdisciplinary Notes to provide a thorough description of the factors leading to the behavior, interventions (non-pharmacological) attempted, and the effectiveness of the attempted interventions, physician /responsible party notification as appropriate and any identified side effects. A record review of the Behavior/Intervention Monthly Flow Record and dated 4/2022 for Resident 80 revealed target behaviors had occurred 15 times between 4/1/22 and 4/14/22. A record review of the Progress Notes dated 3/22/22 through 4/15/22 for Resident 80 revealed that on 4/11/22 at 21:45 PM, (gender) still could not sit long in the dining room to wait for supper. [MEDICATION(S)] given with HS (hour of sleep) meds. A record review of the Progress Notes dated 3/22/22 through 4/15/22 for Resident 80 revealed an entry 4/8/22 at 23:41 that read seemed restless after talking to (gender) spouse on the phone. Increased prn [MEDICATION(S)] given. An interview with the DON on 04/18/22 at 09:45, after review of the Progress Notes dated 4/1/22 through 4/15/22 for Resident 80, confirmed that non-pharmacological interventions are a facility expectation and should have been documented. C. A record review of the demographic information for Resident 84 titled Admission Record revealed an admitted [DATE]. A record review of the Order Summary Report dated 4/14/22 revealed Resident 84 had the following orders which affected mood and behaviors: -[MEDICATION(S)] Tablet 0.5 MG Give 0.5 tablet by mouth every 12 hours as needed for anxiety until 04/01/2023 -[MEDICATION(S)] Sprinkles Capsule Delayed Release Sprinkle 125 MG ([MEDICATION(S)]) Give 1 capsule by mouth two times a day related to ALZHEIMER'S DISEASE WITH LATE ONSET (G30.1) *Do NOT crush or chew -[MEDICATION(S)] Sprinkles Capsule Delayed Release Sprinkle 125 MG ([MEDICATION(S)]) Give 2 capsule by mouth one time a day related to ALZHEIMER'S ISEASE WITH LATE ONSET (G30.1) *Do NOT crush or chew* -[MEDICATION(S)] [MEDICATION(S)] Tablet Disintegrating 30 MG ([MEDICATION(S)]) Give 1 tablet by mouth one time a day related to PSYCHOPHYSIOLOGIC [CONDITION(S)] (F51. 04) -[MEDICATION(S)] Tablet 100 MG ([MEDICATION(S)]) Give 1 tablet by mouth two times a day related to MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED (F32.9) A record review of the MAR dated 4/1/22-4/30/22 revealed that the PRN [MEDICATION(S)] had been given on 4/3/22, 4/4/22, and 4/6/22. A record review of the Progress Notes dated 4/1/22 through 4/13/22, revealed the following entries related to the administration of the PRN [MEDICATION(S)]: 4/3/22 04:14 AM Note Text: CNA summoned me to resident's room. Resident woke up Very confused. Denied pain but was agitated. Resident was helped back into bed after a while and prn [MEDICATION(S)] administered. Resting quietly in bed now. A record review of the Progress Notes dated 4/1/22 through 4/13/22, revealed no documentation related to the PRN [MEDICATION(S)] given on 4/4/22 or 4/6/22. A record review of the document titled Behavior/intervention Monthly Flow Record dated 4/2022 for Resident 84 revealed target behaviors of statements of sadness and self isolation. The record review of the document titled Behavior/intervention Monthly Flow Record dated 4/2022 for Resident 84 no episodes of target behaviors occurring anytime between 4/1/22 and 4/17/22. A record review of the Progress Notes for Resident 84 dated 3/31/22 through 4/13/22 revealed an entry that read as follows: 4/1/2022 00:40 Nursing Note Note Text: 102/45, 63, 18, 97.7, 92% RA, New Admit Day #2, Resident awake, restless in bed, kicking pillows off bed, denies any pain or discomfort, peri cares provided, reposition change with bil heels off loaded, and fluids given, resident says that feels so much better, pancake call light in place for safety. A record review of the Progress Notes for Resident 84 dated 3/31/22 through 4/13/22 revealed an entry that read as follows: 4/3/2022 04:14 Nursing Note Note Text: CNA summoned me to resident's room. Resident woke up very confused. Denied pain but was agitated. VS within normal limits. BS 147. Foley patent and draining clear yellow urine. Resident was helped back into bed after a while and prn [MEDICATION(S)] administered. Resting quietly in bed now. An interview with the DON on 04/18/22 at 09:45, after review of the Behavior/Intervention Monthly Flow Record and dated 4/2022 for Resident 47 and compared to the Progress Notes dated 4/1/22 through 4/15/22 for Resident 47 confirmed that the two documents should match regarding out of character responses and did not. The interview also confirmed that non-pharmacological interventions were to be tried and documented and were not. D. A review of Resident 50's active orders as of 4/18/22 revealed that the resident had an order for [MEDICATION(S)] (an antipsychotic medication frequently ordered for nausea and vomiting) Tablet 10 (milligrams) MG Give 1 tablet by mouth every 6 hours as needed for Nausea and Vomiting. The start date for this order was 3/3/22, and there was no end date. An interview with the Assistant Director of Nursing (ADON) A on 4/18/22 at 1:31 PM confirmed that the medication had been ordered with no end date. The ADON further confirmed that the medication should have had only a 14 day duration without being re-evaluated by the provider.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on record review and interview, the facility failed to provide nursing care to prevent the potential for constipation for Resident 47, 80 and 84. The sample size was 4. The facility identified a census of 87. FINDINGS ARE: A. A record review of the document titled Task:Bowel Movement Look Back 30 days and covering days 3/20/22 through 4/18/22 revealed Resident 47 had no bowel movement (BM) documented for days 4/2/22, 4/3/22, 4/4/22, 4/10/22, 4/11/22, 4/14/22, 4/15/22 and 4/16/22. A record review of the Order Summary Report dated 4/14/22 revealed that Resident 47 had the following medication orders which affected bowel care: -Milk of Magnesia Suspension ( MOM) 400 MG/5ML Give 30 ml by mouth every 24 hours as needed (PRN) for Constipation May give daily for constipation -Dulcolax Suppository ([MEDICATION(S)]) Insert 1 application rectally every 72 hours as needed for constipation Every 3 days prn -[MEDICATION(S)] Powder 17 GM/SCOOP ([MEDICATION(S)]) Give 1 scoop by mouth one time a day for Constipation mix with 4-6oz of liquid -Senna Plus Tablet 8.6-50 MG (Sennosides-[MEDICATION(S)] Sodium)Give 2 tablet by mouth two times a day for bowel management -[MEDICATION(S)]-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth four times a day for Shoulder and back pain related to PAIN, UNSPECIFIED An interview on 04/18/22 at 10:49 AM with the Director of Nursing (DON) confirmed that the facility bowel care policy was to give PRN MOM on day 2 of no BM and give Dulcolax supp on day 3 of no BM Record review of the Order Summary Report dated 4/14/22 revealed Resident 47 to be taking routine [MEDICATION(S)] for pain, which has the potential to increase the risk for constipation. A record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . B. A record review of the document titled Task:Bowel Movement Look Back 30 days and covering days 3/22/22through 4/18/22 revealed Resident 80 had no bowel movement (BM) documented for the following days: 3/26/22, 3/27/22, 3/28/22, 4/8/22, 4/9/22, 4/10/22, 4/11/22, and 4/12/22. A record review of the Order Summary Report dated 4/14/22 revealed Resident 84 had the following bowel care orders: -[MEDICATION(S)] Suppository 10 MG Insert 1 suppository rectally as needed for bowel management daily -Milk of Magnesia Suspension 400 MG/5ML ([MEDICATION(S)]) Give 30 ml by mouth as needed for bowel management daily -[MEDICATION(S)] Powder ([MEDICATION(S)] 1450) Give 17 gram by mouth one time a day for bowel management *Mix in 4-8 ounces of preferred fluids* -Senna S Tablet 8.6-50 MG (Sennosides-[MEDICATION(S)] Sodium) Give 2 tablet by mouth one time a day for bowel management A record review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 4/18/22 at 03:45 PM with the DON after review of the bowel pattern documentation and the March 2022 and April 2022 MAR's for Resident 80 confirmed that prune juice had been given on 3/29 and that an attempt to give PRN MOM had been refused on 4/11/22 and MOM had been given on 4/12/22. The interview with the DON confirmed that the bowel care protocol had not been followed. C. A record review of the demographic information for Resident 84 titled Admission Record revealed an admitted [DATE]. A record review of the document titled Task:Bowel Movement Look Back 30 days and covering days 3/30/22through 4/18/22 revealed Resident 84 had no bowel movement (BM) documented for the following days: 4/8/22, 4/9/22, 4/10/22, 4/11/22, 4/13/22, 4/14/22, 4/16/22 and 4/17/22. A record review of the Order Summary Report dated 4/14/22 revealed Resident 84 had the following orders which affect bowel care: -[MEDICATION(S)] Suppository 10 MG Insert 1 suppository rectally as needed for bowel management daily -Metamucil Fiber Packet ([MEDICATION(S)]) Give 3.4 gram by mouth one time a day for bowel management *Mix in 8 ounces of referred fluids* -Milk of Magnesia Suspension 1200 MG/15ML ([MEDICATION(S)]) Give 30 ml by mouth every 24 hours as needed for Bowel Management started on 4/6/22 -[MEDICATION(S)] Powder ([MEDICATION(S)] 1450) Give 17 gram by mouth one time a day for bowel management *Mix in 4-8 ounces of preferred fluids* -Senna S Tablet 8.6-50 MG (Sennosides-[MEDICATION(S)] Sodium) Give 2 tablet by mouth one time a day for bowel management A record review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with the DON on 4/19/22 after review of the BM documentation for Resident 84, revealed prune juice had been given on 4/9/22, 4/14/22 and 4/17/22 and confirmed that the facility bowel care program had not been followed, and PRN MOM should have been.

Licensure Reference Number 175 NAC 12-006.09D4 Based on observation, record review and interview; the facility failed to ensure that restorative services [therapeutic practice and training to restore and to maintain physical function] were implemented as recommended by Physical Therapy after services were discontinued for 1 (Resident 44) of 1 resident reviewed for restorative services. The facility census was 87. Findings are: Record review of Resident 44's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 2/16/22 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified that Resident 44 required extensive assistance with transfers and walking in and out of room and was not steady with moving from surface to surface, walking or moving from a seated to standing position. Record review of Resident 44's Physical Therapy Therapist Progress and Discharge Summary dated 3/16/22 revealed: Services were started on 3/1/22 and continued through 3/15/22. Analysis of Functional Outcome/Clinical Impression revealed that Resident 44 demonstrated progress in transfers and ambulation that improved to minimal assistance. Impact on Burden of Care / Daily Life revealed that Resident 44 had shown gains in strength and balance which allowed for improvement with transfers and ambulation . Discharge Plans & Instructions revealed Resident 44 was to remain in Long Term Care [LTC] with restorative services. The Discharge Summary was signed by Physical Therapist [PT] C. Observation on 04/13/22 at 10:34 AM revealed Resident 44 seated in a wheelchair in the residents room. In an interview on 04/13/22 at 10:34 AM, Resident 44 stated that [gender] had therapy in the recent past but it was stopped and hasn't had any exercises since that time. Interview on 04/14/22 at 12:15 PM Restorative aide [RA] B confirmed that Resident 44 was not on a Restorative program. Interview on 04/14/22 at 02:04 PM with Assistant Director of Nursing (ADON) A confirmed that the PT C did recommend restorative services after Resident 44's discharge from therapy services and that the referral was not communicated to restorative services. ADON A further confirmed that restorative services were not initiated as recommended.

Licensure Reference Number 12-006.11D Based on observation, record review and interview; the facility failed to ensure a cold lettuce salad temperature was 41 degrees Fahrenheit or lower before serving which had the potential to cause foodborne illness. This had the potential to affect 10 of 82 residents who could have been served lettuce salad prepared in the kitchen. The facility census was 88. Findings are: An observation on 9/3/20 from 11:30 AM - 12:05 PM revealed the DM (Dietary Manager) checked food temperatures prior to serving lunch. DM checked the temperature of the lettuce salad and was 41.5 degrees. DM then put the container with the lettuce salad back into the freezer and did this several times until the temperature was 39.9 degrees and then wrote that temperature down on the facility daily food temperature log. Per Nebraska State Food Code Dated 7/21/2016 3-202.11 Temperature. (A) Except as specified in (B) of this section, refrigerated, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked to a temperature and for a time specified under §§ 3-401.11 - 3-401.13 and received hot shall be at a temperature of 57oC (135oF) or above. P shall be at a temperature of 5oC (41oF) or below when received. P An interview on 9/3/20 at 12:10 PM with Dietician revealed the cold lettuce salad should have been thrown out and went immediately to have the kitchen discard the lettuce salad. An interview on 9/8/20 with DM revealed the container the lettuce salad was in on 9/3/20 would have had approximately 10 servings.

Based on record reviews and interview, the facility failed to provide notification of non-coverage of Medicare A benefits within 2 days prior to the end of coverage for 2 Residents (Residents 291 and 292). The sample size was 25 and the facility census was 88. Findings are: 09/08/20 02:58 PM A record review of the Notice of Medicare Non-Coverage (NOMNC, a notice provided to a patient covered under Medicare that specific services will no longer be covered) for Resident 291 revealed the end of the Medicare coverage was 7/24/20 and the date on the NOMNC was 7/24/20. 09/08/20 02:58 PM A record review of the NOMNC for Resident 292 revealed the last covered day from Medicare was 3/2/20 and that Resident 292 had signed the NOMNC on 3/3/20. 09/08/20 02:20 PM An interview with the facility social worker confirmed the NOMNC for Resident's 291 and 292 did not occur 2 days prior to the last covered day of services 09/08/20 02:20 PM After review of the NOMNC's provided, an interview with the facility Director of Nursing confirmed the notification of non-coverage for Resident 291 and Resident 292, did not occur 2 days prior to the notices given.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on record review and interviews, the facility failed to review and revise the 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 Resident 29's recent onset of confusion. The sample size was 25 and the facility census was 88. Findings are: A record review of Resident 29's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) revealed a BIMS ( Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 15 revealed Resident 29 was not cognitively impaired. 09/01/20 09:50 AM An interview with Resident 29 revealed Resident 29 was alert, oriented to person, place and time and was interviewable. 09/02/20 07:50 AM An interview with Resident 29 revealed Resident 29 was confused to place and time. 09/02/20 07:53 AM An interview with RN-D revealed Resident 29 had intermittent confusion. 09/03/20 4:56 PM An interview with Resident 29's family member revealed Resident 29's confusion was believed to be due to loss of routine and began when the visitor restrictions were put implemented. The interview also revealed Resident 29 previously would keep track of the day by the activity scheduled and would attend daily. 09/08/20 02:26 PM An interview with the facility DON confirmed the confusion, refusals to see a psychiatrist and refusals to take antidepressant medication was not on the care plan for Resident 29. A record review of Resident 29's CCP revealed Resident 29 was capable of making personal choices for daily engagement. The review of the CCP for Resident 29 revealed no mention of Resident 29's new onset of confusion. The record review revealed that Resident 29's CCP did not address the antidepressant medication trialed on 07/17/20.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D5 Based on record review and interviews, the facility failed to provide behavioral health care and services related to Resident 29's depression. The sample size was 25 and the facility census was 88. Findings are: A record review of the Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) for Resident 29 revealed a concern for an alteration in the psychosocial well-being due to Covid-19 (a mild to severe respiratory illness that is caused by a coronavirus) as well as a potential for depression related to a decline in independence and admission to the facility. The record review of the CCP for revealed that Resident 29 had expressed thoughts Resident 29 would be better off dead. 09/03/20 03:45 PM An interview with LPN-B revealed Resident 29 has been confused since Covid-19 restrictions had been implemented. 09/03/20 4:56 PM An interview with Resident 29's family member revealed Resident 29's confusion was believed to be due to loss of routine and began when the visitor restrictions were implemented. A record review of the physician's orders [REDACTED]. 09/03/20 4:56 PM An interview with Resident 29's family member revealed Resident 29's confusion to be due to loss of routine. The interview revealed Resident 29 would keep track of the day by the activity scheduled and would attend daily. The interview with Resident 29's family member revealed the confusion had worsened since the visitor restrictions were implemented. The interview revealed Resident 29's confusion worsened when on the [MEDICATION NAME]. 09/08/20 07:35 AM An interview with RN-E revealed Resident 29's orientation level continues to vary and becomes worse in the evening time. The interview with RN-E revealed no behavior sheet in the book, and documentation of confusion and or depressive behaviors for Resident 29. 09/08/20 08:24 AM An interview with the DON revealed the behavior book is for those residents with psych [DIAGNOSES REDACTED]. The interview with the DON confirmed no treatment for [REDACTED]. The interview with the DON revealed Resident 29 refused to see psych doctors and disliked taking new medications.

Based on record review and interview the facility failed to ensure a level 2 PASARR ( Pre-Admission Screening and Resident Review) Program had been completed on one resident (Resident 2) of 1 sampled resident, when newly diagnosed with [REDACTED]. The facility census was 96. Findings are: Record Review of PASSAR Level one completed in 2012 did not recommend the Level II. This PASSAR identified Bi-Polar Disorder but did not identify the Schizo-effective Disorder, Mania, [MEDICAL CONDITION] Disorder, and Depression with psychiatric features, treatment refractory [MEDICAL CONDITIONS], Atypical [MEDICAL CONDITION]. Record review of Note to Attending Physician/Prescriber revealed; Resident 2 received antipsychotic medication and the clarification for [DIAGNOSES REDACTED]. Record review of initial [DIAGNOSES REDACTED]. An interview on 02/19/19 at 04:17 PM with the DON (Director of Nurse) confirmed; Resident 2 had not been reassessed for PASSAR level 2 after the [DIAGNOSES REDACTED]. An interview on 02/21/19 at 03:29 PM with the SSD (Social Services Director) confirmed the re-evaluation PASSAR had not been submitted. An interview on 02/21/19 at 03:40 PM with the SSD confirmed; that information had been sent to the psychiatrist on 02/19/19. The information had been received by the facility on 02/21/19 and had been sent to Ascend for re-evaluation.

License and Reference Number 175 NAC 12 Based on observation, record review and interview, the facility failed to ensure that residents care plans were individualized to meet the the residents fluid needs. This had the potential to effect 2 residents, Residents # 21 and # 28. The facility census was 96. Resident #21 02/14/19 03:38 PM observed in room and does not respond to verbal cues. 02/19/19 10:30 AM observed in room and does not respond to verbal cues. Record review of the residents MDS (Minimum Data Set is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes and non-critical access hospitals with Medicare swing bed agreements dated 08/28/18 revealed a BIMS (Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively at the moment) of 2 indicated severely impaired cognition. Extensive assist with eating and drinking. Resident unable to voice preferences on MDS. Record review of the resident care plan dated 4/28/18 revealed no plan to address the residents inability to choose what fluids to consume, when to consume fluids or how much fluids to consume. On 02/21/19 at 12:10 PM an Interview with LPN(Licensed Practical Nurse)3 D confirmed the resident does not have the ability to choose what fluids to consume, when to consume fluids or how much fluids to consume. Resident #28 On 02/14/19 at 2:35 PM resident observed in bed with eyes open does not respond to verbal cues. On 02/20/19 at 10:16 AM resident observed in bed with eyes open does not respond to verbal cues. Record review of the residents MDS dated [DATE] revealed a BIMS of 2. Extensive assist with eating and drinking. Resident unable to voice preferences on MDS. Record review of the resident care plan dated 12/3/18 revealed no plan to address the residents inability to choose what fluids to consume, when to consume fluids or how much fluids to consume. On 02/21/19 at 12:10 PM an interview with LPN D confirmed the resident does not have the ability to choose what to consume, when to consume fluids or how much to consume.

LICENSURE REFERENCE 175 NAC 12-006.17 Based on observation, interview and record review the facility failed to follow infection control practice to prevent cross contamination between residents, affecting two residents (Residents 47 and 82). The facility census was 90. Findings are A. Observation of Resident 47's cares on 8/12/15 at 8:08 AM revealed: -The resident was lying in bed with a horseshoe pillow supporting the resident's head and arms. -NA (Nurses Aide) K provided the resident's cares. -During the cares NA K washed the NA's hands for 10 seconds before providing catheter cares. -The NA dropped the residents urinary catheter (tube inserted into the bladder to drain urine) drainage bag on the floor during cares. The NA picked up the bag from the floor. The urinary catheter drainage bag was not in the protective coverage bag. -The Restorative Coordinator assisted NA K with the resident's transfer. NA K attached the urinary catheter drainage bag onto the NA's uniform slacks during the transfer to the resident's wheelchair. After the transfer, NA K put the urinary catheter drainage bag into a protective cover on the wheelchair. The NA washed hands less than 1 second. Interview with the Director of Nursing (DON) on 8/13/15 at 2 PM revealed that the urinary catheter drainage bag should not be placed on the staff's uniform during transfers. B. Observation of Medication Pass on 8/10/15 between 8:15 AM and 8:45 AM revealed: -RN (Registered Nurse) A did hand washing at 8:15 AM for 12 seconds -RN A did hand washing at 8:32 AM for 10 seconds -RN A did hand washing at 8:45 AM for 13 seconds C. Observation of Resident 82's toileting cares on 8/12/15 revealed: -NA L provided the resident's cares -During the cares, NA L applied gloves with no prior hand washing prior to providing the cares -NA L assisted Resident 82 with hand washing after completing the cares. -NA L did hand washing for self when cares were completed for less than 10 seconds. Interview on 8/12/15 at 1:45 PM with Administrator revealed that handwashing was to be 20 seconds per performance check sheets. The facility's Handwashing/Hand Hygiene Infection Control Nursing Services Policy and Procedure Manual 2001 MED-PASS, Inc (Revised April 2012) 5. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions:

LICENSURE REFERENCE 175 NAC 12-006.10D Based on observation, interview, and record review the staff failed to administer one medication according to the physician's orders [REDACTED]. Twenty-five medication opportunities were observed with two errors resulting in an 8% medication error rate. The facility census was 90. Findings are: A. Observation of Resident 37's medication administration on 8/11/15 at 8:43 AM revealed: -RN (Registered Nurse) A prepared the residents medication that included [MEDICATION NAME] (proton-pump inhibitor used a backflow of acid or reflux), [MEDICATION NAME] (used to treat allergies [REDACTED]. -The label for [MEDICATION NAME] 20 mg (milligrams) said to give 30 minutes before the meal. -The resident was at the dining room table eating breakfast. -RN A gave the resident the medications. Interview with RN A on 8/11/15 at 8:47 AM revealed that the [MEDICATION NAME] should have been given sooner. Review of DAVIS DRUG GUIDE for NURSES, FOURTEENTH EDITION stated Administer doses before meals, preferably the morning. B. Interview with LPN (Licensed Practical Nurse) F on 8/12/15 at 11:50 AM revealed that the LPN did not need to check for [DEVICE] placement since it was checked for Resident 88 earlier in the day. The LPN stated that it was checked every 8 hours and would be checked at 4 PM today. Observation of Resident 88's medication administration on 8/12/15 at 11:55 AM revealed: -LPN F poured 10 ml (milliliter)/ 200 mg of [MEDICATION NAME] ([MEDICATION NAME]) into a medication cup. -LPN F did not check for placement of the resident's [DEVICE] placement. -LPN F poured approximately 30 ml of water into a 60 ml syringe into the [DEVICE]. -The LPN poured the medication into the syringe that went directly into the [DEVICE] and then finished with approximately 30 ml of water into the g tube. Review of Resident 88's Admission/ Re-admission orders [REDACTED]. Review of the facility Administering Medications through an Enteral Tube revised December 2012 stated that for gastrostomy (G tubes) check tube placement by auscultation by placing a 60 ml syringe containing 10 ml of air and listening to the whooshing sound while the air from the tube was injected into the tubing into the stomach. Interview with the DON (Director of Nursing) on 8/12/15 at 2:20 PM revealed that placements of the [DEVICE] should be checked each time a [DEVICE] medication was given.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and interview, the facility failed to safely secure 2 residents (Residents 1 and 2) during transport in the facility van from a resident sample size of 5. The facility census was 100. Findings are: A. Review of Resident 1's ER (Emergency) Injury Summary dated 8/10/10 revealed that the resident had sustained a fall with a C2 (2nd cervical vertebrae) type 3 fracture; and abrasions to the posterior scalp and left hand. Review of Resident 1's Spine Trauma Consult dated 8/10/10 revealed that the resident was in a van today and when the van moved forward, the resident's wheelchair fell backwards, and the resident struck (gender) head. The resident denied loss of consciousness. The resident complained of neck pain. The resident was able to shrug the resident's shoulders and elevate the resident's legs off the bed. The resident denied paresthesia (tingling sensation) in the resident's arms or legs. The C spine (Cervical spine) x-ray revealed an acute C2 type-3 fracture through the body with minimal displacement. The physician ordered a Miami J neck collar for the resident to wear. Review of Resident 1 Nurse's Notes on 8/10/10 at 4 PM revealed that the resident's wheelchair tipped over in the van and the resident was taken to the doctor's office. The resident was transported from the doctor's office to the hospital ER. Review of Resident 1's Annual MDS (Minimum Data Set: a federally mandated comprehensive care plan used for care planning) dated 6/20/10 revealed that the resident required limited assistance for transfers and ambulation. The resident was able to eat independently with set up assistance. The resident did not have range of motion limitations. Review of Resident 1's Significant Change MDS dated [DATE] revealed that the resident required extensive to total assistance with all activities of daily living including eating. The resident was non ambulatory. The resident had other range of motion limitations. Review of Resident 1's Physician Facsimile revealed: -On 8/12/10 at 2:40 pm the facility staff notified the physician that the resident was having pain and requested a routine pain medication. The physician ordered Percocet 5/325 mg (milligrams) 1 orally every 6 hours. -On 8/17/10 Nutrition Review stated that chewing was painful for the resident and resident's food intake had declined. An order was received to change the resident's diet from a ground meat diet to a pureed diet. The resident was fed all meals. -On 8/25/10 the resident complained constantly of pain even though on Percocet 5/325 1 po (orally) (orally) (orally) qid (4 times daily) (4 times daily) (4 times daily) and Tylenol for breakthrough pain. Resident 1's physician progress notes [REDACTED]. The resident was weakly able to move all extremities. The resident could raise both legs, but could not fully raise (gender) arms. The cervical x-ray 8/17/10 showed no displacement of the C2 fracture, but function is less. A MRI (Magnetic Resonance Imaging) was ordered. Review of Resident 1's physician progress notes [REDACTED]. The resident had tight stenosis with spinal cord compression. Review of Resident 1's Progress Note dated 8/27/10 revealed that the resident's C1-5 fusions due to Cervical 2 fracture with stenosis. Review of Resident 1's Pain Assessment revealed: -On 3/20/10 and 6/18/10 the resident did not display signs of pain. -On 8/12/10 the resident displayed non-verbal signs of pain as evidenced by: crying/ moaning; aggression; increased body movements; guarding of the neck; facial grimacing; increased restlessness; and irritability. The resident only had relief from pain treatments 10% of the time. -On 8/31/10 the resident demonstrated non-verbal signs of pain with increased rest periods. The resident's pain treatments provided 100% relief. Review of Resident 1's Community Transfer Sheet dated 8/31/10 revealed that the resident had Prafo braces for hand contractures. The resident had red non blanchable sport to the resident's occipital lobe of the head (back of the head). The resident had skin breakdown from the Miami J neck collar on the front and back of the resident's chest on admission and now was wearing a soft neck collar due to the resident's poor skin integrity. Review of Resident 1's Nurse's Notes dated 9/5/10 at 1 pm revealed that the resident had an elevated temperature of 100.6 degrees F and an increase in wound drainage noted to the lower portion of the resident's dressing. The skin surround the staples were red and green drainage was around the staples. The resident was transported to the hospital. Interview with RN (Registered Nurse) A on 9/2/10 at 12:30 PM revealed that the resident was hospitalized for [REDACTED]. Review of the Van Driver A's personnel file revealed that the van driver's last competency for van driving was completed on 9/13/06. The van driver's MVR (Motor Vehicle Record) was checked yearly per the facility policy, but Van Driver A did not have the yearly competency as required per their facility policy. Review of Van Driver A's interview with facility staff, dated 8/11/10, following the accident which occurred on 8/10/10 revealed that the van driver did not secure the resident's wheelchair with the front straps. When the van driver accelerated the van on 33rd and South Streets in Lincoln, the van driver heard a boom and "Let me up!" The van driver stopped the van and went to the back where the van driver found the resident tipped over in the wheelchair with blood on the floor. The van driver assisted the resident to an upright position. A police officer assisted and the resident was transported to the resident's physician's office and the resident was later transported to the hospital for evaluation. Interview with the facility Administrator on 9/2/10 at 3 PM revealed that Van Driver A was the van program instructor which started in 2006 and therefore Van Driver A did not have a competency since 2006 in the van driver's record. Interview with the Administrator on 9/2/10 at 3:15 PM revealed that Van Driver A was instructed on the blue van in which the accident occurred when it was new by the corporate staff a year ago, but there is no documentation of the orientation to the new van found by the administrator. B. Review of records identified that Resident 2 was involved in an accident while riding in the facility van on 08/24/2010 at 10:20AM. Records identify that Resident 2 was in a wheelchair that was positioned in the back of the van for transporting to a scheduled physician appointment. The van was at a complete stop at the intersection of South Street and 20th. When Employee B (the van driver) accelerated from the stop turning onto South Street. Resident 2 tipped over backward while sitting in the wheelchair. Resident 2 was quickly transported by ambulance to BryanLGH East for emergent care. emergency room services and assessments revealed that Resident 2 had bruises on the left arm and chest and an abrasion on the back of head. Extensive x-raying and a CT scan was done to rule out any further injuries. Morphine was administered for pain and ice bags were positioned over bruised areas. Resident 2 was released on the same day and returned to Milder Manor. Facility Administration and Director of Nursing as well as family member were immediately notified of the incident. Observation of Resident 2 during the Noon Meal on 09/07/2010 and interview with Employee C, assisting Resident 2, revealed: -Resident 2 had to be fed prior to the accident as well as the same. Resident 2 has a fair appetite and drinks fluids with assist. Employee C stated that everything is the same for Resident 2 as before the accident. Interview with the facility Administrator on 09/07/2010 at 1:30PM revealed: It has been acknowledged that the van driver, a long time employee of the facility was approved to drive the van and do so as a substitute for the regular full-time driver. This employee had driven this specific van before. During the investigation Employee B acknowledged that the forward straps had not been secured to the front wheelchair wheels to secure the chair for transport. The driver explained, "I forgot". The van was taken out of service and sent to the home office for inspection. Employee B had attended the required inservice on 08/19/2010 that reviewed the facility policy and procedure on proper restraint of wheelchairs in the van. Employee B is no longer allowed to drive the facility vans. Resident 2 is recovering from the accident injuries without observed complications. Resident 2 has returned to a regular routine and employees observe previous demeanor prior to the accident.