Every finding on record at Westfield Quality Care of Aurora

Licensure Reference Number 175 NAC 12-006.02(H)Based on observations, record review, and interview the facility failed to ensure a thorough investigation for 3 of 3 resident to resident abuse incidents affecting Residents 3, 4, 6, 1, and 2; and failed to develop interventions to protect other residents from further adverse behaviors for 2 residents (Residents 6 and 1). The facility census was 54.Findings are:A.Record review of the facility policy titled Abuse, Neglect, and Exploitation dated June 2025 revealed that it is the facility policy to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse and neglect. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation occur. Written procedures for investigations include:1- Identifying staff responsible for the investigation.2- Exercising caution in handling evidence.3- Investigating different types of alleged violations.4- Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations.5- Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause.6- Providing complete and thorough documentation of the investigation. The facility will make efforts to ensure that all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Efforts include examining the alleged victim for signs of injury, increased supervision, room or staffing changes to protect the resident from the alleged perpetrator, and revision of the resident's care plan. Record review of the admission Record dated 3/4/26 for Resident 4 revealed that Resident 4 admitted into the facility on [DATE] and lives in the facility memory care unit. Diagnoses included dementia, high blood pressure, and osteoporosis. Record review of the admission Record dated 3/4/26 for Resident 3 revealed that Resident 3 admitted into the facility on 6/20/23 and lives in the facility memory care unit. Diagnoses included anxiety disorder, depression, and myalgia (muscle aches and pains). Record review of the progress note dated 9/27/25 at 5:46 PM for Resident 4 revealed thatstaff witnessed Resident 4 walking to the dining room and through the open door. Resident 4 proceeded into the dining room. Staff went to the dining room to check on Resident 4. Staff entered the dining room and heard Resident 4 holler out. Staff witnessed Resident 4 with their pants down with their brief still in place. Resident 4 told the staff member that the other resident had hit them on the bottom and yelled for them to pull their pants up (a resident to resident abuse incident). The residents were separated. Resident 4 was toileted. The other resident returned to their room. 15-minute checks were started on both residents. Record review of the progress note dated 9/27/25 at 6:01 PM for Resident 3 revealed thatstaff witnessed another resident walking to the dining room and through the open door. The other resident proceeded into the dining room. Staff went to the dining room to check on the resident that entered. Resident 3 was in the dining room sitting at table. Staff entered the dining room and heard the other resident holler out. Staff witnessed the other resident with their pants down with their brief still in place. The other resident told the staff member that Resident 3 had hit them on the bottom and that Resident 3 yelled for them to pull their pants up (a resident to resident abuse incident). The residents were separated. The other resident was toileted. Resident 3 returned to their room. 15-minute checks were started on both residents. Record review of the progress note for Resident 4 dated 9/27/25 at 5:49 PM revealed that the nurse called the Adult Protective Services (APS) hotline to report the resident to resident abuse incident. Record review of the facility investigation report dated 9/29/25 revealed that it was for the Resident 3 to Resident 4 abuse incident on 9/27/25. The report documented the incident as a physical altercation that occurred on 9/27/25 at 5:47 PM. The section titled Equipment/Causal factor potentially involved contained no information. The section titled Interventions to prevent the accident/incident from reoccurring revealed that the facility immediately separated the residents and Resident 4 was taken to the bathroom and checked by the nurse. No injuries were noted and both residents were put on 15 minute checks. The investigation report packet contained a copy of progress notes dated 10/1/25 (printed on 10/1/25) for Resident 3 with the progress notes from 9/25/25 at 9:49 AM through 10/1/25 at 5:32 AM. The investigation report packet contained a copy of the care plan for Resident 3. The care plan had an entry dated 9/27/25 that Resident 3 had an altercation with another resident who was trying to void in the dining room. Resident 3 intervened and slapped the resident on the brief and told them to pull their pants up. The facility investigation report contained no documentation of identifying and interviewing any involved persons and witnesses. The investigation report documented the resident to resident incident but did not include investigation of the incident. Interview on 3/4/26 at 5:12 PM with the Facility Administrator (FA) confirmed that the facility did not do interviews with staff or residents for the resident to resident investigation and did not complete and document a thorough investigation for the incident as required. B.Record review of the admission Record dated 3/4/26 for Resident 4 revealed that Resident 4 admitted into the facility on [DATE] and lives in the facility memory care unit. Diagnoses included dementia, high blood pressure, and osteoporosis. Record review of the admission Record dated 3/4/26 for Resident 6 revealed that Resident 6 admitted into the facility on 8/13/25 and lives in the facility memory care unit. Diagnoses include dementia with agitation, major depressive disorder, and Other Conduct Disorders (persistent pattern of behavior that involves severe antisocial actions like aggression and destruction of property).Record review of the progress note for Resident 4 dated10/12/25 at 7:00 PM revealed that the nurse aide witnessed Resident 4 being hit in the upper back by another resident. Resident 4 was in the hallway and was attempting to go into the other resident's room. The nurse aide separated the residents and notified this nurse. Resident 4 was assessed and no marks, redness, or bruising were noted. Resident 4 denied pain. The DON and resident power of attorney were notified. Record review of the progress note dated 10/12/25 at 7:09 PM for Resident 6 revealed that a nurse aide witnessed Resident 6 hit another resident in the upper back. Resident 6 was in the hallway when the other resident began to enter the room of Resident 6. Resident 6 walked up to the other resident and hit them in the back. The nurse aide separated the residents and notified the nurse. Resident 6 was redirected back to their room. The Director of Nursing was notified. Record review of the progress note for Resident 4 dated 10/12/25 at 7:14 PM revealed that the nurse called the Adult Protective Services (APS) hotline to report the resident to resident abuse incident. Record review of the facility investigation report dated 10/14/25 revealed that it was for the Resident 6 to Resident 4 abuse incident on 10/12/25. The report documented the incident as a physical altercation that occurred on 10/12/25 at 6:30 PM. The section titled Equipment/Causal factor potentially involved revealed close quarters with two wandering residents. The section titled Interventions to prevent the accident/incident from reoccurring revealed that the facility would continue separation between the two residents, intervene when they are wandering together with guided distraction. Resident 6 was placed on 15 minute checks. The investigation report packet contained a copy of progress notes dated 10/13/25 for Resident 6 with progress notes from 10/12/25 at 7:09 PM through 10/13/25 at 3:06 AM. The investigation report packet contained a copy of page 4 of 7 of the care plan for Resident 6. The care plan had an entry dated 10/12/25 that read 15 minute checks and monitoring after physical altercation with other residents. The facility investigation report contained no documentation of identifying and interviewing any involved persons and witnesses. The investigation report documented the resident to resident incident but did not include investigation of the incident. Interview on 3/4/26 at 5:12 PM with the Facility Administrator (FA) confirmed that the facility did not do interviews with staff or residents for the resident to resident investigation and did not complete and document a thorough investigation for the incident as required. C.Record review of the facility policy titled Abuse, Neglect, and Exploitation dated June 2025 revealed that it is the facility policy to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse and neglect. The section titled Prevention of Abuse, Neglect and Exploitation revealed that the facility will establish a safe environment that supports policies and protocols for preventing sexual abuse. The facility will identify, correct, and intervene in situations in which abuse and neglect are more likely to occur. The facility will assure that staff assigned have the knowledge of the individual resident's care needs and behavioral symptoms. The identification, ongoing assessment, care planning of appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. Record review of the admission Record dated 3/4/26 for Resident 2 revealed that Resident 2 admitted into the facility on 9/17/24 and lives in the facility memory care unit. Diagnoses included Alzheimer's Dementia, depression, and high blood pressure. Record review of the admission Record dated 3/4/26 for Resident 1 revealed that Resident 1 admitted into the facility on 1/12/26 and lives in the facility memory care unit. Diagnoses included vascular dementia, anxiety disorder, and stroke. Record review of the progress note for Resident 1 dated 2/4/26 revealed that Resident 1 was being sexually inappropriate to staff and other resident's family members. Resident 1 attempted to reach out and grab a staff member and visitor's breast at two separate times. Resident 1 made a vulgar comment about touching staff member's genitals. Resident 1 was informed that the behavior was inappropriate and staff attempted to redirect Resident 1 away from others. Record review of the progress note for Resident 1 dated 2/6/26 at 9:34 AM revealed that the facility spoke to the nurse practitioner related to Resident 1 having increased inappropriate behaviors of groping others. Record review of the progress note for Resident 1 dated 2/14/26 at 6:30 PM revealed that police arrived at the facility and took a statement from staff regarding an incident. Record review of the progress note for Resident 2 dated 2/16/26 at 12:31 PM revealed that the resident's physician faxed back to the facility regarding incident with another resident on 2/14/26.Record review of the physician notification dated 2/14/26 revealed that Resident 2 was found in the dining room with Resident 1. Resident 1 had their hands in the groin area of Resident 2. Record review of the facility investigation report dated 2/16/26 revealed that it was for the Resident 1 to Resident 2 sexual abuse incident on 2/14/26. The report revealed that on 2/14/26 at 5:10 PM the medication aide notified the nurse that they were needed. The nurse noticed Resident 2 in the dining room sitting on their buttocks with their pants and brief around their knees upon the nurse's arrival. The medication aide explained that Resident 2 did not fall. Resident 2 sat down. The medication aide explained that the medication aide had placed Resident 2 in the dining room for the meal. Resident 1 was in Resident 1's room at that time. The medication aide revealed that they went down the hall to give medication to a resident and brought another resident to the dining room. The medication aide revealed that they witnessed Resident 2 with their pants pushed down and Resident 1 had their hand in Resident 2's groin area. Resident 1 immediately went to their room upon seeing the medication aide return to the dining room. The section titled Equipment/Causal factor potentially involved revealed Leaving resident in dining room by self The section titled Interventions to prevent the accident/incident from reoccurring revealed that the facility immediately separated Resident 1 and Resident 2. Resident 2 was assessed with no injury noted. Resident 2 was assisted to a standing position and redressed. Resident 1 was placed on 15 minute checks. The investigation report packet contained a copy of the 15 minute check logs for Resident 1 dated 2/14/26 through 2/16/26. The investigation report packet contained a copy of page 10 of 13 of the care plan for Resident 1. The care plan had an entry dated 2/14/26 that Resident 1 and Resident 2 were immediately separated. Resident 2 was assessed for injury and none was noted. Resident 1 was put on 15 minute checks. The investigation report packet contained provider recommendations for Resident 1 dated 2/5/26 for medication changes for Resident 1 due to sexual behaviors extending to other residents and family members that visit the memory care unit (this was prior to the 2/14/26 resident to resident sexual abuse incident). The facility investigation report contained no documentation of identifying and interviewing any involved persons and witnesses. The investigation report documented the resident to resident sexual abuse incident but did not include investigation of the incident. Interview on 3/4/26 at 5:12 PM with the Facility Administrator (FA) confirmed that the facility did not do interviews with staff or residents for the resident to resident investigation and did not complete and document a thorough investigation for the incident as required.D.Record review of the facility policy titled Abuse, Neglect, and Exploitation dated June 2025 revealed that it is the facility policy to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse and neglect. The facility will make efforts to ensure that all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Efforts include examining the alleged victim for signs of injury, increased supervision, room or staffing changes to protect the resident from the alleged perpetrator, and revision of the resident's care plan. The section titled Prevention of Abuse, Neglect and Exploitation revealed that the facility will establish a safe environment that supports policies and protocols for preventing sexual abuse. The facility will identify, correct, and intervene in situations in which abuse and neglect are more likely to occur. The facility will assure that staff assigned have the knowledge of the individual resident's care needs and behavioral symptoms. The identification, ongoing assessment, care planning of appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. Record review of the facility policy titled Dementia Care dated 4/1/25 revealed that it is the facility policy to provide the appropriate treatment and services to every resident who displays sings of, or is diagnosed with, dementia to meet his or her highest practicable physical, mental, and psychosocial well-being. The facility will assess, develop, and implement care plans. The care plan goals will be achievable and the facility will provide resources necessary for the resident to be successful in meeting their goals. The care plan interventions will be related to each resident's individual symptomology. Care and services will be person-centered and reflect each resident's individual goals while maximizing safety. Individualized non-pharmacological approaches to care will be utilized. The care plan goals and interventions will be monitored on an ongoing basis for effectiveness and will be reviewed/revised as necessary. All staff will be trained on dementia and dementia care practices to ensure that they have the appropriate competencies and skill sets to ensure resident's safety. Record review of the admission Record dated 3/4/26 for Resident 4 revealed that Resident 4 admitted into the facility on [DATE] and lives in the facility memory care unit. Diagnoses included dementia, high blood pressure, and osteoporosis. Record review of the admission Record dated 3/4/26 for Resident 6 revealed that Resident 6 admitted into the facility on 8/13/25 and lives in the facility memory care unit. Diagnoses include dementia with agitation, major depressive disorder, and Other Conduct Disorders (persistent pattern of behavior that involves severe antisocial actions like aggression and destruction of property).Record review of the progress note for Resident 4 dated10/12/25 at 7:00 PM revealed that the nurse aide witnessed Resident 4 being hit in the upper back by another resident. Resident 4 was in the hallway and was attempting to go into the other resident's room. The nurse aide separated the residents and notified this nurse. Resident 4 was assessed and no marks, redness, or bruising were noted. Resident 4 denied pain. The DON and resident power of attorney were notified. Record review of the progress note dated 10/12/25 at 7:09 PM for Resident 6 revealed that a nurse aide witnessed Resident 6 hit another resident in the upper back. Resident 6 was in the hallway when the other resident began to enter the room of Resident 6. Resident 6 walked up to the other resident and hit them in the back. The nurse aide separated the residents and notified the nurse. Resident 6 was redirected back to their room. The Director of Nursing was notified. Record review of the progress note for Resident 4 dated 10/12/25 at 7:14 PM revealed that the nurse called the Adult Protective Services (APS) hotline to report the resident to resident abuse incident. Record review of the care plan dated 3/4/26 for Resident 6 revealed that the care plan had an entry dated 10/11/25 that read 30 minute checks and monitoring after physical altercation (this intervention was started prior to the Resident 6 to Resident 4 abuse incident on 10/12/25). The care plan had an entry dated 10/12/25 that read 15 minute checks and monitoring after physical altercation with other residents, ended 11/2/25. The care plan had no new interventions developed and implemented for the 10/12/25 resident to resident abuse to prevent Resident 6 from physically abusing other residents.Record review of the progress note for Resident 6 dated 11/2/25 at 3:04 AM revealed that Resident 6 was knocking on another resident's door. The other resident opened the door. The two residents began to verbally argue. The nurse aide attempted to verbally redirect them but was not effective. Resident 6 then began to punch the other resident. The nurse aide was able to separate the residents when another nurse aide and the nurse entered the memory care unit. Record review of the progress note for Resident 6 dated 12/18/26 revealed that Resident 6 has been physically aggressive this shift. Resident 6 gets upset when seeing other residents walking and talking in the hallway. Record review of the progress note for Resident 6 dated 1/6/26 at 1:05 PM revealed that Resident 6 stood up and punched another resident in the face. Staff immediately intervened and assisted Resident 6 back to their room.Record review of the progress note for Resident 6 dated 2/14/26 at 5:01 AM revealed that Resident 6 showed irritability towards others. Resident 6 became aggressive and was hard to redirect.Record review of the progress note for Resident 6 dated 3/4/26 at 12:18 PM revealed that Resident 6 is always on the go. Observation on 3/4/26 at 11:56 AM in the memory care unit dining room revealed that Resident 6 entered the dining room unattended and walked around. Resident 6 exited the dining room and walked down the hall towards other residents before entering Resident 6's room. Observation on 3/4/26 at 1:21 PM at the memory care dining room revealed that Resident 6 walked unattended into the dining room. Medication Aide-B (MA-B) directed Resident 6 to a chair at a table with Resident 1. Resident 6 sat down in the chair. Interview on 3/4/26 at 4:08 PM with Nurse Aide-C (NA-C) revealed that NA-C was not aware of any care plan interventions to protect other residents from Resident 6. NA-C revealed that staff try to keep Resident 6 within arm's length of staff when Resident 6 is out of their room. Interview on 3/4/26 at 4:55 PM with Medication Aide-D (MA-D) confirmed that there are resident to resident incidents in the memory care unit involving Resident 6. MA-D revealed that staff keep an eye on Resident 6 when Resident 6 gets close to a group of residents to prevent Resident 6 from initiating resident to resident incidents. MA-D revealed that staff stand between Resident 6 and other residents and try to redirect Resident 6.Interview on 3/4/26 at 5:14 PM with the facility Assistant Director of Nursing (ADON) confirmed that the facility did not develop any new interventions beyond the initial actions to prevent resident to resident incidents by Resident 6 after the 10/12/25 resident to resident abuse incident. E.Record review of the admission Record dated 3/4/26 for Resident 2 revealed that Resident 2 admitted into the facility on 9/17/24 and lives in the facility memory care unit. Diagnoses included Alzheimer's Dementia, depression, and high blood pressure. Record review of the admission Record dated 3/4/26 for Resident 1 revealed that Resident 1 admitted into the facility on 1/12/26 and lives in the facility memory care unit. Diagnoses included vascular dementia, anxiety disorder, and stroke. Record review of the progress note for Resident 1 dated 2/4/26 revealed that Resident 1 was being sexually inappropriate to staff and other resident's family members. Resident 1 attempted to reach out and grab a staff member and visitor's breast at two separate times. Resident 1 made a vulgar comment about touching staff member's genitals. Resident 1 was informed that the behavior was inappropriate and staff attempted to redirect Resident 1 away from others. Record review of the progress note for Resident 1 dated 2/6/26 at 9:34 AM revealed that the facility spoke to the nurse practitioner related to Resident 1 having increased inappropriate behaviors of groping others. Record review of the progress note for Resident 1 dated 2/14/26 at 6:30 PM revealed that police arrived at the facility and took a statement from staff regarding an incident. Record review of the progress note for Resident 2 dated 2/16/26 at 12:31 PM revealed that the resident's physician faxed back to the facility regarding incident with another resident on 2/14/26.Record review of the physician notification dated 2/14/26 revealed that Resident 2 was found in the dining room with Resident 1. Resident 1 had their hands in the groin area of Resident 2. Record review of the care plan dated 3/4/26 for Resident 1 revealed that the care plan had an entry dated 2/14/26 that Resident 1 and Resident 2 were immediately separated. Resident 2 was assessed for injury and none was noted. Resident 1 was put on 15 minute checks. The care plan had an entry dated 2/14/26 that an orange magnetic gait was placed in the doorway to keep other residents from entering the room of Resident 1. The care plan had no new interventions developed and implemented for the 2/14/26 resident to resident sexual abuse to prevent Resident 1 from sexually or physically abusing other residents, visitors, or staff.Record review of the progress note for Resident 1 dated 2/17/26 at 6:07 PM revealed that staff had to repeatedly tell Resident 1 to go back to their room and not touch staff and other residents. Record review of the progress note for Resident 1 dated 2/27/26 at 1:27 PM revealed that Resident 1 told the medication aide that the medication aide had a sexy ass. Resident 1 was redirected.Record review of the progress note for Resident 1 dated 3/2/26 at 4:23 PM revealed that Resident 1 approached a staff member and told the staff member to turn around. The staff told Resident 1 that is not appropriate and told Resident 1 to back up. Resident 1 told the staff that they were not moving. Resident 1 told the staff to turn around I need to spank you. The staff member tried again to get Resident 1 to withdraw but Resident 1 continued to refuse. Interview on 3/4/26 at 12:05 PM with Medication Aide-A (MA-A) revealed that Resident 1 continues to have inappropriate behaviors towards staff, residents, and family members. MA-A revealed that staff try not to have their backs towards Resident 1 to protect themselves. MA-A revealed that staff try to keep their eye on Resident 1 to protect other residents and family from inappropriate behaviors by Resident 1. MA-A revealed that Resident 1 is very fast and it is a challenge to keep an eye on Resident 1. MA-A revealed that after medication changes Resident 1 leveled out for a few days but has returned to inappropriate behaviors as prior to the medication changes. MA-A was not aware of any specific care plan interventions for Resident 1 to protect residents, family, and staff from inappropriate behavior. Interview on 3/4/26 at 12:10 PM with Medication Aide-B (MA-B) revealed that Resident 1 was pretty good and not exhibiting inappropriate behaviors for a few days last week but this week Resident 1 is having behaviors. Observation on 3/4/26 at 10:52 AM outside the room of Resident 1 revealed that the orange mesh gate was hanging from the left side of the doorway and was not in place across the doorway. Observation on 3/4/26 at 1:45 PM in the memory care unit dining room revealed that Resident 1 pushed the chair back from the table. Resident 1 stood up and walked out of the dining room. Resident 1 looked down the hallway and then entered Resident 1's room. Interview on 3/4/26 at 4:08 PM with Nurse Aide-C (NA-C) revealed that staff are to document 15 minute checks for Resident 1. NA-C revealed that staff are to be with Resident 1 when Resident 1 is out of their room. NA-C was not aware if this was a care planned intervention for Resident 1. Observation on 3/4/26 at 4:54 PM in the memory care unit revealed that Resident 1 walked from the tv area in the middle of the unit towards the resident's room. Resident 1 was unattended. 4 residents of the opposite sex were seated in the tv area along with 2 staff. Resident 1 entered their room. Interview on 3/4/26 at 5:14 PM with the facility Assistant Director of Nursing (ADON) confirmed that the facility did not develop any new interventions beyond the initial actions to prevent resident to resident incidents by Resident 1 after the 2/14/26 resident to resident sexual abuse incident.

Licensure Reference Number 175NAC 12-006.04(H)(ii)(2) Based on observation, record review, and interview the facility failed to ensure that it employed a Certified Dietary Manager (CDM) (a CDM has completed education to be a nationally recognized expert in managing dietary operations and ensuring food safety) to oversee the facility food service. This affected all facility residents. The facility census was 50. Findings are: Record review of the facility Dietary Manager Job Description dated 2018 revealed that minimum requirements include one of the following: Certification as a Dietary Manager (Certified Dietary Manager) or Certification as a Food Service Manager. Major duties and responsibilities include maintaining a clean and sanitary environment; overseeing safe and timely meal preparation including the provision of meals and or supplements in accordance with resident's needs-preference-and care plan; monitoring regular and therapeutic diets including texture of foods and liquids to meet the specialized needs of residents. The employee acknowledgement on the job description was signed by the facility Dietary Manager on 6/26/23. Interview on 4/1/25 at 1:23 PM with the Registered Dietitian (RD) revealed that the RD is in the facility every other Tuesday. The RD confirmed that the RD is not employed full-time by the facility. The RD confirmed that the identified facility Dietary Manager (DM) is not a Certified Dietary Manager. Observation on 4/1/25 at 1:24 PM in the facility kitchen revealed that the DM was present and communicating with dietary staff and directing dietary staff. Interview on 4/1/25 at 1:24 PM with the facility Dietary Manager confirmed that the DM is not a Certified Dietary Manager. The DM revealed that it was an issue last year during the facility licensure survey that the DM was not a Certified Dietary Manager. The DM revealed that they registered for the class to become a Certified Dietary Manager after the licensure survey last year but did not start it. The DM revealed that the facility has had 4 different Facility Administrators in the past year. The DM revealed that the facility Business Office Manager (BOM) was to be the preceptor for the CDM class but the BOM left. The DM revealed that the facility was 4 months without a registered dietitian and that the current dietitian has been in place for only a couple of months. Interview on 4/7/25 at 4:47 PM with the Facility Administrator (FA) confirmed that the current facility DM is not a Certified Dietary Manager or a Certified Food Service Manager as required. The FA confirmed that the facility does not currently have a Certified Dietary Manager or a full-time Registered Dietitian.

Licensure Reference Number 175 NAC 12-006.11(D) Based on observation, record review, and interview; the facility failed to ensure that foods were held at the required temperatures during meal service to ensure meals were palatable and at an appetizing temperature; and the facility failed to ensure that pureed foods (a cooked food item that has been ground with a blender into a smooth, soft, pudding-like consistency for residents with difficulty chewing or swallowing) were prepared to maintain nutritive value for 1 of 1 residents (Resident 43). The facility census was 50. Findings are: A. Record review of the facility policy titled Food Temperatures dated 2021 revealed that the temperatures of all food items will be taken and properly recorded prior to service of each meal. All hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit (F). Temperatures should be taken periodically to assure hot foods stay above 135F during the holding and plating process and until food leaves the service area. Record review of the facility policy titled Open Style Dining dated 3/2/21 revealed that individuals will be provided choices of what to eat, when to eat, and who to dine with. The policy revealed that nursing and/or food and nutrition services staff will offer food and beverage choices to the individual at the point of service and report an individual's food and beverage choices to the staff members responsible for serving the food. Food and nutrition services staff will serve food and beverage choices made with consideration given to any dietary restrictions and/or texture modifications. The director of food and nutrition services (Dietary Manager) will observe the meals served for preferences, portion sizes, temperature, flavor, variety, and service accuracy. Interview on 4/1/25 at 11:05 AM with Resident 22 revealed that the hot foods could be hotter when served sometimes. Interview on 4/1/25 at 1:41 PM with Resident 38 revealed that the food served at the facility is not always hot. Resident 38 revealed that when the food received is not hot enough there is no second meal choice. Resident 38 revealed that they do not like all the different types of chicken dishes served. Resident 38 revealed that the menu has too many meals with chicken. Resident 38 revealed that they do not find cold chicken appetizing. Interview on 4/1/25 at 3:19 PM with a resident that requested to remain anonymous revealed that the hot foods served were only at room temperature. The resident revealed that there was not much choice for alternate foods. The resident revealed that vegetables like broccoli were overcooked and mushy. The resident revealed that they didn't like mushy vegetables and they were usually not hot when received. Observation on 4/2/25 at 7:59 AM in the main dining room revealed that Resident 22 was seated in a wheelchair at a table. Resident 22 was served the breakfast meal consisting of 2 servings of breakfast pizza and a piece of toast. Resident 22 immediately picked up the breakfast pizza and took a bite. Resident 22 continued to take bites of the pizza. Interview on 4/2/25 at 8:01 AM with Resident 22 revealed that the breakfast pizza was warm and wished it was hotter. Resident 22 revealed that they liked pizza and would eat cold pizza. Observation on 4/2/25 at 8:06 AM in the main dining room revealed that the breakfast meal of 2 pieces of breakfast pizza was served to Resident 38. Resident 38 immediately began to eat using the fork. Resident 38 revealed that the pizza tasted really good but that it could be warmer. Observation on 4/3/25 at 12:01 PM in the facility food service pod revealed that Dietary Cook-L (DC-L) obtained a thermometer. DC-L placed the thermometer into the pan of beef taco meat in the pan on the steam table. The temperature was 153.9 F. DC-L wiped off the thermometer and placed the thermometer into the pan of refried beans on the steam table. The temperature of the beans was 148.5 F. DC-L folded back the foil covering the pans and began to plate resident meals. Observation on 4/3/25 at 12:58 PM in the facility food service pod revealed that all residents had been served the lunch meal. Interview on 4/3/25 at 12:58 PM with the facility Dietary Manager (DM) in the food service pod revealed that the facility usually did not check food temperatures at the end of meal service. The DM revealed that food temperatures were checked and recorded prior to meal service. This surveyor requested that the DM obtain the temperatures of the taco meat and the refried beans at this time. The DM used the thermometer to check the temperature of the taco meat. The temperature of the taco meat was 106.3 F. DM obtained a temperature of the refried beans of 132.1 F. The DM revealed that the steam table had not been turned on for the lunch meal. The DM confirmed that the taco meat and the refried beans were required to be held at a temperature of 135 F or higher. The DM confirmed that the taco meat and refried beans were not held at the required temperature to ensure food safety and appetizing temperatures. Interview on 4/3/25 at 1:10 PM with Resident 22 revealed that the beef soft taco served to the resident was not warm enough for their liking. B. Record review of the facility policy titled General Food Preparation and Handling dated 2021 revealed that food items will be prepared to conserve nutritive value. Record review of the facility policy titled Pureed dated 2022 revealed NEVER USE WATER AS THE LIQUID ADDED TO A PUREED ITEM. If the liquid drained from the prepared item is not to be utilized, and no specific liquid is listed as an ingredient to be used on the pureed recipe, the following liquids would be acceptable to use when pureeing foods: prepared broth, gravy, sauce, milk, juice and melted margarine/butter. Record review of the Dining Manager Pureed Beef Soft Taco recipe dated 2024 revealed that if the product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth consistency. Observation on 4/3/25 at 11:43 AM in the facility kitchen revealed that Dietary Cook-L (DC-L) obtained the mixing container for the blender and used a blue handled scoop to place 1 scoop of the taco meat into the container. DC-L used tongs to place a tong full of diced tomato and a tong full of chopped onion into the container. DC-L placed 2 tongs full of shredded cheese into the container. DC-L poured a small serving of salsa into the container. The time was now 11:48 AM. DC-L turned on the water at the prep sink and added 5 tablespoons of tap water into the container. DC-L began to blend the food in the container. DC-L stopped and went to the prep table and obtained a tortilla and placed it into the blender container. DC-L continued to blend the food in the container to a pureed consistency. DC-L poured the pureed food from the blender container onto a divided plate for Resident 43. DC-L asked Dietary Cook-M (DC-M) for a spatula. DC-M went to the sink and washed the hands for a total of 7 seconds. DC-M handed a spatula to DC-L. DC-L used the spatula to remove the remaining pureed food from the blender container onto the divided plate. Interview on 4/7/25 at 3:18 PM with the DM confirmed that the recipe for the pureed beef soft taco recipe directions revealed that if the product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth consistency. The DM confirmed that water was not to be used to thin the puree as it reduced the nutritive value of the puree for Resident 43.

Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, interview, and record review; the facility failed to ensure that dietary staff performed hand washing to prevent the potential for cross contamination and food borne illness during food preparation and food service; the facility failed to maintain held foods within the required safe temperature range during meal service to prevent the potential for foodborne illness; the facility failed to perform daily testing of sanitizer chemical concentration to ensure sanitizer was at the required levels for use; and the facility failed to maintain dietary equipment and areas free of soiling and debris. This had the potential to affect all residents who resided within the facility. The facility census was 50. Findings are: A. Record review of the facility policy titled General Food Preparation and Handling dated 2021 revealed that food items will be prepared to conserve nutritive value and keep free of harmful organisms and substances. The kitchen surfaces and equipment will be cleaned and sanitized as appropriate. Bare hands should never touch ready to eat raw food directly. Disposable gloves are a single use item and should be discarded after each use. Employees should wash hands prior to putting gloves on and after removing gloves. Food should be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact of prepared foods. Any utensil or serving dish must be thoroughly cleaned and sanitized prior to use. Tops of canned foods should be washed before opening. Staff will handle utensils, cups, glasses, and dishes in such a way as to avoid touching surfaces that food or drink will come in contact with. Tongs or other serving utensils will be used to serve breads or other items to avoid bare hand contact with foods. Record review of the facility policy titled Hand Washing dated 2021 revealed that employees will wash hands as frequently as needed throughout the day using proper hand washing procedures. Hands and exposed portions of arms should be washed immediately before engaging in food preparation. The When to wash hands section revealed that hands are to be washed when entering the kitchen at the start of a shift; after touching bare human body parts other than clean hands and wrists; after using the restroom; after coughing, sneezing, using a tissue, using tobacco, eating or drinking; after handling soiled equipment or utensils; during food preparation as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks; when switching between working with raw food and working with ready to eat food; before donning (putting on) disposable gloves for working with food and after gloves are removed; after engaging in other activities that contaminate the hands. The section titled How to wash hands revealed to turn on the faucet using a paper towel to avoid contaminating the faucet; wet hands and forearms with warm water and apply an antibacterial soap; scrub well with soap and additional water as needed, scrubbing all areas thoroughly; scrub for a minimum of 10 to 15 seconds within the 20 second hand washing procedure; rinse with clean running water; dry hands with paper towel; use the paper towel to turn the faucet off and discard the towel. Observation on 4/3/25 at 9:49 AM in the facility kitchen revealed that Dietary Cook-L (DC-L) reviewed the recipe for the pineapple upside down cake. DC-L did not perform hand washing. DC-L put disposable gloves on. DC-L measured water into a pitcher and poured white cake mix into a large mixing bowl. DC-L added the water to the bowl and stirred the mix with a whisk. DC-L went into the walk in refrigerator and exited with a square of butter. DC-L measured the butter per recipe and cut the measured amount from the square of butter with a knife. DC-L used the gloved hands to put the butter into a container and took the container to the microwave in the food service pod. DC-L returned to the kitchen. DC-L removed the gloves and did not perform hand washing. DC-L exited the kitchen and went to the dry storage room across the hall. DC-L obtained a can of crushed pineapple from the dry storage room and returned into the kitchen. DC-L did not perform hand washing. DC-L opened the can of crushed pineapple and placed it into a colander to drain in the sink. DC-L went to the sink and turned on the water with the bare hands. DC-L wet the hands and applied soap. DC-L obtained a paper towel and dried the hands. The total time for hand washing was 6 seconds. DC-L picked up a can of non-stick cooking spray and sprayed the inside of a baking pan. DC-L put on gloves and poured the crushed pineapple into the baking pan. (DC-L did not perform hand washing prior to putting on the gloves). DC-L spread out the pineapple in the bottom of the pan using the gloved hands. DC-L removed the gloves and went to the food service pod and returned into the kitchen with the melted butter. (DC-L did not perform hand washing). DC-L poured melted butter into a small mixing pan. DC-L put on gloves. (DC-L did not perform hand washing). DC-L went to the shelves by the walk-in refrigerator and obtained 2 packages of brown sugar. DC-L cut open the 2 packages of brown sugar and poured them into the pan with the melted butter. DC-L attempted to mix the butter and brown sugar with a whisk. DC-L then sat the whisk down and used the gloved hands to mix the butter and brown sugar. DC-L removed the gloves. DC-L did not perform hand washing. DC-L dumped the mix from the pan on top of the crushed pineapple in the baking pan and used a spoon to mix the pineapple and brown sugar mixture in the baking pan. DC-L went to the handwashing sink and washed the hands for a total of 4 seconds and dried the hands. DC-L put on gloves. DC-L used the gloved hands to spread the mixture evenly in the baking pan. DC-L poured the cake mix into the baking pan and spread it evenly with a spatula. DC-L opened the oven and placed the baking pan in the oven. DC-L removed a cloth from the red sanitizer bucket on the counter by the prep sink and wiped off the prep table. DC-L removed the gloves. DC-L did not perform hand washing. Observation on 4/3/25 at 10:14 AM in the facility kitchen revealed that DC-L removed the white tub containing a tube of raw hamburger from the walk-in refrigerator and sat it on the prep table. DC-L put a glove on the ungloved right hand. DC-L used scissors to cut open the top of the wrap on the tube of raw hamburger. DC-L sat the scissors on the prep table and a small amount of raw hamburger was visible on the scissors. DC-L emptied the raw hamburger from the tube into a pan on the stove. DC-L pushed the raw hamburger down in the pan using the gloved hands. DC-L removed the gloves and discarded the gloves along with the wrap from the raw hamburger tube. DC-L did not wash the hands. DC-L went to the dry storage room across the hall from the kitchen and grabbed two packages of dried refried pinto beans with the bare hands and returned into the kitchen. DC-L sat the packages on the prep table on top of a small clump of raw hamburger. DC-L picked up a spoon from the prep table and stirred the ground beef cooking on the stove. DC-L had not washed the hands. DC-L placed the spoon on the prep table. The time was now 10:26 AM. Dietary Cook-M (DC-M) picked up a can of non-stick cooking spray and sprayed the inside of a pan and placed a liner in it with the bare hands. DC-M cut open the two bags of refried beans and poured them into the pan that was sitting on the prep table where the clump of raw hamburger had been. DC-M poured the water from a pitcher into the pan and then picked up the pan off the north prep table and moved it onto the middle prep table. DC-M placed the pan into the oven. Observation on 4/3/25 at 10:40 AM in the facility kitchen revealed that DC-L removed the pan of hamburger from the stove and poured the hamburger into a colander on the top of the dishwasher sink. DC-L then transferred the hamburger from the colander back into the pan. DC-L placed the pan of hamburger back on the stove. DC-L measured water into a pitcher in the prep sink. DC-L opened a package of taco seasoning and poured the taco seasoning into the water in the pitcher. DC-L used a whisk to mix the seasoning with the water. DC-L poured the pitcher of taco seasoning mix into the pan of hamburger. DC-L carried the pitcher and whisk to the dirty dish shelf adjacent to the dishwasher. DC-L returned to the stove and picked up the spoon from the prep table and stirred the hamburger with the spoon. DC-L had not performed hand washing. DC-L obtained a steam table pan and placed a pan liner in it using the bare hands. The time was now 10:51 AM. DC-L used a spatula to transfer the hamburger taco meat mix into the steam pan. DC-L picked up the spoon off the foil piece on the prep table. DC-L picked up the piece of foil and discarded it into the trash can at the prep table. DC-L pushed the foil down into the trash can with the bare right hand touching the wrap from the tube of raw hamburger. DC-L carried the pan and spoon to the dishwash area. DC-L did not wash the hands. DC-L went to the prep table and adjusted the liner in the pan of hamburger using the bare hands. DC-L carried the pan out into the service pod and placed the pan into the hot holding cart. DC-L returned to the kitchen and picked up a toothpick with the bare hands and poked the toothpick into the cake in several random spots. The time was now 11:00 AM. DC-L and DC-M exited the kitchen and went to the front entry of the facility. DC-L and DC-M exited the front of the building to shop at the mobile scrub vendor truck. Observation on 4/3/25 at 11:24 AM at the front entry of the facility revealed that DC-L and DC-M re-entered the building through the front entrance. They went to the break room near the kitchen for pizza. Observation on 4/3/25 at 11:28 AM in the hall outside the facility kitchen revealed that DC-L stood in the hall outside the kitchen eating a slice of pizza. DC-L put on a hairnet using the bare hands and entered the kitchen. DC-L picked up the coffee drink from a table and exited the kitchen. DC-L put on a red jacket and DC-L, the Dietary Manager (DM), and Nurse Aide-R (NA-R) exited the back of the building. DC-L held a cigarette in the right hand as they exited the building. Observation on 4/3/25 at 11:38 AM in the facility kitchen revealed that Dietary Cook-N (DC-N) went to the sink and wet the hands and applied soap. DC-N scrubbed the hands briefly and rinsed the hands. The total time was 13 seconds. DC-N pushed a cart with a rack of silverware out of the kitchen to the dining room using the bare hands. Observation on 4/3/25 at 11:41 AM in the facility kitchen revealed that DC-L re-entered the building and entered the kitchen. DC-L put on an apron. DC-L went to the sink and performed handwashing for a total of 5 seconds. DC-L walked from the sink to the prep area trash can. DC-L discarded the paper towels into the prep trash can and pushed the paper towels down into the trash can using the bare hands touching the packages from the refried beans and the raw hamburger wrap. DC-L reviewed the recipe for the beef tacos on the prep table. DC-L revealed that DC-L was checking the recipe for the tortilla size. DC-L exited the kitchen and went to the dry storage room across the hall. DC-L returned to the kitchen carrying 6 packages of 8 inch flour tortillas and sat them on the prep table. DC-L did not perform hand washing. DC-L went into the food service pod and brought the pan of taco meat into the kitchen. DC-L obtained the mixing container for the blender and used a blue handled scoop to place 1 scoop of the taco meat into the container. DC-L used tongs to place a tong full of diced tomato and a tong full of chopped onion into the container. DC-L placed 2 tongs full of shredded cheese into the container. DC-L poured a small serving of salsa into the container. The time was now 11:48 AM. DC-L turned on the water at the prep sink and added 5 tablespoons of tap water into the container. DC-L began to blend the food in the container. DC-L stopped and went to the prep table and obtained a tortilla and placed it into the blender container. DC-L continued to blend the food in the container to a pureed texture (a cooked food item that has been ground with a blender into a smooth, soft, pudding-like consistency for residents with difficulty chewing or swallowing). DC-L poured the pureed beef taco from the blender container onto a divided plate for Resident 43. DC-L asked Dietary Cook-M (DC-M) for a spatula. DC-M went to the sink and washed the hands for a total of 7 seconds. DC-M handed a spatula to DC-L. DC-L used the spatula to remove the remaining pureed beef taco from the blender container onto the divided plate. DC-L carried the blender container to the dirty dish sink and used the faucet to rinse the container. DC-L placed the blender container in a dish rack and put it into the dishwasher. DC-L went to the prep table and carried the pan of taco meat out to the hot hold box in the food service pod. DC-L returned to the kitchen and obtained a knife with the bare hands and began to cut the cake in the pan on the prep table. DC-L had not performed hand washing. DC-L went into the dirty dish area and took the blender container out of the dishwasher and carried it to the blender table with the bare hands. DC-L went to the prep table to review the recipe for the cake. DC-L used a spatula to place a slice of cake into the blender container. DC-L went to the walk-in refrigerator and opened the door using the bare hands. DC-L exited with a small container of milk. DC-L poured the milk into the blender container. DC-L pureed the cake. The time was now 11:56 AM. DC-L obtained a piece of foil with the bare hands and covered the divided plate containing the pureed beef taco with foil. DC-L carried the plate into the food service pod and placed the plate into the hot hold box. DC-L returned to the kitchen blender table. DC-L poured the pureed cake into a small clear bowl. Observation on 4/3/25 at 11:57 AM in the facility kitchen revealed that Dietary Aide-O (DA-O) went to the sink and performed handwashing for a total of 7 seconds. DC-O dried the hands with a paper towel. DC-L opened 2 packages of snack cakes and placed them in the blender container. DC-L poured milk into the container. DA-O handed the blender blade to DC-L using the bare hands. DC-L placed the blade and pureed the snack cakes. Observation on 4/3/25 at 12:01 PM in the facility kitchen revealed that Dietary Cook-L (DC-L) entered the food service pod and obtained a thermometer. DC-L did not wash the hands. DC-L placed the thermometer into the pan of beef taco meat in the pan on the steam table. The temperature was 153.9F. DC-L wiped off the thermometer and placed the thermometer into the pan of refried beans on the steam table. The temperature of the beans was 148.5F. DC-L folded back the foil covering the pans with the bare hands and began to plate resident meals. DC-L used a tong to remove a tortilla from the package and place it on a plate. DC-L used the 4 ounce scoop to place a scoop of the taco meat on the tortilla. DC-L plated refried beans on the plate. DC-L used tongs to place tortilla chips on the plate and then slid the tray with the plate to DC-M. DC-L removed the black handled 4 ounce scoop from the pan of taco meat and carried it to the dirty dish sink in the kitchen. DC-L returned to the food service pod and removed a blue handled #16 scoop from the drawer and placed it into the taco meat pan. DC-L had not performed hand washing. DC-L used the blue handled #16 scoop to place a scoop of taco meat on a tortilla on a plate for Resident 49. DC-L used tongs and the bare left index finger to fold the tortilla in half over the taco meat on the plate. DC-L then moved the taco to a different plate. DC-L continued to plate resident meals. Dietary Cook-M (DC-M) exited the food service pod and went through the kitchen to the storage room across the hall from the kitchen. DC-M returned to the food service pod with a container of ensure and put it on a resident tray. DC-M did not perform hand washing. DC-M continued to dish salsa for meal trays. DC-M carried a soiled cup and glass into the kitchen and placed them on the dishwasher counter. DC-M returned to the food service pod. DC-M did not perform hand washing. DC-M carried a glass into the kitchen and used a scoop to put ice into the glass. DC-M carried the glass of ice back to the food service pod and poured liquid into the glass. The time was now 12:51 PM. DC-M picked up a piece of trash from the floor in the food service pod with the bare hands and threw it into the trash can. DC-M went to the sink in the kitchen and washed the hands for a total of 7 seconds. DC-M returned to the food service pod and pour drinks for the room trays using the bare hands. Interview on 4/3/25 at 12:56 PM with DC-M confirmed that during hand washing the hands are to be washed for 20 seconds. Interview on 4/3/25 at 1:03 PM with DC-L revealed that during handwashing the hands are to be scrubbed with soap for at least 20 seconds. DC-L revealed that they usually sing the ABC song to scrub for 20 seconds. Observation on 4/3/25 at 1:04 PM in the facility kitchen revealed that Dietary Aide-O (DA-O) performed handwashing at the sink for a total of 10 seconds. DA-O confirmed that the handwashing should take at least 30 seconds. Interview on 4/3/25 at 1:05 PM with the facility Dietary Manager (DM) confirmed that dietary staff are to follow the facility procedure for handwashing. The DM confirmed that the hands should be washed before and after putting on gloves, after handling raw foods, when switching tasks, and after returning to the kitchen. The DM confirmed that hand washing is to be performed prior to food service. The DM confirmed that the hands are to be washed for at least a minimum of 20 seconds. B. Record review of the facility policy titled Food Temperatures dated 2021 revealed that the temperatures of all food items will be taken and properly recorded prior to service of each meal. All hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit (F). Hot foods may not fall below 135F after cooking. Temperatures should be taken periodically to assure hot foods stay above 135F during the holding and plating process and until food leaves the service area. Hold hot foods at or above 135F to keep food out of the temperature danger zone (foodborne illness zone). Record review of the facility policy titled Critical Temperatures for Safe Food Handling dated 2021 revealed that the foodborne illness zone is when foods are at a temperature between 41F-134F. Hot foods are to be maintained at 135F or above so they are not in the temperature danger zone. The policy revealed that temperatures between 41F-134F allow rapid bacteria growth. Observation on 4/3/25 at 12:01 PM in the facility food service pod revealed that Dietary Cook-L (DC-L) obtained a thermometer. DC-L placed the thermometer into the pan of beef taco meat in the pan on the steam table. The temperature was 153.9F. DC-L wiped off the thermometer and placed the thermometer into the pan of refried beans on the steam table. The temperature of the beans was 148.5F. DC-L folded back the foil covering the pans and began to plate resident meals. Observation on 4/3/25 at 12:58 PM in the facility food service pod revealed that all residents had been served the lunch meal. Interview on 4/3/25 at 12:58 PM with the facility Dietary Manager (DM) in the food service pod revealed that the facility usually does not check food temperatures at the end of meal service. The DM revealed that food temperatures are checked and recorded prior to meal service. This surveyor requested that the DM obtain the temperatures of the taco meat and the refried beans at this time. The DM used the thermometer to check the temperature of the taco meat. The temperature of the taco meat was 106.3F. DM obtained a temperature of the refried beans of 132.1F. The DM revealed that the steam table had not been turned on for the lunch meal. The DM confirmed that the taco meat and the refried beans were not held at the required temperature of 135F or higher. The DM confirmed that the taco meat and refried beans were not held at the required temperature to ensure food safety and minimize bacterial growth as required. C. Record review of the facility policy titled General Food Preparation and Handling dated 2021 revealed that food items will be prepared to conserve nutritive value and keep free of harmful organisms and substances. The kitchen surfaces and equipment will be cleaned and sanitized as appropriate. Observation on 4/2/25 at 11:16 AM in the facility kitchen revealed an Ecolab SmartPower Sanitizer dispenser for dispensing the sanitizer solution. A sign with instructions for testing the sanitizer solution chemical concentration was to the right of the sanitizer dispenser. A bottle of test strips was visible in the light blue tray to the right of the sign. No log for documenting test results of the sanitizer chemical concentration was located. Interview on 4/2/25 at 11:21 AM with Dietary Cook-N (DC-N) revealed that the sanitizer buckets are washed in the dishwasher and that the sanitizer is dispensed prior to each cleaning period. DC-N revealed that Ecolab is here often to check things. DC-N is unaware of testing of the sanitizer chemical concentration to ensure effectiveness. Observation in the facility kitchen on 4/2/25 at 12:45 PM revealed that Dietary Aide-O (DA-O) filled a red bucket with sanitizer solution from the dispenser. DA-O carried the bucket out of the kitchen to the dining room. Observation on 4/2/25 at 1:25 PM in the south section of the main dining room revealed that DA-O was clearing used dishware off the tables and wiping the tables with a towel using the sanitizer solution from the red sanitizer bucket. Interview with DA-O revealed that the sanitizer solution is good for 4 hours and then they have to make new solution. DA-O revealed that the sanitizer concentration is to be tested using the testing strip tabs and thinks it is checked 1 or 2 times daily. DA-O is not aware of anywhere to log the result of the testing of the sanitizer chemical concentration. DA-O confirmed that DA-O does not do testing of the sanitizer chemical concentration. Observation on 4/3/25 at 9:28 AM in the north side of the main dining room revealed that DC-N was clearing tables and wiping off the tables with the towel from the red sanitizer bucket. Interview on 4/3/25 at 9:29 AM with DC-N confirmed that DC-N filled the sanitizer bucket with sanitizer. DC-N revealed that new sanitizer solution is obtained for each cleaning period. DC-N confirmed that DC-N did not test the sanitizer chemical concentration and that the sanitizer concentration is checked by Ecolab. DC-N revealed that DC-N does not know how to use the little test strips. Interview on 4/7/25 at 3:01 PM with the facility Dietary Manager (DM) revealed that the Ecolab representative comes to the facility on ce monthly. The DM revealed that staff change out the sanitizer solution for each meal. The DM confirmed that the facility staff does not test the sanitizer chemical concentration. The DM revealed that the Ecolab representative tests the sanitizer when in the facility. The DM revealed that the facility does not have a manufacturer manual for the Smart Power Sanitizer dispenser. The DM provided the phone number for the facility Ecolab representative. Interview on 4/7/25 at 3:34 PM per phone with the facility Ecolab Representative confirmed that they are the representative for the facility. The representative revealed that the facility should be testing the chemical concentration of the sanitizer solution every day at a minimum to ensure its effectiveness. The representative revealed that most facilities maintain a log to document the testing of the sanitizer chemical concentration once or twice daily, but this facility was not documenting any testing. Interview on 4/7/25 at 3:46 PM with the DM revealed that plate covers are washed in the dishwasher after meals. The DM revealed that during meal service the staff use the sanitizer solution to clean the meal trays and the plate covers. The DM revealed that the facility has not received testing strips to test the sanitizer chemical concentration. This surveyor showed the DM the bottle of test strips in the light blue shelf next to the Smart Power Sanitizer dispenser. The DM was unsure when they got the test strips. The DM revealed that it would be easy to log testing of the chemical concentration as the facility already has logs available to document testing. The DM provided a blank undated log titled Sanitization Buckets PPM (parts per million- the measure of chemical concentration) from the DM office. The DM revealed that the log is 2 pages as there is a line for documenting test results each day during the month. Record review of the undated log titled Sanitization Buckets PPM revealed that it was to be labeled with the month/year and type of sanitizer. The line level required was pre-filled with 200PPM. The log had a row for each day of the month to document the time, checked by (staff performing the test), and the sanitizer chemical concentration result. Record review of the Smart Power Sink and Surface Cleaner Sanitizer Product Specification Document dated 5/22/20 section labeled To Sanitize Hard, Non-Porous Food Contact Surfaces revealed that fresh solution must be prepared daily, when the use solution becomes visibly dirty, or when the use solution tests below sanitizing concentration range. This product will kill viruses, including Norovirus (a very contagious group of viruses that cause severe vomiting and diarrhea), on hard, non-porous food contact surfaces when used according to these directions. D. Record review of the facility Resident Rights dated 2012 revealed that the nursing facility must care for residents in a manner and in an environment that promotes maintenance or enhancement of a resident's quality of life. Promote care for residents in a manner and in an environment that maintains or enhances a resident's dignity and respect recognizing his or her individuality. The nursing facility must provide a safe, clean, comfortable, and home-like environment. The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Record review of the facility Dietary Manager Job Description dated 2018 revealed that minimum requirements include one of the following: Certification as a Dietary Manager or Certification as a Food Service Manager. Major duties and responsibilities include maintaining a clean and sanitary environment; overseeing safe and timely meal preparation including the provision of meals and or supplements in accordance with resident's needs-preference-and care plan; monitoring regular and therapeutic diets including texture of foods and liquids to meet the specialized needs of residents. Record review of the facility policy titled General Food Preparation and Handling dated 2021 revealed that food items will be prepared to conserve nutritive value and keep free of harmful organisms and substances. The kitchen will be kept neat and orderly. The kitchen surfaces and equipment will be cleaned and sanitized as appropriate. Observation on 4/1/25 at 8:38 AM in the facility kitchen revealed that 3 loaves of bread were scattered on the floor of the walk-in freezer. The floor of the walk-in refrigerator was soiled with food debris and onion skins scattered throughout the floor. The entry ramp inside the walk-in refrigerator was soiled with food debris and dried yellowish liquid spill. The shelf above the stove had greasy buildup and chunks of brownish debris on it. Observation on 4/2/25 at 11:04 AM in the facility food service pod revealed that the black top of the coffee maker was soiled with dusty gray debris buildup. The wall behind the service counter had brownish splash drop stains. The laminated Snack Bar sign was soiled with brownish dried splash drop stains. Observation on 4/2/25 at 11:33 AM in the beverage area in the main dining room revealed that it contained a dispenser for ice. The black top was soiled with dusty gray debris. A juice dispenser sat next to the ice dispenser. The black top of the juice dispenser revealed that it was soiled with dusty gray debris. A tea dispenser sat next to the juice dispenser. The black top of the tea dispenser was soiled with dusty gray debris buildup. Observation on 4/2/25 at 3:30 PM in the beverage area in the main dining room revealed that the facility Dietary Manager (DM), Maintenance Supervisor (MS), and Dietary Cook-M (DC-M) went to the beverage dispensers. The DM removed the black lid soiled with dusty gray debris buildup from the top of the tea dispenser using the bare hands. The MS removed a large plastic bag filled with tea from inside the tea dispenser. The DM placed the lid back on the top of the tea dispenser. The DM did not clean the lid. The MS carried the plastic bag with tea out of the dining room. Interview on 4/7/25 at 10:14 AM with the DM revealed that the facility food service cleaning is documented through a phone app by dietary staff. Dietary staff are assigned cleaning tasks and completion is documented in the app. The DM revealed that the DM will try to do a printout of the cleaning. Observation on 4/7/25 at 10:48 AM in the facility kitchen revealed that the floor of the walk-in refrigerator remained soiled with food debris. The entry ramp inside the walk-in remained soiled with food debris and dried yellowish liquid spill. The greasy buildup and chunks of brownish debris on the shelf above the stove remained. Observation on 4/7/25 at 10:50 AM in the main dining room beverage area revealed that the black top of the ice machine at the beverage counter remained soiled with dusty gray debris. The black top of the juice dispenser remained soiled with dusty gray debris. The black top of the tea dispenser remained soiled with dusty gray debris buildup. Observation in the food service pod revealed that the black top of the coffee maker remained soiled with dusty gray debris buildup and a dark clump of unidentified material. The wall behind the service counter had brownish splash drop stains. The laminated Snack Bar sign remained soiled with brownish dried splash drop stains. Interview on 4/7/25 at 1:50 PM with the DM revealed that the DM was unable to print cleaning documentation from the app used to document cleaning tasks for dietary staff. DM revealed that most cleaning tasks were to be completed weekly. The DM revealed that the cleaning of the range hood filters was a monthly task. The DM confirmed that the shelf above the stove was greasy and was soiled with brownish debris. The DM confirmed that cleaning of the shelf above the stove was to be completed weekly on Saturdays, but confirmed it was not done. The DM confirmed that the coffee maker in the service pod had soiling on the black top, the wall behind the coffeemaker had soiling, and the Snack Bar laminated sign had soiling that had not been cleaned. The DM revealed that the ice cream machine next to the coffeemaker was removed last week and the wall had not been cleaned. The DM revealed that staff were to clean the dining room beverage area weekly. The DM confirmed that the top of the iced tea dispenser, juice dispenser, and ice machine were soiled with gray fluffy debris and had not been cleaned. The DM revealed that cleaning of the top of the machines was not listed on the cleaning task and would be added.

Licensure Reference Number 175 NAC 12-006.01(g)(h) Based on interviews and record reviews, the facility failed to notify the Department in writing within 5 working days of vacancy and filling of the Administrator position. This had the potential to affect all facility residents. The facility census was 50. Findings Are: The Facility Administrator (FA) was interviewed on 04/07/2025 at 2:45 PM. The interview with the FA revealed that the Business Office Manager (BOM) was the provisional administrator prior to their tenure which began on 02/14/2025. The BOM was interviewed on 04/07/2025 at 2:49 PM revealing that they were the Provisional Administrator prior to the current Administrator and their term ended on 02/14/2025. The BOD revealed that their tenure began on 01/28/2025, however notified the Department earlier than that date, by submitting a Change of Notification Form to the Department. Records revealed that the Change of Notification Form sent via email to the Department was date stamped as being sent on 01/24/2025 requesting a change of Administrator from one with a service end date of 01/14/2025 and a service start date as 01/15/2025 with a pending license number. On 04/07/2025 at 2:49 PM the BOM revealed that the Department called them and stated the Change of Notification Form was declined. The BOM revealed that the Department declined the form due to not having an Administrator license the date the form was submitted. The BOM revealed that they had requested a provisional license on 01/24/2025 and submitted the Change of Notification Form on the same day, however, was unaware of the timeline to obtain a provisional license and unaware when the Department needed to be notified on vacancy and filling of the Administrator position. The BOM then revealed that their provisional license was not activated until 01/28/2025 and advised by the Department to resubmit the Change of Notification Form to the Department once the provisional license was available or another person was selected to fill the position.

Licensure Reference Number 175 NAC 12-006.19(C) Based on observations, interviews, and record review, the facility failed to properly handle clean and soiled linens throughout the building, this had the potential to affect all facility residents. The facility failed to [NAME] resident care equipment in a manner to prevent transfer of microorganisms for 2 of 3 sampled residents, Resident 7 and Resident 30, and failed to clean and disinfect glucometers between resident use for 2 of 3 sampled residents, Resident #0 and Resident #34. The facility census was 50. Findings are: A. An observation on 04/01/2025 at 12:45 PM, Housekeeper-J (HSK-J) was observed pulling a cart down the 200-hall, bumping into the fire door, pulling it closed. The cart was observed to be open, with its flap to cover one side of the cart pulled up and over, exposing the full cart of clean linens. HSK-J continues to pull the cart to the SPA room, where the linens were placed into the room for resident use. HSK-J was observed to not use hand sanitizer. HSK-J pulled the cart to hall 300 with the cart remaining open and exposed. HSK-J entered the SPA room for 300-hall and was observed to be storing linens for resident use, again not hand sanitizing. HSK-J pulled the cart towards 100-hall, entered the SPA room, coming out of the room and again not hand sanitizing. An observation on 04/03/2025 at 10:15 AM Laundry Aide-H (LA-H) was observed pushing a cart down 200-hall. The cart was observed to be open, with its flap to cover one side of the cart pulled up and over, exposing the full cart of clean linens. On top of the cart were comforters, also exposed. LA-H continues to push the cart to the SPA room, where the linens were placed into the room for resident use. LA-H was observed to not use hand sanitizer. LA-H pushed the cart to hall 300 with the cart remaining open and exposed. LA-H entered the SPA room for 300-hall and was observed to be storing linens for resident use, again not hand sanitizing. An observation on 04/03/2025 at 11:31 AM LA-H and Laundry Aide-G (LA-G) were observed walking through the building pushing a cart exiting the 400-hall secure unit wearing Personal Protective Equipment (PPE) gowns. LA-H and LA-G were interviewed why they were wearing PPE gowns so they would not get their clothing dirty, when asked if they thought wearing gowns throughout the facility was part of the policy, LA-H and LA-G both stated they were unaware of the policy. LA-H revealed that they were not trained, however do attend monthly educational events that do not reflect infection control or information related to their position or job duties. The Infection Preventionist (IP) was interviewed on 04/03/2025 at 12:00 PM regarding education for housekeeping and laundry aides. The IP revealed an education sheet titled, handling soiled linens and trash dated 03/28/2025 signed by LA-H, LA-G and HSK-J stating they were recently educated. A review of a facility education sheet reveals directions on how and when to wear a gown when picking up trash and soiled linens, stating: Do not hold dirty linens against your uniform at any time. When collecting dirty linen, please wear a gown (found in clean linen room) once soiled linen is in cart, remove gown and place in with other soiled laundry. Change your gown for each hall. Do not wear a gown throughout the facility. A review of a facility policy titled, Infection Prevention and Control date reviewed and revised April 2025 revealed: Standard Precautions: -All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. Linens: -Environmental services staff shall not handle soiled linen unless it is properly bagged. An interview on 04/07/2025 at 9:30 AM with the IP confirmed that staff should have clean and soiled linen cart covered when transporting clean or dirty linens throughout the facility. The IP also confirmed that staff should not be wearing gowns throughout the facility for any reason. 49382 B. Review of a facility policy titled Standard Precautions Infection Control Protocol dated 05/2025 revealed Resident care equipment should be handled in a manner that prevents transfer of microorganisms to other and to the environment. In and observation completed on 04/02/2025 from 11:43 AM to 12:05 PM the following was observed: -Registered Nurse F (RN-F) knocked and entered Resident 7 room. Resident 7 was lying flat on their back in their bed. The nurse told the resident that they were going to check the residents blood sugar then kneeled at the resident bed side. The RN placed the glucometer directly on the bed to the right side of the resident. The RN did not place a barrier down between the resident's bed linens and the glucometer to prevent the transfer of microorganisms. -RN-F Knocked and entered Resident 30 room. Resident 30 was sitting in their recliner with their over bed table on their right side. The nurse told the resident that they were going to check the residents blood sugar and placed the glucometer on the resident's bed side table on top of the residents open crossword book. The RN did not place a barrier down between the resident's book and the glucometer to prevent the transfer of microorganisms. In an interview completed on 04/02/2025 at 12:05 PM with RN-F, RN-F confirmed that they did place a barrier between the glucometer and surfaces to prevent the transfer of microorganisms from the surface to the glucometer. In an interview completed on 04/02/2025 at 2:50 PM with the Director of Nursing (DON), the DON confirmed that a barrier should be placed between surfaces to prevent the transfer of microorganisms to the glucometer. C. Review of a facility policy titled Glucometer Disinfection and dated 04/2025 revealed the facility will ensure blood glucometers will be cleaned and disinfected after each use. The procedure for cleansing and disinfecting steps were listed to retrieve 2 disinfectant wipes from the container, use the first wipe to clean and remove heavy soil blood and or other contaminants from the surface of the glucometer. After cleaning use the second wipe to disinfect the glucometer thoroughly with the disinfectant wipe and allow the glucometer to air dry. In an observation completed on 04/02/2025 at 11:43 AM RN-F was observed to use a glucometer to obtain Resident 30's blood sugar. The RN then returned to the medication cart and placed the glucometer on top of the cart. The RN then pushed the medication cart across the hallway to Resident 34 room and used the glucometer to obtain Resident 34's blood sugar. The RN returned to the medication cart and placed the glucometer into the top drawer of the medication cart. The RN did not clean and disinfect the glucometer after each use. In an interview completed on 04/02/2025 at 12:05 PM with RN-F, RN-F confirmed that they did not clean and disinfect the glucometer after using it on Resident 30 and Resident 34. The RN confirmed it was the facility policy to clean and disinfect the glucometer after use. In an interview completed on 04/02/2025 at 2:50 PM with the Director of Nursing (DON), the DON confirmed that the facility policy was for the glucometer to be cleaned and disinfected after each use.

Licensure Reference Number 175NAC 1-009.01(B) Licensure Reference Number 175NAC 12-006.19 Based on observation, record review, and interview; the facility failed to ensure resident rooms were kept free of soiling and debris for 19 of 24 residents (Residents 38, 3, 2, 12, 47, 37, 28, 22,16, 23, 35, 43, 44, 21, 15, 34, 49, 26, and 29); and the facility failed to maintain facility toilet seats in a cleanable condition for 3 of 24 residents (Residents 47, 34, and 49). The facility census was 50. Findings are: A. Record review of the undated facility Admission Packet revealed that the facility agrees to provide the following service for the prevailing basic monthly rate: Furnish room, meals, linens, laundry service, nursing care, housekeeping and maintenance, restorative care, assistance with social service needs and recreational activity programs. Record review of the facility Resident Rights dated 2012 revealed that the nursing facility must care for residents in a manner and in an environment that promotes maintenance or enhancement of a resident's quality of life. Promote care for residents in a manner and in an environment that maintains or enhances a resident's dignity and respect recognizing his or her individuality. The nursing facility must provide a safe, clean, comfortable, and home-like environment. The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Observation on 4/1/25 at 11:58 AM in the room of Resident 38 revealed that the bathroom exhaust vent cover was soiled with thick white/gray fuzzy debris. Some of the debris floated to the floor as the vent was touched with a 1-ply square of toilet paper as it was tested for functioning. The bathroom floor was sticky and smelled of urine. The white wall on the left side of the toilet was soiled with dried yellow urine. Pieces of black/brown colored debris were stuck on the wall of the bathroom next to the bathroom light switch. Observation on 4/1/25 at 12:01 PM in the room of Resident 3 revealed that the bathroom exhaust vent cover was soiled with thick white/gray fuzzy debris. Some of the debris floated to the floor as the vent was touched with a 1-ply square of toilet paper as it was tested for functioning. Observation on 4/1/25 at 12:04 PM in the room of Resident 2 revealed that the bathroom exhaust vent cover was soiled with thick white/gray fuzzy debris. The hot water handle of the bathroom sink was soiled with yellow/tan dried crusty debris. Observation on 4/1/25 at 12:08 PM in the room of Resident 12 revealed that the bathroom exhaust vent was soiled with thick white/gray fuzzy debris that floated to the floor as the vent was touched with a 1-ply square of toilet paper as it was tested for functioning. Observation on 4/1/25 at 12:12 PM in the room of Resident 47 revealed that the bathroom floor was sticky and soiled with yellow food crumb debris. The bathroom exhaust vent cover was soiled with thick white/gray fuzzy debris that fell to the floor as the vent was touched with a 1-ply square of toilet paper as it was tested for functioning. The toilet seat was cracked and a section from the crack was soiled with an approximately 4 centimeter by 5 centimeter area of dark brown stool per visual measurement. The resident room had crumbs and food debris scattered about the room and in front of the heating/cooling unit. Observation on 4/1/25 at 12:16 PM in the room of Resident 37 revealed that the bathroom exhaust vent cover was soiled with thick white/gray fuzzy debris. Observation on 4/1/25 at 12:15 PM in the room of Resident 28 revealed that the bathroom exhaust vent cover was soiled with thick white/gray fuzzy debris that floated to the floor as the vent was touched with a 1-ply square of toilet paper as it was tested for functioning. Observation on 4/1/25 at 12:20 PM in the room of Resident 22 revealed that the bathroom exhaust vent cover was soiled with thick white/gray fuzzy debris. Observation on 4/1/25 at 12:24 PM in the room of Resident 16 revealed that the bathroom vent cover was soiled with thick white/gray fuzzy debris. The bathroom floor was sticky. The resident room floor was soiled with crumbs and other scattered debris. Housekeeper-K (HSK-K) entered the resident room. Interview on 4/1/25 at 12:27 PM with HSK-K confirmed that the bathroom exhaust vent was soiled in the room of Resident 16. HSK-K revealed that cleaning the vents is not on their housekeeping cleaning checklist. Observation on 4/1/25 at 1:47 PM in the room of Resident 23 revealed that the bathroom exhaust vent cover was soiled with thick gray fuzzy debris. Observation on 4/1/25 at 1:50 PM in the room of Resident 35 revealed that the bathroom exhaust vent cover was soiled with thick white/gray fuzzy debris. Observation on 4/1/25 at 2:02 PM in the room of Resident 43 revealed that the bathroom exhaust vent cover was soiled with a thick blanket of grey fuzzy debris. Observation on 4/1/25 at 2:32 PM in the room of Resident 44 revealed that the bathroom exhaust vent cover was soiled with thick white/gray fuzzy debris. The room had a urine odor. A urinal full of urine sat on the over bed table in the room. Observation on 4/1/25 at 2:35 PM in the room of Resident 21 revealed that the bathroom smelled of urine. The bathroom exhaust vent cover was soiled with thick white/gray fuzzy debris. Observation on 4/1/25 at 3:08 PM in the room of Resident 15 revealed that the bathroom exhaust vent was soiled with thick white/gray fuzzy debris. Observation on 4/1/25 at 4:05 PM in the room of Resident 34 revealed that the bathroom exhaust vent cover was soiled with thick white/gray fuzzy debris. Observation on 4/1/25 at 4:17 PM in the room of Resident 49 revealed that the bathroom exhaust vent was soiled with thick white/gray fuzzy debris. Observation on 4/1/25 at 4:28 PM in the room of Resident 26 revealed that the bathroom exhaust vent cover was soiled with a blanket of thick gray fuzzy debris. Observation on 4/1/25 at 5:08 PM in the room of Resident 29 revealed that the bathroom exhaust vent cover was soiled with thick white/gray fuzzy debris. Interview on 4/1/25 at 1:13 PM with Housekeeper-I (HSK-I) revealed that individual resident rooms get cleaned every other day. HSK-I revealed there are 2 housekeepers and 4 halls, so they each do the resident rooms on 1 hall daily. HSK-I revealed that there is a checklist in the housekeeping room that lists areas of the resident room that are to be completed during cleaning of the resident room. HSK-I revealed that it is difficult to complete all of the cleaning tasks with only 2 housekeepers each day. Record review of the undated Housekeeping Resident Room Checklist (Daily) revealed that housekeeping staff are to visually inspect for dust/debris, food, sticky surfaces, soiled surfaces, and trash. The checklist revealed that any surface in need of cleaning will be spot cleaned. The checklist revealed that staff will sanitize sink handles, toilet, and light switches during every room cleaning. Interview on 4/1/25 at 1:24 PM with the facility Dietary Manager (DM) revealed that the DM is also the facility housekeeping manager. The DM revealed that resident rooms are to be cleaned every other day. The DM revealed that some rooms are scheduled for daily cleaning due to some residents that spill popcorn or other items on the floor frequently. The DM revealed that maintenance cleans the bathroom vents. Observation on 4/1/25 at 1:54 PM with the Facility Administrator (FA) in the room of Resident 28 confirmed that the bathroom vent was covered with thick gray/white fluffy debris and needed to be cleaned. This surveyor requested documentation of vent cleaning for the resident rooms. Interview on 4/1/25 at 2:52 PM with the FA confirmed that the facility did not have documentation of vent cleaning for the bathroom exhaust vents for Residents 38, 3, 2, 12, 47, 37, 28, 22,16, 23, 35, 43, 44, 21, 15, 34, 49, 26, and 29. The FA confirmed that the bathroom vents for those residents were soiled and needed to be cleaned and that the facility was working to clean them now. The FA revealed that the cleaning of the vents will be scheduled for cleaning weekly or at some other frequency. The FA revealed that the Maintenance Supervisor (MS) is new and that the DM is new to the housekeeping supervisor role. The FA revealed that neither of them had a scheduled cleaning or a checklist to ensure the bathroom exhaust vents were cleaned. Observation on 4/7/25 at 1:56 PM in the room of Resident 38 with the DM confirmed that the wall beside the toilet is soiled with yellow urine splattering and needed to be cleaned. The DM confirmed the presence of the black/brown soiling debris stuck on the wall next to the light switch in the bathroom. Interview on 4/7/25 at 1:56 PM with the DM confirmed that cleaning of the walls in the resident room and bathroom are not on the cleaning checklist for the housekeepers. This surveyor revealed that the urine splattering and the black/brown debris stuck on the wall next to the bathroom light switch in the bathroom of Resident 38 remained uncleaned since first observed on 4/1/25. The DM confirmed that the housekeepers should have performed spot cleaning for the soiling on the walls. B. Observation on 4/1/25 at 12:12 PM in the room of Resident 47 revealed that the toilet seat was cracked across the left side of the seat. A section of the top of the toilet seat from the crack was soiled with a 4 centimeter by 5 centimeter area of dark brown stool per visual measurement. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 2/20/25 for Resident 47 revealed that Resident 47 required supervision for toilet transfers (getting on and off the toilet). The MDS revealed that Resident 47 was frequently incontinent of urine and occasionally incontinent of stool. Record review of the care plan (an individualized written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) dated 4/7/25 for Resident 47 revealed that Resident 47 is able to participate in the transfer to the toilet with partial staff support and needs substantial support with hygiene. Observation on 4/7/25 from 1:56 PM- 2:04 PM with the Dietary Manager (DM) and Maintenance Supervisor (MS) confirmed that the toilet seat in the room of Resident 47 was cracked through and was a hazard as well as a non-cleanable surface. C. Observation on 4/1/25 at 4:05 PM in the room of Resident 34 revealed that the toilet seat was discolored and worn. The toilet seat had deep scratches on the top right side. Record review of the MDS dated [DATE] for Resident 34 revealed that Resident 34 was independent with transferring on and off the toilet. The MDS revealed that Resident 34 was frequently incontinent of urine and frequently incontinent of stool. Record review of the care plan dated 4/7/25 for Resident 34 revealed that Resident 34 transfers independently. Resident 34 needs support with toilet hygiene. Observation on 4/7/25 from 1:56 PM- 2:04 PM with the Dietary Manager (DM) and Maintenance Supervisor (MS) confirmed that the top right side of the toilet seat in the room of Resident 34 had deep scratches and was not a cleanable surface. D. Observation on 4/1/25 at 4:17 PM in the room of Resident 49 revealed that the toilet seat was worn and discolored. The top of the toilet seat at the rear was chipped measuring approximately 3 centimeters by 2 centimeters per visual measurement. Record review of the MDS dated [DATE] for Resident 49 revealed that Resident 49 required supervision for toilet transfers. The MDS revealed that Resident 49 is frequently incontinent of urine and occasionally incontinent of stool. Record review of the care plan dated 4/1/25 for Resident 49 revealed that Resident 49 is able to participate in toilet use. Observation on 4/7/25 from 1:56 PM- 2:04 PM with the Dietary Manager (DM) and Maintenance Supervisor (MS) confirmed that the rear top of the toilet seat in the room of Resident 49 was worn and chipped and was not a cleanable surface and needed to be replaced.

Licensure Reference Number 175 NAC 12-006.10(D) Based on observation, record review, and interview; the facility failed to have a medication error rate of 5% or less. This affected 4 (Resident 9, 45, 48, and 49) of 7 sampled residents. The facility census was 50. Findings are: A record review of a facility policy titled Medication Administration and dated 04/2025 revealed to administer medications with in 60 minutes prior to or after the scheduled time and ensure that the six rights of medication administration are followed including the right time. A. A record review of a Medication Administration Record dated 04/02/2025 revealed Resident 9 was admitted to the facility on [DATE] with diagnoses of Hypothyroidism (a deficiency of thyroid hormone). The resident had an order to receive Levothyroxin (thyroid hormone supplement) tablet 25 micrograms once daily with directions to administer the medication 30 minutes prior to other medications and or eating and Levothyroxin (thyroid hormone supplement) tablet 200 micrograms once daily with directions to administer the medication 30 minutes prior to other medications and or eating. In an observation completed on 04/02/2025 at 8:48 AM of medication administration by Medication Aide B (MA-B), MA-B prepared Resident 9's medications including the two Levothyroxine tablets. Resident 9 was sitting in the dinning area with a plate containing food stuff in front of them. The resident was observed to take a bite of food as MA-B walked over to the table. MA-B identified them selves and informed Resident 9 they had their medications. The MA placed the prepared medication onto a spoon and using the spoon assisted the resident to take the medications then gave the resident a drink. The MA then returned to the medication cart and signed the medications as administered. In an interview with MA-B on 04/02/2025 at 09:30, MA-B confirmed that the direction for the Levothyroxine tablets stated to be given 30 minutes prior to other medications and or eating. The MA confirmed that they did not follow these directions and administered the medication with other medications and after the resident had already started eating. In an interview conducted on 04/02/2025 at 3:30 PM with the Director of Nursing (DON), the DON confirmed that provider directions for administration of Resident 9's Levothyroxine were not followed, and this was a medication error. B. A review of a Medication Administration Record dated 04/02/2025 revealed Resident 45 was admitted to the facility on [DATE] with diagnoses that included Hypertension (high blood pressure), Urinary Frequency (the need to urinate frequently), Depression (a mood disorder characterized by persistent feelings of sadness and loss of interest that can interfere with daily life), Pain, and Dementia (a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior). The resident had orders to receive Metoprolol (a medication used to treat high blood pressure) tablet 12.5 milligrams daily, Ocuvite with Lutein (a Vitamin supplement for eye health) tablet daily, Myrbetriq (medication for urinary frequency) 50 milligram tablet daily, Sertraline (a antidepressant medication) 50 milligram tablet daily, Acetminophen (analgesic/pain medication) 325 milligram 2 tablets twice daily, and Memantine (a medication to treat dementia) 10 milligrams daily. All the medications had a scheduled administration time of 8:00 AM. In an observation completed on 04/02/2025 at 9:10 AM of medication administration by MA-B, MA-B prepared the medications for Resident 45 at the medication cart and placed them into a clear plastic cup. MA-B then proceeded to assist Resident 45 place the medications in their mouth and then take a drink. The medication aide returned to the medication cart and signed the medications as administered. In an interview with MA-B on 04/02/2025 at 9:30 AM the MA confirmed that medications were to be administered 60 minutes/1 hour prior to or post scheduled administration time. The MA confirmed that the scheduled administration time for the medications was 8:00 AM and it was after 9:00 AM so the medications were not administered during the correct time period. In an interview conducted on 04/02/2025 at 3:30 PM with the Director of Nursing (DON), the DON confirmed that the scheduled administration time for Resident 45's medications was 8:00 AM and administering the medications after 9:00 AM was a medication error. C. A review of a Medication Administration Record dated 04/02/2025 revealed Resident 48 was admitted to the facility on [DATE] with diagnoses that included Atherosclerotic Heart Disease (the buildup of fats, cholesterol and other substances in and on the artery walls), Hypertension (high blood pressure), and Osteoprosis (a condition that is characterized by decrease in bone mass with decreased density and enlargement of bone spaces producing porosity and fragility). The resident had orders to receive Asprin (an antiplatelet medication) 81 milligrams daily, Lisinopril (a medication used to treat high blood pressure) 5 milligrams daily, and Oyster Shell Calcium with Vitamin D (a Mineral and Vitamin supplement medication) 2 tablets daily. All the medications had a scheduled administration time of 8:00 AM. In an observation completed on 04/02/2025 at 9:15 AM of medication administration by MA-B, MA-B prepared the medications for Resident 48 at the medication cart and placed them into a clear plastic cup. MA-B then proceeded to assist Resident 48 place the medication in their mouth and then take a drink. The medication aide returned to the medication cart and signed the medications as administered. In an interview with MA-B on 04/02/2025 at 9:30 AM the MA confirmed that medications were to be administered 60 minutes/1 hour prior to or post scheduled administration time. The MA confirmed that the scheduled administration time for the medications was 8:00 AM and it was after 9:00 AM so the medications were not administered during the correct time period. In an interview conducted on 04/02/2025 at 3:30 PM with the Director of Nursing (DON), the DON confirmed that the scheduled administration time for Resident 45's medications was 8:00 AM and administering the medications after 9:00 AM was a medication error. D. A review of a Medication Administration Record dated 04/02/2025 revealed Resident 49 was admitted to the facility on [DATE] with diagnoses that included Depression (a mood disorder characterized by persistent feelings of sadness and loss of interest that can interfere with daily life), Anxiety (an abnormal and overwhelming sense of apprehension and fear often marked by physical signs, by doubt concerning the reality and nature of the threat, and by self-doubt about one's capacity to cope with it), Pain, Hypertension (high blood pressure), Dementia (a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior), and Vitamin D Deficiency. The resident had orders to receive Duloxetine (an antidepressant medication) 30milligram daily, Lorazepam (an antianxiety medication) 0.5 milligrams 3 times a day, Meloxicam (a nonsteroidal anti-inflammatory medication used to reduce pain) 7.5 milligrams daily, Metoprolol (a medication used to treat high blood pressure) 50 milligrams 2 times a day, Quetiapine (an antipsychotic medication used to treat sever psychosis and mood disorders) 100 milligrams daily, Spironolactone (a medication used to treat high blood pressure and heart failure) 25 milligrams daily, Tramadol (an narcotic analgesic/pain medication) 100 milligrams daily, and Vitamin D3 2000 (a vitamin supplement) units daily. All the medication had a scheduled administration time of 8:00 AM. In an observation completed on 04/02/2025 at 9:20 AM of medication administration by MA-B, MA-B prepared the medications for Resident 49 at the medication cart and placed them into a clear plastic cup. MA-B then proceeded to assist Resident 49 place the medications in their mouth and then take a drink. The medication aide returned to the medication cart and signed the medications as administered. In an interview with MA-B on 04/02/2025 at 9:30 AM the MA confirmed that medications were to be administered 60 minutes/1 hour prior to or post scheduled administration time. The MA confirmed that the scheduled administration time for the medications was 8:00 AM and it was after 9:00 AM so the medications were not administered during the correct time period. In an interview conducted on 04/02/2025 at 3:30 PM with the Director of Nursing (DON), the DON confirmed that the scheduled administration time for Resident 49's medications was 8:00 AM and administering the medications after 9:00 AM was a medication error.

Licensure Reference Number 175NAC 12-006.11(A)(i) Based on observation, record review, and interview; the facility failed to ensure that facility menus were followed to provide the required food portions to meet resident nutritional needs for 14 of 15 residents observed (Residents 49, 44, 32,16, 40, 19, 1, 22, 47, 8, 15, 39, 13, and 6). The facility census was 50. Findings are: Record review of the facility policy titled Open Style Dining dated 3/2/21 revealed that individuals will be provided choices of what to eat, when to eat, and who to dine with. The policy revealed that nursing and/or food and nutrition services staff will offer food and beverage choices to the individual at the point of service and report an individual's food and beverage choices to the staff members responsible for serving the food. Food and nutrition services staff will serve food and beverage choices made with consideration given to any dietary restrictions and/or texture modifications. The director of food and nutrition services (Dietary Manager) will observe the meals served for preferences, portion sizes, temperature, flavor, variety, and service accuracy. Record review of the facility policy titled Portion Control dated 2021 revealed that individuals will receive the appropriate portions of food as outlined on the menu. Control at the point of service is necessary to assure that accurate portion sizes are served. Menus should be posted at the tray line so staff can refer to the proper portions for each diet. Food should be served with ladles, scoops, and spoons of standard sizes. Portions that are too small result in the individual not receiving the nutrients needed. The policy listed the serving utensil sizes and corresponding ounces. A #16 scoop is 2 ounces. A #12 scoop is 2.67 ounces. Record review of the facility 2025 Week At a Glance Menu for 4/3/25 revealed the lunch menu was a beef soft taco, refried beans, lettuce, tomato, onion, chips and salsa, and pineapple upside down cake. Record review of the facility Dining Manager Beef Soft Taco recipe dated 2024 revealed that dietary staff were to fill each tortilla with a #12 dipper (a scoop that serves 2.67 ounces) serving of the taco meat to serve to each resident. The serving size of the #12 dipper was to be used for residents on regular diet, controlled carbohydrate diet (CCHO), and mechanical soft diet. Observation on 4/3/25 at 12:01 PM in the facility food service pod revealed that Dietary Cook-M (DC-M) placed serving utensils into the items on the steam table. DC-M placed a black handled 4 ounce scoop into the taco meat. Observation on 4/3/25 at 12:05 PM in the facility food service pod revealed that Dietary Cook-L (DC-L) stood at the steam table and began to plate the first resident meal. DC-L used a tong to remove a tortilla from the package and place it on a plate. DC-L used the 4 ounce scoop to place a scoop of the taco meat on the tortilla. DC-L plated refried beans on the plate. DC-L used tongs to place tortilla chips on the plate and then slid the tray with the plate to DC-M. DC-L removed the black handled 4 ounce scoop from the pan of taco meat and carried it to the dirty dish sink in the kitchen. DC-L returned to the food service pod and removed a blue handled #16 scoop (a scoop that serves 2 ounces) from the drawer and placed it into the taco meat pan. DC-L used the blue handled #16 scoop to place a scoop of taco meat on a tortilla on a plate for Resident 49 (a resident on a regular diet). DC-L continued to plate resident meals using the blue handled #16 (2 ounce serving) to serve the taco meat. DC-L served 2 ounces of taco meat onto the tortilla for Resident 44 (a resident on a controlled carbohydrate diet (CCHO)). DC-L served 2 ounces of taco meat onto the tortilla for Resident 32 (a resident on a regular diet). DC-L served 2 ounces of taco meat onto the tortilla for Resident 16 (a resident on a regular diet). DC-L served 2 ounces of taco meat onto the tortilla for Resident 40 (a resident on a regular diet). DC-L served 2 ounces of taco meat onto the tortilla for Resident 19 (a resident on a CCHO diet). DC-L served 2 ounces of taco meat onto the tortilla for Resident 1 (a resident on a CCHO diet). DC-L served 2 ounces of taco meat onto the tortilla for Resident 22 (a resident on a regular diet). The time was now 12:49 PM. DC-L began to plate room tray meals. DC-L served 2 ounces of taco meat onto the tortilla for Resident 47 (a resident on a CCHO diet). DC-L served 2 ounces of taco meat onto the tortilla for Resident 8 (a resident on a regular diet). DC-L served 2 ounces of taco meat onto the tortilla for Resident 15 (a resident on a CCHO diet). DC-L served 2 ounces of taco meat onto the tortilla for Resident 39 (a resident on a regular diet). DC-L served 2 ounces of taco meat onto the tortilla for Resident 13 (a resident on a regular diet). DC-L served 2 ounces of taco meat onto the tortilla for Resident 6 (a resident on a regular diet). Interview on 4/3/25 at 12:55 PM with DC-L revealed that DC-L felt that the black handled scoop for the taco meat was too big. DC-L revealed that they decided to use the blue handled #16 scoop to serve the rest of the taco meat to residents. DC-L confirmed that they did not verify the serving size to be used per the recipe for the beef soft taco. Interview on 4/3/25 at 1:01 PM with the facility Dietary Manager (DM) confirmed that the #16 scoop that was used for serving the taco meat was a 2 ounce serving. The DM confirmed that the recipe directed that a #12 (2.67 ounce) scoop was to be used for serving the taco meat. The DM confirmed that the residents were not served the required amount of taco meat.

Licensure Reference Number 175 NAC 12-006.05(S) Based on observation, record review, and interview; the facility failed to promote or maintain dignity for 1 (Resident 37) of 2 sampled residents. The facility census was 50. Findings are: A record review of the facility supplied admission packet revealed a document labeled Nursing Facility Resident Rights dated 2012. Review of this document revealed the resident has the right to be cared for in a manner and environment that maintains or enhances a resident's dignity. A record review of a facility policy titled Abuse, Neglect and Exploitation dated 09/13/2022 revealed it is the policy of the facility to provide protections for the health, welfare and rights of each resident. A record review of an Admission Record dated 04/01/2025 indicated that the facility admitted Resident 37 on 01/24/2024 with diagnoses of Alzheimer's disease (a degenerative brain disease of unknown cause that usually starts in late middle age or in old age, that results in progressive memory loss, impaired thinking, disorientation, and changes in personality and mood), peripheral vascular disease (vascular disease affecting blood vessels outside the heart and especially those vessels supplying the extremities), and chronic kidney disease (a progressive loss of kidney function). The Annual Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 01/02/2025 revealed Resident 37 had short- and long-term memory problems and their cognitive skills for daily decision making was severely impaired. The resident was dependent on staff assistance with eating, dressing, bed mobility, toilet use, and transfers. In an interview completed on 04/01/2025 at 10:29 AM with Resident 37's responsible party, revealed concern due to staff not keeping the resident's dress pulled down over their legs and this was causing the resident's lower portion of body to be exposed frequently when the individual visited the resident at the facility. In an observation completed on 04/01/2025 at 11:40 AM, Resident 37 was observed to be sitting in their room in the wheelchair. The resident was visible/in direct line of site from the hallway. Resident 37's lower half of their body was uncovered, exposing the resident's bare legs and up to the resident's groin. Resident 37's room was located at the beginning of the hallway just inside the entrance to the secured unit of the facility. In an observation completed on 04/01/2025 at 1:39 PM, Resident 37 was observed to be sitting in their wheelchair in their room with the lower half of their body exposed. The resident's bare legs were visible from the hallway. The resident had a blanket covering their trunk and lap/groin area. In an observation completed on 04/02/2025 at 3:32 PM, Resident 37 was observed to be sitting in their wheelchair in the commons area with 5 other residents, one of these residents was (opposite gender). Resident 37's legs, up to their groin area, were exposed revealing bare skin/legs as well as the resident's white incontinence product. A blanket was observed to the right side of Resident 37 on the floor. In an observation completed on 04/02/2025 at 3:40 PM, Nurse Aide (NA)-Q walked by Resident 37. NA-Q stopped beside Resident 37 and picked up the blanket off the floor and placed it over the resident's legs and groin area. In an observation completed on 04/02/2025 at 3:52 PM, Resident 37 was observed to be sitting in their wheelchair in the commons area with 3 other residents, one of these residents was (opposite gender). The (opposite gender) resident was sitting directly across the commons area from Resident 37. Resident 37's legs up to groin area were exposed revealing bare skin/legs as well as the resident's white incontinence product. A blanket was observed under the right side of the resident's wheelchair on the floor. In an interview completed on 04/02/2025 at 4:05 PM with NA-Q, NA-Q confirmed Resident 37's bare skin/legs up to groin were exposed while sitting in the commons area with other residents. The NA stated they did not know why the resident did not have any pants and only dresses available for clothing. The NA confirmed that Resident 37 often removed the blanket used to cover the lower half of their body. In an observation completed on 04/03/2025 at 7:28 AM Resident 37 was observed to be sitting in their wheelchair in their room with the lower half of their body exposed. The resident's bare legs were visible from the hallway. In an interview completed on 04/03/2025 at 1:32 PM with NA-E, NA-E stated Resident 37 only had dresses available for clothing and would always move legs or remove the blanket from over their legs causing the resident's legs and lower half of their body to be exposed for others to see. In an observation completed on 04/07/2025 at 1:15 PM Resident 37 was observed to be sitting in their wheelchair in the dining area with 2 other residents present in the area. The lower half of Resident 37's body was uncovered, exposing their bare legs to upper thighs. In an interview completed on 04/07/2025 at 1:16 PM with NA-A, NA-A confirmed that Resident 37 sitting in view of others with the lower half of their body exposed was not promoting dignity for Resident 37. In an interview completed on 04/07/2025 at 2:15 PM with the Director of Nursing (DON), the DON confirmed that allowing a resident to sit with in view of others with the lower portion of their body exposed or uncovered did not promote or maintain Resident 37's dignity.

Licensure Reference Number 175 NAC 12-006.05(D) Based on record review and interview, the facility failed to inform and or educate the resident and or their representative in advance of the risks or possible side effects of the use of psychotropic medication for 2 (Resident 35 and Resident 49) of 2 sampled residents. The facility census was 50. Findings are: A record review of a facility policy titled Use of Psychotropic Medication (a medication that affects the brain and central nervous system to alter mood, behavior, thoughts, and perception) dated 04/2024 revealed Residents and or representatives shall be educated on the risks and benefits of psychotropic drug use. A. A record review of an Admission Record revealed the facility admitted Resident 35 on 12/21/2023 with diagnoses of neurocognitive disorder with Lewy bodies (a degenerative brain disorder) and anxiety disorder (an abnormal and overwhelming sense of apprehension and fear often marked by physical signs, by doubt concerning the reality and nature of the threat, and by self-doubt about one's capacity to cope with it). A record review of a Quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 03/13/2025 revealed Resident 35 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 4/15 indicating the resident had severe cognitive impairment. The resident required supervision or touching assistance with eating and partial to moderate assistance with bed mobility transfers and toilet use. The resident was coded to have received routine psychotropic medications. A record review of Resident 35's Electronic Medical Record (EMR) conducted on 04/02/2025 revealed that Resident 35 had physician orders to receive: -Halperidol (a psychotropic medication) 1 milligram tablet once daily with a start date of 10/15/2024, -Quetiapine (a psychotropic medication) 50 milligrams twice daily with a start date of 03/29/2024, -Quetiapine (a psychotropic medication) 100 milligrams at bedtime daily with a start date of 03/29/2024, and -Sertraline (a psychotropic medication) 100 milligrams daily with a start date of 02/09/2024. Resident 35's medication administration record revealed the resident to have received all these medications every day for the prior 30 days. A record review of a facility supplied document titled Consent to Receive Psychotropic Medication and dated 04/01/2025 revealed each above listed psychotropic medication dosage and frequency listed with a specific titled area possible side effects. There were no possible side effects listed for the psychotropic medications on the document. There was no resident or representative signature present verifying notification of the possible side effects of the psychotropic medications. In an interview completed on 04/07/2025 at 2:18 PM with the Director of Nursing (DON), the DON confirmed that no possible side effects were listed for the psychotropic medication on the document. The DON confirmed that the document was not signed by the responsible party verifying they were notified of the possible side effects and or risks of the psychotropic medication. The DON confirmed that the facility policy was not followed. B. A record review of an Admission Record revealed the facility admitted Resident 49 on 02/13/2025 with diagnoses of dementia (a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior), depression (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks and is accompanied by irritability, fatigue, poor concentration, sleep disturbances, weight gain or loss, feelings of worthlessness or guilt, and sometimes suicidal tendencies), and anxiety disorder (an abnormal and overwhelming sense of apprehension and fear often marked by physical signs, by doubt concerning the reality and nature of the threat, and by self-doubt about one's capacity to cope with it). A record review of an Admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 02/21/2025 revealed Resident 49 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 4/15 indicating the resident had severe cognitive impairment. The resident required supervision or touching assistance with eating and bed mobility partial to moderate assistance with transfers and toilet use. The resident was coded to have received routine psychotropic medications. A record review of Resident 49's Electronic Medical Record (EMR) conducted on 04/02/2025 revealed that resident 49 had physician orders to receive: -Duloxetine (a psychotropic medication) 30 milligrams (MG) daily with a start date of 02/14/2025, -Lorazepam (a psychotropic medication) 0.5 MG three times a day with a start date of 03/07/2025, -Quetiapine (a psychotropic medication) 100 MG twice daily with a start date of 02/13/2025, and -Trazadone (a psychotropic medication) 50 MG at bed time with a start date of 02/13/2025. Resident 49's medication administration record revealed the resident to have received all these medications every day for the last 30 days. A record review of a facility supplied document titled Consent to Receive Psychotropic Medication and dated 02/13/2025 revealed each above listed psychotropic medication dosage and frequency listed with a specific titled area possible side effects. There were no possible side effects listed for the psychotropic medications on the document. There was no resident or representative signature present verifying notification of the possible side effects of the psychotropic medications. In an interview completed on 04/07/2025 at 2:18 PM with the Director of Nursing (DON), the DON confirmed that no possible side effects were listed for the psychotropic medication on the document. The DON confirmed that the document was not signed by the responsible party verifying they were notified of the possible side effects and or risks of the psychotropic medication. The DON confirmed that the facility policy was not followed.

Licensure Reference Number 175 NAC ,d+[DATE].12(E) Based on observation, record review, and interview; the facility failed to ensure an insulin pen was labeled for 1 (Resident 34) of 4 sampled residents. The facility census was 50. Findings are: A. A record review of a facility policy titled Insulin Pen and dated ,d+[DATE] revealed that insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and date opened. A record review of an Admission Record revealed that the facility admitted Resident 34 on [DATE] with diagnoses that included Diabetes (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production). A record review of a Quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated [DATE] revealed Resident 34 received insulin injections 7 days a week. A record review of Resident 34's Medication Administration Record (MAR) on [DATE] revealed Resident 34 had orders to receive Lantus (an injectable insulin medication used to treat elevated blood sugar and Diabetes) 15 units subcutaneously once daily. In an observation completed on [DATE] at 11:43 AM Registered Nurse F (RN-F) prepared an insulin pen for administration to Resident 34. RN-F removed the cap, cleansed the tip of the pen with an alcohol wipe, screwed on a needle cap, primed the pen, visualized a drip of insulin on the needle tip, and dialed the dose of insulin to be administered. The RN then proceeded to administer the insulin to Resident 34 then returned to the medication cart. Inspection of the insulin pen revealed the pharmacy label attached to the insulin pen as well as a white sticker labeled Date opened, expiration date and initial. There was no information written on the pen to reflect open date or expiration date. In an interview completed on [DATE] at 12:05 PM RN-F confirmed that there was no opened date or expiration date written on the insulin pen. The RN confirmed that insulin pens were only good for 28 days after opening or being stored at room temperature. The RN confirmed that without a date of when was opened written on the pen there was no way to know when the insulin expired. The RN confirmed that an opened date or expiration date is to be written on each insulin pen sticker and was not on this pen. In an interview completed on [DATE] at 2:50 PM with the Director of Nursing (DON), the DON confirmed that the facility policy was for insulin pens to be labeled with the open date and that this was not done for Resident 34's insulin pen.

Licensure Reference Number 175 NAC ,d+[DATE].09 Based on record review, observations, and interviews, the facility failed to complete control testing on the facility glucometers (a machine that is used to monitor blood sugar levels) each night in order to maintain accurate blood sugar readings for the administration of sliding scale insulins and to ensure the accuracy of all blood sugars being monitored in the facility. This affected 6 residents who received Sliding Scale Insulin. (Residents 8, 9, 17, 30, 31, and 34). The facility failed to ensure that thorough skin checks were implemented for 1 Resident (Resident 30), of 4 sampled Residents. The facility census was 53. Findings are: A. Record Review of the Medline Evencare Proview Users glucometer manual reviewed at the facility dated 2018 states the following: The purpose of the control solution testing is to validate that the EVENCARE ProView Meter is working properly with the test strips. You should perform a control solution test when: 1.) Using the meter for the first time. 2.) Using a new package of EVENCARE ProView Blood Glucose Test Strips. 3.) At least once per week to verify that the meter and test strips are working properly together. 3.) If the test strip bottle is left open. 4.) The meter is dropped. 5.) You suspect the meter and test strips are not working properly together. 6.) A patient's test results do not agree with how they feel. 7.) A patient's readings appear to be abnormally high or low. 8.) Test strips have been exposed to a condition outside the specified storage conditions. 9.) Practicing your testing technique IMPORTANT: If the control test result falls outside of the range provided, do the following: 1.) Do not test the patient's blood glucose. 2.) Make sure you are using EVENCARE ProView Glucose Control Solution. 3.) Make sure the testing environment is between 50?F-104?F. 4.) Make sure glucose control solution and test strips have not expired. 5.) Repeat the test with a new test strip. 6.) Control solution test results will be stored in the meter memory with a control solution bottle symbol. 7.) If the problem persists, contact Medline Technical Service Center at [DATE]-2131 between 8:00 am and 5:00 pm (Central Time), Monday through Friday. IMPORTANT: 8.) DO NOT reuse test strips. 9.) Repeat with another level of control solution. IMPORTANT: o Use only EVENCARE ProView Glucose Control Solutions with the EVENCARE ProView Blood Glucose Test Strips. Other brands of control solutions will produce inaccurate results. o Always check the expiration date of the control solution. DO NOT use expired control solution. 22 ProView EVENCARE(R) (Trademark) Meter Setup o Record the date on the bottle when opening a new bottle of control solution. Discard any unused control solution three months after the opening date. o Control solutions are good three months after opening date or until the last day of the month of expiration, whichever comes first. o DO NOT FREEZE. Store the control solutions at room temperature of 39.2 degrees F - 86 degrees F. https://www.medline.com/media/catalog/Docs/MKT/MAN_EvenCare%20ProView%20Users%20Guide.pdf Dated 2018. Record Review of the Glucometer QC (calibration) log dated [DATE] revealed calibration information for [DATE] to [DATE]. The Glucometer QC log contained four columns: 1. Date, 2. High, 3. Low, and 4. Signature. The boxes for the high and low contained two numbers separated by a slash without an identifier for which glucometer from which the numbers corresponded. There were no columns for the high and low control ranges and no differentiation of which numerical entries corresponded to which of the two glucometers the nursing staff calibrated on the Glucometer QC log. Numbers for the HIGH and the LOW were completed only on [DATE], 7, 15, 17, 19, 20, 21, 26, 30, and 31. All other dates were blank. There was a signature with each entry. [DATE] there is a recorded reading of low for one glucometer in the low column. There is no indication that the glucometer was discarded or a new one calibrated. [DATE] both low readings were recorded as low/low. There are no further readings recorded or indication that either glucometer was discarded or replaced. [DATE] both readings recorded are low/low. There is again no indication that either monitor has been discarded or replaced nor is there a recalibration recorded. [DATE] has one low reading of low is recorded with no verification of replacing the glucometer and no further recalibration recorded. [DATE] has a recorded calibration of the low number as low. This has not recorded recalibration or indication that the monitor has been replaced. Because the control ranges differ and records do not include the ranges or parameters for the actual calibration numbers, it is impossible to ascertain what the correct ranges were for the month of January. Record Review of the Glucometer QC (calibration) log dated February 2024 revealed calibration information for [DATE] to [DATE]. The Glucometer QC log contained four columns: 1. Date, 2. High, 3. Low, and 4. Signature. The boxes for the high and low contained two numbers separated by a slash without an identifier for which glucometer from which the numbers corresponded. There were no columns for the high and low control ranges and no differentiation of which numerical entries corresponded to which of the two glucometers the nursing staff calibrated on the Glucometer QC log. Numbers for the HIGH and the LOW were completed only on February 1, 2, 4, 5, 8, 9, 11, 15, 16, 19, 20, 23, 24, 27, 28, and 29. All other dates were blank. There was a signature with each entry. Because the control ranges differ and records do not include the ranges or parameters for the actual calibration numbers, it is impossible to ascertain what the correct ranges were for the month of February. Record Review of the Glucometer QC (calibration) log dated [DATE] revealed calibration information for [DATE] to [DATE]. The Glucometer QC log contained four columns: 1. Date, 2. High, 3. Low, and 4. Signature. The boxes for the high and low contained two numbers separated by a slash without an identifier for which glucometer from which the numbers corresponded. There were no columns for the high and low control ranges and no differentiation of which numerical entries corresponded to which of the two glucometers the nursing staff calibrated on the Glucometer QC log. Numbers for the HIGH and the LOW were completed only on [DATE], 7, 13, 14, 15, 20, 21, and 22. All other dates were blank. There was a signature with each entry. Because the control ranges differ and records do not include the ranges or parameters for the actual calibration numbers, it is impossible to ascertain what the correct ranges were for the month of March. Record Review of the Glucometer QC (calibration) log dated [DATE], and reviewed on [DATE], revealed information through the date of [DATE]. The Glucometer QC log contained four columns: 1. Date, 2. High, 3. Low, and 4. Signature. The boxes for the high and low contained two numbers separated by a slash without an identifier for which glucometer from which the numbers corresponded. There was no column for the control range and no differentiation of which numerical entries corresponded to which of the two glucometers nursing staff calibrated on the Glucometer QC log. Numbers for the high and the low were completed for the ,d+[DATE] through the ,d+[DATE] with two numbers in each box. Signatures were only on the dates of ,d+[DATE], ,d+[DATE], and ,d+[DATE]. Because the control ranges differ and records do not include the ranges or parameters for the actual calibration numbers, it is impossible to ascertain what the correct ranges for the dates prior to [DATE]. However, [DATE] going forward, the ranges were on the glucometer strips that were being used. Record review of the Glucometer QC (calibration) log dated [DATE], and reviewed on [DATE], had now been completed through [DATE], had no entry on ,d+[DATE], had new entries for the ,d+[DATE] and ,d+[DATE], and all entries now had a signature except for ,d+[DATE] and ,d+[DATE]. No late entry was noted on the signatures. As of [DATE] the ranges were not recorded but the survey team was able to observe the ranges on the glucose monitoring strips. Calibration concerns are as follows: -The recorded calibration numbers on [DATE] were (,d+[DATE]) high and (,d+[DATE]) low with no indication as to which entry matches which of the two glucometers used daily. -The recorded calibration numbers on [DATE] were (,d+[DATE]) high and (,d+[DATE]) low with no indication as to which entry matches which of the two glucometers used daily. -The recorded calibration numbers on [DATE] were (,d+[DATE]) high and (,d+[DATE]) low with no indication as to which entry matches which of the two glucometers used daily. -The acceptable range for the glucometer strips for the calibration for the low range was 70 to 94 and the acceptable range for the high was ,d+[DATE]. -The calibration numbers for the high ranged from 302 to 330 on the three nights recorded and none fall within the acceptable range of (,d+[DATE]). -The calibration numbers for the low ranged from 39 to 48 on the three nights recorded and none fall within the acceptable range of (,d+[DATE]). -There is no indication that the DON (Director of Nursing) had been informed. -There is no indication that the calibration had been done again. -There is no indication that the glucometers were replaced. An observation on [DATE] at 10:30 AM revealed that two different boxes of glucose control solutions were opened on the medication cart. Neither box nor any of the 4 glucose control solutions were label with the date opened. Glucose strips were opened and not labeled with the date opened. The Control range for the low solution (solution 2) was (70 to 94) and the high solution (solution 3) was (221 to 301). An observation on [DATE] at 10:30 AM. Registered Nurse (RN)-A performed a glucose calibration test on the current glucose monitor. RN-A first opened one box of the glucose control solution and then the second box stating RN-A was looking for the box and vials that were labeled. Two boxes were in the medication cart opened, but not labeled. RN-A labeled the glucose controls to be used for the control test prior to proceeding. RN-A stated that the night shift does the Controls every night and RN-A had not done a control test for quite some time so took the time to read through the Medline Evencare manual. The blood glucose test strips were also not labeled, and RN-A labeled the test strips. After rolling the testing solution, RN-A prepared to test the monitor. The first step performed was to clean the monitor with a disinfectant wipe, then donned gloves, inserted the test strip into the monitor and tried to add a drop of the low solution for the first test. Unable to get the test drop on the test strip, RN-A then took a clean plastic medicine cup, dropped the solution in the cup and dipped the test strip into the cup. The result was 84. At this point, RN-A checked to see that the control number fell within the control range that was noted on the Glucose strips, which it did. She repeated this process with the second control solution and got a reading of 237 which fell within the range of the controls. RN-A then logged these readings in the newly created Glucose Calibration logbook. Interview on [DATE] at 10:30 AM with RN-A confirmed it is the night staff that performs the Glucometer Calibration check each night. Day staff do not do the calibrations. The facility always uses 2 glucometers. If the resident glucometer readings are high or low, no recheck of the blood sugar is performed at that time. Instead, a new glucometer check will be completed once the resident has eaten or about an hour after the insulin has been given a spot check may be done. RN-A confirmed that if a blood glucose is either high or low, they will not go back to check to see if the calibration has been completed. RN-A revealed that they had been taught only to retest the controls if opening a new test lot and had not completed new control tests when RN-B opened new bottle of glucometers strips that morning. RN-A further revealed that if the tests are out of range, one is not to use the test strips and must obtain a new bottle. RN-A revealed that the glucose controls and the Glucometer strips only last 30 days after opening. RN-A confirmed there had been no education on the new Glucose Calibration logbook. Observation on [DATE] at 10:45 AM RN-B was then asked to perform a quality control test of the blood glucose monitor using the other monitor kept on the medicine cart. RN-B does work nights occasionally and performs the Glucose calibration testing on those nights worked. Using the same control solutions that were now dated and the same glucose control strips, RN-B cleaned the surface of the area where the test took place with a disinfectant wipe, then laid a clean tissue down on the surface. Each bottle of glucose control solution was then cleansed with alcohol, the lid removed, and the bottle and corresponding lid set in front of each bottle of control solution. RN-B then dropped on drop of solution from the first bottle on the tissue and the next bottle on the top of the cap. This was repeated for the second bottle of control solution. Each control was tested . The low solution result was 87 and the high solution result was 278. Each of these test results were checked against the glucose strips and were within range. RN-B then record the test results on a different page than RN-A had recorded on and had a difficult time trying to note what needed to be recorded on the new glucose control sheets that RN-B had not yet been educated on. After the calibration tests were completed, RN-B put all the testing supplies away and discarding the used test strips and the tissue, the surface was cleansed with another disinfecting cloth. Interview on [DATE] at 10:45 AM with RN-B confirmed that RN-B does occasionally work the night shift. Night shift does do the Glucometer controls and day shift does not. If a blood glucometer control reading is out of range, controls should be run once again. If the controls are still out of range, one should try a new box of controls. The other option would be to call the DON at home or get a new glucometer in the med room and test the new glucometer. RN-B stated the glucose controls, and the glucose test strips are only good for 30 days each once opened. RN-B confirmed there had been no training or education for entering information into the new Glucose Calibration logbook. Observation on [DATE] at 10:30 to 11:00 AM was made that the facility uses two different glucometers each day and that neither glucometer had been labeled to differentiate the two glucometers from each other. Observation on [DATE] at 11:45 PM with the DON reveals that there are no numbers in the glucometer memory that are in the 30's or 40's for the past 9 days. (The recorded numbers for the Glucose QC calibration for the lows were all within the 30's and 40's on the calibration log and were the easiest to search for at the time.) The glucometer memory was searched in its entirety. The second glucometer that had been used by RN-A had just been replaced as the battery life was finished and the DON was unable to access any glucometer readings from that glucometer as it had been destroyed. Interview on [DATE] at 11:45 PM with the DON confirmed that there were no numbers on the glucometer for the past 9 days that were in the 30's or 40's and thus no calibrations had been completed on the monitor. Because these numbers were not identified, the recorded numbers for the high control calibrations were not searched. DON stated that this was extremely concerning to her and close to her as these readings must be accurate when giving the sliding scale insulin. Record review of the facility's policy on Blood Glucose Monitoring states in paragraph 6 of the policy explanation that calibration checks on glucometers must be performed nightly as per manufacturer's instructions. In paragraph 20 under procedures the policy states that critical test results must be reported to the physician timely. Interview on [DATE] at 11:00 AM with Human Resources and Staff Educator (HR) confirm there are no education or nursing staff competencies or testing annually for Blood Glucose Calibrations or the use of Insulin Pens. Interview on [DATE] at 11:04 with a representative from EvenCare Proview monitors confirm that glucose control ranges do differ from one bottle of test strips to the next. However, at no time when doing glucose control calibrations should the monitor ever read high or low. The representative again confirm that if the monitor has a reading of high or low during the calibration, then there is something wrong with the glucometer itself. 45613 B. Interview on [DATE] at 09:35 AM with Licensed Practial Nurse (LPN-L) confirmed that there is a folder at the nurse's desk that has a log sheet and calibration of the glucometers is completed during the night shift. Interview on [DATE] at 10:39 AM with LPN-M confirmed that calibration of the glucometers only happens about 50% of the time during the night shift and when it the control solution test is out of range staff is supposed to call the DON. During the night shift of [DATE]-[DATE] calibration did not get done due to being the only nurse working and it was a busy night. It was also confirmed that LPN-M did not know when the bottles of solution and/or the testing strips expired after opening or if they were dated. LPN-M confirmed that night shift doesn't ever run out of testing supplies and (gender) has never had to open a new bottle. The facility completed the following plan of correction to correct the concern on [DATE]. Abatement Statement: The Director of Nursing will provide hands on training including demonstration and teach back with every professional nurse in the facility prior to professional nurse working on the floor or administering insulin. Teaching will start [DATE] with nurses on duty currently. If the the glucose reading is out of range, the professional nurse will: -Make sure the glucose strips being used are accurate for glucose machine being used. -Make sure the glucose strips strips have not expired. -Repeat the test with a new test strip. -If continues to be out of range do not use the glucose monitor. Place out of range monitor in Director of Nursing's mailbox. -Use alternate monitor after completing control checks. Director of Nursing or Designee will attempt controls on out-of-range glucose monitor during daily audit. If in range, glucose monitor can be returned to the floor for use. If continues to be out of range, Director of Nursing or Designee will call Medline technical service for further direction. The above steps will be placed in the front of the glucose log for staff to reference. Will also be added to the competency training packets. -All professional nurses that work the floor will be trained by Tuesday, [DATE]th, 2024. -New glucometer logs have been put in place with all required information including lot number, expiration date, control values, glucose reading, and nurse completing check. The above training will also include a detailed explanation of the new logs with visual reminders placed in glucose logbook for refreshers if needed. The Director of Nursing or designee will audit the glucometer logs daily for 30 days verifying log documentation to glucometer memory by verifying date, time, and value. -Going forward any new hired professional nurses will be required to complete the same training prior to working without a trainer on the floor. 50105 C. An interview on [DATE] at 11:19 AM with Resident 30 revealed there was a sore on the top the left foot, pointing to the tongue portion of the shoe. When interviewed about treatments or pain, the Resident stated no treatments are done because nursing has not seen it and there is some irritation. An interview on [DATE] at 1:34 PM with Resident 30 revealed nursing completed skin checks while in the shower or whirlpool bath. Resident 30 revealed that baths are provided 3x's a week and the scheduled dates are on Monday, Wednesday, and Friday's. A record review of Resident 30's assessment titled Skin Observation dated [DATE] revealed redness to bilateral abdominal folds, groin and under breasts. Oral cavity pink/moist. There was no documentation about a sore on top of the foot. The skin observation was signed by Registered Nurse (RN)-A on [DATE]. Record review of Resident 30's chart revealed no Skin Observation documented between [DATE] and [DATE]. The facility did not complete a skin assessment for 12 days and the facility policy indicated a skin assessment was to be completed at least weekly. A record review of Resident 30's assessment titled Skin Observation dated [DATE] revealed redness to bilateral abdominal folds, groin and under breasts. Oral cavity pink/moist. There was no documentation about a sore on top of the foot. The skin observation was signed by RN-A on [DATE]. During an interview on [DATE] at 02:45 PM with RN-A and an additional surveyor revealed that RN-A completed a skin check with Resident 30 and revealed that the feet for Resident 30 were not observed during the skin observation. In an interview on [DATE] at 2:49 PM with the DON about the expectations of a thorough skin observation and if not observing the feet were part of the skin observation process. The DON revealed that a thorough skin check is to be completed weekly and that it includes observations of the Resident's feet. On [DATE] at 2:54 PM, the DON and nursing surveyor went to Resident 30's room to identify the sore Resident 30 were reporting to the surveyor. The observation with the DON and the nurse surveyor of Resident 30's foot revealed a popped blister on the top of Resident 30's foot. Record review revealed documentation in the progress notes dated [DATE] reporting to the physician via fax about the popped blister on top of Resident 30's foot and a request for treatment. The facility was unable to locate the fax from the physician. No specific cause was identified for the blister; therefore no preventative measures were put into place. Additional progress notes dated [DATE] revealed a response from the physician for treatment and continued monitoring. Review of a facility policy titled Pressure Injury Prevention Guidelines dated 2021 with a revised date by the facility on [DATE] revealed that to prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all Residents who are assessed at risk or who have a pressure injury present. The policy explanation and compliance guidelines for the facility provide: a. individualized interventions will address specific factors identified in the Resident's risk assessment, skin assessment, and any pressure injury assessment (e.g. moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). b. in the absence of prevention orders, the licensed nurse will utilize nursing judgement in accordance with pressure injury prevention guidelines to provide care and will notify physician to obtain orders. Review of a facility policy titled Pressure Injury Prevention and Management dated 2022 with a revised date by the facility on [DATE] revealed: this facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. The policy explanation and compliance guidelines for the facility state: a. the facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. b. the interventions for prevention and to promote healing reveals: after completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan hat includes measurable foals for prevention and management of pressure injuries with appropriate interventions. c. monitoring: the DON, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record.

Licensure Reference Number 175NAC 12-006.05(19) Based on observation, record review, and interview; the facility failed to ensure residents could access their personal resident trust funds on weekends. This affected 46 of 53 residents. With the facility stated census of 53. Findings are: In an interview with Resident 30 on 04/08/2024 at 11:36 AM, Resident 30 revealed [gender] was unable to access resident trust funds on the weekend. In an interview on 04/10/2024 at 12:58 PM with Business Office Manager (BOM), confirmed that residents do not have access to resident trust account funds on the weekends, Saturday's, and Sunday's. BOM revealed [gender] was unaware that residents should have access to their funds on the weekends. BOM further revealed there was no policy or procedure in place for residents to access their funds on the weekends.

Licensure Reference Number 175 NAC 12-006.07C Based on record review and staff interviews; the facility Quality Assessment Performance Improvement plan (QAPI) failed to identify ongoing issues relevant to F567, F645, F684, F865 and F880 and Emergency Preparedness (EP) regulation relevant to E-0004, E-0006, E0015, E0024, E0036. This deficient practice had the potential to affect all residents who reside in the facility. The facility staff identified a census of 92. Findings are: Review of the facility's policy dated 3/2023, titled Quality Assurance and Performance Improvement (QAPI) revealed, that it is the policy of the facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides. It is the responsibility of the Quality Assessment and Assurance Committee (QAA) to design the QAPI program. The QAPI plan will address the following: - Design and scope of the facility's QAPI program and QAA Committee responsibilities and actions. - Policies and procedures will be in place for feedback, data collection, and monitoring. Data is to be collected from all departments. -A priority of the program will focus on resident safety, health outcomes, and quality of care. A commitment to quality assessment and performance improvement by the management. The QAPI program will be ongoing, comprehensive, and will the full range of quality care and services provided by the facility. The facility will maintain documentation and evidence of it's ongoing QAPI program. Results of the standard and extended survey revealed the facility was cited for failing to follow regulations: -E-0004 The facility failed to develop, implement and updated the EP plan. -E-0006, The facility failed to implement an all hazard approach for the facility EP plan. -E-0015, the facility failed to have good faith notice of action for subsistence needs in the emergency plan. -E-0024, The facility failed to have policies and procedures for volunteers for emergency staffing strategies. -E0036, The facility failed to implement and maintain an emergency preparedness plan with a testing and training plan for communication, risk assessment and return demonstration of staff knowledge of emergency procedures. -F567, The facility administration failed to ensure residents funds were available from trust accounts. -F645, The facility failed to ensure a Preadmission Screening and Resident Review (PASARR), (a screening program mandated by the federal Centers for Medicare and Medicaid Services (CMS). -F684, The facility failed to ensure education and competencies were reviewed with licensed practical nurses and registered nurses annually prior to performing glucometer calibrations. -F865, The facility failed to have an effective QAPI program that identified ongoing issues and failed to implement plans to address the ongoing issues. -F880. The failed to develop and implement a water management program for the prevention of Legionella. This had the potential to affect all residents residing in the facility, and perform indwelling catheter (tube placed into the bladder to drain urine) care in a manner that reduced the risk of infection. Interview on 4/15/24 at 11:59 AM with the Infection Preventionist (IP) revealed that IP was in charge of QAPI. The IP further confirmed there was no active facility Performance Improvement Program (PIP) and the facility has not done one in the last year. It was also confirmed there was no system in place for data collection to identify ongoing concerns in the facility or a way to monitor and correct them for the QAPI process. Interview on 4/15/24 at 12:02 PM with the Administrator (ADM) revealed they were unaware there should be a ongoing and active QAPI Program for the facility to identify problems within the facility or a way to monitor and correct them. Interview on 4/15/24 at 12:05 PM with the ADM revealed the areas of deficient practice were not identified or monitored by the QAA committee or QAPI.

Licensure Reference Number 175NAC 12-006.17D Based on observation, record review, and interview the facility failed to develop and implement a water Legionella management program in the facility. This had the potential to affect all residents residing in the facility, and failed to perform indwelling catheter (tube placed into the bladder to drain urine)care in a manner that reduced the risk of infection for 2 residents, (Resident #27 and Resident #21), of 4 sampled residents. The facility stated census was 53. Findings are: A. Review of a facility policy titled Water Management Program dated 03/19/2024, indicated A water management team has been established to develop and implement the facility's water management program. The Maintenance Director maintains documentation that describes the facility's water system. A copy is kept in the water management program binder. A risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system. Review of a facility policy titled Legionella Surveillance dated 01/2024, indicated Legionella surveillance is one component of the facility's water management plan for reducing the risk of Legionella and other opportunistic pathogens in the facility's water system. In an interview conducted on 04/10/2024 at 2:00 PM the Physical Plant Manager (PPM) stated was not aware of a facility water plan would discuss with the facility Administrator. In an interview conducted on 04/10/2024 at 2:30 PM the facility Administrator (ADM) revealed the facility had no completed water management program. B. Review of an Admission Record revealed the facility admitted Resident #27 on 12/07/2020 with diagnoses that of Neuromuscular Dysfunction of the bladder, (which is a condition where a person cannot control their bladder function), history of urinary tract infections, (which is an infection in any part of the kidneys or bladder), and Multiple Sclerosis (which is a disease where then nerves of the central nervous system do not work correctly). The Quarterly Minimum Data Set, (MDS, a federally mandated assessment tool used for care planning) with an Assessment Reference Date (ARD) of 02/22/2024 revealed Resident #27 had an indwelling urinary catheter and was dependent on staff assistance for personal hygiene and toilet use. Review of Resident #27's Care Plan, which is a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident, listed a focus of urinary catheter due to neurogenic bladder with interventions to follow standards of care all dated 10/20/2022. In an observation completed on 04/09/2024 at 10:06 AM with Resident #27 in their room lying on their back in the bed Medication Assistant F (MA) used a washcloth moistened with soap and water and wiped Resident #27 left upper inner thigh then folded the cloth and wiped Resident #27 right upper inner thigh. MA-F discarded the cloth into a plastic bag at the foot of the resident's bed. MA-F obtained another washcloth moistened with soap and water and wiped Resident #27's pubic area in a downward motion. MA-F folded the cloth, used their left hand and grasped the catheter tubing at the level of the resident's outer pubic area and took the moistened cloth and wiped the catheter in a downward motion approximately 1-2 inches down the tubing. MA-F then discarded the cloth into the plastic bag at the foot of the resident's bed. In an interview on 04/09/2024 at 10:32 AM with MA-F, MA-F confirmed that the labia should have been separated and cleansing of the catheter tubing should have started at Resident #27's meatus. In an interview on 04/10/2024 at 1:30 PM with the Director of Nursing, the DON confirmed that the catheter should have been cleaned from the meatus down the catheter approximately 3 inches. C. Review of an Admission Record revealed the facility admitted Resident #21 on 10/21/2023 with diagnoses of Intellectual Disability (which described a person with certain limitations in cognitive functioning and other skills for daily living), Chronic wound of the right mid foot and heel, history of urinary tract infections (which is an infection in any part of the kidneys or bladder), and Benign Prostatic Hyperplasia (which is an enlargement of the prostate gland that surrounds the male urethra). The Quarterly Minimum Data Set with ARD) of 02/01/2024 revealed Resident #21 had an indwelling urinary catheter and was dependent on staff assistance for personal hygiene and toilet use. Record review of Resident #21's Care Plan listed a focus of urinary catheter with interventions to follow standards of care all dated 11/01/2023. In an observation completed on 04/09/2024 at 3:40 PM with Resident #21 in their room lying on their back in the bed Medication Assistant G (MA-G) used a washcloth moistened with soap and water to wipe Resident #21' left upper inner thigh, folded the cloth, then used the cloth to wipe the resident's right upper inner thigh. MA-G discarded the cloth into a plastic bag at the foot of the bed and obtained another soap and water moistened cloth. MA-G grasped Resident #21 catheter tubing at the meatus and used the cloth to wipe down the catheter tubing approximately 4 inches. MA-G then disposed of the cloth into the plastic bag at the foot of the bed. NA-G did not cleanse from the meatus down the shaft of Resident #21's penis. In an interview on 04/09/2024 at 4:10 PM with MA-G confirmed that they did not cleanse the resident from the meatus and down the shaft of the penis. In an interview on 04/10/2024 at 1:30 PM with the Director of Nursing, the (DON) confirmed that the MA should have cleansed the shaft of the penis with one cloth then the catheter tubing with another cloth. B. Review of a facility policy titled Catheter Care, dated 01/2024 revealed the following information: -#9, gently separate the labia, which are the folds of skin of the female genitals, to expose the urinary meatus, which is the opening where the urine comes from the body. -#10, wipe from front to back with a clean cloth moistened with water and perineal cleaner (soap). - #11,use a new part of the cloth or different cloth for each side. - #12,with a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place to not pull on the catheter. -#15 using a circular motion, cleanse the meatus with a clean cloth moistened with water and perineal cleanser (soap). -#16 with a new moistened cloth, start at the urinary meatus moving down, cleanse the shaft of the penis. -#17 with a new moistened cloth, starting at the urinary meatus moving outward, wipe the catheter making sure to hold the catheter in place to not pull on the catheter.

The facility failed to ensure a Preadmission Screening and Resident Review (PASARR), (a screening program mandated by the federal Centers for Medicare and Medicaid Services (CMS) to ensure that nursing home applicants and residents with mental illness and intellectual/developmental disabilities are appropriately placed and receive necessary services to meet their needs) was completed prior to admission to the facility and reflected the residents mental illness for 1 resident, (Resident 34), of 4 sampled residents. The facility census was 53. Findings: Review of a facility policy titled Resident Assessment-Coordination with PASARR Program dated 01/2024 indicated that all applicants to the facility will be screened for serious mental disorders, (which are disorders that affect mood, thinking, and behavior), upon admission and a comprehensive evaluation by the appropriate state-designated authority to determine whether the individual has a mental disorder, intellectual disorder (which are disorders that limit a person's ability to learn at an expected level and function in daily life), or related conditions prior to admission. Review of an Admission Record indicated the facility admitted Resident 34 on 03/10/2022 with diagnoses that of Type 2 Diabetes, (which is a condition that happens because of a problem in the way the body regulates and uses sugar as fuel), unspecified psychosis, (which is a diagnosis for psychosis with out a known cause not due to a substance or physical condition), and cerebral infarction, (which is when the blood floor to the brain is slowed or stopped causing brain cells to die off). The Quarterly Minimum Data Set (MDS, which is a mandatory comprehensive assessment tool that measures the health status of nursing home residents and is used for care planning), with an Assessment Reference Date (ARD) of 03/28/2024 revealed that Resident 34 had a Brief Interview for Mental Status score of 13 indicating the resident was cognitively intact. The resident had no mood or behavior problems and was receiving no psychotropic (mood altering) medications. The MDS revealed that Resident 34 had an active diagnosis of a Psychotic Disorder, (which is mental disorder characterized by a disconnection from reality) other than schizophrenia. Review of a facility supplied document titled Kepro Level 1 Screen dated 03/11/2022 revealed documentation in section 3 part 1 that no mental health diagnosis was known or suspected of Resident 34. In an interview on 04/09/2024 at 3:30 PM with the Social Worker (SW), SW confirmed that Resident 34 was admitted to the facility on [DATE] with a diagnosis of unspecified psychosis. SW confirmed that this mental illness was not reflected on the Kepro Level 1 Screen that was completed on 03/11/2022. SW confirmed that Resident 34 was admitted to the facility on [DATE] and the PASARR was not completed until 03/11/2022 and the facility policy is for this to be completed prior to admission.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11C LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, interview and record review, the facility failed to A) ensure food was dated upon opening, B) failed to ensure dishwasher temperatures were maintained to ensure the sanitization of utensils to prevent the potential for food borne illness for 55 of 55 residents receiving food from the kitchen and C) failed to serve food and fluids in a manner to prevent cross contamination. This practice had the potential to affect all residents. The facility census was 55. Findings Are: A. Observation of the kitchen on 04/05/23 at 08:30 AM revealed 1 stack of 3 boxes and another stack of 2 boxes on the floor. In the freezer, observation revealed; -3 bags of pasta noodles opened and undated and not in a sealed container, -1 bag of instant mashed potatoes opened and undated and not in a sealed container, -1 bag of cheese sauce mix opened and undated and not in a sealed container, -1 bag of brown gravy mix opened and undated and not in a sealed container, -a large Tupperware container containing a white powdered substance with no labeling or date on it, -a bag of carrots opened and undated and not in a sealed container, -a bag of hash-browns opened and undated and not in a sealed container, -a bag of dinner rolls opened and undated and not in a sealed container. In the Refrigerator, observation revealed; -1 stack of sliced cheese wrapped in plastic wrap opened and undated, -a bag of hard-boiled eggs opened and undated, -a bag of frosting opened and undated. An interview on 4/5/23 at 08:45 AM with CDM (Certified Dietary Manager)-K confirmed all the items which were opened should contain dates. On 04/6/23 at 07:50 AM, observation revealed DA (Dietary Aide)-L to have long hair outside the hairnet while pouring water for breakfast service. Interview on 4/6/23 at 07:50 AM with DA-L revealed that DA-L's hairnet should cover all their hair. A walkthrough of the freezer on 04/6/23 at 07:50 AM revealed a bag of blueberries and a bag of cubed meat which were open and undated. An interview on 04/6/23 at 07:52 AM with Cook-M, after inspection of the blueberries and the cubed meat, confirmed that the items were open and undated and should be dated upon opening. A record review of the facility policy titled Food Storage dated 2021 revealed that plastic containers with tight fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated. B. An observation on 04/05/23 at 08:30 AM of the dishwasher revealed a wash temperature of 138 degrees F (Fahrenheit) and rinse temperature of 170 degrees F that decreased to 150 degrees F prior to the end of the rinse cycle. During an interview on 4/5/23 at 08:45 AM with CDM-K revealed that the facility received a new dishwasher 2 weeks ago and no temperature logs were being done. The interview revealed that the dishwasher was a heat sanitization machine and staff produced a log which had temperature instructions to staff which read Wash 150 degrees, Rinse 160 degrees and final rinse of 180 degrees. CDM-K confirmed that these were minimum temperatures required to sanitize the dishes being used. The interview revealed the dishwasher was a high temp machine (sanitize dishes using water over 180 degrees Fahrenheit). An interview with the facility MS-N on 4/5/23 at 09:40 AM confirmed that ECO-Lab (A science-based program developed by our food safety and public health experts) had set the dishwasher washing temp at 155 degrees and the rinse temperature at 180-185 degrees when installed. A record review of the document titled 1.0 Specification Information for the dishwasher revealed the following: -Wash Temperature (Minimum)(F)(Fahrenheit) 150 degrees -Wash Temperature (Recommended)(F) 160 degrees -Rinse Temperature (Minimum)(F) 180-195 degrees -Rinse Temperature (Recommended)(F) 185 degrees A record review of the service document from ECO-LAB dated 4/5/23 at 01:10 PM revealed the kitchen dish washing machine and all chemical dispensers are in good working order and calibrated for cleaning and sanitizing. The dishwashing machine temperature is maintaining 180 degrees on rinse cycle however, with the below 140-degree water temp requirement coming into the dishwasher we are having issues maintaining 150-155 degrees on the wash temp. MS-N is looking into the situation as far as we found a missing circulation pump in the water system. 45613 C. An Observation on 04/05/23 at 12:22 PM of NA-J (Nurse Aide) served resident with hand on top of a fruit cup. No hand hygiene was observed. Observation on 04/05/23 at 12:33 PM of DA-H passing juice, milk and coffee from a cart in the dining rooms placing fingers on the top rim of the glass. No hand hygiene was observed. Interview on 04/06/23 at 01:15 PM with CDM-K confirmed staff should not be grabbing the tops of cups. Bare hands should not be touching eating and drinking surfaces. 39282 D. On 04/05/23 at 12:10 PM observation of DA-H passing juice and milk to residents for lunch placed their hands over the glasses and cups, touched the floor, their face, and the residents outer wear. No hand hygiene was completed. Observation of the noon meal on 4/5/23 at 12:22 PM revealed DA-H (Dietary Aide) served Resident 47 and handed the resident a fruit cup with DA-H's hand on top of cup.

Based on interview and record review, the facility failed to inform residents, families and/or representatives of confirmed Covid-19 cases within the facility. This had the potential to affect all residents. The facility census was 55. Findings Are: An interview on 04/05/23 at 12:58 PM revealed Resident 52's representative had not been notified of the facility's Covid-19 status since admission on 12/28/22. An interview on 4/6/23 at 11:30 AM with the facility Administrator revealed that only the families/representatives of Covid-19 positive residents were updated of the facility's Covid-19 status. 39282 An interview with Resident 47's spouse, on 4/5/23 at 11:00 AM confirmed the resident's spouse had not been notified of any of the COVID 19 outbreaks. A review of the facility's undated testing logs and of positive residents and staff revealed positive staff and residents on the following dates: -1/13/23, 3 staff and 2 residents; -3/3/23, 1 staff and 1 resident; -3/17/23, 1 staff and 1 resident; -3/24/23, 1 staff. An intervies on 4-10-23 at 10:25 AM with the Director of Nursing confirmed that emails or letters were not sent out after each positive case. The DON revealed a weekly update was placed on the nursing homes Facebook page.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.4C3a(6) Based on interview and record review, the facility failed to notify the physician and Resident 52's representative of a significant weight loss for Resident 52. This affected 1 of 1 residents sampled (Resident 52). The facility identified a census of 55. Findings Are: A record review of the weights documented from 1/1/23 through 4/4/23 for Resident 52 revealed the following weights: -4/4/2023 1:55PM, 144.0 Lbs (pounds); -4/4/2023 1:52PM, 144.0 Lbs -3/31/2023 1:35PM, 143.5 Lbs -3/31/2023 1:26PM, 143.5 Lbs -3/28/2023 1:41PM, 147.0 Lbs -3/28/2023 1:37PM, 147.0 Lbs -3/9/2023 1:46PM, 152.5 Lbs -3/9/2023 1:34PM, 152.5 Lbs -3/7/2023 3:04PM, 153.5 Lbs -2/20/2023 1:59PM, 150.0 Lbs -2/13/2023 12:38PM, 149.0 Lbs -2/9/2023 1:59PM, 149.0 Lbs -2/6/2023 12:46PM, 148.5 Lbs -2/6/2023 12:42PM, 148.5 Lbs -2/3/2023 1:59PM, 151.0 Lbs -1/30/2023 1:44PM, 155.5 Lbs -1/26/2023 1:12PM, 154.0 Lbs -1/15/2023 1:57PM, 153.0 Lbs -1/15/2023 1:54PM, 153.0 Lbs -1/9/2023 3:50PM, 154.5 Lbs -1/4/2023 12:09PM, 151.5 Lbs -1/1/2023 1:59PM, 152.0 Lbs -On 03/07/2023, Resident 52 weighed 153 lbs. On 04/04/2023, the resident weighed 144 pounds which is a -5.88 % loss. -On 01/09/2023, Resident 52 weighed 154 lbs. On 04/04/2023, the resident weighed 144 pounds which is a -6.49 % loss since admission A record review of the Progress Notes dated 4/5/22 through 4/10/23 for Resident 52 revealed no family/representative or physician notification related to weight loss. An interview on 04/10/23 at 4:19 PM with the facility DON (Director of Nursing) confirmed that no family/representative notification existed.

LICENSURE REFERENCE NUMBER 175-NAC 12-006.09D2a, 12-006.09D2b Based on observation, record reviews, and interviews, the facility failed to prevent avoidable pressure ulcers from developing after 3 residents were identified as at risk for pressure ulcers (Resident 33, 29, and 36); the facility failed to ensure other areas of pressure ulcers did not occur on one resident, Resident 29, out of 3 resident sampled; and failed to ensure pressure ulcers did not deteriorate for 3 out of the 3 sampled residents (Resident 33, 29, and 36). The facility census was 57. Findings are: A.Review of Resident 33's Admission Record dated 5-8-19 revealed the date of admission of 8-24-18 with [DIAGNOSES REDACTED]. Review of Resident 33's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 4-8-19 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 11 which indicated the resident's cognition was moderately impaired. The resident required extensive assist of 2 staff with bed mobility, transfers, dressing, and toileting. Resident 33 did not walk and required extensive assist of 1 staff for locomotion, personal hygiene, and eating. The resident had pain but was not on any scheduled pain medication. Resident 33 used PRN (as needed) pain medications and nonpharmalogical interventions for pain control. The resident had an indwelling urinary catheter. The resident was at risk for pressure ulcers and had 1 current pressure ulcer which was unstageable (Unstageable:Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed). Review of the significant change MDS dated [DATE], which was before the resident developed the pressure ulcer, revealed the resident had a BIMS of 15 to indicate cognition was intact. The resident had weight loss and was not on a weight loss regiment and was at risk for pressure ulcer but did not have any current pressure ulcers at the time of the MDS. The resident required extensive assist of 2 staff with bed mobility, transfers, dressing, and toileting. Interview on 5-6-19 at 11:00 AM with Resident 33 about how the resident first obtained the pressure ulcer on the bottom, the resident revealed when the resident first admitted to the facility the resident sat and sat in the wheelchair and that was the only thing the resident did and the resident ended up getting a sore on the bottom. Review of the PN (Progress Notes) dated 2/13/19 revealed Resident 33 had requested an opioid PRN [MEDICATION NAME] pain medication for complaints of right buttock pain. The Medication Aide administered the medication to the resident but the PN were absent of a nurse assessment to try and determine the cause of the resident's right buttock pain. Review of the PN from 12-24-18 to 2-13-19 revealed the resident had PRN [MEDICATION NAME] several times during this time frame, but this was the first time the resident request the medication for buttock pain. Review of the PN revealed absence of an assessment of the buttock between the day the PRN medication was given until 5 days later when the resident was assessed and found with a stage 2 pressure ulcer. Review of the WPIR (Weekly Pressure Injury Record) form dated 2-18-19 revealed the initial documentation of the stage 2 pressure ulcer (Stage 2: Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). (MONTH) also present as an intact or open/ruptured serum-filled or sero-sanguineous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising) measured 4.5 x 4.5 x 0.1 cm (centimeter) with sero-sanguineous drainage, no odor, no tunneling, surrounding skin was dark pink in color. The location of the PU (pressure ulcer) was diagramed on a drawing on the right ischium (the ischium forms the lower and back part of the hip bone and is located at the lower portion of the buttock). Interventions listed on the WPIR form were to turn the resident every 2 hours, a pressure relieving cushion (but did not document for the chair or the bed), and treat with [MEDICATION NAME] (a zinc oxide-based barrier that protects against moisture). The Physician and Registered Dietician were notified and resident was identified at significant weight loss. Review of Resident 33's admission Braden Scale dated 8-24-18 revealed a score of 15. (Braden Scale - An assessment tool for Predicating Pressure Sore Risk. The score results indicate:severe risk 9 or less, high risk 10-12, moderate risk 13-14, mild risk 15-18). Review of the initial comprehensive Careplan dated 9-7-18 revealed absence of addressing the potential risk of skin impairment at all, including absence of addressing the resident's mild risk as identified on the Braden scale score of 15. Review of Resident 33's Braden Scale dated 11-30-18 revealed a score of 13 indicated an increase in the resident's risk level to a moderate risk. On 2-17-19 a Braden score of 12 which was a change to high risk of developing pressure sores. Review of the current Careplan revealed the resident's pressure ulcer was addressed with the focus and intervention initiated on 3-12-19 and revised date of 4-22-19. The interventions listed were to educate the importance of position changes to prevent a pressure ulcer dated 3-12-19; required a pressure relief in both seated surface and sleep surface dated 3-12-19; weekly treatment documentation; resident seen by the wound clinic; the resident to be up in a chair only 1 hour a day; the wound VAC treatment, and nutritional interventions. Absent on the Careplan were the focus and the interventions prior to the development of the pressure ulcer on the right buttock in (MONTH) 2019. Review of the PN dated 3-1-19 revealed the resident's urinary catheter was documented as not in place the evening prior so was re-inserted the next day. As a result of the extra moisture, the resident developed a red rash to the penis and scrotum. The Physician was notified of the open area to the right buttock/ischium as worsening. New orders for OT (Occupational Therapy for wheelchair positioning) were received and a wound nurse seen the resident on 3-2-19 for the first time and started the resident on a collagen treatment. Review of the WPIR dated 3-10-19 revealed the PU on the right ischium was now a stage 3 (had deteriorated from a stage 2) (Stage 3: Full thickness skin loss: Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling) and measured 2.8 x 4.1 x 0.3 cm. The PU had an odor with moderate amount of sero-sanguious drainage. The edges were jagged and the wound bed was bright pink, hazy with surrounding skin red, dark pink. The PU had no tunneling or undermining. Review of the PN later on the date 3-10-19 revealed the resident was hospitalized for [REDACTED]. Review of the MDS revealed Resident 33 returned to the facility on [DATE]. Review of the PN revealed absence of documentation of the resident's return from the hospitalization . Review of the PN, the WPIR, and other assessments in the paper and electronic medical record revealed absence of documentation of an assessment of the resident's PU on the right ischium upon return from the hospital so therefore no documentation if the PU was smaller, larger, or the same size. However, the next assessment of the PU was 4 days after the resident returned from the hospital documented on the WPIR dated 3-17-19 which revealed the PU was a stage 3 measured at 3.0 x 4.4 x 0.6 cm with moderate amount of sero-sanquous drainage and larger in size. The ulcer had an odor and the wound bed was black in color but was without any tunneling or undermining. Review of the PN on 3-16-19 the resident received a PRN pain medication [MEDICATION NAME] for severe pain for a sore bottom at 8:05 PM. On 3-17-19 revealed the PU had a foul odor and was very tender to touch. On 3-18-19 the staff educated the resident about the condition of the wound and the resident's options. The resident chose to continue with treatment in the facility at this time and did not want to go to the emergency room or a clinic appointment. The Physician was notified of elevated temp of 100.6 and condition of wound. The Wound Nurse was notified and the resident was started on an antibiotic, new treatment orders, and to start seeing the Wound Doctor with the first appointment schedule for 4-6-19. The resident was also started on [MEDICATION NAME] nutritionally. On 3-21-19 the resident's temperature was 102.8 F and documentation revealed the PU was worsening every day and had tunneled, had a foul smell, and the color of wound was 100% black/gray. The resident had loose bowel movements which contaminated the PU wound dressings causing the dressings to need to be changed frequently. Review of the WPIR form dated 3-22-19 revealed the PU to the right ischium was a stage 3 measured at 3 x 5.2 x 2.0 cm with large amount of very foul drainage. The wound bed was black with tunneling and undermining with surrounding skin red and edges irregular. During the treatment on 3/22 a pocket of pus drained out during the treatment. A culture and sensitivity was not sent out to determine the growth of the bacteria of the wound to determine if the antibiotic the resident was on was the correct antibiotic being used to treat the wound. Review of Consulting Physician Observation/Progress Notes/and New Order form for Resident 33 dated 4-5-19 revealed 1) discontinue previous dressing change to right ischium. 2) start saline wet to dry dressing change bid (twice a day) to right ischium until wound VAC (vacuum assisted closure) was available) 3) When VAC was available, start VAC at 125 mmHg (millimeters) continuous, black sponge, change 3 times a week 4) start a low airloss mattress and the resident to be in bed at all times except for 1 hour total combined time for meals only. No more than 1 hour TOTAL. Interview on 5/8/19 at 3:33 PM with RN-H (Registered Nurse) revealed even though the Consult paper was dated 4-5-19, the resident was actually seen on 4-6-19 as the form was made out the day prior. RN-H confirmed the facility did not provide the resident with an air mattress from the time the PU was found 2-18-19 at a stage 2 until the Physician wrote an order on 4-6-19 when it was a stage 3 . Review of PN dated 5-4-19, 1 month after the Physician had wrote the orders for the resident to be up for 1 hour TOTAL per day, documentation in the PN revealed Resident c/o (complaints of) discomfort to right buttock when up. Resident is up for two meals every day 1 hour each. Review of the Physician's Wound Clinic PN dated 5-3-19 revealed the wound was a stage 4 PU very foul smelling measured larger at 5 x 3.8 cm in size than previous appointment which indicated the pressure ulcer had deteriorated. Per the Doctor's documentation, the resident informed the Doctor the facility staff had not been washing the wound with soap and water but spraying the wound to clean it. As a result the Doctor wrote specific orders the wound needed to be washed with [MEDICATION NAME] soap (a disinfectant and antiseptic that was used for skin disinfection and to clean wounds) to decrease the bacterial counts. The Doctor debrided the center portion of the wound of foul smelling necrotic tissue. The entire 19 square cm wound was debrided down to the bone. Observation on 5/8/19 at 11:00 AM of RN-A and RN-H performed the wound VAC dressing change on Resident 33. Resident 33 was in bed with heel boots on both feet and laid on the right side. RN-A cleansed the overbed table with a disinfectant wipe then laid out the wound supplies. Both RN's washed their hands with soap and water x 20 seconds and applied gloves. RN-A removed the old external and internal wound dressing then removed both gloves and put on new gloves. [MEDICATION NAME] soap was poured onto sterile 4x4 gauze and cleansed the inside of the wound. RN-A removed the soiled gloves and donned new gloves. Dried the wound with sterile gauze then removed the gloves. Next RN-A cleansed a pair of scissors that were on the table with alcohol wipes. Without performing hand hygiene, RN-A put on sterile gloves from the wound VAC supplies and used the scissors to cut up the wound dressing into strips to be used on the resident VAC dressing. RN-A used the same scissors to cut the black foam to cut it down to size to fit inside the resident's stage 3 PU. At one point, RN-A place the black foam inside the wound, then pulled the black foam back out with visible wet drainage on the black foam and used the scissors to cut the foam even smaller. RN-A placed the scissors on the table and continued with the dressing. Once the black foam was placed inside the wound, the contaminated scissors were used again to cut up more of the dressings which were used on the outside of the wound. When the dressing was completed, RN-A cleansed the scissors with an alcohol wipe then placed the scissors into the nurse's uniform pocket. Interview at 11:45 AM with RN-A revealed the nurse used the nurse's own personal scissors for the treatment and carried them in the nurse's uniform pocket and used them throughout the day for various tasks. Review of the CDC's Guidelines for Disinfection and Sterilization in Healthcare Facilities (2008), with format change in (YEAR), methods of sterilization and disinfection revealed high-level items to be disinfected are those items which will come in contact with mucous membrane or nonintact skin. [MEDICATION NAME] alcohol (70-90% ) as a disinfective was only effective in intermediate and low level disinfection items, not high-level items like the scissors would have been in an open wound dressing. Interview on 5-8-19 at 9:45 AM with RN-A revealed Resident 33's PU was a facility acquired (developed after the resident started living and receiving care at the nursing home) pressure ulcer to the right ischium. RN-A revealed interventions for the PU were to reposition the resident every 2 hours, bedrest except for 1 hour a day, and float the heels. RN-A revealed the resident was compliant with the interventions except for nutrition which contributed to the weight loss. Interview on 5-8-19 at 9:45 AM with RN-H revealed Resident 33's PU was measured by the facility nurse weekly on Mondays. After reviewing all of the Weekly wound assessments completed on the Weekly Pressure Injury Record and Wound Nurse dictation, the facility failed to assess the resident's wound weekly twice. On 4-11-19 the PU was assessed but there was absence of an assessment of the wound until 4-23-19 which was a 12 day time frame. The next wound assessment was not completed until 5-2-19 which was a 10 day time frame in which a facility Nurse did not assess, measure the wound, and document if the wound had deteriorated or changes were needed in the resident's P[NAME] (plan of care). According to the Standard of Practice and the recommendation of the NPUAP (National Pressure Ulcer Advisory Panel: Prevention and treatment of [REDACTED]. The rationale listed was to provide an opportunity for the health professional to assess the ulcer more regularly, detect complications as early as possible, and adjust the treatment plan accordingly. Interview on 5-8-19 at 4:20 PM with the DON (Director of Nursing) confirmed the pressure ulcer on the right ischium of Resident 33 was facility acquired. The DON confirmed the current careplan was missing updated interventions regarding heel boots and the 1 hour the resident was to be up should be an interdisciplinary Care Team planning as to how it was to be planned out for the resident's day and interventions should have been on the careplan to impact Activities, Psychosocial, Nutritional, Nursing and all disciplines should have addressed it on the careplan. The DON revealed the DON felt the deterioration of the wound was a result of the hospitalization and not the facilities lack of assessments and interventions prior to the wound being found when the resident was complaining of pain and being more aggressive with interventions. B. Review of Resident 29's Admission Record dated 5-10-19 revealed date of admission 12-10-18 with [DIAGNOSES REDACTED]. Interview on 5/13/19 at 9:41 AM with RN-A revealed Resident 29 had 2 current pressure ulcer's, 1 on the heel and 1 on the buttock and both were facility acquired and neither wound had been debrided. Review of Resident 29's MDS dated [DATE] revealed a BIMs score of 8 indicated the resident's cognition was moderately impaired. The resident had 1 unstageable (Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) with DTI (Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) in evolution pressure ulcer. Review of Braden Scale score completed on admission 12-10-18 equaled 14 to identify the resident at a moderate risk for pressure ulcer risk. Review of the Baseline Careplan revealed skin care needs: resident had a pressure ulcer/injury to the posterior right wrist of 0.5 cm length. Resident wore a right wrist brace. Interventions were to cleanse the area and apply a Band-Aid. Review of admission Careplan revealed focus of pressure ulcer risk prevention was addressed on 1-5-19. Interventions listed were to educate on causes of skin breakdown, reasons for frequent repositioning, good nutrition, provide pressure relief both in the seated surface and in the bed, dated 1-5-19. The only revised intervention was 3-6-19 if the resident refused treatment to confer with the resident, careplan team, and family to try and determine why and try alternate methods. The Wound Nurse was to see the resident weekly. PU Site #1: Review of the 'Weekly Pressure Injury Record' initiated 1-15-19 revealed on the right heel an unstageable, dark purple/black measured at 1.8 x 4 cm and a dark red/purple area measured 2.9 x 4 cm pressure ulcer. The most recent documentation revealed of the right heel dated 5-1-19 the pressure ulcer was staged at a stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling) measured at 1.8 x 1.4 x 0.2 cm. Review of the Wound Nurse PN dated 3-28-19 revealed the wound was unstageable, eschar 100% with necrotic tissue. Had a pressure reducing device for bed/chair/turn program program. Wound last debrided on 12-10-18. Interview on 05/09/19 at 10:11 AM with RN-H confirmed Resident 29's PU had never been debrided and the documentation was incorrect because the wound was not found until 1-15-19 and yet the Wound Nurse wrote debrided on 12-10-19. RN-H confirmed the wound was a facility acquired pressure ulcer. Observation on 05/09/19 at 09:10 AM revealed LPN-B perform the treatment of [REDACTED]. Observation of the PU revealed an open wound with dark purple/red color without drainage measured 1.5 x 1.5 cm by the nurse. The resident denied any pain at the site. A Braden Scale was also completed on 1-29-19 and scored an 11 which placed the resident at a high risk for pressure ulcers. Site #2: Review of the 'Weekly Pressure Injury Record' initiated on 4-22-19 for a stage 2 pressure ulcer (Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). (MONTH) also present as an intact or open/ruptured serum-filled or sero-sanguineous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising) measured 0.8 x 0.5 cm with surrounding tissue of wound edges attached, intact documented for location as on the left buttock. On 4-26-19 the stage 2 PU measured 0.7 x 1.0 x 0.1 cm with flat surrounding wound edges of pink in color. On 5-2-19 the left buttock was a stage 2 measured at 1.2 x 1.2 of pale pink wound bed. On 5-8-19 the stage 2 now measured 2.3 x 2.4 x 0.1 with wound bed dark pink red and the wound bed was now flat with irregular edges. The treatment remained the same. 05/09/19 10:32 AM Interview on 5-9-19 at 3:50 PM with the DON confirmed Resident 29's pressure ulcers both were facility acquired. The DON also revealed the DON had instructed the staff to place on the Careplan to float the resident's heels and to apply the heel boots on the resident. The DON confirmed neither were documented on the Careplan. Observation on 5/13/19 at 10:05 AM of Resident 29's bilateral buttocks with LPN-L revealed the stage 2 buttock as documented on the Weekly Pressure Injury Records 4-22-19 through 5-8-19 revealed the PU was not on the left buttock but on the right buttock. Interview with LPN-L confirmed the ulcer was on the right buttock and the documentation was incorrect. 05/13/19 10:05 AM observed LPN-L and MA-E perform peri-cares and change the brief while Resident 29 was in bed. Interview with LPN-L revealed the resident was often adamant with refusal to be toileted so a brief and peri-cares would all the resident would allow. LPN-L revealed the resident transferred from the wheelchair to bed with use of a sit to stand and 2 staff but refused to be sat on the toilet so the staff changed the brief in bed. The resident assisted by rolling over and grabbed the positioning bars to assist. Observed PU area on the upper right buttock stage 2 approximate size 2 x 2 x 0.2 cm. There was presence of old [MEDICATION NAME] lotion on the wound so unable to view the wound bed. LPN-L performed the scheduled treatment of [REDACTED]. Before the cares were started LPN-L had asked the resident about pain and the resident had responded the resident responded he had some since the resident had been in bed laying on the bottom. The staff positioned the resident with 2 pillows under both legs to float the heels and had placed the heel foam boots on. The resident was place flat on the resident's back without asking the resident to be placed on the right or left side. LPN-L did ask the resident about pain and the resident had replied The resident had just been up for 1-2 hours in the wheelchair sitting and applying pressure to the buttock pressure ulcer. The next meal was scheduled for 12:00 noon which the resident was observed to be back up in the wheelchair again sitting on the buttock which between the breakfast, the laying on the back and the noon meal back in the wheelchair did not provide much if any pressure relief off of the wound. Observation of the resident's bed revealed absence of an air mattress to provide off loading of pressure to the buttock wound. Interview on 5/13/19 at 4:58 PM with Resident 29 revealed the mattress was ok for comfort, about as comfortable as a military mattress, the the resident went on to say was so so. Observation of the resident revealed the resident was positioned on the back. Review on 5-13-19 of the Physician orders, PN, and Careplan, and Weekly Pressure Injury Record revealed the Physician had not been notified of the deterioration of the resident's wound in how the size had increased in the past 2 weeks and the careplan did not review any new nursing interventions. Review of current careplan dated 4-27-19 revealed focus of pressure ulcer risk prevention was addressed on 1-5-19. Interventions listed were to educate on causes of skin breakdown, reasons for frequent repositioning, good nutrition, provide pressure relief both in the seated surface and in the bed, dated 1-5-19. The revised intervention was 3-6-19 if the resident refused treatment to confer with the resident, careplan team, and family to try and determine why and try alternate methods. The Wound Nurse was to see the resident weekly. There was one notation on 4-27-19 which revealed the resident had a pressure ulcer to the right buttock and [MEDICATION NAME] applied, repositioned, encouraged calories, /protein. Will monitor weekly and PRN The area to the right heel was improving unstageable DTI. Continue with current approached, weekly monitoring and to see the Wound Nurse. Careplan was still absent about the heel boots or to float the heels. The careplan did have documented a history of 2 DTI to bilateral heels and a healed coccyx area. Careplan was absent any new interventions to address the deterioration of the stage 2 PU on the right buttock. C. Record review of Resident 36's Admission Record dated 5-7-19 revealed date of admission 7-9-18 with [DIAGNOSES REDACTED]. Review of Resident 36's admission MDS dated [DATE] revealed the resident was at risk for developing a pressure ulcer but did not have a pressure ulcer. The admission MDS 7-18-18 revealed at risk for pressure ulcer and did not have any. The MDS dated 3.-29-19 revealed resident had 1 current stage 3 PU. Review of the Braden Score dated 7-10-18 equaled an 11 to place the resident at a high risk for developing pressure ulcers. Review on 05/06/19 at 03:38 PM of the 'Weekly Pressure Injury Record' in Wound book revealed initial documentation of a stage 3 PU located on the left lateral foot (per a drawing on a picture as the documentation of the site was blank) dated 1-8-19 measured 1.7 x 1.0 x 0.5 cm described as 100% eschar of the wound bed. Interventions listed as started on 1-8-19 were an antibiotic because of the redness and warmth of a cellutlits, offload pressure to the site, and [MEDICATION NAME] treatment to the wound. Received on 5/13/19 at 4:32 PM Resident 36's Baseline Careplan which was undated and not titled but confirmed with MDS-C it was the original Baseline CarePlan. The careplan revealed the resident had derma sleeves to arms and legs at all times, heel protectors, special cushion and mattress were blank, and the resident was to be turned every 2 hours. Review of current Careplan revealed a focus to address potential pressure ulcers was developed 1-6-19 which was 2 days prior to the date the resident' stage 3 PU was found. The interventions listed were: treatments as ordered and the resident was seen by the Wound Care Nurse. The treatment as of 3-25-19 for the stage 3 PU was listed with revision date of 4-4-19; assess/record/monitor wound healing weekly and PRN as the resident dated 1-6-19; educate the resident, family, and caregivers as to cause of skin breakdown and importance of cares dated 1-6-19; monitor nutritional status, 2 cal supplement was given dated 4-4-19. Absence on the care plan was the resident to wear heel boots or to float the heels. Record review of 1/14/2019 Nutrition/Dietary Note Note revealed Quarterly review completed by Dietary Manager (not Registered Dietician) the resident continued on regular puree textured diet with thin liquids. The wound to the left heel was unstageable. The resident continued with nutritional supplementation of [MEDICATION NAME] BID. The resident's current body weight was 111#. No weight triggers at that time. An 8.2% loss since admit did not trigger the 10% loss in 180 days. No further concerns at that time. Review of documentation revealed the first time the RD, Registered Dietician, evaluated the resident for the pressure ulcer and nutritional needs was 2 months later on 3-19-19 in the Nutrition/Dietary Note Note: Resident 36 continued with skin ulcer to left lateral foot--takes Multivitamin. The diet was pureed with thin liquids, oral intake variable with fair to good fluids; offered 60 cc of 2 Cal BID (twice a day) (240k, 10 grams of protein) for extra kcal/protein to aid with healing. The resident's current body weight was 110#, weight stable x 30/90 days, weight was down 2.7% x 180 days. Will fax the provider and request to increase 2 Cal to 90 cc three times a day (540k, 25g protein) to help with wound healing. Will monitor closely. Dietary assessment dated [DATE] revealed the resident was a high risk at 27 for nutritional impairment. Observation on 5-9-19 at the noon meal revealed Resident 36 was served turkey casserole for dinner and per the State Agency Surveyor who observed the meal service, the resident was not served the correct portion of protein for the meal which was required to help with wound healing. Observation on 5-9-19 at 1:55 PM of RN-A and LPN-B performed the treatment to Resident 36' left foot PU. The resident was laying in bed on the back without the heels being floated or heel boots on when we entered the room. Interview with LPN-B revealed the resident had a shower before lunch, then had lunch, then was laid down by the nurse aides. Both nurses washed hands x 20 seconds. RN-A had a pair of scissors with the treatment supplies obtained from the treatment cart prior and cleaned the scissors with an alcohol wipe instead of a disinfectant wipe. The nurses applied gloves and RN-A removed the old dressing from the wound then removed the old gloves then applied new gloves and applied the new collagen wound dressing to the wound followed by the foam dressing on top. After completion of the dressing change. Old gloves were removed and both nurses looked for the heel boots to be placed on the resident feet but they could not find them anywhere in the room. They searched the closet, the drawers, and could not find them. LPN-B revealed LPN-B would ask the staff in case the heel boots had became soiled and someone placed in the laundry. The nurses placed 2 pillows under the feet and floated the heels. RN-A cleansed the scissors with alcohol wipes then placed them back into the treatment cart. Both nurses cleaned their hands with soap and water x 20 seconds at least. Interview with RN-A revealed the resident had interventions for the foot of repositioning every 2 hours because the resident did not move self at all in bed and the heel boots were to be worn at all times. Observation of the resident's bed revealed absence of an air mattress on it. The most recent measurement on 5-6-19 of the left lateral foot revealed a stage 3 measured at 1.2 x 1.9 x 0.01 cm described as beefy red wound bed with red exudate. Review of the WPUPR (Weekly Pressure Ulcer Progress Report) forms from initial documentation on 1-8-19 through 3-4-19 measurements of 1.8 x 1.4 x 0,1 cm with moderate serosanguionous drainage with wound bed red and granulation tissue the wound was improving. Review of the PN (Progress Notes) the treatment was changed to apply collagen to wound bed and cover with a foam dressing every other day and PRN for excess drainage. Review of the (MONTH) 2019 TARS revealed the order was on the TAR but there was absence of documentation of the completion of the treatment except for 1 time on 3-11-19. all of the rest of the scheduled and PRN treatment documentation to the PU on the left foot were blank from (MONTH) 5 to the 31. Review of the (MONTH) 2019 TARS revealed the order was listed but blank for completion of the treatment for [REDACTED]. Review of the (MONTH) TARS revealed the order was listed and documentation started on (MONTH) 9. During the time frame of when the wound treatments were not documented as being completed, review review of the WPUPR forms dated 3-19-19 revealed 2.7 x 3.0 x 0.4 cm, the wound bed was red with yellow tissue and deteriorating per the documentation. On 3-21-19 the PU measured 3.1 x 2.8 x 0.4 with sero-sangu (TRUNCATED)

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07 Based on record review and interviews; the facility's Quality Assurance Committee (QA) failed to develop and implement plans of actions to correct issues of deficient practice relevant to resident care and services and the facility failed to implement effective plans of action to maintain correction for 4 previously cited areas of deficient practice identified F638, F657, F812, and F880. This had the potential to affect all residents that reside in the facility. The facility census was 57. Findings are: Record review of the Statement of Deficiencies for the annual survey completed 1-25-18 revealed citations at F638, F657, F812, and F880. The facility was found to be deficient in the area of regulatory compliance after the tasks of the annual standard survey were completed on 5-15-19. The facility failed to maintain corrections for the regulatin identified as repeat deficiencies and failed to identify and develop plans of action to prevent deficient practice in the areas identified below. Please refer to the Tag citations for specific detailed findings: E035 F606 F623 F638 F641 F644 F655 F656 F657 F658 F684 F686 F689 F695 F700 F726 F801 F803 F812 F814 F842 F867 F880 F883 State of Nebraska: NUMBER 175 NAC12-006.04B and 12-006.16F Interview on 5-15-19 at 3:03 PM with the Administrator revealed the facility moved over to the new building in (MONTH) (YEAR) and the Administrator and the current DON, who had not been the DON until about (MONTH) (YEAR), had worked hard at trying to build a strong Administrative team in the facility and have had several staff turnovers in the Administrative team. With the changeover of the new company they had discovered many issues which have had to be addressed. Their goals and process they had worked on had been training of the Administrative staff and nurses to be accountable and to focus on identifying the residents risk factors first to strive for a culture of being proactive with resident care versus reactive. The facility also changed over to a new computerized medical record at the same time as the move last April. The facility was still not all electronic for their medical record during the survey but were working on it continuously. Along with the staff changes, the move, and many process changes including the new EHR (electronic health record), the Administration and DON had identified areas they need to re-focus on for the upcoming year.

Licensure Reference Number 175 NAC 12-006.09D2a Based on record review, interview and observation; the facility failed to prevent pressure sores from occurring for 2 residents (Residents 20 and 68.) and failed to have ongoing communication with the physician regarding the condition of the wound for one resident (Resident 20). The faciity census was 55 and 37 residents were on sample. Findings are: Interview with Licensed Practical Nurse (LPN) C on 4/17/12 at approximately 11:15 AM revealed that Resident 20 had no pressure ulcers (wounds that form whenever prolonged pressure is applied to skin covering bony prominences) at the present time. Review of Resident 20's Minimum Data Set (MDS - A federally mandated comprehensive assessment tool used for care planning) dated 11/2/11 revealed Resident 20 was at risk of developing a pressure sore, had one wound that was classified as venous or diabetic and received a pressure reliving device for the bed and chair as well as nutritional interventions and ointments or dressings. A follow up MDS dated 1/20/12 revealed Resident 20 had a pressure sore that was unstageable due to slough and/or eschar (piece of dead tissue that is cast off from the surface of the skin) that is necrotic (tissue death due to disease or injury). An additional intervention of a turning and repositioning schedule was noted. Review of a telephone order dated 12/14/11 revealed a written notification to Resident 20's physician that Resident 20 had sustained a bruise to back of the left heel measuring 7.5 cm (centimeters) x 4.8 cm. Staff to observe till healed. Review of Resident 20's Physicians Order Summary dated 12/14/11 stated N.O (nursing order) heel protectors on all all times check q (every) shift and monitor bilat (bilateral) heels q shift Review of a fax to Resident 20's physician dated 12/15/12 revealed, "noticed a suspected deep tissue injury (an injury to a patients underlying tissue below the skin's surface that results from prolonged pressure in an area) to back of L heel. Pink blancheable area that wraps around back of heel measures 5 cm x 13 cm has a callous fluid filled blister with purple discoloration measures 3.0 x 7.5 cm. No open areas. ..." No new physician orders [REDACTED]. Review of Resident 20's Plan of treatment for [REDACTED]." Review of a physician's visit form dated 12/16/11 revealed, "Please look at back of L heel." Review of the physician's response revealed that the L heel was not addressed by the physician. Review of Resident 20's Interdisciplinary Progress Notes dated 12/27/12 revealed - notes L heel spongy w/ hard scab like area w/ (with) 3 areas <.1 cm that appears to be opened. Reddish brown drainage observed. Uno boots on while up and heel protectors in bed. Review of Resident 20's Interdisciplinary Progress Notes dated 12/28/11 indicated the area to the left heel was a "Suspected deep tissue area". There was no corresponding physician's notification with these findings. Review of Resident 20's Wound Assessments from 1/31/12 to 3/14/12 identified that Resident 20's wound contained necrotic tissue with the edges of the scab peeling. No physician notification or updates of the necrotic tissue and peeling scab were found in the record. Review of a dictated physician's Nursing Home Visit dated 3/22/12 revealed, "has heel protectors on for heel irritation"....History of [MEDICAL CONDITION] with prior toe amputations. Physical Examination: has the heel protectors on feet, toes are warm and dry with no wounds. has two toes missing from left foot and three from right. Review of a fax to Resident 20's physician dated 4/16/12 revealed, "unstageable pressure ulcer to L heel is hard, dark brown - black eschar (with) loose edges. Now is draining scant amts (amounts) of yellow-brown drainage with strong odor. Please advise. With a physicians response of 'rounds on Thursday. May be degenerating scab. Monitor." Review of a physician's visit form dated 4/19/12 revealed, "Reason for Visit: L (left) heel ulcer. MD finding/Diagnosis/Orders: Surgeon Eval for L heel may need debridement (removal of unhealthy tissue from a wound to promote healing)..." Review of the physician's visit form from the surgeon dated 4/19/12 revealed, "Reason for visit: Debridement of L heel. Dressing and tx (treatment) orders needed. MD findings/Diagnosis/Orders: Decaying heel ulcer. left heel. Culture and sensitivity done this date. Debridement for necrotic tissue..... Return Monday AM." Review of Resident 20's previous Care Plan updated on 12/11 revealed, "Lt heel callous fluid filled blister with purple discoloration. Heel protectors all times, MVI with zinc- updated MD PRN (as needed), Observe for changes report to Doc. Review of Resident 20's Current Care Plan dated 2/14/12 revealed there was only an identified problem for a POTENTIAL for skin breakdown and that a plan of care for the area to the left heel was not implemented until 4/17/12. Observation of Resident 20 on 4/23/12 at 11:01 AM revealed Resident 20 sitting in the wheelchair with the back of Resident 20's heels resting against the ledge of the wheelchair pedal. Observation of Resident 20's left heel with the Wound nurse on 4/19/12 at 9:47 am revealed a blackened heel with separation of edges surrounding the area that appeared to be draining. The Wound nurse reported the surrounding skin used to be pink and the black scab was intact and now the surrounding skin is black and the scab is peeling with a foul odor. The Wound Nurse further stated the wound had been "stable" since prior to Monday. Interview with the Nurse Consultant on 4/19/12 at approximately 9:00 AM revealed that there was no current treatment to Resident 20's left heel to observe except for possibly application of an ointment as the area was stable. Interview with the Nurse Consultant on 4/19/12 at 9:40 AM revealed that Resident 20's physician would be seeing the heel today and that there was currently no order for any treatment. Interview with the Nurse Consultant on 4/19/12 at 9:41 AM revealed that the physician had actually already seen Resident 20's heel and ordered Resident 20 to be seen at the wound clinic for debridement today. Follow up interview with LPN C on 4/24/12 at 9:21 am revealed LPN C was aware of the area to Resident 20's left heel. LPN C further stated that the area began as a blister to the heel. Interview with the wound nurse on 4/24/12 at 11:46 AM revealed that Resident 20 used to rest the back of (Resident 20's) feet on the w/c pedals which is what caused the area to the left heel. When questioned if the w/c pedals were changed in order to prevent Resident 20 from resting the back of the heel against the pedal, the wound nurse stated ,"haven't done that yet". The Wound Nurse further confirmed that there was no further documentation that the physician was notified of necrotic tissue or the presence of eschar. Interview with the Unit Manager on 4/24/12 at approximately 2:30 PM revealed that Resident 20's culture of the wound had returned and the physician had ordered [MEDICATION NAME] (antibiotic) to be initiated intravenously. B. Review of Resident 68's MDS dated [DATE] indicates that resident was at risk for developing pressure ulcers but that at the time of admission Resident 68 did not have any unhealed pressure ulcers. The MDS further revealed that the only skin treatment was a pressure reducing device for bed. Review of a fax dated 1/11/12 the facility notified Resident 68's physician that a pressure area had developed on the "left inner buttock." The fax also stated that "Area not noted on admission." Review of Resident 68's care plan revealed that a pressure relieving cushion (ROHO) "to wheel chair or recliner" was added the day after the pressure ulcer was found. Review of a wound assessment dated [DATE] under progress notes revealed, "ROHO (a specialized cushion for pressure relief) seat cushion added to chair of choice and staff educated on use from wheel chair to recliner." Review of a wound assessment for Resident 68, dated 1/20/12, under progress notes revealed "Area to left inner buttocks has worsened since prior assessment." Review of a fax to Resident 68's physician dated 1/21/12 states, "Resident is choosing to spend most of time in recliner, occasionally repositions to wheel chair." On 4/23/12 at 9:30 AM observation was made of Resident 68 seated in recliner with no pressure relieving cushion in the recliner. It was noted that the ROHO cushion was in Resident 68's wheel chair and when checked appeared not to have enough air in it. At this time the wound care nurse was asked to assess if the ROHO had enough air and responded, "It could use a little more air." Resident 68 was present and asked if a cushion was available for Resident 68's recliner. "Not one like that, (pointing to the ROHO) one not so big."