**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175-12.006.09(H)(iv)(2) Based on observations, interviews and record review, the facility failed to provide toileting interventions for one (Resident 11) of two sampled residents, which had the potential to cause skin breakdown and bladder infection. The facility identified a census of 56. Findings are: Record review of Resident 11's Census Data revealed the resident was readmitted to the facility on [DATE]. Record review of Resident 11's Face Sheet revealed the resident admitted to the facility with the following diagnosis: Unspecified dementia, unspecified severity, with behavioral disturbance, polyosteoarthritis, Parkinson's Disease and muscle weakness. Record review of Resident 11's 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 12/05/2024 revealed under Section C the Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment, the resident had a score of 5, indicating severe cognitive impairment. Section H0200 shows a zero for toileting plan. Section GG indicated the resident was dependent for toileting and maximum assistance for transfers and bed mobility. Record review of Resident 11's Care Plan last revised 12/25/2024 revealed no toileting plan under Activities of Daily Living (ADL) problem, and toilet before meals listed under the Fall problem. The Problem for bladder incontinence related to Dementia, Impaired mobility did not reveal any toileting plan. Record review of Resident 11's Bladder Assessment form dated 12/05/2024 indicated the resident needed a toileting schedule before and after meals, at bedtime and for activities. No evidence of a 3-day bowel and bladder hourly elimination diary noted in chart. Record review of the facility's Bowel and Bladder Management Standard policy last revised 4/18/2017 revealed under Identification and Assessment, C. a bladder assessment is done on admission, quarterly, annually and with significant change for residents, and when there is a change in continence. Assessment is completed after 3 days of hourly elimination diary is completed but not later than 8 days after admission. An observation on 2/24/2025 at 1:07 PM of Resident 11 revealed resident in room sitting up in wheelchair facing the closed door with a tray table in front of the resident while the resident attempted to feed self the noon meal. Resident in isolation in room for Covid 19 infection. An observation on 2/25/2025 at 7:15 AM of Resident 11 revealed resident in the restroom with staff being assisted with morning cares for the day. An observation on 2/25/2025 at 9:05 AM of Resident 11 revealed resident sitting in wheelchair facing closed door with a tray table in front of the resident with remainder of resident's breakfast sitting on tray table and the resident holding the call light. An observation on 2/25/2025 at 10:14 AM of Resident 11 revealed resident continued to be sitting in wheelchair in front of closed door with breakfast tray sitting on the tray table in front of the resident. An observation on 2/25/2025 at 10:45 AM of Resident 11 revealed resident continued to be sitting in wheelchair in front of closed door, staff member removing room tray. An observation on 2/25/2025 from 11:25 AM to 11:40 AM revealed Nurse Aide (NA)-A transferring Resident 11 with a gait belt from the wheelchair to the toilet. Resident 11's sweatpants were visibly soaked with urine to below the knees and the wheelchair cushion was also noted to be wet with urine, and the incontinent pull up was saturated with tan colored urine. Resident verbalized that pants and wheelchair were wet. NA-A removed soiled sweatpants and pull up while the resident was sitting on the toilet. NA-A assisted the resident to stand and obtained 4 peri wipes and placed them together. NA-A then cleansed the resident by doing 4 swipes from the lower center of the buttocks crease to top of the buttocks crease using the same wipes folding once, and the wipes had visible feces on them. No incontinent cares provided to peri area, hips, thighs, or outer buttocks. NA-A removed the soiled gloves, and without the benefit of hand hygiene, NA-A put a clean pull up and pants on the resident. NA-A then assisted the resident to sit down in the wheelchair on the wet cushion without cleaning the cushion. An interview with NA-A on 2/25/2025 at 11:30 AM confirmed that Resident 11 is not on a toileting plan and that the resident was saturated with urine and the NA did not think about cleansing the buttocks, hips and back of legs. NA-A also confirmed that no hand hygiene had been completed at any time during the cares, nor new gloves applied. Record review of Monitoring Frequent checks form dated 2/25/2025 that was placed outside Resident 11's door due to being in isolation with documentation being required every 15 minutes to indicate the resident's activity during that time, documentation revealed resident was toileted at 7:30 AM and 11:30 AM. An interview with the Director of Nursing (DON) on 2/26/2025 at 10:27 AM confirmed that Resident 11 does have bladder incontinence, dementia and impaired mobility so there should be some type of toileting plan. When discussing the Monitoring Frequent checks form with the DON, the DON confirmed that Resident 11 should have been toileted between 7:30 and 11:30 AM. The DON also confirmed that NA-A did not follow expectations for incontinence cares or cleansing of the wheelchair cushion. An interview with the MDS nurse on 2/26/25 at 1:45 PM confirmed that Resident 11 would benefit from a toileting plan and that the Bladder Assessment form completed by nursing on 12/05/2024 should have prompted a toileting schedule. The MDS nurse also confirmed that according to the electronic charting system for the nurse aides, Resident 11 is only toileted at 4 AM, 7 AM, 11 AM, 5 PM and 7 PM, with no toileting documented between these times, and confirmed that is not enough.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 12-006.09(H)(iii)(1) Based on observations, interviews, and record review, the facility failed to put interventions in place to prevent a pressure ulcer for one (Resident 20) of three sampled residents. The facility identified a census of 56. Record review of Resident 20's Census Data revealed resident admitted [DATE]. Record review of Resident 20's Face Sheet admitted with the following diagnosis: Pain in right hip, pain in right knee, Type 2 Diabetes Mellitus (DM II), Primary Hypertension (HTN), chronic kidney disease (CKD), Muscle weakness, Difficulty in walking, Chronic Pain, Lead Induced Gout. Record review of Resident 20's admission Minimum Data Set (MDS) (A federally mandated assessment that captures the resident physical and mental capabilities and care needs) dated 01/02/2025 revealed the following: Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment: score:13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment) a score of 15 indicating Resident 20 was cognitively intact. Section GG revealed resident is dependent with transfers and toileting, touch assistance with bed mobility and set up for eating. Section GG0115 revealed Impairment on one side of the upper and lower extremity. Sections M0100 determination of pressure ulcer injury risk marked No. Braden marked Yes M0150 risk for pressure ulcer marked as a Yes. M0210 unhealed pressure ulcers/injuries marked as a No. M1040 other ulcers, wounds and skin problems marked Yes. M1200 Skin and ulcer/injury treatments marked as a Yes with pressure reducing device for chair and bed. Sections K0520 Nutritional approaches marked Therapeutic diet (specialized diet varies for low salt, diabetic, low cholesterol). Record review of Resident 20's Baseline Care Plan dated 12/27/2024 revealed the following: Braden score of 18 indicating at risk for skin breakdown, pressure relieving cushion in the wheelchair and mattress to the bed. Offer assist with repositioning during nursing rounds and PM (an abbreviation for post meridiem, which means afternoon). Skin assessment routinely. Assist of one for transfers/walking with walker. Physical and Occupational therapies to evaluate and treat. Bed at knee height. Offer assist with toileting during AM/HS (morning/evening) cares, before/after meals, during nursing rounds and PRN (when needed). Record review of Resident 20's Progress Note dated 02/03/2025 at 3:45 PM revealed the following: Reported by staff that resident had a possible pressure area to L) heel. Upon assessment noted area to L) (left) lateral heel that is an oval in shape. Area is dark pink to light purple in color and does not blanche, area staged as a deep tissue injury (DTI is damage to the tissues beneath the skin that can occur due to sustained pressure). Area measures 2.1 cm (centimeter) x 1.3 cm, no OA (pressumed abreviation for Open Area) noted and res. denies pain at time of assessment. Treatment initiated to paint with betadine BID until healed. Prevlon boots (a medical device that helps relieve pressure on the heels) also to be initiated while in bed. Call made to notify son, message left. PCP (Primary Care Physician) notified per fax. Record review of Resident 20's Care Plan updated on 02/03/2025 skin or wound integrity with new Focus for the following: Actual impairment to skin integrity of left lateral (side) heel related to Diabetes, Edema (swelling), with Suspected deep tissue injury. Goal to prevent new skin problems through the next review of 04/03/2025 and second goal is Skin will be free from complications or worsening condition through the next review of 04/03/2025. Interventions are to do a Braden scale (Risk assessment tool used to identify patients at risk of developing pressure ulcers) quarterly and PRN, Dietician to evaluate resident nutrition as needed, float heels using pillows or off-loading boots PRN, Paint left heel wound with betadine twice daily until healed, Weekly and PRN skin monitoring by professional nurse. Record review of Resident 20's Braden Scale for Predicting Pressure Sore Risk-V2 Effective date of 12/27/2024 revealed a score of 18 which is a Category of AT Risk. Record review of Resident 20's Braden Scale for Predicting Pressure Sore Risk-V2 Effective date of 01/05/2025 revealed a score of 16 Category of At Risk. Record review of Resident 20's Braden Scale for Predicting Pressure Sore Risk-V2 effective date of 02/10/2025 revealed score of 17 Category of At Risk. Record review of Resident 20's Pressure Ulcer Record dated 02/03/2025 revealed a deep tissue injury measuring 2.1 cm x 3.1 cm area to left lateral heel and is oval and dark pink to light purple in color. No open area noted. Initiated betadine twice daily and heel boots. Record review of Resident 20's Pressure Ulcer Record dated 02/13/2025 revealed a deep tissue injury measuring 2.1 cm x 3.1 cm area pink. Prevlon boots and betadine continued. Record review of Resident 20's Pressure Ulcer Record dated 02/20/2025 revealed a deep tissue injury measuring 2.1 cm x 3.1 cm area pink. Blue boots in bed and betadine continued-improving. Record review of Resident 20's weights revealed: 12/27/2024 179.6 pounds 02/27/2025 191.5 pounds Record review of Resident 20's Physician Visit Communication Form dated 02/04/2025 revealed reason for visit/fax for weights stating there was a 14.5-pound weight increase since admission on [DATE]. Had 2+ pitting edema. Record review of Resident 20's Physician Visit Communication Form dated 02/04/2025 revealed reason for visit/fax due to continues to have deep tissue pressure injury to heel. Wound status is still approximated (close fit of wound edges), and discoloration has improved the last few weeks. Current treatment is to paint with betadine two times daily (BID). Has blue boots which is mostly compliant with. Also is not on any nutritional supplement at this time with physician response to continue with current orders and reviewed and agree with the plan of care. Record review on 02/27/2025 at 0820 AM of the Facility's Policy on Skin and Wound Management Standard Revised on 04/2019 revealed: Key Elements: - Edema wear/TED hose can cause injuries! Must be removed and skin assessed every shift. Check top of foot and around Achillies (back of lower leg above ankle) and knees. - Deep Tissue Pressure Injury (DTPI) can develop 48-72 hours after pressure is relieved. Assess new admissions every day at least for the first 72 hours. - Braden Scale for Predicting Pressure Ulcer Risk will be completed at bedside upon admission/readmission, daily times three then every week times three more weeks then quarterly, annually and PRN. - Repositioning. Heels should be floated (not touching any surface) using pillows or off-loading boot. - Routine Skin check. Weekly basis done by RN/LPN. - Monitoring. Team members will perform routine skin inspections with bathing and cares. Identified concerns will be documented on the Skin Care Alert Tool. Any findings should be documented on pressure or non-pressure forms -It is the expectation that all charge nurses will be knowledgeable and involved in preventing, identifying, assessing, treating, and documenting all skin and wound conditions. Observation on 02/25/2025 at 10:20 AM revealed Resident 20 sitting in recliner chair with feet on floor and edema wear on lower legs, diabetic shoes on feet. Stated, I have pain in my legs and back which is at a 5 and is tolerable. Complained of having a sore on her foot that doesn't hurt. Could not recall which foot it was. Interview with Licensed Practical Nurse (LPN)-F on 02/25/2025 at 10:35 AM confirmed that Resident 20 did have a deep tissue injury on left lateral heel and treatment was to put betadine on area two times daily. Observation of LPN-F on 02/25/2025 at 4:00 PM revealed with treatment to left lateral heel and wound that skin is intact and dark purple in color. No odor. LPN-F pressed on the wound and Resident 20 stated, It doesn't hurt. Had diabetic shoes on prior to treatment. Sitting in recliner with feet down following treatment. Observation on 02/26/25 at 8:40 AM revealed Resident 20 laying in bed with eyes closed. Does not have Prevlon boots on feet or heels floated with pillow. Observation on 02/26/2025 at 12:35 PM revealed Resident 20 sitting up in wheelchair without feet elevated. Edema wear on lower extremities with no shoes or Prevlon boots on feet. Interview with Nurse Aide (NA)-A on 02/26/2025 at 11:50 AM revealed that Resident 20 did not have blue off-loading boots on feet. Stated, If Resident 20 is up in the chair or wheelchair there should have been a pillow under lower legs to float heels and/or wear the off-loading boots and have feet up. Interview with Registered Nurse (RN)-G on 02/26/2025 at 12:00 Noon revealed that if the resident is found to have a pressure sore the nurse is to go assess it and measure the area. Get the Wound Nurse (WN) or other nursing staff from leadership to come look at it. The nurse would then contact the doctor and call the family. Interview with Dietary Manager (DM) on 02/26/2025 at 1:10 PM revealed DM is notified of wounds in the Risk Management Meeting held weekly and nursing. Stated, I would then do a dietary assessment on the resident and notify the Dietician. DM stated, I didn't notify the Dietician about Resident 20's wound yet because I didn't know if nursing management wanted Resident 20 to have any supplements. DM stated, I must have missed that Risk Meeting because I'm not sure what went on. Interview with Wound Nurse (WN) on 02/26/2025 at 12:40 PM confirmed that Resident 20 had a deep tissue injury to left heel and was not admitted with a pressure sore. WN confirmed Resident 20 had an increased weight gain in the month of 01/2025. WN is to discuss any issues of skin or wound issues in the Risk Management meeting held weekly. WN stated The nurse or me are to assess the wound weekly on the Pressure Ulcer Record. WN was given the copy of the Pressure Ulcer Record and asked if it was done weekly and dates on the record were as follows: 02/03/2025, 02/13/2025, and 02/20/2025. WN confirmed to not having the Pressure Ulcer Record done weekly following the initial evaluation. Interview with Therapy Manager (TM) on 02/26/2025 at 1:32 PM revealed that Resident 20 came off skilled services due to a decline. Stated, I did not know or get contacted from Nursing Management that Resident 20 had a deep pressure injury on left heel and would of assessed what pressure relieving devices would prevent further decline of heel wound. Interview with Occupational Therapist (OT) on 02/26/2025 at 2:00 PM revealed that on admission started working with Resident 20 and was unaware of the pressure wound on the left heel. Stated nursing management is supposed to contact us and then we assess for positioning and off-loading the pressure area. OT confirmed Resident 20 has Diabetic Shoes on when up in recliner or wheelchair and they do help relieve pressure but to be total pressure free would have to be specific off-loading devices for that area. Stated I just took Resident 20 off skilled services this past week. Interview with Corporate Nurse (Corp. Nurse) on 02/26/2025 at 4:20 PM revealed the staff are to follow the Skin and Wound management policy. If the resident is at risk for wounds, nursing staff are to put the resident on a pressure relieving mattress and cushion for the chair or wheelchair. The management staff have a weekly Risk Management Meeting where all the information on Residents conditions is discussed. We record it in the Shared Drive for other management to read. Training is done for skin and wound management on hire and annually for nursing staff members.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175-12-.006.09(H)(v) Based on observations, interviews and record reviews the facility failed to provide therapy or restorative services for one (Resident 38) of one sampled resident to prevent decline of resident condition. The facility identified a census of 56. Findings are: Record review of Resident 38's Census Data revealed the resident was admitted [DATE]. Record review of Resident 38's Face sheet revealed the resident was admitted with the following diagnosis: Weakness, Parkinsonism, Pain in left hip, Age related Osteoporosis without current pathological fracture, other Chronic pain. admitted to hospice 4/30/2024, removed from hospice 12/13/2024 due to slowed progression of disease and overall improvement. Record review of Resident 38's Significant change Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a residents functional capabilities and helps nursing home staff identify health problems) dated 12/20/2024 significant change: Section C, Brief Interview for Mental Status (BIMS), a brief screener that aids in detecting cognitive impairment score:13-15: cognitively intact, 8-12: moderately impaired,0-7: severe impairment) Resident had a score of 7 indicating severe impairment. Section GG showed Eating-Maximum assist, toileting Dependent, Bed mobility Dependent, transfers Dependent. Section O no special treatments including hospice, Section J question 14000 indicated the resident does not have a life expectancy of under 6 months. Record Review of Resident 38's Care Plan: ADLS revealed Dependent for all cares 2 assist (A) except eating is 1A. No Care Plan for therapy or restorative. Care Plan revised on 5/02/24 showed terminal prognosis related to terminal diagnosis Atherosclerotic Heart Disease of Native Coronary with unspecified angina pectoris. Terminal prognosis and hospice remain on care plan even though patient removed from hospice 12/20/2024. Record review of Resident 38 progress note date 12/14/2024 indicated resident came off hospice no documentation found that resident went on comfort care. An interview on 2/24/2025 with Resident 38's Resident Representative (RR) at 12:50 PM revealed the resident came off hospice over a month ago and restorative was requested and the facility told them they did not have restorative available right now. A few weeks later they were told someone was hired but still no restorative was offered or therapy screen completed. An interview with Licensed Practical Nurse (LPN)-E on 2/26/2025 at 9:05 AM revealed that Resident 38 would cooperate and benefit from restorative. An interview with the Therapy Director (TD), on 2/26/2025 at 9:25 AM revealed that Resident 38 is on hospice. Further discussion revealed the TD was told by nursing the resident remained on comfort care. When TD was asked what the process would be if a resident gets removed off hospice, the TD replied, they would typically screen and get an order to evaluate and treat and then determine a restorative program if therapy was not appropriate. An observation on 2/26/2025 at 3:09 PM revealed Resident 38 sitting in wheelchair, when cued to raise arms and open hands, resident complied and participated and stated that feels good. An interview with RR on 2/26/2025 at 3:50 PM confirmed family would like therapy to screen Resident 38 and that a different sibling had relayed that information several times to the facility. The RR went on to say that with Resident 38 having Parkinsons, Residents 38's legs get stiff but when you move them around the resident can stand better and tells family that it feels good to move them. An interview with Social Service Director (SSD) on 2/26/2025 at 3:45 PM confirmed Resident 38's RR wanted restorative or physical therapy for Resident 38. SSD also confirmed that 11/13/2025 was the last care plan completed, and 12/20/2024 the resident had a significant change and was taken off hospice. SSD stated, we should have had a care plan meeting then, it was a lack of communication and that is what I told the RR. SSD also verbalized there really is no process if someone comes off hospice that this is something they will have to investigate and fix the process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3) Based on interview, observations and record reviews, the facility failed to obtain a physician's order for the settings of CPAP (Continuous Positive Airway Pressure -a treatment that uses mild air pressure to keep your breathing airways open), and ensure the machine has a filter for one (Resident 109) of one sampled residents. The facility had a census of 56. Record review of Resident 109's admission record dated [DATE] revealed Resident 109 admitted to the facility on [DATE]. Observation on [DATE] at 1:35 PM revealed Resident 109's CPAP machine has no filter in the machine. Record review of Resident 109's Physician orders dated [DATE] revealed: -CPAP per home settings, on at HS (hour of sleep) off in AM every day and night shift -start date [DATE]. Record review of Resident 109's assessment dated [DATE] revealed Resident's BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) was 14, indicating that Resident 109 in cognitively intact. Observation on [DATE] at 9:30 AM of Resident 109's CPAP machine did not have a filter. Record review of Resident 109's Diagnosis dated [DATE] revealed: Chronic Obstructive Pulmonary Disease, and Obstructive Sleep Apnea. Observation on [DATE] at 2:00 PM of Resident 109's CPAP machine did not have a filter. Interview on [DATE] at 2:04 PM with DON confirmed that Resident 109's CPAP machine did not have a filter and that the facility needed to obtain the specific CPAP home settings according to the physician orders for the CPAP settings. Record review of Continuous positive airway pressure (CPAP) use dated [DATE] revealed: Continuous positive airway pressure (CPAP) provides constant positive pressure into the patient's airway to help hold the airway open, mobilize secretions, treat atelectasis, and generally ease the work of breathing period. CPAP helps treat moderate to severe obstructive sleep apnea. CPAP keeps the patients airway open, from the nares to the alveoli, thereby increasing functional residual capacity and improving gas exchange. Inspect all equipment and supplies if a product is expired, is defective, or has compromised integrity, remove it from the patient, use, label it as expired or defective, and report the expiration or defect as directed by your facility. -Verify the practitioner's order. -Documentation associated with continuous positive airway pressure (CPAP) use includes CPAP settings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.18, 1-005.06 (D)(E)(F) The facility failed to ensure staff wore masks above the nose and below the chin, the laundry staff performed hand hygiene for at least 20 seconds, the CPAP (Continuous Positive Airway Pressure -a treatment that uses mild air pressure to keep your breathing airways open), mask was cleaned every day for Resident 109, failed to have a barrier on the counter outside of a Covid positive resident's room where laundry items were placed, provide peri care after incontinence for Resident 11, and staff failed to remove PPE (Personal Protective Equipment used to protect healthcare workers, patients, and others from potentially contacting and/or spreading potential infections) correctly when exiting a positive Covid 19 residents room to prevent the potential spread of Covid 19. This had the potential to affect all residents in the facility. The facility had a census of 56. Findings are: A) Observation on 2/24/25 at 11:00 AM the entry desk of the facility has a tan-colored zone signage saying that masks are required. Record review of Transmission Based Precaution list with residents with Covid positive in rooms 307, 401, 403, 408, and 412. Observation on 2/24/25 at 11:04 AM of Guest Relations Staff Member (GR-C) had mask on below the nose. Observation on 2/24/25 at 4:14 PM of Guest Relations Staff Member (GR-D) had mask on below the nose. Observation on 2/25/25 at 9:12 AM of GR-D had mask on below the nose. Interview with Director of Nursing (DON) on 2/26/25 at 1:52 PM revealed that masks should be wore above the nose and below the chin. Record review of Covid 19 Education dated January 2021 revealed: Follow facility PPE instructions: -Wear a mask over your nose and mouth. B) Observation on 2/26/25 at 7:35 AM of hand washing by laundry staff member (LS-B). LS-B had placed linens in the wash machine, then removed their gown, goggles and gloves. LS-B performed hand hygiene with soap and water for 12 seconds. Interview on 2/26/25 at 7:40 AM with LS-B confirmed [gender] should have washed hands for 20 seconds. Interview on 2/26/25 at 9:30 AM with Houseker/Laundry Supervisor (HLS) confirmed that hand washing should be for 20 seconds. Record review of Covid-19 Guidelines Policy dated 10/20 revealed: purpose of this guideline is to provide clarification to policies and procedures the facility will take regarding COVID-19, to minimize exposure and properly identify residents, team members and visitors. With clinical features and risk for COVID-19. Prevention measures: -Wash your hands for at least 20 seconds. -When to perform hand hygiene. -After touching a resident or handling their belongings. -After any contact with body fluids. -After handling contaminated items (linens, garbage, briefs, etcetera. -Before and after gloving. C) Observation on 2/24/25 at 1:35 PM of Resident 109's CPAP (Continuous Positive Airway Pressure - a treatment that uses mild air pressure to keep your breathing airways open) revealed mask seal has facial oils on it. Interview on 2/24/25 at 1:37 PM with Resident 109 revealed the facility doesn't clean the mask. Record review of Resident 109's assessment dated [DATE] revealed Resident's BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) was 14, which indicated that Resident 109 is cognitively intact. Record review of Resident 109's Diagnosis dated 2/25/25 revealed: Chronic Obstructive Pulmonary Disease, and Obstructive Sleep Apnea. Record review of Resident 109's admission record dated 2/25/25 revealed admission to facility was 2/21/25. Observation on 2/25/25 at 9:30 AM revealed Resident 109's CPAP mask with white specks of debris on inside of mask and facial oils on the seal of the mask. Observation on 2/25/25 at 2:00 PM revealed Resident 109's CPAP mask had white specks of debris on inside of mask and facial oils on seal of the mask. Interview on 2/25/25 at 2:04 PM with DON confirmed the CPAP masks should be cleaned every day. Observation on 2/27/25 at 2:07 PM revealed Resident 109's CPAP has white specks of debris on the inside the CPAP mask. Record review of Resident 109's Physician Orders dated 2/25/25 revealed: -Daily CPAP cleaning: Wipe the portion of the mask that comes in contact with the resident's skin with damp cloth. Empty remaining water from the humidifier chamber, fill the chamber with soapy warm water and shake vigorously. Rinse the chamber with clean water and air-dry every day shift. Record review of Using Oxygen with Your CPAP/Bi-Level Unit policy undated revealed: Cleaning your CPAP/Bi-Level Equipment- Daily cleaning: -Wipe the portion of the mask that comes in contact with your skin with a damp cloth. This removes most skin oil from the mask. Record review of Continuous positive airway pressure (CPAP) use dated 11/18/24 revealed: Continuous positive airway pressure (CPAP) provides constant positive pressure into the patient's airway to help hold the airway open, mobilize secretions, treat atelectasis, and generally ease the work of breathing period. CPAP helps treat moderate to severe obstructive sleep apnea. CPAP keeps the patients open air and tire airway open, from the nares to the alveoli, therefore increasing functional residual capacity and improving gas exchange. -When the CPAP therapy is complete, follow these steps. Clean and disinfect the usable equipment according to the manufacturer's instructions and store it properly. D) Observation on 2/26/25 at 1:10 PM of LS-B delivering resident's laundry on hallway 300. LS-B placed a Covid positive resident's laundry on the nurse-server counter outside their room without sanitizing the counter or placing the laundry in a bag. Interview with LS-B on 2/26/25 at 1:18 PM revealed [gender] was not sure how to place the laundry of Covid positive residents on the nurse server counter without contaminating the clothes. Interview with the DON on 2/26/25 at 1:52 PM confirmed the laundry of Covid positive residents should be placed on a barrier on the nurse server counter outside of the resident's room. E) Record review of Resident 11's Census Data revealed the resident was readmitted to the facility on [DATE]. Record review of Resident 11's Face Sheet revealed the resident admitted with the following diagnosis: Unspecified dementia, unspecified severity, with behavioral disturbance, polyosteoarthritis, Parkinson's Disease and muscle weakness. Record review of Resident 11's 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 12/05/2024 revealed under Section C the Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment, the resident had a score of 5, indicating severe cognitive impairment. Section H0200 shows a zero for toileting plan. Section GG indicated the resident was dependent for toileting and maximum assistance for transfers and bed mobility. An observation on 2/25/2025 from 11:25 AM to 11:40 AM revealed Nurse Aide (NA)-A was in Resident 11's room wearing a face shield, N-95 mask, isolation gown and gloves as resident was in isolation due to having Covid-19 infection. NA-A was transferring Resident 11 with gait belt from wheelchair to toilet. Resident 11's sweatpants were visibly soaked with urine to below the knees and the wheelchair cushion was also noted to be wet with urine, and the incontinent pull up was saturated with tan colored urine. Resident verbalized that pants and wheelchair were wet. NA-A removed the soiled sweatpants and pull up while resident was sitting on the toilet. NA-A assisted the resident to stand and obtained 4 peri wipes and placed them together. NA-A then cleansed the resident by doing 4 swipes from the lower center of the buttocks crease to top of the buttocks crease using the same wipes folding once, and the wipes had visible feces on them. No incontinent cares provided to peri area, hips, thighs, or outer buttocks. NA-A removed soiled gloves, and without the benefit of hand hygiene or new gloves, NA-A put a clean pull up and pants on the resident. NA-A then assisted the resident to sit down in the wheelchair on the wet cushion without cleaning the cushion. NA-A continued to complete cares, without gloves on in an isolation room. NA-A completed cares, then when getting ready to exit room, NA-A used soiled hands and grabbed the inside of the isolation gown at the neck to remove the gown, touching the NA's clothing and skin below. NA-A used hand sanitizer, exited the room with face shield and mask on, took the face shield off and placed it on the counter outside the room, instead of a trash container. No further hand hygiene observed. An interview with NA-A on 2/25/2025 at 11:30 AM confirmed that Resident 11 is not on a toileting plan and that the resident was saturated with urine and the NA did not think about cleansing the buttocks, hips and back of legs. NA-A also confirmed that no hand hygiene had been completed at any time during the cares, nor new gloves applied. An interview with the Director of Nursing (DON) on 2/26/2025 at 10:27 AM confirmed that NA-A did not follow expectations for incontinence cares for Resident 11 due to not cleansing areas exposed to urine and not using separate wipes during cares. DON also confirmed NA-A should have cleansed the wheelchair cushion after incontinence, and did not remove the isolation gown or dispose of face shield correctly. Record review of Donning and Doffing Competency last revised 3/2021 with Sequence for safe removal of personal protective equipment (PPE) under number 2: place face shield in designated receptacle for reprocessing, otherwise, discard in waste container. Number 2 of the Competency revealed removal of gown to reach up to the shoulders and carefully pull gown down and away from the body, rolling the gown and placing in receptacle. Review of Mosby's textbook for Nursing Assistants, 6th edition, page 382: Incontinence can put a resident at risk for skin irritation, infection, and pressure ulcers if good skin care not performed with incontinence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006.09D Based on interview and record review; the facility failed to ensure parameters (a range) for 1 (Resident 17) of 5 sampled resident's Amlodipine (a blood pressure medication) were followed, and at least 8 ounces of fluid were given to 1 (Resident 17) of 5 sampled resident's four times a day per the physician's order. The facility census was 52. Findings are: In an interview on 03/20/2024 at 3:45 PM, the facility's Administrator confirmed the facility did not have a following provider orders policy, procedure, or guideline. A record review of Resident 17's Clinical Census dated 03/19/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 17's Medical Diagnosis dated 03/21/2024 revealed the resident had diagnoses of: Essential (Primary) Hypertension (high blood pressure), Unspecified Systolic (Congestive) Heart Failure, Cardiomyopathy, Unspecified (disease of the heart muscle), Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris (plaque build-up in the arteries, Presence of Cardiac Pacemaker (a device use to stimulate the heart), and Dementia In Other Diseases Classified Elsewhere, Moderate With Anxiety (confusion with worry). A record review of Resident 17's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 12/19/2023, revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 0 which indicated the resident was severely cognitively impaired. The resident was dependent on staff for all activities of daily living. A record review of Resident 17's active Care Plan revealed the resident had a Focus area of being at risk for altered cardiovascular (heart and vessels) related to Pacemaker and Cardiomyopathy. The Care Plan identified an intervention of providing medications and labs as per physician's order and monitor the resident's blood pressures and pulse weekly and as needed. A. A record review of Resident 17's Order Summary Report dated 03/21/2024 revealed the resident had an order of: Amlodipine Besylate Tablet 5 milligrams (MG), Give 1 tablet by mouth in the morning for Hypertension. Hold Amlodipine if Systolic (1st number in blood pressure (BP) reading) less than 110 or Diastolic (2nd number in BP reading) less than 50 or if pulse less than 60 beats per minute. A record review of Resident 17's Physician Visit/Communication Form (v6) dated 04/24/2019 revealed a reason for visit/fax of Resident 17 was to start Amlodipine due to the resident's blood pressure being elevated. The provider responded with parameters for the medication of: to hold if the systolic BP less than 110, diastolic BP less than 50, and hold if pulse less than 60. A record review of Resident 17's Medication Administration Record (MAR) dated February 2024 and March 2024 revealed Amlodipine was administered outside of parameters on the following dates: -02/05/2024 was administered with a BP of 104/71, -02/11/2024 was administered with a pulse of 59, -03/03/2024 was administered with a BP of 108/72, -03/05/2024 was administered with a BP of 105/68, -03/13/2024 was administered with a BP of 103/59, -03/14/2024 was administered with a BP of 109/64. In an interview on 03/20/2024 at 7:50 AM, Licensed Practical Nurse (LPN)-B revealed Resident 17's Amlodipine was not to be administered if the systolic BP was less than 110, the diastolic BP was less than 50, or the pulse was less than 60. LPN-B confirmed that the Amlodipine was administer with out-of-range parameters on the above dates and should not have been. In an interview on 03/20/2024 at 7:53 AM, Medication Aide (MA)-F confirmed MA-F administered a dose of Amlodipine on 03/14/2024 to Resident 17 with a Systolic BP reading of 109 and should not have. In an interview on 03/20/2024 at 2:20 PM, the Director of Nursing (DON) confirmed the MA was responsible for documenting the BP on the MAR and should not have administered the Amlodipine if it was not within the parameters the provider specified on the orders. B. A record review of Resident 17's Order Summary Report dated 03/19/2024 revealed the resident had an order of: Give 8 ounces (oz) of fluid QID (four times a day) for increase fluids. A record review of Resident 17's Physician Visit/Communication Form (v6) dated 12/13/2022 revealed an order to increase fluids - 84 oz per day. A record review of Resident 17's Nutritional Risk Assessment V3 dated 12/16/2022 revealed the Registered Dietician documented: 12/13/2024 MD wrote to increase fluids to 84oz per day (2450cc) on [DATE]oz QID for added fluids. A record review of Resident 17's MAR Dated January 2024 revealed the only days that 8 oz of fluids were administered 4 times per day were: -01/01/2024 -01/02/2024 -01/03/2024 -01/04/2024 -01/09/2024 -01/12/2024 -01/15/2024 A record review of Resident 17's MAR dated February 2024 revealed the only day the resident was given 8oz of fluids 4 times per day was on 02/04/2024. A record review of Resident 17's MAR dated March 2024 revealed the only day the resident was given 8oz of fluids 4 times per day was on 03/13/2024. In an interview on 03/19/2024 at 2:56 PM, the DON confirmed that the provider did order a specific fluid intake parameter and the facility's RD changed it to 4 times per day on 12/18/2023. In an interview on 03/20/2024 at 7:50 AM, LPN-B confirmed LPN-B reviewed January - March 2024 MARs the resident did not get 8oz of fluid 4 times per day or 84 oz per day and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006.09D6(5) Based on observation, interview, and record review, the facility failed to ensure a valid oxygen order was followed for 1 (Resident 30) of 2 sampled residents. The facility census was 52. Findings are: In an interview on 03/20/2024 at 3:45 PM, the facility's Administrator confirmed the facility did not have an oxygen policy, procedure, or guideline. A record review of Resident 30's Clinical Census dated 03/20/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 30's Medical Diagnosis dated 03/20/2024 revealed the resident had diagnoses of Unspecified Bacterial Pneumonia, Obstructive Sleep Apnea (periods of not breathing when sleeping), Acute Combined Systolic (congestive) and Diastolic (Congestive) Heart Failure, Cerebral Infarction, Unspecified (stroke), and Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety (confusion without behaviors). A record review of Resident 30's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 12/28/2023 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 14 which indicated the resident was cognitively aware. The resident was dependent on staff for toileting, bathing, lower body dressing, putting on and taking off footwear, partial/moderate assistance for oral hygiene (cleaning), and substantial/maximal assistance for upper body dressing. The MDS revealed Resident 30 was on continuous oxygen when discharged . A record review of Resident 30's Clinical Physician's Orders dated 03/20/2024 revealed the resident had an order for: Oxygen at all times to keep oxygen saturation (percent oxygen in bleed) above 90 percent (%). An observation on 03/18/2024 at 2:59 PM revealed Resident 30 had a nasal cannula (tubing that goes in nose to deliver oxygen) on and oxygen was set at 2 liters per minute (l/m). An observation on 03/20/2024 at 8:20 AM revealed Resident 30 was seated in the dining room with a nasal cannula in the nose but the flowmeter on the oxygen tank was set at 0. In an interview on 03/20/2024 at 8:23 AM, Resident 30 confirmed he was supposed to be on the oxygen all the time since the last hospital visit. Resident 30 confirmed the oxygen was supposed to be set at 2 l/m. An observation on 03/20/2024 at 8:27 AM with the Director of Nursing (DON) revealed Resident 30 was seated in the dining room with a nasal cannula in the nose and oxygen tank flowmeter was set at 0. The DON turn the dial on the oxygen tank flowmeter to a setting of 1 l/m. In an interview on 03/20/2024 at 8:27 AM, the DON confirmed the oxygen was set at 0 and the resident had an order for oxygen as needed and that the DON set the oxygen to 1 l/m and the order did not contain a specific liter flow. The DON confirmed Resident 30 does request the oxygen to be on for comfort. A record review of Resident 30's Patient Discharge Instructions from the hospital dated 01/25/2024 with the DON revealed the provider ordered: Oxygen at 2 l/m at all times. In an interview on 03/20/2024 at 1:01 PM, the DON confirmed Resident 30 should worn the oxygen all the time and it should have been set at 2 l/m per the provider's discharge instructions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. A record review of the facility's undated Medication Aide Procedure Checklist Topical (applied to skin) Medication revealed the facility staff was to apply gloves, apply the topical medication according to the five rights, remove gloves and discard into waste container, then wash and dry hands thoroughly when applying topical medication. A record review of facility's Hand Hygiene (cleaning) policy with a revision date of 09/12/2017 revealed the staff were to use gloves before contact with blood and body fluids, and non-intact skin (skin that was open). The policy revealed the staff was to perform proper hand hygiene to prevent the transmission of infectious agents after contact with inanimate objects (non-living items). A record review Resident 29's Clinical Census dated 03/21/2024 revealed that the facility admitted Resident 29 on 07/26/2022. A record review of Resident 29's Medical Diagnosis dated 03/19/2024 revealed a diagnoses of Systemic Lupus Erythematosus (SLE)(the body's immune system attacks healthy tissue), Unspecified. Essential (Primary) Hypertension (high blood pressure), Hypo-Osmolality (low blood nutrients and electrolytes) and Hyponatremia (low sodium), Hypokalemia (low calcium), Hypothyroid (low throid levels), Peripheral Vascular Disease (low blood flow in extremities), Unspecified, Anorexia (unknow eating disorder), Unspecified Protein-Calorie Malnutrition (reduced nutrition status), and Chilblains (inflamed or swollen patches and blisters on the hands and feet). A record review of Resident 29's Care Plan with an admission date of 04/13/2022 revealed Resident 29 was an extensive assist with dressing lower body, one assist to dress upper body, extensive assist of one for bed mobility and bathing, one assist for stand pivot transfer with a gait belt, extensive assist for toilet use, and one assist for personal hygiene. The Care Plan dated 04/13/2022 revealed a focus area of: Impaired immunity related to chronic steroid use; Lupus and long-term steroid use with interventions of zinc barrier cream to buttocks with peri cares (cleaning after bowel elimination), alternating pressure mattress, and encourage repositioning. The Care Plan did not reveal a focus area or interventions for coccyx wound (open area on buttocks). A record review of Resident 29's Order Summary Report dated 03/19/2024 revealed the resident had an order for: Triad Hydrophilic Wound Dress External Paste (Wound Dressings) Apply to wound on coccyx topically two times a day for chronic skin integrity issue(s). May cover with Mepilex (dressing) border- remove bottom border when applying. Peel back Mepilex and reapply with TRIAD cream application, if the dressing is intact and not wrinkled up. In an observation on 03/20/2024 at 9:15 AM A observation of Licensed Practical Nurse (LPN)-B, charge nurse, completed Triad cream treatment. LPN-B washed hands and donned (put on) a glove to the right hand only. LPN-B used ungloved left hand to peel up the bottom portion of the Mepilex which was located to Resident 29's coccyx area. With the right gloved hand LPN-B placed the Triad cream on Resident 29's open wound, then replaced the bottom portion of the Mepilex that was peeled up. LPN-B then donned glove to the left hand and obtained a peri wipe. LPN-B performed a wipe on the resident's peri area. LPN-B wiped from front to back and placed the wipe in the trash, LPN-B then obtained a clean wipe and wiped the outer portion of resident's bottom and placed wipe in the trash. LPN-B then pulled up Resident 29's pants. LPN-B removed gloves and performed hand hygiene. The observation did not reveal LPN-B donned a glove on the left hand to prior to touching the coccyx to peel up bottom portion of Mepilex or that LPN-B performed hand hygiene prior to donning a glove on the left hand. In an interview on 03/20/2024 at 9:30 AM, LPN-B, charge nurse, confirmed staff was to wear gloves on both hands when performing a wound treatment, and that this time only the right hand was gloved. LPN-B confirmed that LPN-B did not perform hand hygiene or glove prior to working with the Mepilex dressing located on the coccyx area. C. A record review of the undated Infection Prevention Guide to Long-Term Care Interdisciplinary and Support Services guideline provided by the Infection Preventionist (IP) revealed the following were factors that should be monitored to minimize the risk for infection transmission associated with soiled linen and clothing: -Soiled linen should be handled as little as possible and with minimal agitation to prevent microbial contamination of the air and any healthcare personnel or other individuals in the adjacent area. -All soiled linen should be handled as if contaminated and should be bagged and put into laundry carts at the location where it is collected. -Soiled linen should be placed in impervious bags, placed in designated carts, and transported to a holding area for either on site processing or scheduled pick up by the contracted laundry service. -Facilities that provide hampers in resident rooms for soiled clothing must be emptied per schedule; clothing should be bagged prior to removal from the room. -All used linen is considered contaminated as a standard precaution. In an interview on 03/20/2024 at 4:13 PM, the IP confirmed that the facility does not have a policy regarding transport of soiled linen. A record review of facility's Hand Hygiene policy with a revision date of 09/12/2017 revealed that the staff was to perform proper hand hygiene to prevent the transmission of infectious agents after contact with inanimate objects. An observation on 03/19/2024 at 10:30 AM revealed Medication Aide (MA)-D came out of Resident 203's room with an unbagged towel and a washcloth in the left hand. The observation did not reveal gloves on the hands of MA-D. MA-D then crossed the hallway to the soiled utility room and MA-D entered the soiled utility and placed the towel and washcloth in the soiled linen bin. MA-D then left the soiled utility room. The observation did not reveal hand hygiene was performed by MA-D after carrying the soiled linens that were placed in the soiled linen bin. MA-D then exited the soiled utility room and shut the door. No hand hygiene or sanitizing was observed for MA-D. MA-D then walked down the hallway and entered resident's room [ROOM NUMBER]. An observation on 03/19/2024 at 10:36 AM revealed MA-D came out of residents' room [ROOM NUMBER]. No gloves were present. MA-D carried a black garbage bag in one hand, and a towel and washcloth without a bag in the other hand. MA-D then crossed the hallway to the soiled utility room. MA-D entered the soiled utility and placed black garbage bag in bin, and the towel/washcloth in the soiled linen bin. MA-D then left the soiled utility room and no hand sanitizing was observed from MA-D after carrying the soiled linens that were placed in the soiled linen bin. MA-D then walked down the hallway not stopping to complete hand hygiene, MA-D walked off the unit. An Observation of Nursing Assistant (NA)-E on 03/20/2024 at 1:25 PM revealed NA-E wheeled Resident 21 from dining room to room [ROOM NUMBER]. NA-E entered room [ROOM NUMBER] with the resident and shut the door. At 1:35 PM NA-E exited room [ROOM NUMBER] holding a black garbage bag in the left hand and a towel and washcloth with a wet appearance in the right hand. No gloves were observed NA-E hands. NA-E then crossed the hallway to the soiled utility room. NA-E opened the door and placed the black bag into a trash bin and placed the linens into a soiled linen bin. NA-E held the soiled utility room door open with foot. NA-E then came out of the soiled utility room and walked down the hallway turning to leave the unit. No hand hygiene or sanitizing observed. In an interview with NA-E on 03/20/2024 1:36 PM confirmed that linens were not in a bag while walking from room [ROOM NUMBER] to the soiled utility and that they were to be placed in a bag, to be transported. NA-E also confirmed that gloves were not worn with the soiled linen transport. An interview with Director of Nursing (DON) on 03/20/2024 at 1:45 PM confirmed that the expectation for carrying dirty linens and laundry to the soiled utility room were that all linens were to be placed in a bag for staff transport. Liscensure Reference Number 12-006.18C Liscensure Reference Number 12-006.17D The facility failed to ensure proper hand hygiene and gloving was performed during wound care for Resident 29, failed to ensure contaminated laundry was carried in a manner to prevent cross contmination and hand hygiene was performed after transportation, failed to ensure Resident 21's Neb kit was cleaned after each treatment. The facility census was 52. D. A record review of the facility's Nebulizer Therapy, Small Volume policy dated 11/17/2017 revealed the staff should rinse the nebulizer with sterile water and allow to air dry or discard it after each treatment. A record review of Resident 21's Clinical Census dated 03/20/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 21's Medical Diagnosis dated 03/20/2024 revealed the resident had diagnoses of Personal History of Traumatic Brain Injury, Diffuse Traumatic Brain Injury with Loss of Consciousness of Unspecified Duration, and Hemiplegia, Unspecified Affecting Right Dominant Side (loss of movement on right side). A record review of Resident 21's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 06/29/2023 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 10 which indicated the resident was moderately cognitively impaired. The resident was supervision or touching assistance for oral hygiene (cleaning), dependent for bathing, and substantial/maximal assistance with all other activities of daily living except eating. A record review of Resident 21's Care Plan with an admission date of 07/10/2019 did not reveal the resident had a Focus area or interventions for nebulizer treatments. An observation on 03/18/2024 at 10:26 AM revealed there was a nebulizer kit and mask draped over the nebulizer on the bedside table. The mask had a coating of facial oils on it and there was a residual (small, left over amount) of medication remaining in the nebulizer cup. An observation on 03/19/2024 at 10:46 AM revealed there was a nebulizer kit and mask in the black infection control bag. The mask had a coating of facial oils on it and there was a residual of medication remaining in the nebulizer cup. An observation on 03/20/2024 at 8:00 AM revealed there was a nebulizer kit and mask in the black infection control bag. The mask had a coating of facial oils on it and there was a residual of medication remaining in the nebulizer cup. A record review of Resident 21's Order Summary Report dated 03/20/2024 revealed an order of Albuterol Sulfate Nebulization Solution (a medication that is inhaled to relax the muscle around the tubes in the lungs and allow them to open) every 6 hours as needed. A record review of Resident 21's Medication Administration Record (MAR) dated March 2024 revealed the resident's Albuterol Sulfate Nebulization solution was administered on: -03/04/2024 at 1:45 AM -03/07/2024 at 2:03 AM and 1:38 PM -03/08/2024 at 3:02 PM -03/10/2024 at 9:17 AM -03/11/2024 at 12:14 AM -03/12/2024 at 12:30 AM -03/16/2024 at 7:47 AM and 16:53 PM -03/17/2024 at 1:30 AM and 4:40 PM -03/19/2024 at 7:14 AM An observation on 03/20/2024 at 9:15 AM with Licensed Practical Nurse (LPN)-B revealed there was a nebulizer kit and mask in the black infection control bag. The mask had a coating of facial oils on it and there was a residual of medication remaining in the nebulizer cup. In an interview on 03/20/2024 at 9:15 AM, LPN-B confirmed LPN-B observed Resident 21's Nebulizer mask and nebulizer kit had not been cleaned since the last treatment and should have been. LPN-C confirmed the staff was to clean the nebulizer kit and mask after each treatment.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on interview and record review, the facility staff failed to ensure physician's orders were followed when a thyroid medication was discontinued to ensure there were not adverse effects from discontinuing the medication for Resident 19. This affected 1 of 5 sampled residents. The facility identified a census of 52 at the time of survey. Findings are: Review of Resident 19's admission Record revealed an admission date of 10/6/22 Review of Resident 19's diagnoses listed on the care plan dated 12/22/22 revealed Resident 19 had a diagnosis of hypothyroidism Hypothyroidism is an underactive thyroid gland. Hypothyroidism means that the thyroid gland can ' t make enough thyroid hormone to keep the body running normally. Thyroid hormone helps the body use energy, stay warm and keep the brain, heart, muscles, and other organs working as they should). Review of Resident 19's laboratory report dated 10/25/2022 revealed the following order: stop levothyroxine & recheck TSH in 3 months. (TSH stands for thyroid stimulating hormone. A TSH test is a blood test that measures this hormone. TSH levels that are too high or too low may be a sign of a thyroid problem. The thyroid is a small, butterfly-shaped gland in the front of your neck. Your thyroid makes hormones that control how your body uses energy. Thyroid hormones affect nearly every organ in your body, including your heart. They help control your weight, body temperature, muscle strength, and even your mood. If you don't have enough thyroid hormones in your blood, many of your body functions slow down. If you have too much, many body functions speed up). Review of Resident 19's MAR (Medication Administration Record) for October 2022 revealed the levothyroxine was administered to Resident 19 during the month of October until it was discontinued as ordered 10/25/22. Review of Resident 19's MAR for November and December 2022; and January, February, March, and April 2023 revealed the levothyroxine was no longer being administered to Resident 19 as was ordered. Review of Resident 19's Progress Notes dated October 25, 2022 to April 11, 2023 revealed no documentation a TSH had been completed 3 months after the levothyroxine was discontinued as was ordered. Review of Resident 19's EHR (Electronic Health Record) revealed no documentation the TSH was completed 3 months after the levothyroxine was discontinued. Interview with the DON (Director of Nursing) on 04/12/23 at 12:17 PM confirmed the TSH did not get checked for Resident 19 as ordered. The DON revealed when the order was scanned into the EHR, the nurse was not alerted to note and and sign it off to make sure the order was carried out. Interview with the DON on 4/12/23 at 12:34 PM revealed they had contacted the medical provider's medical clinic to determine if the TSH had been done there and the DON confirmed it had not been completed for Resident 19. The DON revealed the facility didn't have a policy for following medical provider's orders; the staff were just expected to follow standards of practice and the regulations.

Licensure Reference Number 175NAC 12-006.11A1 Based on observation, record review, and interview the facility failed to ensure that dietary staff followed the menus for food serving sizes for resident foods and failed to prepare foods following the facility recipes. This affected 28 residents (Residents 31, 44, 25, 7, 26, 19, 39, 12, 20, 24, 3, 30, 29, 2, 45, 49, 13, 16, 23, 10, 28, 6, 47, 38, 35, 37, 4, and 18). The facility census was 52. Findings are: A. Record review of the undated Diet Spreadsheet (a menu with serving sizes to be provided for resident meals) provided by the facility on 4/12/23 revealed it was the Diet Spreadsheet for Week 1 Day 4 of the menu cycle. The Diet Spreadsheet revealed that the portion (serving) size for the pureed (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) chicken and dressing casserole was two dips of a number 8 dipper (a measured serving utensil) (A single number 8 dipper is 4 ounces of food. Per the menu, two dips were required for the 8-ounce total portion size to be served per the menu.). Observation on 4/12/23 at 11:11 AM in the facility kitchen revealed that Dietary Cook-A (DC-A) picked up an empty ivory bowl from the table and placed 2 dark blue number 16 dips (2 ounces per dip) of the chicken and dressing casserole into the ivory bowl (a total serving of 4 ounces was placed into the bowl). DC-A sat the bowl on the table next to the blender. Observation on 4/12/23 at 11:20 AM in the facility kitchen revealed that DC-A poured the 4 ounces of chicken and dressing casserole from the small ivory bowl into the blender. DC-A added a small amount of milk to the blender bowl. DC-A operated the blender to puree the chicken and dressing casserole. DC-A used a spoon to move the pureed casserole from the blender bowl into the small ivory bowl. DC-A placed the bowl of puree casserole into the warmer cart. Observation on 4/12/23 at 12:48 PM in the facility kitchen revealed that DC-A walked to the warmer cart and opened it. DC-A removed the ivory bowl of pureed chicken and dressing casserole and an ivory bowl of the pureed green beans from the warmer. DC-A carried the bowls to the steam table. DC-A picked up the bowl of pureed chicken and dressing casserole and the bowl of pureed green beans and sat them on a tray for Resident 31. Interview on 4/13/23 at 9:52 AM with the consultant Registered Dietitian (RD) confirmed that the expectation was for the Dietary [NAME] to serve an 8-ounce portion of the chicken and dressing casserole per the menu. The RD confirmed that the pureed chicken and dressing casserole portion should have been an 8-ounce serving per the menu and not the 4-ounce serving that was provided to the resident. B. Record review of the undated Diet Spreadsheet (a menu with serving sizes to be provided for resident meals) provided by the facility on 4/12/23 revealed it was the Diet Spreadsheet for Week 1 Day 4 of the menu cycle. The Diet Spreadsheet revealed that the portion (serving) size for the regular diet chicken and dressing casserole was 8 ounces total portion size to be served per the menu. Observation on 4/12/23 at 11:46 AM in the facility kitchen revealed that Dietary Cook-A (DC-A) began to remove the covers from the food items on the steam table. A gray number 8 dipper (a serving utensil for serving 4 ounces of food) sat on the steam table counter in front of the pan of chicken and dressing casserole. DC-A picked up a plate. DC-A picked up the number 8 (4 ounce) dipper. DC-A placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 44. DC-A sat the plate on the tray in the service window to be served to Resident 44. (DC-A did not serve 8 ounces of the chicken and dressing casserole as directed by the menu). DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 25. DC-A sat the plate on the tray in the service window to be served to Resident 25. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 7. DC-A sat the plate on the tray in the service window to be served to Resident 7. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 26. DC-A sat the plate on the tray in the service window to be served to Resident 26. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 19. DC-A sat the plate on the tray in the service window to be served to Resident 19. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 39. DC-A sat the plate on the tray in the service window to be served to Resident 39. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 12. DC-A sat the plate on the tray in the service window to be served to Resident 12. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 20. DC-A sat the plate on the tray in the service window to be served to Resident 20. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 24. DC-A sat the plate on the tray in the service window to be served to Resident 24. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 3. DC-A sat the plate on the tray in the service window to be served to Resident 3. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 30. DC-A sat the plate on the tray in the service window to be served to Resident 30. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 29. DC-A sat the plate on the tray in the service window to be served to Resident 29. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 2. DC-A sat the plate on the tray in the service window to be served to Resident 2. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 45. DC-A sat the plate on the tray in the service window to be served to Resident 45. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 49. DC-A sat the plate on the tray in the service window to be served to Resident 49. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 13. DC-A sat the plate on the tray in the service window to be served to Resident 13. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 16. DC-A sat the plate on the tray in the service window to be served to Resident 16. The time was now 12:19 PM. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 23. DC-A sat the plate on the tray in the service window to be served to Resident 23. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 10. DC-A sat the plate on the tray in the service window to be served to Resident 10. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 28. DC-A sat the plate on the tray in the service window to be served to Resident 28. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 6. DC-A sat the plate on the tray in the service window to be served to Resident 6. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 47. DC-A sat the plate on the tray in the service window to be served to Resident 47. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for a guest of Resident 53. DC-A sat the plate on the tray in the service window to be served to the guest of Resident 53. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 38. DC-A sat the plate on the tray in the service window to be served to Resident 38. DC-A walked to the warmer cart and opened it. DC-A removed an ivory bowl of pureed chicken and dressing casserole and an ivory bowl of the pureed green beans from the warmer. DC-A carried the bowls to the steam table. DC-A sat the bowls on the counter of the steam table. DC-A picked up the plate for Resident 35 and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 35. DC-A sat the plate on the tray in the service window to be served to Resident 35. DC-A picked up the bowl of pureed chicken and dressing casserole and the bowl of pureed green beans and sat them on a tray in the service window for Resident 31. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 37. DC-A sat the plate on the tray in the service window to be served to Resident 37. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 4. DC-A sat the plate on the tray in the service window to be served to Resident 4. DC-A picked up a plate and placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 18. DC-A sat the plate on the tray in the service window to be served to Resident 18. The time was now 12:54 PM. DC-A revealed that all residents were served except for 1 resident that was out of the facility at an appointment. Interview on 4/12/23 at 12:55 PM with DC-A confirmed that the gray number 8 dipper scoop used to serve the chicken and dressing casserole was a 4-ounce scoop. Interview on 4/13/23 at 9:52 AM with the consultant Registered Dietitian (RD) confirmed that the expectation was for the dietary cook to serve an 8-ounce portion of the chicken and dressing casserole per the menu. The RD confirmed that the dietary cook should have served an 8-ounce portion of the chicken and dressing casserole and not the 4-ounce serving that was provided to the residents.

B. Record review of personnel files revealed that the Dietary Manager (DM) did not have a certificate for the dietary manager position. Interview with the DM on 4/12/23 at 3:03PM revealed that employment began in March 2023. The DM started class for the CDM course on 3/30/23. The DM does not have the required amount of required training in previous employment. Interview on 4/13/23 at 9:52AM with Registered Dietician revealed that the facility DM did not have the required documented certification. Licensure Reference Number 175NAC 12-006.04D2 Based on record review and interview the facility failed to ensure that the facility Dietary Manager had the required credentials to meet the regulatory guidelines for the position. This had the potential to affect food service provided to 52 of 52 residents who are served food from the facility kitchen. The facility census was 52. Findings are: A. Record review of the undated facility Dietary Supervisor (Manager) Job Description revealed the section titled Professional Qualifications. The professional qualifications revealed that Dietary Supervisors are qualified as a food service supervisor. Interview on 4/12/23 at 3:02 PM with the facility Dietary Manager (DM) confirmed that the DM is not a certified dietary manager. The DM revealed that the consultant Registered Dietitian (RD) has been in the facility a couple of times since the DM started working in the facility. The DM revealed that the consultant RD was to be in the facility twice a month. The DM revealed that the DM started the certified dietary manager training course on 3/30/23. The DM confirmed that the DM had worked as a dietary cook in food service settings, but not in a long-term care food service setting. The DM confirmed that they did not have managerial experience in a long-term care food service setting and had not worked in food service in long term care. Interview on 4/13/23 at 9:52 AM with the consultant RD revealed that the RD is not full time in the facility. The RD revealed that the RD is in the facility one day every other week and as needed. The RD confirmed that the facility DM is not a certified dietary manager.

E. Observation of DC- A at 12:00PM on 4/12/23 during serving in facility kitchen DC-A put on one glove and opened freezer with un-gloved hand. DC-A did not perform hand washing prior to gloving. Pulls out a frozen hamburger from a bag in the freezer with gloved hand and puts it on a plate. With same glove DC-A took a hamburger bun out of package, opened it and placed the burger inside of bun. Picked up the plate with glove and placed it in microwave with gloved hand, then grabs a bag of chips with un-gloved hand. F. Observation of DC-A at 12:14 PM on 4/12/23 in facility kitchen revealed DC-A scooped up mashed potato's and placed them on a plate and held them over steam table. DC-A then observed dumping potatoes back into pan on steam table. Licensure Reference Number 175NAC 12-006.11E Based on observation, record review, and interview the facility failed to ensure that dietary staff followed food safety procedures for checking the temperatures of resident foods which had the potential to affect all facility residents that received food from the facility kitchen. The facility failed to ensure that staff performed hand washing as required during food preparation, food service, and glove use, and failed to handle plates in a manner to prevent the potential for foodborne illness and cross contamination; failed to ensure that staff handled ready to eat foods in a sanitary manner to prevent the potential for foodborne illness and cross contamination for 11 residents (Residents 21, 51, 42, 5, 8, 1, 17, 36, 50, 43, and 53); and the facility failed to ensure that facility staff delivered meals to residents in a manner to prevent the potential for cross contamination and foodborne illness for 7 residents (Residents 7, 32, 4, 51, 25, 40, and 47). The facility census was 52. Findings are: A. Record review of the Nebraska Food Code, Effective date 7/21/16, 4-302.12 Food Temperature Measuring Devices revealed that food temperature measuring devices shall be provided and readily accessible for use in ensuring attainment and maintenance of food temperatures as specified under Chapter 3. Section 4-602.11 revealed that equipment food-contact surfaces and utensils shall be cleaned: before using or storing a food temperature measuring device (thermometer) and at any time during the operation when contamination may have occurred. Section 4-703.11 revealed that equipment food-contact utensils shall be sanitized in: A) Hot water by immersion for at least 30 seconds, C) Chemical application of sanitizing chemicals by immersion, manual swabbing, brushing, or pressure spraying methods, using a solution as specified under subsection 4-501.114. Observation on 4/12/23 at 10:33 AM in the facility kitchen revealed that Dietary Cook-A (DC-A) opened an alcohol prep pad. DC-A removed the chicken and dressing casserole from the oven and wiped the thermometer with the alcohol prep pad. DC-A inserted the thermometer probe into the casserole and obtained a temperature of 100.3 degrees Fahrenheit (F). The casserole was not at a safe food temperature of 135 F or above. DC-A replaced the foil over the casserole and placed it back into the oven. DC-A sat the thermometer on the table. DC-A removed the pan of polish sausages from the oven. DC-A wiped the thermometer probe and obtained a temperature of 146.1 F. DC-A replaced the foil and returned the pan of polish sausages into the oven. DC-A wiped the thermometer probe and sat it on the table in the same area on the table where it had been placed after obtaining the temperature of the chicken and dressing casserole. DC-A removed the pan of mashed potatoes from the food warmer. DC-A wiped the thermometer probe and obtained a temperature of 124.7 F. DC-A placed the pan of mashed potatoes into the steam oven. DC-A sat the thermometer on the table in the same area on the table where it had been placed after obtaining the temperature of the chicken and dressing casserole. Observation on 4/12/23 at 11:00 AM in the facility kitchen revealed that DC-A put oven mitt gloves on both hands. DC-A removed a pan of gravy from the warmer and sat the pan on the table. DC-A picked up the thermometer from the table. DC-A used the thermometer and obtained a temperature of 180.3 F. DC-A had not disinfected the thermometer probe prior to obtaining the temperature. DC-A carried the thermometer to the kitchen sink marked hand wash only. DC-A rinsed the probe of the thermometer underneath the running water for 3 seconds and then dried it with a paper towel. DC-A sat the thermometer on the table and placed the pan of gravy into the steam table. DC-A removed the pan of mashed potatoes from the steam oven and placed the pan into the steam table. DC-A picked up the thermometer and placed the probe of the thermometer into the pan of the mashed potatoes. DC-A obtained a temperature of 181.5 F with the thermometer. DC-A had not disinfected the thermometer prior to obtaining the temperature of the mashed potatoes. DC-A sat the thermometer on the soiled cutting board on the table. DC-A removed the pan of polish sausages from the oven and sat the pan on the stove. DC-A picked up the thermometer and pierced several polish sausages with the probe of the thermometer. DC-A obtained the temperature of the polish sausages at 198.8 F. DC-A had not disinfected the thermometer prior to obtaining the temperature of the polish sausages. DC-A sat the thermometer on the table. DC-A moved the pan of polish sausages into the steam table. DC-A removed the chicken and dressing casserole from the oven and sat it on the top of the stove. DC-A picked up the thermometer and inserted the thermometer probe into the casserole. DC-A obtained a temperature of 183.2 F for the casserole. DC-A had not disinfected the thermometer before using it to obtain the temperature of the casserole. DC-A sat the thermometer on the table. DC-A placed the pan with the chicken and dressing casserole into the steam table. Interview on 4/13/23 at 9:52 AM with the consultant Registered Dietitian (RD) confirmed that dietary staff obtain food temperatures when they are placed in the steam table. The RD confirmed that the staff are required to sanitize the thermometer before using it. The RD revealed that staff may rinse the thermometer to remove heavy foods such as gravy from the thermometer but must then disinfect it by wiping it with an alcohol prep pad or a rag with sanitizer solution. B. Record review of the facility policy titled Hand Hygiene (hand washing with soap and water or alcohol-based hand sanitizer) Competency dated 12/2019 revealed the procedure steps for washing the hands with soap and water. Staff are to wet the hands. Staff apply soap and using friction lather and rub the hands together for a full 20 seconds. Rinse the hands well and dry the hands. The policy revealed that staff are to wash hands whenever hands are soiled, after handling contaminated items, before and after gloving, and whenever indicated. Record review of the Nebraska Food Code, Effective date 7/21/16, 81-2,272.10* (Replaces 2013 Food Code 3-301.11 (B), (C), (D) and (E) Preventing Contamination from Hands) * revealed: (3) Except when washing fruits and vegetables, food employees shall minimize bare hand and arm contact with exposed food. Observation on 4/12/23 at 9:21 AM in the facility kitchen revealed that DC-A reviewed the Wednesday lunch menu of chicken and dressing casserole, green beans, polish sausage with kraut on a bun, mashed potatoes with gravy, and mandarin orange cake. DC-A grabbed the handle of the door to the walk-in refrigerator with the bare hands and opened the door. DC-A entered the walk-in refrigerator and carried one opened package and one unopened package of polish sausages to the table. DC-A cut open the unopened package of sausages and emptied them into a pan. DC-A used the bare hands and repositioned the polish sausages in the pan. DC-A then opened the partial package of sausages and dumped them into the pan. DC-A went to the sink and applied soap to the dry hands. DC-A wet a hand and scrubbed the hands with soap for 13 seconds. DC-A rinsed and dried the hands. (DC-A did not scrub the hands for at least 20 seconds as required). DC-A placed foil over the pan and placed the pan of sausages into the oven at 9:30 AM. DC-A opened a jar of sauerkraut with the bare hands and poured it into a pan using a fork. DC-A discarded the empty jar into the trash and went to the sink. DC-A applied soap to the dry hands. DC-A wet a hand and scrubbed the hands with soap for 12 seconds. DC-A rinsed and dried the hands. DC-A put foil over the pan of sauerkraut and placed the pan into the oven. DC-A went to the walk-in refrigerator and opened it with the bare hands. DC-A entered the walk-in refrigerator and carried out the pan of chicken and dressing casserole. DC-A put the pan into the oven. DC-A grabbed the handle to the dry storage room with the bare hands and opened the door. DC-A went into the dry storage room and brought out a can of green beans. DC-A used the opener mounted on the edge of the table to open the can. DC-A grabbed the lid of the can with the bare hands and lifted it slightly. DC-A poured the can of beans into a pan. DC-A added butter to the pan of green beans using a knife. DC-A covered the pan of beans with foil and placed them into the oven. The time was now 9:38 AM. DC-A added a measured amount of water into a measuring pitcher and poured it with the milk into the large mixer bowl. DC-A added melted butter and 3/4 tablespoon salt and 3/4 tablespoon of pepper into the mixer bowl. DC-A used a pair of scissors and opened a package of instant potatoes and poured them into the mixer bowl. DC-A opened a second package of instant potatoes and emptied it into the mixer bowl. DC-A started the mixer. DC-A obtained a large pan and sprayed it with non-stick spray. DC-A placed the pan on a table and sat the mixer bowl of mashed potatoes next to it. DC-A used a spatula to transfer the potatoes from the bowl into the pan. DC-A carried the empty mixer bowl into the dirty dish room (a room for collecting and washing used/soiled tableware and cookware). DC-A went to the sink and applied soap to the dry hand. DC-A wet the hand and scrubbed the hands with soap for 8 seconds. DC-A rinsed and dried the hands. DC-A reentered the kitchen. (DC-A did not perform the required handwashing after touching contaminated dishware in the dirty dish room). DC-A covered the pan of mashed potatoes with clear plastic wrap and placed the pan into the warmer cart. The time was now 9:52 AM. DC-A went to the sink and applied soap to the dry hand and scrubbed the hands with soap for 6 seconds. DC-A rinsed and dried the hands. DC-A opened a second jar of sauerkraut. DC-A put a pair of oven mitt gloves on the hands and removed the pan of sauerkraut from the oven and removed the foil from the top of the pan. DC-A poured the jar of sauerkraut into the pan. DC-A covered the pan with the foil and returned it to the oven. Observation on 4/12/23 at 11:11 AM in the facility kitchen revealed that DC-A picked up an empty ivory bowl from the table and placed 2 dark blue handled number 16 dipper scoops of the chicken and dressing casserole into the ivory bowl. DC-A sat the bowl on the table next to the blender. DC-A placed two pieces of cake into the blender and added some milk. DC-A started the blender to puree (a food item that has been ground with a blender into a smooth, soft, pudding-like consistency for residents with difficulty chewing or swallowing) the cake. DC-A then took one of the ivory bowls and placed 1 green handled scoop of green beans into the bowl. DC-A went to the kitchen sink and applied soap and wet the hands. DC-A scrubbed the hands with soap for 12 seconds and then rinsed and dried the hands. DC-A obtained a nosey cup (a cup that has a cut out on the non-drinking side so that they can be tilted without interference by the nose. This allows the drinker to avoid tilting the head back to minimize the chance of choking) and returned to the blender. DC-A poured half of the pureed cake from the blender into an ivory bowl and then poured the rest into the nosey cup. DC-A carried the blender bowl into the dirty dish room and moved some soiled dishware with the bare hands. DC-A returned to the kitchen. DC-A did not wash the hands. DC-A placed clear wrap over the nosey cup of pureed cake and the bowl of pureed cake. DC-A left them on the table. DC-A picked up the cutting board from the table and carried it into the dirty dish room. DC-A returned to the kitchen and did not perform hand washing. The time was now 11:20 AM. DC-A went to the dry storage room and grabbed the handle of the door with the bare hands. DC-A opened the door and entered the dry storage room. DC-A exited the room and returned to the table with a bag of Cheetos. DC-A picked up a clear small bowl with the bare hands and placed the bowl in the bag with the bare hand and scooped a bowlful of Cheetos out of the bag. DC-A sat the bowl of Cheetos on the table. DC-A carried the bag of Cheetos back into the dry storage room. DC-A entered the dirty dish room and moved trays of clean dishes away from the dishwasher with the bare hands. DC-A walked back into the kitchen. DC-A did not wash the hands. DC-A grabbed the door handle of the refrigerator with the bare hands and opened the refrigerator door. DC-A removed a jar of pickle slices and sat the jar on the table. DC-A put a disposable glove on the right hand and used the gloved hand to grab pickle slices from inside the jar. DC-A placed the pickle slices into a small disposable condiment bowl. DC-A did not wash the hands before putting on the disposable glove as required. DC-A walked back into the dirty dish room. DC-A removed the disposable glove from their right hand and discarded it. DC-A picked up the blender bowl that had just been washed in the dishwasher. DC-A carried the blender bowl to the blender and poured the chicken and dressing casserole from the small ivory dish into the blender. DC-A added a small amount of milk to the blender bowl. DC-A operated the blender to puree the casserole. DC-A used a spoon to move the pureed casserole from the blender bowl into the small ivory bowl. DC-A placed the bowl of pureed casserole into the warmer cart. DC-A carried the blender bowl from the kitchen into the dirty dish room and put it on a dishwasher tray. DC-A placed the tray into the dishwasher and started the dishwasher. DC-A went to the sink in the dirty dish room and applied soap to the dry hand. DC-A wet the hands. DC-A scrubbed the hands with soap for 11 seconds and then rinsed and shook the water from the hands. DC-A then rinsed the hands underneath running water again and scrubbed the arms to halfway between the wrist and the elbow without soap. DC-A shook the water from the hands and then dried the hands. DC-A removed the blender bowl from the dishwasher and carried it into the kitchen. DC-A placed the blender bowl on the blender and poured the green beans from the ivory bowl into the blender. DC-A pureed the green beans. DC-A poured the pureed green beans into the small ivory bowl and carried it to the table and sat it on the table. DC-A added an unmeasured amount of thickener powder and stated that it should not be runny like soup. DC-A placed a piece of clear plastic wrap over the top of the bowl. DC-A used the bare hands to grab the handle of the warmer cart. DC-A opened the warmer cart and placed the bowl into the warmer cart. Observation on 4/12/23 at 11:43 AM in the facility kitchen revealed that DC-A opened the refrigerator door with the bare hands and removed a plastic storage bag containing pancakes. DC-A did not perform hand washing prior to putting a disposable glove on the right hand. DC-A carried the bag to the table. DC-A reached into the bag with the gloved hand and removed two pancakes and placed them on a plate. DC-A returned the storage bag into the refrigerator. DC-A removed and discarded the glove from the right hand. DC-A did not perform hand washing after removing the glove as required. DC-A picked up a plastic meal tray and sat it on the table. DC-A removed some small plastic condiment containers from a bag on the shelf above the table. DC-A used the fingers of the bare hands to reach inside each container as DC-A separated them from the stack of containers removed from the bag. DC-A sat the individual containers on the plastic tray. DC-A used the bare hands to grab the handle of the refrigerator door and opened the refrigerator. DC-A removed a container of butter. DC-A used a purple handled scoop to place a scoop of the butter into each of the 5 small containers on the tray. DC-A laid a strip of clear plastic wrap over the small containers. DC-A picked up a worn stained box from the shelf above the table and removed an individual serving container of syrup and sat it on the table. The time was now 11:46 AM. DC-A did not wash the hands. DC-A used the bare hands and began to remove the covers from the food items on the steam table. DC-A placed a dark blue handled dipper scoop in the pan of gravy. DC-A picked up a plate from the stack of plates in the plate warmer with the thumb on the top surface of the plate. DC-A began to plate the first lunch meal. DC-A plated a polish dog with no bun for Resident 34. The polish dog rolled into the thumb of DC-A. DC-A picked up another plate with the thumb on the top of the plate. DC-A plated a polish dog on a bun for an unidentified new resident to the facility. DC-A picked up a plate with the thumb on the top of the plate. DC-A plated a polish dog on a bun for Resident 5. DC-A picked up a plate with the thumb on the top of the plate. DC-A placed one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 44. DC-A picked up a plate with the thumb on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 25. The time was now 11:55 AM. DC-A walked from the steam table to the warmer cart and opened it with the bare hands. DC-A then walked back to the table with the resident menus next to the steam table. DC-A touched the front of their face mask with the fingers and thumb of their left hand. DC-A picked up a plate with the thumb of the left hand on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 7. DC-A picked up the nosey cup of pureed cake from the table and placed it on a tray for Resident 21. The time was now 11:59 AM. DC-A picked up a plate with the thumb of the left hand on the top of the plate and placed a scoop of mashed potatoes on the plate for Resident 21. DC-A used the fingers of the bare right hand and picked something off the scoop of mashed potatoes along with a small amount of the potatoes. DC-A threw it into the trash can by the kitchen sink. DC-A sat the plate on the tray for Resident 21. DC-A picked up a plate with the thumb on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 26. DC-A touched the front of their face mask with the fingers and thumb of the right hand as DC-A walked to the refrigerator. DC-A grabbed the door handle with the bare hands and opened the door of the refrigerator. DC-A removed a package of hamburger patties from the refrigerator and sat the package on the table. DC-A put a disposable glove on their right hand and used the gloved hand to reach into the package and remove a hamburger patty. DC-A did not perform hand washing before putting on the glove as required. DC-A sat the hamburger patty on a plate. DC-A grabbed a package of hamburger buns from the shelf above the table. DC-A opened the package and removed a bun from inside the package with the right gloved hand. DC-A placed the hamburger patty on the bun on the plate and placed the plate into the microwave. DC-A grabbed a package of potato chips from a container of potato chip packages using the gloved hand. DC-A sat the bag of chips on the counter of the steam table. DC-A removed the glove from the right hand and discarded it in the trash can by the sink in the kitchen. DC-A rinsed the hands underneath running water for 3 seconds and dried the hands. DC-A did not use soap or follow the facility process for handwashing. DC-A picked up a plate with the thumb on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 19. DC-A touched the front of their face mask with the fingers and thumb of the left hand as DC-A walked to the table with the resident menus. DC-A carried some of the menus and sat them on the steam table counter. DC-A picked up a plate with the thumb of the plate on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 39. DC-A picked up a plate with the thumb on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 12. DC-A picked up a plate with the thumb on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 20. DC-A picked up a plate with the thumb of the left hand on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 24. DC-A picked up a plate with the thumb on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 3. DC-A picked up a plate with the thumb on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 30. DC-A grabbed the front of their face mask with the fingers and thumb of the left hand. DC-A grabbed more resident menus and placed them on the steam tray counter. DC-A picked up a plate with the thumb of the left hand on the top of the plate and placed a polish sausage on the plate using the tongs for Resident 8. DC-A picked up a plate with the thumb on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 29. DC-A picked up a plate with the thumb on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 2. DC-A picked up a plate with the thumb on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 45. An unidentified Nurse Aide brought a plate to the kitchen service window and notified DC-A that Resident 8 wanted a bun. DC-A grabbed the plate with the thumb on the top of the plate and placed a bun on the plate and moved the polish sausage onto the bun for Resident 8. DC-A picked up a plate with the thumb on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 49. DC-A picked up a plate with the thumb on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 13. DC-A picked up a plate with the thumb of the left hand on the top of the plate. DC-A placed a bun on the plate and placed a polish sausage in the bun for Resident 1. DC-A picked up a plate with the thumb on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 16. DC-A picked up a plate with the thumb on the top of the plate and placed a bun on the plate. DC-A tried to place a polish sausage in the bun and used the bare fingers of the left hand to help open the bun to get the polish sausage into the bun for Resident 17. The time was now 12:19 PM. DC-A picked up a plate with the thumb on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 23. DC-A grabbed the front of their face mask with the thumb and fingers of the left hand as they adjusted the mask. DC-A picked up a plate with the thumb of the left hand on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 10. DC-A picked up a plate with the thumb of the left hand on the top of the plate and placed a bun on the plate. DC-A then placed a polish sausage into the bun. DC-A sat the plate on the counter of the steam table. DC-A used the bare right hand to grab and move the bun with the polish sausage to a different location on the plate for Resident 51. DC-A placed a scoop of mashed potatoes and a ladle of gravy on the plate for Resident 51. DC-A grabbed their face mask with the fingers and thumb of the left hand as they walked to the table to grab additional resident menus. DC-A placed the menus on the counter of the steam table and picked up a plate with the thumb of the left hand on the top of the plate for Resident 9. DC-A reviewed the menu for Resident 9 and stated that the resident wanted a whole boiled egg heated up. DC-A walked into the dirty dish room and placed some water into a small pitcher. DC-A returned to the kitchen from the dirty dish room and did not perform hand washing. DC-A put a disposable glove on the right hand. DC-A did not perform hand washing before putting on the glove as required. DC-A went to the refrigerator and grabbed the handle of the door and opened the door. DC-A removed a package of hard-boiled eggs from the refrigerator and sat it on the table. DC-A removed a hard-boiled egg from inside the package using the gloved right hand. DC-A placed the egg into the pitcher of water. DC-A returned to the steam table. DC-A removed and discarded the glove. DC-A did not perform hand washing as required. DC-A picked up a plate with the thumb on the top of the plate and plated a scoop of mashed potatoes and a polish sausage onto the plate for Resident 9. DC-A picked up a new plate with the thumb on the top of the plate and placed a bun and polish sausage on it for Resident 36. DC-A picked up a plate with the thumb on the top of the plate and plated a polish sausage with no bun onto a plate for Resident 42. The polish sausage rolled against the thumb of DC-A. The time was now 12:28 PM. DC-A picked up the pitcher with the hard- boiled egg and carried it to a sink in the kitchen. DC-A poured the water out of the pitcher and then poured the egg into a small bowl. DC-A took the empty pitcher from the kitchen into the dirty dish room. DC-A walked back into the kitchen from the dirty dish room and did not perform hand washing. DC-A adjusted their mask with the fingers and thumb of the left hand as they walked to the table with the resident menus. DC-A sorted through the menus with their bare hands. DC-A carried some menus to the counter of the steam table. DC-A picked up a plate with the thumb of the left hand on the top of the plate. DC-A placed a bun on the plate and then placed a polish sausage into the bun for Resident 50. DC-A went to the sink in the kitchen and applied soap to the dry hand and wet the hands. DC-A scrubbed the hands with soap for 11 seconds and then rinsed and dried the hands. DC-A grabbed the front of their facemask with the fingers and thumb of the left hand and adjusted the facemask as they returned to the steam table. DC-A picked up a plate with the thumb of the left hand on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 28. DC-A adjusted their face mask with the fingers and thumb of the left hand. DC-A picked up a plate with the thumb on the top of the plate and plated a bun on the plate for Resident 43. DC-A adjusted their face mask with the fingers and thumb of the left hand as they walked from the steam table to the table with the resident menus. DC-A returned to the steam table and sat some of the menus on the counter of the steam table. DC-A picked up a plate with the thumb of the left hand on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 6. DC-A adjusted their face mask with the fingers and thumb of the left hand. DC-A picked up a plate with their thumb on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 47. DC-A adjusted their face mask with the fingers and thumb of the left hand on the front of the face mask. DC-A picked up a plate with the thumb of the left hand on the top of the plate for Resident 40. DC-A placed a bun on the plate. DC-A looked at the menu for Resident 40 again and removed the bun from the plate and placed it back into the bag. DC-A placed a polish sausage on the plate for Resident 40. DC-A adjusted their face mask by grabbing the front of the face mask with the fingers and thumb of the left hand. DC-A grabbed some menus from the table and reviewed them. DC-A touched their face mask with the fingers and thumb of the left hand. DC-A picked up a plate with the thumb of the left hand on the top of the plate and plated a bun and a polish sausage in the bun on the plate for Resident 53. DC-A picked up a plate with the thumb on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for a guest of Resident 53. DC-A adjusted their face mask by grabbing the front of the face mask with the fingers and thumb of the left hand. DC-A picked up a plate with the thumb of the left hand on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 38. DC-A walked to the table with the menus. DC-A returned to the steam table and picked up a plate with the thumb of the left hand on the top of the plate and plated a scoop of mashed potatoes and gravy onto the plate for Resident 54. DC-A picked up a new plate with the thumb of the left hand on the top of the plate and plated a scoop of mashed potatoes and gravy onto the plate for Resident 27. DC-A grabbed the front of their face mask with the fingers and thumb of the left hand. DC-A pinched the nose strip of the face mask. DC-A picked up a plate with the thumb of the left hand on the top of the plate for Resident 35. DC-A sat the plate down. DC-A walked to the warmer cart and opened it with the bare hands. DC-A removed the ivory bowl of pureed green beans and the ivory bowl of the pureed chicken and dressing casserole. DC-A carried the bowls to the steam table. DC-A picked up the plate for Resident 35 with the thumb on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 35. DC-A picked up the bowl of pureed chicken and dressing casserole and the bowl of pureed green beans and sat them on a tray in the service window for Resident 31. DC-A picked up a plate with the thumb on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 37. DC-A picked up a plate with the thumb on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 4. DC-A picked up a plate with the thumb on the top of the plate and plated one 4-ounce scoop of the chicken and dressing casserole onto the plate for Resident 18. Interview on 4/13/23 at 9:52 AM with the consultant Registered Dietitian (RD) confirmed that the expectation was for dietary staff to perform handwashing after returning to the kitchen from the dirty dish room, after opening doors if doing prep, after touching their face mask, before putting on disposable gloves, and after removing gloves. The RD confirmed that dietary staff are expected to follow the facility policy for performing handwashing including wetting the hands before applying soap instead of applying soap to dry hands. The RD confirmed that the staff need to scrub the hands with soap for at least 20 seconds when performing handwashing. The RD confirmed that staff are to handle plates in a manner so that no part of the hands are on the top of the plates. C. Observation on 4/12/23 at 11:00 AM in the facility kitchen revealed that DC-A stood at the table. DC-A used the bare hands to split open the hot dog buns. DC-A continued to split open all the hotdog buns using the bare hands. DC-A returned the split hot dog buns into the two bun packages. DC-A carried one package of buns to the steam table and sat them on the steam table. Observation on 4/12/23 at 11:59 AM in the facility kitchen revealed that DC-A picked up a plate with the thumb of the left hand on the top of the [TRUNCATED]