Every finding on record at York General Hearthstone

175 NAC12-006.09(D) Based on record review and interviews, the facility failed to accurately code a Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) reflected that an anticoagulant (medication to prevent blood clots from forming) was being given. This affected one (Resident 2) out of the six sampled residents. The facility census was 77.Findings are:Record review of Resident 2's admission MDS dated [DATE] revealed that the resident was admitted on [DATE] with a Brief Interview for Mental Status,(BIMS- a test used to get a quick snapshot of a resident's cognitive function, scores from 0-15, the higher the score, the higher the cognitive function) scored a 14 which means that Resident 2 is cognitively intact and that the resident was on an oral antibiotic (an essential medication to kill bacteria) and an anticoagulant.Record review of Resident 2's of the facility initiated care plan dated 12/30/2025 revealed that the resident is at risk for abnormal bleeding or hemorrhage because of the use of an anticoagulant. Resident 2's care plan also revealed that the staff are to administer anticoagulants as prescribed by the physician.During an interview on 03/05/2026 at 1:12 PM with Registered Nurse (RN-B), confirmed Resident 2's revealed that the resident has not taken an anticoagulant since admission. RN-B also confirmed that the resident was admitted on Plavix (an antiplatelet medication used to prevent platelets from sticking together).During an interview on 03/05/2026 at 1:20 PM with RN-A confirmed that the MDS was marked incorrectly and that the resident had not taken an anticoagulant since admission to the facility. RN-A also confirmed that the resident assessment instrument (RAI-a standardized, comprehensive framework used in nursing homes to assess a resident's functional, medical and psychosocial status) is used to ensure MDS accuracy.Record Review on 03/10/2026 of the CMS's RAI Version 3.0 Manual N0415: High-Risk Drug Classes: Use and Indication, revealed not to code antiplatelet medications such as: aspirin/extended release, dipyridamole or clopidogrel as an anticoagulant.

Licensure Reference Number 175 NAC 12-006.09Based on record review and interview, the facility failed to ensure ongoing monitoring and assessments were completed to assess for potential adverse effects from antipsychotic medications for Resident 52 and to assess for appropriateness of a physical restraint for Resident 79. The sample size was 5 and the facility census was 77. Findings are:Review of facility policy titled Care Plan Procedures dated 6/2024 revealed that the nurse coordinator is responsible for ensuring compliance of procedures.Review of the facility assessment, last reviewed January 2026 revealed that staff will be trained on resident assessments upon hire and as needed with nurses.A.Review of facility policy titled Psychotropic Medications dated 6/2024 revealed the following:- AIMS (Abnormal Involuntary Movement Scate - assessment of antipsychotic medications to detect and monitor tardive dyskinesia) assessment to be completed for all residents receiving anti-psychotic medication- AIMS evaluation to be completed minimally on a bi-annual basis- medications reviewed monthly by consulting pharmacist, every 60 days by attending physician, and quarterly and as needed by nursing.Record review of Resident 52's physician orders revealed an order dated 10/3/2025 for OLANZapine Oral Tablet 2.5 MG an antipsychotic medication used to treat psychosis - a disconnection from reality.Record review of current physician and nursing orders dated 3/9/2026 did not reveal an order for AIMS assessment to be completed.Record review of Resident 52's Minimum Data Set - (MDS a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) revealed an admission to the facility date of 8/2/2021.Review of Resident 52's diagnosis list revealed a diagnosis of Dementia with behavior disturbances.Record review of Resident 52's careplan revealed an intervention of ANTI-PSYCHOTIC USE: Give medication as ordered per Physician/Psychiatric Services. AIMS testing per facility protocol. Monitor/Document side effects and effectiveness. Date Initiated: 10/14/2025.During an interview on 03/05/2026 at 11:41 AM the Director of Nursing (DON) confirmed the AIMS was not done and that an assessment should have been completed. The unit coordinators usually do the AIMS assessments but it was missed. The MDS nurse and pharmacy did not catch it or recommend that the AIMS gets completed.During an interview on 03/05/2026 at 1:20 PM RN (Registered Nurse)- A the Clinical Reimbursement Coordinator confirmed that (gender) sent out an email list to the unit managers about the upcoming MDS and the due dates.During an interview on 03/05/2026 at 1:39 PM RN - B the Unit Coordinator was not aware of what nursing assessments need to be completed before the MDS due date.During an interview on 03/05/2026 1:42 PM RN - A confirmed there was a lack of communication regarding what nursing assessments need to be completed. It was also confirmed that the MDS coordinator does not complete any assessments on the residents, just reviewed what has been done.During an interview on 03/09/2026 8:18 AM the DON confirmed that maybe the new unit coordinators did not know all the quarterly nursing assessments that they are supposed to be completed. It is not written down on any policy. The MDS nurse and pharmacy review did not catch the missing assessment either. B.Review of facility policy titled Physical Restraint Policy dated 9/2025, revealed-restraints shall be applied only for the purpose of resident safety or when used to assist the resident to maintain or attain his/her highest practical mental and psychosocial functioning.-nurse coordinators will assure that proper assessments/evaluations have been complete and will be put on the residents careplan.-licensed nurse will assess/document use ongoing and chart quarterly.Record review of Resident 79's MDS revealed an admission date to the facility of 3/23/2024.Record review of Resident 79's careplan revealed a Positioning wedge for DX of Abnormal Posture Positioning and Comfort. Resident non-ambulatory. Date Initiated: 03/26/2025Follow facility policy and procedure on physical restraint use. Date Initiated: 03/26/2025Licensed nurse will address physical restraint UDA quarterly and with significant change. Date Initiated: 03/26/2025.Record review of physician order for a wedge pillow for positioning dated 3/27/25.During an interview on 03/05/2026 at 1:45 PM, NA (Nursing Assistant) - D confirmed that Resident 79 can not get out of bed with the wedges in place.During an interview on 03/05/2026 at 1:45 PM, LPN (Licensed Practical Nurse) - C confirmed that Resident 79 had positioning wedges on both sides of (gender) while in bed. The resident is not able to get out of bed with these in place.During an interview on 03/09/2026 at 7:51 AM, DON confirmed that the restraint assessment was not done quarterly and should have been.During an interview on 03/09/2026 at 8:18 AM, DON confirmed that maybe the unit coordinators did not know all the quarterly nursing assessments that they are supposed to be doing. It is not written down on any policy either.During an interview on 03/09/2026 at 10:34 AM, LPN - C the Unit Coordinator confirmed that the MDS nurse lets them know when each resident's MDS is due and (gender) puts the quarterly assessments into the MAR for the floor nurses to complete, but sometimes they get missed.

Licensure Reference Number 175 NAC 12-006.05(4) Based on interview and record review, the facility failed to provide the bathing preferences for 3 (Residents 8, 12, and 78) of 7 sampled residents. The facility census was 85 at the time of survey. Findings are: A record review of the facility's Bathing Policy dated 5/2023 revealed residents will be provided bathing per request or as per facility schedule protocol and partial baths may be given between regular bathing schedules. A record review of the facility's Careplan Policy dated 7/2009 revealed the following: - Careplan will address problem, intervention, and goals. - Nursing Coordinator will be responsible for assuring this is initiated. - Ongoing changes to Careplans are made accordingly. A. A record review of Resident 8's Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 7/9/2023, revealed an admitted to the facility of 8/16/2005 and a Brief Interview for Mental Status (BIMS - a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 10, indicating low cognitive function. A record review of the task care within Resident 8's electronic medical record (EHR) for September and October 2023 revealed that Resident 8 received baths on 9/16/23, 9/30/23, 10/6/23, and 10/12/23. A record review of Resident 8's progress notes dated 9/1/23- 10/17/23 revealed no bathing refusals or documentation related to bathing. A record review of Resident 8's Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) last review dated 9/3/23, revealed no resident preferences listed indicating when or how often the resident would like a bath. An interview on 10/16/23 at 1:22 PM with Licensed Practical Nurse (LPN) - A confirmed that Resident 8 did not have a bath for 14 days with no baths documented from 9/16/23 until 9/30/23. LPN - A further confirmed there was no documentation of bathing in the EHR and there would be no other place it would have been documented. An interview on 10/17/23 at 11:37 AM with LPN - A confirmed that Resident 8 did not have a Preference sheet filled out for bathing times and preferences on how often was not on the CCP and it should have been. No bathing audits or bathing schedules were provided. B. A record review of Resident 12's CCP, last reviewed dated 8/23/23 revealed an admitted [DATE]. A record review of Resident 12's MDS dated [DATE] revealed a BIMS score of 14 indicating high level of cognition. An interview with Resident 12 on 10/11/23 at 12:54 PM revealed that the resident wanted to receive 2 baths per week and that the resident had not been receiving 2 baths per week. Resident had told family members and was going to take it up with the staff. Resident 12 also confirmed that no baths were offered or refused from 10/1/23-10/10/23. A record review of the EHR for September and October 2023 revealed that Resident 12 received a bath on 9/8/23, 10/10/23 and 10/14/23. An interview on 10/17/23 at 10:12 AM with Registered Nurse (RN) - B revealed there was no documentation in the EHR of Resident 12 refusing baths, or any other baths documented for the months of September or October. RN - B further revealed that Resident 12's bath preference was not on the CCP and should have been. No bathing audits or bathing schedules were provided. C. A record review of Resident 78's MDS dated [DATE] revealed a BIMS score of 15 indicating resident is cognitively intact. A record review of Resident 78's CCP, date created 8/31/23 revealed an admitted to the facility of 8/31/23. An interview on 10/11/23 at 01:56 PM with Resident 78 revealed that they had not received 2 baths a week per their preference. A record review of Resident 78's EHR for baths for October 2023 revealed baths documented on 10/4/23 and 10/9/23. A record review of Resident 78's progress notes dated 10/1/23- 10/17/23 revealed no bathing refusals, no pericares, no bed baths offered, and no behaviors documented. An interview on 10/17/23 at 11:36 AM with LPN - A revealed there was no other documentation of bathing. No bathing audits or bathing schedules were provided. An interview on 10/17/23 at 11:37 PM with LPN - A revealed that Resident 78 did not have a Preference sheet filled out and bathing preferences were not on the CCP. An interview on 10/16/23 at 03:29 PM with the Director of Nursing (DON) confirmed there is no facility policy for the Preference Sheet to indicate residents bathing preferences but the resident preferences sheet should have been filled out for Residents 8, 12, and 78. An interview 10/17/23 12:50 PM with the DON confirmed that the facility staff should be following the facility's bathing policy for resident preferences and the CCP should have been updated and the resident preference sheet should have been scanned into the residents documents.

Based on observation, record review and interview, the facility failed to A) prevent the potential spread of Covid-19 (a mild to severe respiratory illness that is caused by a coronavirus)related to a staff member working a scheduled shift despite failing Covid-19 screening symptoms, and B) prevent the potential for cross contamination by not performing hand hygiene between assisting residents with their meals. This had the potential to affect 17 residents. The facility census was 82. FINDINGS ARE: A. A record review of the facility staff screening logs titled Hearthstone Staff Kiosk Log (06/30/2022-8/31/2022) revealed that on 07/19/2022 at 06:08 PM, NA-I (Nurse Aide) had a temperature listed of 100.4 degrees. A record review of the facility policy titled Coronavirus Surveillance and dated 3/2020 read as follows: C. Screening for visitors and staff; 1. Signs or symptoms of respiratory infection, such as fever, cough, shortness of breath, or sore throat or other symptoms of coronavirus (i.e. chills, muscle pain, headache, new loss of taste or smell). E. Staff who have a fever or signs and symptoms of a respiratory infection shall not report to work. An interview with the facility Director of Nursing (DON) on 08/31/22 at 03:27 PM revealed that the facility expectation of a fever was anything above 100.3 degrees. The interview with the DON on 08/31/22 at 03:27 PM, after review of the kiosk logs confirmed that on 07/19/2022 at 06:08 PM, NA-I should not have been allowed to work. When a copy of the timecard for NA-I was requested, the DON revealed that NA-I was no longer employed with the facility and that the name badge had been wiped clean and given to a new employee. B. Observation on 8/31/22 at 12:36 PM of MA-D (Mediction aide) assisting 2 residents to eat in the 300 hall dining room revealed MA-D didn't perform hand hygiene in between assisting the 2 residents. A record review of Hand Hygiene Policy, approved by Infection Control Committee on 1/21 revealed under: l. Patient/Resident Care Personnel A. # 1. Alcohol based hand rub to be used: b. Before having contact with patients/residents. Interview on 09/01/22 at 01:15 PM with Dietary Manager confirmed that all staff should wash hands in between residents.

Based on record review and interview, the facility failed to provide written notice of transfer to the hospital for Resident 17. This affected 1 of 1 residents sampled for hospitalization . The facility census was 82. Findings are: A review of Resident 17's Electronic Health Record (EHR) revealed that the resident had an emergency transfer to the hospital on 5/23/22. A Progress Note from 5/23/22 at 5:45 PM revealed that the resident's Power of Attorney was notified of transfer per phone. An interview conducted on 9/7/22 at 8:44 AM with the Director of Nursing (DON) confirmed that the facility was unable to provide documentation of a written notice of transfer being provided to the resident or resident representative. The DON further confirmed that one had not been done for that date.

Based on interview and record review, the facility staff failed to provide documentation that a written notice of SNFABN (Skilled Nursing Facility Advance Beneficiary Notice-a notice issued to a resident and/or their responsible party to inform them that Medicare will likely no longer pay for their services) and NOMNC (Notice of Medicare Non-Coverage-a notice issued to residents and/or their representative notifying them of when their Medicare coverage would end and how to file an appeal) was issued to 1 resident (Resident 31) of 3 sampled residents within the required time frame, denying the resident/resident representative the opportunity to appeal the facility's decision to discontinue Medicare A benefits. The facility census was 82. Findings are: A review of the form Beneficiary Notice-Residents discharged Within the Last Six Months completed by the facility revealed that Resident 31 was discharged from a Medicare covered Part A stay on 4/6/22 and remained in the facility. The facility initiated the discharge form Medicare Part A Services when benefit days had not been exhausted. A review of the form SNF (Skilled Nursing Facility) Beneficiary Protection notification Review completed by the facility revealed a last Covered Day for the resident of 4/5/22. A review of the NOMNC for Resident 31 revealed that the effective date that coverage for Medicare Part A Services would end was 4/4/22. This form was signed by the resident on 4/4/22. A review of the SNFABN for Resident 31 revealed that beginning on 4/5/22 the resident may be responsible for costs related to an Inpatient Skilled Nursing Facility Stay. This form was signed by the resident on 4/4/22. An interview conducted on 9/7/22 at 7:45 AM with the Business Office Director (BOD) G confirmed that the NOMNC and the SNFABN were both signed less than 2 days prior to the end of coverage.

Licensure Reference Number 175 NAC 12-006.09D5b Based on interviews and record reviews, the facility failed to provide a comprehensive assessment for 1 sampled resided (Resident 42) regarding current interests and activities. The facility identified a census of 82. Findings are: A record review of Resident 42's most recent activity quarterly progress note dated 12/28/2021 revealed Resident 42 watches television and reads. An interview on 09/06/22 at 09:45 AM with Activities Staff - E confirmed Resident 42 cannot see well enough to read or to watch television. A record review of Resident 42's annual Minimum Data Set (MDS: a comprehensive assessment of each resident's functional capabilities], dated 4/2/22 revealed the facility staff assessed the following about the resident: -Section F question F0500 was answered it is very important for Resident 42 to have books, newspapers and magazines to read. -Brief Interview for Mental Status (BIMS - a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) was a score of 4. According to the MDS manual a score of 0-7 indicated a severe cognitive impairment. An interview with Med Aide - D on 9/7/22 at 08:44 AM confirmed that Resident 42 is not able to read. A record review of the facility Activity Policy dated 8/20 revealed in #1. Each resident's interest and needs will be assessed on a routine basis. An interview on 09/07/22 at 09:20 AM with Activity Director - F confirmed that there is no activity assessment done in the computer in the year of 2022 and also confirmed that the activity assessments were not done routinely and should have been for Resident 42.

Licensure Reference Number 175 NAC 12-006.09D5 Based on record reviews and interviews, the facility staff failed to identify, document and communicate specific targeted behaviors for 2 sampled residents (Residents 36 and 42). The facility identified with a census of 82. Findings are: A. A record review of the Behavior Policy dated 03/22 and titled Behavior Tracking and Documentation revealed nothing regarding identifying target behaviors. The policy read as follows related to behavior monitoring: 4. Mood and Behavior Tracking and Documentation a. Mood and behavior tracking will be completed by direct care staff to identify6 any mood and behavior patterns, interventions attempted, and the outcome of approaches. b. The interdisciplinary team will document behaviors and care plan approaches and interventions in the medical record. This documentation will be completed on admission and as needed. c. Mood and behavior tracking and documentation will be reviewed by the interdisciplinary behavior subcommittee as needed to determine trends and effectiveness of care plan interventions. B. A record review of Resident 36's current orders revealed orders for the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] Tablet 2.5 MG (antipsychotic medication, a medication used to treat [CONDITION(S)]) -[MEDICATION(S)] Tablet (antidepressant medication, a medication used to treat major depressive disorder, some anxiety disorders, some chronic pain conditions and or to help manage some addictions). A record review of Resident 36's Quarterly Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities) dated 8/15/22 revealed a Brief Interview for Mental Status (BIMS - a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) which indicated a score of 3. According to the MDS manual a score of 0-7 indicated a severe cognitive impairment. The MDS also revealed Resident 36 taking antipsychotic and antidepressant medications for 7 days. A record review of Resident 36's comprehensive careplan Comprehensive Care Plan (CCP - written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) revealed no target behaviors noted for antipsychotic or antidepressant medications. An interview on 09/06/22 at 02:25 PM with the Director of Nurses (DON) confirmed there are no target behaviors for [CONDITION(S)] medications listed on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) or in the resident's comprehensive careplan. C. A record review of Resident 42's current orders revealed orders for the following medication: - [MEDICATION(S)] Tablet 0.5 MG (antipsychotic medication, a medication used to treat [CONDITION(S)]). A record review of Resident 42's MAR and TAR revealed no target behaviors listed. A record review of Resident 42's CCP revealed [CONDITION(S)] Medications used for Dementia with Behaviors, Delusions and Agitations. No target behaviors noted. A record review of Resident 42's MDS dated [DATE] revealed [CONDITION(S)] medications were used 2 times. An interview on 09/06/22 at 02:25 PM with the Director of Nurses (DON) confirmed there are no target behaviors for [CONDITION(S)] medications listed on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) or in the resident's comprehensive careplan.

LICENSURE REFERENCE NUMBER 12-006.09D LICENSURE REFERENCE NUMBER 12-006.12B(5) Based on record review and interview, the facility failed to ensure residents were free from unnecessary meds related to the use of pain medications given without pain ratings and non-pharmacological interventions for Resident 3. The sample size was 1. The facility census was 82. FINDINGS ARE: A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 5/19/22, section C, revealed Resident 3 had a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 7. A record review of the Active Orders Report ran on 9/1/22 revealed Resident 3 had the following pain medications ordered: -Acetaminophen (an over-the-counter medication used for mild to moderate pain or discomfort) Tablet Give 650 mg (milligrams) by mouth three times a day for pain. -Acetaminophen Tablet 500 MG Give 2 tablet by mouth every 6 hours as needed for pain Give 500mg 2 tabs = 1000mg. A record review of the Active Orders Report ran on 9/1/22 revealed a new order for routine Acetaminophen for pain had been initiated for Resident 3, the order reads as follows: -Acetaminophen Tablet 325 MG Give 650 mg by mouth three times a day for pain do not exceed 4Grams in 24 hours give 325mg tab X2 = 650mg. -Order Date 09/01/2022 0744 The record review of the Tylenol administration which began on 9/1/22 revealed no numerical pain rating or pain assessment with administration of pain medications documented on the September 2022 MAR for Resident 3. The record review of the Tylenol administration which began on 9/1/22 revealed no nonpharmacological interventions documented on the September 2022 MAR for Resident 3. A record review of the facility policy titled Pain Management with an original date of 01/02, effective dated 04/18 that reads as follows: -IV. 1) Use of a standard scale for assessing pain is essential. The Hearthstone's choice of pain intensity scale is 0-10 with: 0 equal to NO PAIN 5 equal to MODERATE PAIN 10 equal to Worst POSSIBLE PAIN -The tool is universally used and understood throughout the continuum of the care delivery system and is included in current pain evaluation. -2) The PAINAD Scale will be used for residents who are cognitively impaired. Total scores range from 0-10 (based on 0-2 for five times). The items scored are: Breathing, Negative Vocalization, Facial expression, Body Language and Console ability. Obtained scores are not to be used to infer absolute pain intensity. PAINAD scores are not necessarily equal to numerical pain scale scores. Scores are to be compared to the previous scores received, an increased score suggests an increase in pain, while a lower score suggests pain is decreased. Instructions: Observe the resident for 3-5 minutes during activity w/movement (such as bathing, turning, transferring). For each of the items included in the PAINAD, select the score (0,1,2) that reflects the current state of the person's behavior. Add the score for each item to achieve a total score. NOTE: Behavior observation scores should be considered in conjunction with knowledge of existing painful conditions and report from an individual knowledgeable of the person and their pain behaviors. Some residents may not demonstrate obvious pain behaviors or cues. VI. Communicate evaluation findings with the resident's physician for possible change in both pharmacological and non-pharmacological pain relief measures based on current clinically accepted guidelines. Nursing may implement the following as a nursing measure: massage, warm blankets, warm moist packs, warm blankets, and repositioning. VII. There is a wide range of pharmacological, physical, and behavior treatments related to the differing etiologies of pain, but analgesics should be held until the cause of pain is determined. Non-pharmacologic intervention should be initiated with or prior to analgesics depending on the severity of pain. A record review of the pain scale ratings listed under the Vitals tab for Resident 3 were not found to have three times daily pain rating but were documented as follows: 9/1/2022 08:01 1 PAINAD 8/31/2022 09:57 5 PAINAD 8/18/2022 17:10 0 Numerical 8/16/2022 21:36 0 PAINAD 8/16/2022 20:00 5 PAINAD 8/3/2022 04:56 0 PAINAD 8/2/2022 18:20 0 Numerical 8/2/2022 11:06 3 PAINAD 8/2/2022 03:10 0 PAINAD 8/1/2022 21:12 0 PAINAD An interview on 09/06/22 at 02:27 PM with the DON (Director of Nursing) revealed that the facility expectation for pain monitoring or assessment was reviewed quarterly and not completed more frequently at this time.

Licensure Reference 175 NAC 12-006.09B Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS-a comprehensive assessment of the resident's functional abilities) regarding falls for 2 residents (57 and 75) out of 7 sampled for falls reflected the status of the resident at the time of the MDS assessment. The facility's census was 82. Findings are: A. A review of the facility's Monthly Fall Line Listing for July 2021 to August 2022 revealed that Resident 57 fell on [DATE] with a minor injury and fell on [DATE] with no injury. A review of Resident 57's 5-day MDS dated [DATE] revealed question J1900A was marked 2, indicating the resident had 2 falls without injury. J1900B was marked 0, indicating no falls with injury (except major). This category would include abrasions. J1900C was marked 0, indicating no falls with major injury. A review of Resident 57's Admission MDS dated [DATE] revealed question J1900A was marked 1, indicating the resident had 1 fall without injury. J1900B was marked 0, indicating no falls with injury (except major). This category would include abrasions. J1900C was marked 0, indicating no falls with major injury. An interview conducted on 9/1/22 2:07 PM with the MDS nurse confirmed that on the 5-day MDS dated [DATE] 1 of the falls should have been coded as a fall with no injury, so J1900A should have been 1, and J1900B should have been 1. An interview conducted on 9/1/22 at 2:15 PM with the MDS nurse confirmed that the fall on the Admission MDS dated [DATE] was coded twice on 2 different MDS. B. A review of the facility's Monthly Fall Line Listing for July 2021 to August 2022 revealed that Resident 75 had a fall with minor injury on 12/15/21. A review of the resident's Quarterly MDS dated [DATE] revealed question J1800 Has the resident had any falls since admission/entry or reentry or the prior assessment, whichever is more recent? was answered no, indicating the resident had not fallen since the previous MDS dated [DATE]. An interview conducted on 9/1/22 2:07 PM with the MDS nurse confirmed that the fall from 12/15/21 was not coded on the MDS.

Based on record reviews and interviews, the facility failed to ensure measures in place to prevent the potential spread of Covid-19 (a mild to severe respiratory illness that is contagious and caused by a coronavirus) were followed related to Covid-19 testing per CMS (Center for Medicare and Medicaid Services) guidelines and county transmission rates (COVID-19 Community Levels are a new tool to help communities decide what prevention steps to take based on the latest data. Levels can be low, medium, or high.) This had the potential to affect all residents. The facility census was 82. FINDINGS ARE: An interview on 6/16/22 at 08:50 AM with the facility Administrator revealed that the facility had one room which was a gray zone room due to a resident with new admission status. Continued interview with the Administrator revealed that the facility ICP (Infection Control Preventionist) was responsible for testing all unvaccinated staff for Covid-19. An interview with the facility IPC at 09:02 AM revealed that the facility currently had no Covid-19 positive cases amongst staff or residents. The interview revealed that the last positive case of Covid-19 within the facility was a laundry staff member who was found to have had minimal prior resident contact. An interview with the facility Administrator on 6/16/22 at 10:30 AM confirmed that the current county transmission rates were Red or high which required Covid-19 testing twice weekly for unvaccinated staff members. A record review of the staff Covid-19 testing logs had been reviewed in relation to routine testing for unvaccinated staff and revealed that 3 of 3 staff reviewed had not been tested two time weekly over the last 60 days. A record review of the Covid-19 testing logs when compared to staff timecards, revealed that MA-F (Medication Aide) had gone 6 days, 9 days and 7 days between Covid-19 tests between the time of 5/5/22 to 6/16/22. The record review revealed that MA-F had continued to work directly with residents during this timeframe. A record review of the Covid-19 testing logs when compared to staff timecards, revealed that AA-G (Activity Assistant) had gone 6 days and 7 days between Covid-19 tests between the time of 5/5/22 to 6/16/22. The record review revealed that AA-G had continued to work within the facility during this timeframe. A record review of the Covid-19 testing logs when compared to staff timecards, revealed that NA-H (Nurse Aide) had not been tested since 5/27/22 yet had worked directly with residents on 6 occasions since 6/10/22. An interview with the DON (Director of Nursing) on 6/16/22 at 11:25 AM after review of the timecards and testing dates for MA-F, AA-G and NA-H, confirmed that staff had not been tested twice weekly for Covid-19 and should have been.

Based on record review and interview, the facility failed to ensure that each resident received Notice of Medicare Non Coverage Form CMS -NOMNC to 2 of 3 residents sampled, (Resident 83 and 136). Findings are: Records review of residents discharged from Medicare part A services prior to exhausting benefits , revealed that Residents 83 and 136 were not given the required Medicare Advanced Beneficiary Notice of Non-Coverage) a notices (a notice informing the resident of their right to appeal the decision to be discharged from Medicare part A services). On 6/15/21 at 3:57 PM an interview with the SSD (Social Services Designee) revealed that there were no CMS Medicare Advanced Beneficiary Notices of Non Coverage given to Resident 83 and 136, upon being discharged from Medicare Part A services. Record review of Resident 83's Discharge Notice from Medicare dated 4/28/21 revealed the resident's services would end on 4/29/21, and the resident was not issued a Medicare Advanced Beneficiary Notice of Non-Coverage. Record review of resident 136's Discharge Notice from Medicare dated 6/7/21 revealed the resident's services would end on 6/8/21, and the and the resident was not issued a Medicare Advanced Beneficiary Notice of Non-Coverage. Interview with the SSD on 6/16/21 11 at 11:00 AM revealed she had not given these notices to any resident that voluntary discharged to home.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B1(2) Based on interview and record review, the facility failed to complete a significant change assessment for Resident 24 related to the level of assistance required with ADL's (Activities of Daily Living). The sample size was 18. The facility identified a census of 87. FINDINGS ARE: A record review completed on 06/14/21 at 02:31 PM of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 1/1/21 and the MDS dated [DATE], section G, revealed that Resident 24 had changed from requiring a 1 person assist to requiring a 2 person assist in the areas of bed mobility, transfer ability, dressing, toileting, and personal hygiene. An interview with the MDS Nurse conducted on 06/16/21 at 04:15 PM revealed that a change in ADL (Activities of Daily Living) assistance for Resident 24 had been indicated on the 4/1/21 MDS due to a need for increased assistance for safety reasons. The MDS Nurse also confirmed that a significant change MDS should have been completed and wasn't completed. On 06/16/21 at 04:39 PM an interview with the facility MDS Nurse reported an addendum had been added to the MDS of 4/1/21 explaining the reason for the decline indicated.

Based on interview and record review, the facility failed to ensure a PASARR (Pre-Admission Screening and Resident Review - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes) referral was completed following a new qualifying diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility had a total census of 87 residents. The findings are: A review of a PASARR Level 1 Screen Outcome completed for Resident 67 on 6/5/19 revealed Resident 67 had no known or suspected mental health diagnoses. A review of Resident 67's Electronic Health Record revealed the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Delusional Disorders (9/25/19) -[CONDITION(S)], unspecified (9/25/19) -Anxiety Disorder, unspecified (9/25/19) -Unspecified [CONDITION(S)] not due to a substance or known physiological condition (6/19/19) A review of Resident 67's Annual MDS (Minimun Data Set - a federally-mandated, comprehensive assessment tool used for care planning) dated 4/9/21 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 6/17/21 at 12:01 PM, the Social Services Designee (SSD) confirmed Resident 67 was not referred for a new PASARR evaluation after a new qualifying diagnosis. The SSD reported the facility process was for the nurses to notify the SSD when they received a new mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER]

Licensure Reference Number 175 NAC 12-006.09D2b Based on observation, interview, and record review; the facility failed to ensure treatment and services were provided to promote healing of a pressure ulcer for 1 (Resident 14) sampled resident. The facility had a total census of 87 residents. The findings are: Observations on 06/15/21 at 9:52 AM and 06/16/21 at 10:05 AM revealed Resident 14 lying in bed on Resident 14's left side. Resident 14 had a wound on Resident 14's sacral area (the area at the bottom of the spine, just above the buttocks) and a wound vac (a vacuum-assisted closure of a wound - a type of therapy using a suction pump, tubing, and a dressing to gently pull fluid from the wound and promote healing) was in place. A review of Resident 14's MDS, (Minimun Data Set - a federally-mandated, comprehensive assessment tool used for care planning) dated 1/5/21, revealed Resident 14 had an unstageable pressure ulcer due to coverage of wound bed by slough (dead tissue, usually cream or yellow in color) and/or eschar (dry, black, hard necrotic tissue). A review of Resident 14's MDS, dated [DATE], revealed Resident 14 had an unstageable pressure ulcer due to coverage of wound bed by slough or eschar. A review of Resident 14's MDS, dated [DATE], revealed Resident 14 had an unstageable pressure ulcer due to coverage of wound bed by slough or eschar. A review of Resident 14's MDS, dated [DATE], revealed Resident 14 had an unstageable pressure ulcer due to coverage of wound bed by slough or eschar. A review of Resident 14's MDS, dated [DATE], revealed Resident 14 had an unstageable pressure ulcer due to coverage of wound bed by slough or eschar. A review of Resident 14's Progress Notes revealed the following wound assessment documentation: -1/6/21 - Whirlpool bath given this shift. Dressing changed coccyx area. Wound bed present pale, pink tissue with granulation noted. No active or dried drainage present. Wound bed measuring 0.5cm x 0.3cm. No s/s (signs/symptoms) infection. Periwound tissue intact with slight maceration - (Resident 14) is frequently incontinent of bowel and bladder. Staff perform peri-cares after each incontinent episode, however, (Resident 14) is resistive and refuses at times. Treatment done as ordered. -2/5/21 - With dressing change this date, note open area to upper gluteal cleft. Area is approx. 0.5cm circular. There is also a superficial open area on bilateral lower inner buttocks that are apprx 1cm x 0.5cm. All areas cleansed well and dressings applied for protection. Therabond to open area in coccyx area . -3/10/21 - (Resident 14) returned from hospital No new skin breakdown noted, same sacral wound to top of crevice of buttocks. Therabond was applied and duoderm to cover. Will make follow up appointment with wound doctor to evaluate for any additional treatment. -4/5/21 - Dressing off open area on coccyx. Open area is 1cm x 0.5cm x 0.5cm (depth of wound). Surrounding tissue intact. Wound bed is pink. New therabond applied with [MEDICATION(S)] dressing. -5/5/21 - Coccyx wound is 1.4cm x 0.5cm x 0.3cm. Wound base is pink, surrounding skin intact. Gluteal cleft skin from wound to anus is intact. Nursing educated on need to have (Resident 14) in bed off back except for meals. Nursing to limit time in sitting position. -5/12/21 - (Resident 14) lying in bed on (Resident 14's) left side, sacral wound measuring 1cm x 0.4cm with 0.9cm of depth. Tunneling noted from 7 o'clock to 4 o'clock region of approximately 0.9cm. No drainage noted to old dressing. Note wound bed to be of pink/light red in color without necrotic/eschar tissue. Surrounding skin to be intact, pale white scar like tissue. Wound vac applied as ordered per recent (Doctor Name) office visit. Resident tolerated treatment without any signs/symptoms of pain noted. -5/17/21 - (Resident 14) lying in bed on left side, sacral wound of outside measuring 2cm x 0.7cm with 1.2cm of depth. Tunneling noted from 10 o'clock to 3 o'clock region of approximately 1cm. Wound vac canister does have drainage present of dark type brown color. No drainage to wound noted during dressing change. Note wound bed to be of beefy/bright red in color with approximately less than 10% light yellow/white tissue. Surrounding skin to be intact, pale pink scar like tissue. Wound vac applied as ordered -5/24/21 - (Resident 14) lying in bed - air mattress on left side, sacral wound of outside measuring 1.6cm x 0.6cm with 1.4cm of depth. Tunneling 12 o'clock to 6 o'clock region of approximately 1cm. Tunneling of 6 o'clock to 9 o'clock region of approximately 1.5cm. Tunneling of 9 o'clock to 12 o'clock region of approximately 2cm. Wound bed to be of light/pale pink in color with center of a thin layer of white/gray measuring approximately 0.4cm in diameter. Surrounding skin is intact with approximately 0.5cm of light redness surrounding the open wound -6/2/21 - (Resident 14) lying in bed - air mattress on left side, sacral wound of outside measuring 1.8cm x 0.9cm with 1.2cm of depth. No tunneling noted 12 o'clock to 6 o'clock region. Tunneling of 6 o'clock to 11 o'clock region of approximately 2.5cm. No tunneling 11 o'clock to 12 o'clock region. Wound bed to be of beefy red in color with no slough or necrotic tissue noted. Surrounding outside skin is intact. Wound vac canister with scant amount of bright red and yellow colored drainage . -6/9/21 - (Resident 14) lying in bed, air mattress, on left side, sacral wound of outside measuring 1.5cm x 0.8cm with 2.8cm of depth. Tunneling noted 11 o'clock to 3 o'clock region of approximately 2.3cm. Tunneling noted 3 o'clock to 6 o'clock region of approximately 1.3cm. No tunneling noted to the 6 o'clock to 11 o'clock region. Wound bed to be of light pink in color. At bottom of wound bed, note color to be of white, thin covering. Surrounding outside skin is intact. Wound vac canister with scant amount of bright red and yellow colored drainage . A review of Resident 14's 2021 TARs (Treatment Administration Records) revealed the treatment utilized for Resident 14's sacral wound from 1/07/21 - 5/12/21 was Therabond (an antimicrobial wound dressing) - applied damp to wound bed and covered with Duoderm (a thin, transparent dressing that adheres to the skin). A review of the facility's Skin Ulcer Assessment Documentation and Notification Policy, last reviewed 3/2020, revealed the following: -Purpose: All ulcers will have weekly documentation by a professional nurse, physical therapy staff person or a professional in wound management. More immediate reassessment as well as reevaluation of the treatment plan is necessary with no improvement or decline in overall condition or in the pressure ulcer itself within 14 days. -Procedure: A. All ulcer (pressure, arterial, diabetic neuropathic, [CONDITION(S)], etc.) assessments will be documented on in skin progress note. C. The National Pressure Ulcer Advisory Panel Staging System will be used to stage pressure ulcers. All other ulcers will be classified as either partial or full thickness wounds. 3. Stage III: Full thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to but not through the underlying fascia. The ulcer presents clinically as a deep crater with or without undermining or adjacent tissues. 4. Stage IV: Full thickness skin loss with extensive tissue destruction, tissue necrosis or damage to the muscle, bone or supportive structures. Undermining and [MEDICATION(S)] tracts also may be associated with Stage IV ulcers. 5. Unstageable: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough and/or eschar in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either Stage III or IV. D. The initial evaluation and documentation of any ulcer will be completed by an RN (Registered Nurse), LPN (Licensed Practical Nurse) or MD (Medical Doctor). E. Subsequent evaluation will be done weekly by RN, LPN, or MD. Documentation should be done weekly to include if any changes of status, complications, or changes in treatment, size, drainage, or pain. F. The resident's physician will be notified on all ulcers to ensure correct coding on the MDS. G. The Diet Tech or Registered Dietician will be notified to review need for nutritional supplements. H. The Assessment Coordinator will be notified of all ulcers to ensure correct coding on the MDS. I. If no improvement has been seen in the ulcer after two weeks of treatment or if the wound condition is deteriorating, the physician will be contacted. J. The resident will be assessed for signs/symptoms of pain with dressing changes and medicated with analgesics as needed. In an interview on 6/17/21 at 9:19 AM, the DON (Director of Nursing) confirmed prior to 5/5/21 Resident 14's sacral wound was not being measured weekly and weekly assessments of the wound were not being documented. In an interview on 6/17/21 at 2:11 PM, Nurse Unit Coordinator - A confirmed the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse Unit Coordinator - A provided documentation that Resident 14 was seen by a vascular surgeon for wound follow-up on 2/8/21 and 4/12/21 with no change in treatment.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D6 Based on observation, interview and record review; the facility failed to ensure the provision of respiratory care in accordance tp prevent contamination related to nebulizer and oxygen tubing for Residents 8, 24, 29. The sample size was 18. The facility identified a census of 87. FINDINGS ARE: An observation on 06/15/21 at 02:39 PM revealed Resident 29's oxygen tubing had been connected to the wheelchair oxygen tank and found with the nasal cannula resting on the tire of the wheelchair. An observation on 06/16/21 at 10:22 AM revealed the nebulizer tubing for Resident 24 to be on the floor. An observation on 06/16/21 at 10:52 AM revealed Resident 8's oxygen tubing laying on the floor with the nasal cannula touching the floor. An observation on 06/16/21 at 02:31 PM revealed Resident 24's nebulizer kit being stored on machine with moisture inside the kit and tubing. A record review conducted on 06/16/21 at 02:51 PM of the facility policy titled Medication Administration-nebulized medication and dated 9/2017, revealed step 7 to read as follows; when medication is completely nebulized, turn off flow meter, assure all medication/liquid is out of the equipment and store tubing and set up on a clean surface, let air dry. Key Point - rinse after use. A record review conducted on 06/16/21 at 02:51 PM of the facility policy titled Oxygen Administration and dated 3/2020, does not address the handling of oxygen tubing after initial set up. An interview with the Unit Manager of the 600 hall conducted on 06/16/21 at 04:00 PM, after review of photos of respiratory equipment, confirmed nebulizer tubing and oxygen tubing had not been stored properly when not in use. An interview with the DON on 06/17/21 at 08:25 AM revealed that the facility had adjusted the respiratory care policy related to storage of equipment. A record review on 06/17/21 at 10:18 AM of the active orders list for Resident 29 revealed the following oxygen order; Oxygen 1-5L via mask or nasal cannula to maintain O2 sats greater than 90% *Notify Dr/PAC* as needed for supplementation A record review on 06/17/21 at 10:18 AM of the TAR (Treatment Administration Record) dated June 2021 for Resident 29 revealed no documentation of the continuous liter flow currently being given for the oxygen. An interview with the Unit Manager conducted on 06/17/21 at 12:30 PM after review of the June 2021 TAR confirmed the level of liter flow of oxygen being given continuously for Resident 29 did not exist and should have.

Based on observation, record review and interview; the facility failed to prevent and contain COVID-19 by: A) The facility failed to ensure isolation gowns covered exposed skin on the upper extremities for residents that required Transmission based precautions. B) The facility failed to ensure staff were screened for Covid 19 prior to entry to the building. C) The facility failed to implement a process to ensure employees had donned PPE prior to entering areas were other staff and residents were located. Findings are: A. An observation on 10/7/20 at 11:00 AM- 11:20 AM of LPN (Licensed Practical Nurse) B donning (putting on) PPE (personal protective equipment) to enter Resident 1's room who in transmission based precautions. LPN B was already wearing a surgical mask and goggles, donned a reusable patient gown that was short sleeved, gloves and then placed another surgical mask over current surgical mask. LPN B then entered Resident 1's room and picked up disposable dishes on bedside table and threw them away in trash can inside room. Upon exiting the room, LPN B doffed (removed) gloves and placed in trash can by the door to the room, then removed patient gown by touching the inside of the top of the gown and bringing it forward and rolled up gown with the outside of gown together and touching only the inside of the gown and placed into linen bag by the door to the room, LPN B then removed outer surgical mask by touching only the elastic straps and put in trash can by the door to the room. LPN B then exited the room and immediately performed hand hygiene using hand sanitizer and then went directly to a sink in the dining room area on hallway and washed hands and arms up to elbows. Record review of CDC (Center for Disease Control and Prevention) Sequence for Putting on Personal Protective Equipment (PPE) states: 1. Gown -Fully cover torso from neck to knees, arms to end of wrists, and wrap around the back -Fasten in back of neck and waist Record review of COVID-19 Resident Cohorting via Zone Color and PPE revealed Gray Zone (Transitional zone) is for residents who are being transferred from the hospital/outside facilities (but have no known exposure COVID-19) are usually kept in this zone for 14 days and if remains asymptomatic at the end of the 14 days will be moved to Green Zone. Grey zone PPE that should be used is gown, gloves, eye protection and N95 mask (N95 preferred, if no N95, then surgical mask with face shield). An interview on 10/7/20 at 11:53 AM with DON (Director of Nursing) revealed the facility is using short sleeve patient gowns as reusable gowns for grey zone isolation rooms. An interview on 10/7/20 at 02:05 PM with DON revealed the facility is removing all short sleeved gowns and will use reusable long sleeved lab coats instead. B. An observation on 10/07/20 at 3:00 PM of NA-A in the hallway near the private dining area, no face mask. NA-A walked toward the staff screening station. Record review of Daily Staff Screening logs dated 10/7/20 revealed NA-A's screening information was not located on the log. An interview on 10/7/20 at 11:30 AM with the DON confirmed staff screened themselves at this time and call the house supervisors number if they have any negative responses to the COVID questionnaire. An interview on 10/07/20 at 3:22 PM with the Administrator confirmed NA-A's screening information was not on the staff screening log. The Administrator reported it was the expectation that everyone who entered the facility were screened. C. An observation on 10/07/20 at 3:00 PM of NA (Nurse Aide) A standing in the hallway near the private dining area without a face mask on. NA -A waved and walked into the hallway toward the staff screening station. NA-A went to the CRC (Community Relations Coordinators) office in the front of the building near the entrance where a resident (wearing a mask) was sitting. NA-A and CRC had a conversation. An interview on 10/07/20 at 3:00 PM with NA-A confirmed they were an employee with the facility and worked part time. An interview on 10/7/20 at 3:00 PM with the CRC confirmed; NA -A was an employee, part time and was not wearing a mask in the hall. The CRC confirmed the NA-A was required to have a mask on in the facility. Record review of an Email dated September 27, 2020 from the IP (Infection Preventionist) Subject: Covid Testing and Precautions Update revealed: Precautions that need to take place for all employees: All employees who are out on the halls are required to wear N95 masks with a face shield. The face shields protect and keep the N95 mask clean. For now, we will be using one N95 per employee, per shift and our face shields can be disinfected and re-used (please put your name on your face shield). For breaks, you will leave the floor wearing your N95 Mask/face shield and may remove them in the break room or Great room, making sure to lay the mask with the outside toward the table and disinfect the face shield prior to placing it down with the foam part toward the table. We will have designated areas for this. Please try to avoid touching the face mask and face shield and if you do wash your hands with soap and water or hand sanitizer. An interview on 10/07/20 at 3:22 PM with the Administrator confirmed; employees were required to wear a mask in the building, reported NA-A was not in the building to work the floor and had not been on the resident hallways. The Administrator confirmed; residents had been taken out doors via the front entrance near the CRC office.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, interview, and record review; the facility staff failed to serve food to the residents in a manner to prevent potential cross contamination by failing to contain hair, failing to clean soiled services, failing to perform hand hygiene, returning food from the tables to the meal service line, using the same utensils for different residents, and failing to cover food when taking it out of the dining room. This affected 27 residents who received food from the 300 (69, 92, 23, 64, 102, 63, 101, 91, 93, 11, 50, 60, 66, 58, 103, 82, and 17) and 400 (67, 99, 25, 52, 155, 154, 19, 27, 36, and 84) dining rooms and 39 residents who received food from the 100 and 200 dining rooms. The facility identified a census of 106 at the time of survey. Findings are: [NAME] Observation of the 400 dining room on 11/20/19 at 11:06 AM revealed the following: Cook-E had a moustache and beard with no facial hair cover and was standing over the steam table plating food. DA-H (Dietary Aide) also had a beard with no facial hair cover and was taking the plates of food to the residents in the dining room. Observation of the 400 dining room on 11/20/19 at 11:12 AM revealed Resident 99 had a plate of food in front of them. Resident 99 pointed to their hamburger so DA-H picked the plate up that they had already sat down in front of Resident 99 and took it back to Cook-E who then put the plate on the serving area in front of the food on the steam table and cut the burger with a cutter. Cook-E then handed the plate back to DA-H who then took the plate of food back to Resident 99. Cook-E then proceeded to dish food for the other residents. On 11/20/19 at 11:18 AM DA-H dropped the mustard bottle on the floor and put it back on the tray then took a plate of food to Resident 84 using the same tray . DA-H then took a plate of food to Resident 27 with the same tray. DA-H did not do any hand hygiene after picking up the mustard bottle off the floor and was handling the plates of food and did not get a clean tray or clean mustard bottle. On 11/20/19 at 11:22 AM DA-H took a plate of food to Resident 19 with the same tray that DA-H had put the mustard bottle on it that had been dropped on the floor. On 11/20/19 at 11:24 AM DA-I took a slice of cheese to Resident 19 with tongs and touched the tongs onto Resident 19's plate. DA-I then used the same tongs to reach into a bag of cheese slices and DA-I then took the slice of cheese to Resident 36. On 11/20/19 at 11:25 AM DA-H served a plate of food to Resident 25 from the same tray that had the mustard bottle on it that had been dropped on the floor. The mustard bottle was on the tray as Resident 25 received their plate of food. On 11/20/19 at 11:26 AM DA-H took a plate of food to Resident 52 with the same tray. The mustard bottle was on it. DA-H sat the plate down in front of Resident 52. Resident 52 asked for the hamburger to be cut so DA-H took the plate of food back to Cook-E to cut the burger then DA-H put the plate of food back in front of Resident 52 after Cook-E put the plate on the area in front of the steam table and cut it with the same cutter they had used to cut Resident 99's burger. On 11/20/19 at 11:30 AM DA-H served Resident 155 a plate of food from the same tray. DA-H had not done any hand hygiene, cleaned the tray or the mustard bottle and DA-H continued to take food to the residents using the same tray. On 11/20/19 at 11:32 AM DA-H served Resident 154 a plate of food on the same tray and the mustard bottle was on it. On 11/20/19 at 11:33 AM all of the residents in the dining room had been served and received food from Cook-E; Residents 67, 99, 25, 52, 155, 154, 19, 27, 36, and 84 . B. Observation of the 300 dining room on 11/20/19 at 12:11 PM revealed Cook-G was in the kitchen area putting food on plates and putting the plates of food into a pass through window. Cook-G was observed to have a beard and moustache with no facial hair cover. 16 residents received food from Cook-G, Residents 69, 92, 23, 64, 102, 63, 101, 91, 93, 11, 50, 60, 66, 58, 103, 82, and 17. On 11/20/19 at 12:16 PM DA-F prepared Resident 102 a room tray. DA-F covered the plate of food, but did not cover 2 glasses of juice, a glass of water, or a bowl of pudding. NA-K (Nurse Aide) then took the tray out of the dining room across the hall into Resident 102's room. NA-K did not cover the juice, water, or pudding before leaving the dining room with the tray. Interview with the FSS (Food Service Supervisor) on 11/26/19 at 10:23 AM revealed the dietary staff were to wash their hands for 20 seconds when they were soiled. If the dietary staff had a beard they were expected to cover it with a beard net. The expectation would be if the dietary staff dropped anything on the floor they would discard it and do handwashing. If they put the dirty thing on the tray they should have gotten a new tray. If the resident had the plate in front of them the dietary staff person should not have used the same tongs for a different resident after they touched the other residents plate with them. Nursing staff were to cut up the food; they wouldn't want a dirty plate back in the clean meal service area. The staff were supposed to cover food then they took it out of the dining room. Interview with RN-A (Registered Nurse), Infection Control Coordinator, on 11/26/2019 at 10:23 AM revealed that the table setting was considered dirty once the food was taken to the resident so the plates of food should not have been returned to the meal service area. Review of the facility policy Nutrition Services Dress Code dated 9/18 revealed the following: All Nutrition Services staff will wear a hair restraint to cover all hair. Beards on males must be covered with the approved beard net. Review of the facility policy Hand Hygiene dated 11/19 revealed the following: To aide in the prevention of foodborne illness, the dietary personnel shall wash their hands. When to wash hands: Dietary Personnel shall clean their hands and exposed portions of their arms before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles. After touching other human body parts other than clean hands and clean, exposed portions of arms. After handling soiled equipment or utensils. During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. C. Record review of the Nebraska Food Code Book, dated (MONTH) 2012 Section 2-402.11 revealed the following related to hair restraints effectiveness: Good employees shall wear hair restraints such as hats, hair coverings, nets, beard restraints, and clothing that covers exposed food. Clean equipment, utensils and linens and unwrapped single service service and single use articles. Observation on 11/26/19 at 1130 AM and 12:00 PM in the dining area for group revealed the dining area of the 100 and 200 dining area from dietary cook employee had a hair restraint; it did not cover all areas of hair as evidenced by strands of hair exposed at the front, back, sides of the head and facial; hair, mustache and go tee to the chin. Facial hair on dietary employee Cook-E not restrained or covered with hair coverings. Interview on 11/26/19 at 2:00 PM with the FSS (Food Service Supervisor) revealed that there were only 2 residents who took no food by mouth in the facility. Record review of the facility policy of Infection Control and Prevention in the Food Service Department dated (MONTH) (YEAR), revealed that all applicable Federal, State, and local regulations would be followed to prevent any occurrence of food borne illness.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1a Based on interview and record review, the facility staff failed to ensure the resident and/or responsible party received a copy of the baseline care plan and ensure they understood it at the time of admission. This affected 3 of 11 sampled residents (Residents 66, 82, and 101). The facility identified a census of 106 at the time of survey. Findings are: [NAME] Review of Resident 66's Care Plan revealed an admission date of [DATE]. Review of Resident 66's undated Direct Care Staff Admission Information and Resident Preferences (identified as the baseline care plan by the ADON) and Resident 66's Progress Notes revealed no documentation a copy of the baseline care plan was given to the resident or their responsible party and that they understood it at the time of admission. B. Review of Resident 82's Care Plan revealed an admission date of [DATE]. Review of Resident 82's undated Direct Care Staff Admission Information and Resident Preferences (identified as the baseline care plan by the ADON) and Resident 82's Progress Notes revealed no documentation a copy of the baseline care plan was given to the resident or their responsible party and that they understood it at the time of admission . C. Review of Resident 101's Care Plan revealed an admission date of [DATE]. Review of Resident 101's undated Resident Preference (identified as the baseline care plan by the ADON) and Resident 101's Progress Notes revealed no documentation a copy of the baseline care plan was given to the resident or their responsible party and that they understood it at the time of admission. Interview with the ADON (Assistant Director of Nursing) on 11/26/19 at 4:59 PM revealed the facility did not give a copy of the baseline care plan to the family until the initial care plan meeting. Interview with the DON (Director of Nursing) on 11/26/19 at 5:10 PM confirmed the facility did not give a copy of the baseline care plan to the responsible party until they had the initial care plan meeting. Review of Resident 66's Interdisciplinary Care Plan Conference Record dated 8/7/2019 revealed Resident 66's responsible party's signature on the form, 15 days after Resident 66 was admitted to the facility. Review of Resident 82's Interdisciplinary Care Plan Conference Record dated 11/20/2018 revealed Resident 82's responsible party's signature on the form, 15 days after Resident 82 was admitted to the facility. Review of Resident 101's Interdisciplinary Care Plan Conference Record dated 8/13/2019 revealed Resident 101's responsible party's signature on the form, 14 days after Resident 101 was admitted to the facility. Review of the facility policy Care Plan Policy dated 4/19 revealed the following: Care Plans are developed for the benefit of the resident's well being to ensure highest practicable, psychosocial, spiritual, emotional and physical needs are met. The care plan will be resident centered and interdisciplinary, and in coordination of other entities that have interest in the Resident's Care. The resident, family, and any outside entity will be invited to be involved in the residents' care plan conference. All residents will have a care plan that meets guidelines set by State and Federal Regulations and per RAI (Resident Assessment Instrument) Manual.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (6) Based on observation, interview, and record review; the facility staff failed to serve food to the residents in a manner to promote resident dignity by failing to serve all of the residents at the table at the same time and failing to ask permission before putting clothing protectors on the residents. This affected 16 residents who received their meals in the 300 dining room, 19 residents in the 100 dining room, 20 residents in the 200 dining room, and 3 residents in the 500 dining room. The facility identified a census of 106 at the time of survey. Findings are: [NAME] Observation of the 300 dining room on 11/20/19 at 12:08 PM revealed the following: 16 residents were in the dining room. 11/20/19 12:11 PM Cook-G was in the kitchen area putting plates of food into a pass through window. DA-F (Dietary Aide) took the plates of food to the residents. On 11/20/19 at 12:26 PM DA-F served Resident 11 and Resident 63 their meals then served Resident 50 without serving Resident 101 and Resident 91 who were sitting at the table with Resident 11 and Resident 63. DA-F then served Resident 50 and did not serve Resident 60 who was sitting at the same table as Resident 50. DA-F then served Resident 66 and Resident 58 but did not serve Resident 103 who was sitting at the same table as Resident 66 and Resident 58. At 11/20/19 at 12:28 PM DA-F served Resident 60. On 11/20/19 at 12:29 PM DA-F served Resident 91. Resident 101 was not served. On 11/20/19 at 12:31 PM Resident 103 was served. On 11/20/19 at 12:32 PM DA-F served Resident 17 who was sitting at a table with Resident 82. DA-F did not serve Resident 82 and Resident 101 had not been served. Resident 101's table mates (Residents 63, 11, and 91) were eating. On 11/20/19 at 12:34 PM DA-F brought Resident 101 their food. Resident 82 still did not have food and their table mate, Resident 17 was eating. On 11/20/19 at 12:35 PM Resident 82 received their food. Interview with the FSS (Food Service Supervisor) on 11/26/19 at 10:23 AM revealed the dietary staff were supposed to try to serve the entire table. The goal was to serve the entire table at the same time. Review of the undated facility policy Residents Rights revealed the following: Residents have the right to dignity, respect, and quality of life. Review of the Nursing Facility Resident Rights Copyright (YEAR) revealed the following: The resident has the right to: be treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing his/her individuality. B. On 11/20/19 at 11:30 AM an observation of the 100 Dining room revealed that the nursing staff placed clothing protectors on 19 residents in the dining room; without asking permission of the residents. On 11/20/19 at 12:03 PM an observation of the 200 Dining room revealed that the nursing staff placed clothing protectors on 20 residents in the dining room; without asking permission of the residents. Interview on 11/21/19 at 4:15 PM with the DON (Director of Nurses) revealed that the residents just wanted the clothing protectors on. C. On 11/20/19 at 11:39 AM observation of the 500 unit dining room revealed that the dietary staff was not serving the residents at one table before moving to the next. Two residents seated in the back of the dining room at the same table Resident 49 and Resident 80 did not receive their food at the same time. Resident 49 receive the food at 11:55 AM. Two residents at another table were served. Resident 80 received the plate of food at 11:59 AM. Resident 80 did not begin to eat until 12:00 PM.