**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference 175 NAC 12-006.04(F)(i)(5) Based on record reviews and interviews, the facility failed to notify the physician of a significant decline for 1 (Resident 45) of 1 sampled resident. The facility identified a census of 43. Findings are: A record review of a facility policy Notification of Changes with a last revised date of [DATE], under compliance guidelines, indicated the facility must inform the resident's physician within one hour of a change, such as a significant change in the resident's physical condition, such as deterioration or that require a need to alter treatment. A record review of Resident 45's Face Sheet revealed the facility admitted Resident 45 to the facility on [DATE] with Congestive Heart Failure and chronic respiratory failure. It also indicated Resident 45 was discharged due to death on [DATE]. A record review of Resident 45's Orders with a date of [DATE] revealed an order for continuous oxygen at night set at 2 liters per minute (LPM.) A record review of a Resident 45's Progress Notes with a date of [DATE] at 10:01 PM, written by Licensed Practical Nurse (LPN) - A revealed Resident 45 had not been feeling well. Resident 45 had been sitting in their recliner with their oxygen on at 2 LPM. LPN-A checked Resident 45's oxygen saturation and found it to be 73%. LPN-A increased Resident 45's oxygen to 3.5 LPM. The progress note states at 6:50 PM, two nurses got Resident 45 ready for bed and laid Resident 45 in their bed. At 7:15 PM, Resident 45 was found deceased . The progress note indicated the Assistant Director of Nursing (ADON), the Administrator, funeral home, priest, and family were notified. The progress note did not indicate the physician had been notified at any time during Resident 45's decline. A record review of Resident 45's chart revealed no evidence the physician had been notified of Resident 45's significant change of condition. A telephone interview on [DATE] at 9:55 AM with LPN-A revealed on [DATE] around 3:30 PM Resident 45's family wanted Resident 45 to be checked on. LPN-A found Resident 45 to have their mouth open and breathing heavy. LPN-A confirmed the physician had not been notified on [DATE] of Resident 45's decline. An interview on [DATE] at 2:15 PM with the Assistant Director of Nursing confirmed the physician should have been notified of Resident 45's decline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference 175 NAC 12- 006.09(F)(iii) Based on record reviews and interviews, the facility failed to ensure the comprehensive care plans (CCP-sets client goals, identifies activities or action steps needed to achieve these goals, expected dates for each action step, and any resources or support needed to complete the Care Plan) were updated regarding hospice care services for 2 (Resident 30 and 33) of 12 sampled residents. The facility identified a census of 43. Findings are: A. A record review of a facility policy Care Plan Policy with a last reviewed date of 3/2023 revealed services provided or arranged by the facility are to be included as part of the comprehensive care plan. A record review of Hospice-Nursing Facility Agreement Chadron Community Hospital-Hospice with an initial term agreement of 6/11/20215, revealed the agreement is between [NAME] Community Hospital - Hospice and Pioneer Manor. Under section 9.2 Integration of Hospice Plan of Care and Facility Plan of Care indicated the facility is responsible for integrating the Hospice Plan of Care into the facility care plans. A record review of Nursing Home Hospice Admission/Transfer Orders with a date of 8/6/2024 revealed Resident 33 was admitted to Hospice Services on 8/6/24 with medical conditions related of abnormal weight loss, multiple myeloma, pressure ulcer-unstageable, chronic pain, and atrial fibrillation. A record review of Resident 33's undated Care Plan revealed no evidence of Hospice services. An interview on 9/25/2024 at 3:33 PM with the Assistant Director of Nursing (ADON) confirmed Resident 33's care plan did not include Hospice services and should have been updated to include that Resident 33 was receiving Hospice services. B. A record review of Resident 30's admission Record revealed an admission date to the facility of 2/21/23. A record review of Resident 30's Progress Note dated 9/5/24 indicated the resident was admitted to hospice care. A record review of Resident 30's Home Health and Hospice Plan of Care revealed an admission date of 9/5/24 with a primary diagnosis of Abnormal weight loss. A Record review of Resident 30's undated facility CCP revealed no mention of hospice. Record review of a facility policy Care Plan Policy with a last reviewed date of 3/2023 revealed services provided or arranged by the facility are to be included as part of the comprehensive care plan. In an interview on 09/25/24 at 04:25 PM the ADON confirmed that Resident 30's careplan had not been revised after the resident was placed on hospice and it should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(B) Based on record reviews and interviews, the facility failed to ensure the accuracy of Minimum Data Sets (MDS - a federally mandated comprehensive assessment tool used for care planning) of Resident 16's Activities of Daily Living (ADLs) and Resident 10 and 27's anticoagulant use. This affected 3 of 12 sampled residents. The facility identified a census of 43. Findings are: A. A record review of the MDS 3.0 Resident Assessment Instrument (RAI) User's Manual v1.18.11, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities with a date of October 2023 indicated functional status is based on the need for assistance when performing self-care and mobility activities and to record the resident's usual ability to perform these activities within the last 7 days. A record review of Resident 16's Progress Notes with a date of 5/31/2024 revealed Resident 16 required total assistance with dressing, grooming, oral cares, and toileting. Resident 16 required extensive assistance with eating. A record review of Resident 16's Progress Notes with a date of 6/1/2024 revealed Resident 16 required total assistance with all cares. It also indicated staff feed Resident 16 at both meals during this day. A record review of Resident 16's Progress Notes with a date of 6/2/2024 revealed Resident 16 required total assistance with dressing, grooming, bathing, and toileting and extensive assistance with eating this day. A record review of Resident 16's Progress Notes with a date of 6/3/2024 revealed Resident 16 required total assistance with dressing, grooming, bathing, and toileting and extensive assistance with eating this day. A record review of Resident 16's quarterly MDS with a date of 6/6/2024 indicated Resident 16 was independent with eating, oral hygiene, toileting, and bathing. It also indicated that Resident 16 required max assist with upper body dressing and partial assistance with lower body dressing. An interview on 9/24/2024 at 1:28 PM with the MDS Coordinator confirmed the ADL section of Resident 16's MDS were coded incorrectly and should have been coded as dependent, not independent. B. A record review of the MDS 3.0 Resident Assessment Instrument (RAI) User's Manual v1.18.11 dated October 2023 indicated to code aspirin under antiplatelet medication and warfarin or heparin under anticoagulant if the resident had taken within 7 days of the assessment. A record review of Resident 10's admission Record revealed an original admission date to the facility of 6/19/2017. A record review of Resident 10's MDS dated [DATE] in Section N revealed the resident had been taking an anticoagulant and was not marked for taking an antiplatelet. A record review of Resident 10's Order Summary revealed an open ended order for Aspirin with a start date of 11/17/2022. A record review of Resident 10's CCP revealed an approach with a start date of 7/10/2020 that aspirin will be administered everyday. In an interview on 09/24/24 at 2:50 PM the MDS nurse confirmed that aspirin was coded as an anticoagulant, it was further confirmed that the RAI manual is used to ensure MDS accuracy. In an interview on 09/24/24 at 3:59 PM the ADM confirmed there was no MDS Policy, and that the RAI manual is used to confirm MDS accuracy. C. A record review of the MDS 3.0 Resident Assessment Instrument (RAI) User's Manual v1.18.11 dated October 2023 indicated to code aspirin under antiplatelet medication and warfarin or heparin under anticoagulant if the resident had taken within 7 days of the assessment. A record review of Resident 27's admission Record revealed an admission date to the facility on [DATE]. A record review of Resident 27's MDS dated [DATE] in Section N revealed the resident had been taking an anticoagulant and was not marked for taking an antiplatelet. A record review of Resident 27's Order Summary revealed an open ended order for Aspirin with a start date of 1/11/2023. A record review of Resident 27's CCP revealed an approach with a start date of 11/28/2022 that medications will be administered as prescribed. In an interview on 09/24/24 at 2:50 PM the MDS nurse confirmed that aspirin was coded as an anticoagulant, it was further confirmed that the RAI manual is used to ensure MDS accuracy.

B. Observation of Resident 1 on 9/11/23 at 11:01 AM revealed bruising to left lower arm, left hand, right upper arm, and right elbow and skin tears to bilateral wrists. Interview on 9/11/23 at 11:02 AM with Resident 1 revealed that Resident 1 did not know what happened to cause the bruising or skin tears. Record review of Resident 1's wound notes with measurements revealed: - 08/8/23 Bruise to left wrist 6 cm length, and 4 cm width - 08/8/23 Bruise to left hand 11 cm in length, and 8 cm width - 08/8/23 Bruise left ring finger 2 cm length and 1.5 cm width - 08/8/23 Bruise left second finger 1 cm length, and 0.4 cm width - 08/18/23 Skin tear to left wrist 1 cm length, and 0.5 cm width - 08/30/23 Bruise noted to left lower arm 5 cm in length and 2.3 cm in width - 08/30/23 Bruise to right ring finger 2.7 cm in length and 1 cm wide - 08/30/23 Bruise to right second finger. Not healed. No observations recorded. - 09/2/23 Skin tear noted to right wrist with a measurement of 5.4 cm in length, 0.3 cm width A record review of Resident 1's undated CCP revealed skin issues were not addressed on CCP. Interview on 09/13/23 at 9:51 AM with the ADON confirmed Resident 1's skin was not addressed on their CCP. The ADON revealed the Care Plan was not updated with each bruise and skin tear and should have been. Licensure Reference Number 175 NAC 12-006.09C1c Based on observations, record review and interview the facility staff failed to review and revise the Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) to reflect the resident's overall care needs for 2 of 2 (Resident 12 and Resident 1) sampled residents. The facility census was 43 at the time of survey. Findings are: A. Observation of a wound dressing change of Resident 12 on 09/12/23 at 8:00 AM revealed Resident 12 had a pressure ulcer on their right heel which was 4 centimeters in length, 4 centimeters in width, and 0.1 centimeters deep. Resident 12's right heel had moderate exudate and necrotic tissue noted. Record review of Resident 12's wound notes revealed: - 07/31/2023 Pressure ulcer Right Heel 4 centimeters (cm) length, and 6 cm width, and 0.1 cm depth - 08/01/23 Pressure ulcer Right Heel 4.4 cm in length, 5.5 cm width - 08/04/2023 Pressure ulcer Right Heel 4 cm in length, 5.25 cm width - 08/12/2023 Pressure ulcer Right Heel 4 cm in length, 5.5 cm width - 08/18/2023 Pressure ulcer Right Heel 4.2 cm in length, 5 cm width - 08/25/2023 Pressure ulcer Right Heel 5 cm in length, 5 cm width - 09/02/2023 Pressure ulcer Right Heel 5 cm in length, 5 cm width - 09/06/2023 Pressure ulcer Right Heel 4.5 cm in length, 2.5 cm width, and 0.25 cm depth Record review of the Minimum Data Set (MDS) (A Person-Centered, Interdisciplinary Approach to care) quarterly report was updated on 08/17/2023 and Resident 12's right heel pressure ulcer was documented as a stage 2. A record review of Resident 12's undated CCP revealed Resident 12's pressure ulcer was not addressed. Interview on 09/13/23 at 10:11 AM with the Assistant Director of Nurses (ADON), revealed Resident 12's care plan did not identify or document the pressure ulcer on the right heel, preventions, interventions or treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Record review of the facility policy, Water Management Plan with an effective date of April 2022 revealed: A) Number 3 under the section titled Policy Explanation and Compliance Guidelines revealed a risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems. B) Number 6 under the section titled Policy Explanation and Compliance Guidelines revealed that a variety of measures may be used, including physical controls, temperature management, disinfectant level control, visual inspections, or environmental testing for pathogens. C) Number 9 Under the section titled Policy Explanation and Compliance Guidelines revealed that the effectiveness of the water management program shall be evaluated no less than annually. Routine infection control surveillance data, water quality data, and rounding data shall be utilized to validate the effectiveness. Review of facility policy, Infection Prevention and Control Program with an effective date of 11/10/2017 and a revised date of 7/6/2023 revealed: A) A water management program has been established as part of the overall infection prevention and control program. B) Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems. An interview on 09/13/2023 at 8:50 AM with Housekeeping Supervisor (HS) confirmed there was no Legionnaire policy. HS revealed that a policy had been in the works for a long time and HS had tried to reach out for support but received no reply. HS revealed writing of the policy had stalled. An interview on 9/13/2023 at 8:50 AM with HS confirmed testing of the facilities water supply was not being completed. An interview on 09/13/2023 at 9:43 AM with the Administrator confirmed water testing for Legionella was not being completed at the facility. The Administrator confirmed the facility does not have a Legionnaire policy or plan. Licensure Reference Number 175 NAC 12.006.17D Based on observation, record review, and interview; the facility failed to complete hand hygiene when completing wound dressing changes for 1 (Resident 12) of 1 sampled residents. In addition, the facility failed to implement a Legionnaire policy and test the facility's water supply for Legionella which had the potential to affect all residents within the facility. The facility identified a census of 43. Findings are: An observation of wound care on 9/12/23 at 8:00 AM to Resident #12 revealed LPN (Licensed Practical Nurse) A did not perform hand hygiene prior to starting wound care. LPN-A gathered supplies from a tub in Resident #12's closet. LPN-A obtained soap from the dispenser and added water to the tub and placed several 4x4 squares of gauze within the tub. LPN-A applied gloves and removed a gauze from the tub. LPN-A removed [gender] gloves, did not perform hand hygiene, and then removed 3 squares of silversort dressing and cut the dressing using a scissors with bare hands. LPN-A then applied gloves without performing hand hygiene and cleansed Resident # 12's heel wound with soapy gauze and then a betadine gauze. LPN-A then touched a piece of the cut silversorb with the same gloves but then removed them. LPN-A applied new gloves without performing hand hygiene and placed the square of silversorb dressing to the right heel wound. LPN-A then removed their gloves, did not perform hand hygiene, and wrapped Resident #12's right leg with an ACE wrap. LPN-A then applied gloves and cleansed the top of Resident #12's left foot and cleansed blood residue. LPN-A then removed gloves, did not perform hand hygiene, and wrapped Resident #12's left leg with an ACE wrap. LPN-A then washed their hands with soap and water for 5 seconds and left Resident #12's room. An interview on 9-12-2023 at 8:30 AM with LPN-A revealed that LPN-A did not perform hand hygiene while providing wound care. LPN-A revealed that [gender] thought changing gloves took the place of hand hygiene and therefore hand hygiene wasn't necessary. An observation of wound care on 9/13/2023 at 9:30 AM to Resident #12 revealed LPN-B gathered wound supplies from a tub at the top of Resident #12's closet. LPN-B placed soap from the dispenser and water into the tub and placed several 4x4 squares of gauze within the tub. LPN-B applied gloves without performing hand hygiene and removed the gauze from the tub. LPN-B then removed their gloves, did not perform hand hygiene, and removed 3 squares of silversorb dressing and cut the dressing using scissors and bare hands. LPN-B applied gloves and cleansed Resident #12's heel wound with soapy gauze and then betadine gauze. LPN-B applied new gloves, did not perform hand hygiene, and placed a square of silversorb dressing to Resident #12's wound on the back of the left leg. LPN-B then wrapped Resident #12's left leg with gauze and applied tape to secure the wrap. LPN-B continued with the same gloves and applied 2 squares of silversorb dressing to Resident #12's right heel wound. LPN-B then opened a package of absorbent pads and placed it over the silversorb dressing on the right heel wound. LPN-B removed their gloves, did not perform hand hygiene, and wrapped Resident #12's right leg with an ACE wrap. LPN-B removed their gloves, did not perform hand hygiene with either soap and water or hand sanitizer and left Resident #12's room. An interview on 9-13-2023 at 10:00 AM with LPN-B revealed that LPN-B was unaware of the facility hand hygiene policy or that [gender] needed to perform hand hygiene during wound care. Record review of City of [NAME] Springs Pioneer Manor Nursing (Home Hand Hygiene Policy) dated 7/2023, revealed that staff will perform hand hygiene when indicated, using proper technique consistent with accepted standard of practice; before applying and after removing personal protective equipment (PPE), including gloves. Interview on 09-13-23 at 10:00 AM with the ADON (Assistant Director of Nurses) revealed staff are to complete hand hygiene during wound care and just changing gloves without performing hand hygiene was not appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** License Reference Number NAC 12-006.090D Based on observations, record review, and interview; the facility failed to obtain physician discharge orders for medications, outpatient physical and occupational therapy, and an order to discharge 1 of 1 sampled resident (Resident 24) prior to discharging the resident back to the community. The facility identified a census of 43 at the time of survey. Findings are: Observation in Resident 24's room on 8/2/2022 at 10:56 AM, revealed Resident 24 sitting in a recliner with both legs elevated. Resident 24 had a black CAM (controlled ankle motion boot) on the left lower extremity. Interview with Resident 24 on 8/2/2022 at 10:56 AM, revealed resident had fallen at home due to standing up from a chair and getting dizzy. Resident 24 said resident had broken the left ankle on 6/3/2022 and was hospitalized for 1 1/2 to 2 weeks prior to being admitted to the facility. Resident 24 disclosed resident's plan was to return home on 8/8/2022. Resident 24 disclosed that resident lives with resident's daughter and granddaughter. Resident 24's daughter works from home, so would be able to assist resident if needed. Resident 24 had seen the doctor on 8/1/2022 and x-rays (penetrating form of high-energy electromagnetic radiation) of resident's left ankle were performed. Resident 24 said the doctor's office was supposed to be calling the facility on Friday 8/5/2022 to have a conversation regarding the results. Observation in Resident 24's room on 8/3/2022 at 3:09 PM, revealed that resident's belongings were packed. Interview with Resident 24 on 8/3/2022 at 3:09 PM, revealed resident was being discharged that day and resident was waiting for the resident's daughter to pick resident up. Resident 24 disclosed resident's daughter works on the first floor and would be available to assist resident if need. Resident 24 disclosed that as of right now, resident does not have discharge orders for therapy upon return to home. Record review of Resident 24's Progress Notes dated 8/1/2022 at 10:03 AM, revealed the resident was working with therapy for assistance with transfers, undressing, and grooming. Record review of Resident 24's Progress Notes dated 8/2/2022 at 9:01 AM, revealed staff assisted Resident 24 with transfers, getting dressed, getting groomed, and to use the restroom. Record review of Resident 24's Progress Notes dated 8/2/2022 at 9:12 AM, revealed the resident was assisted with transfers, undressing, and set up for grooming. Resident 24 continued to be working with therapy. Record review of Resident 24's Progress note dated 8/3/2022 at 1:03 PM, revealed Resident 24 was extensive assist x1 staff member with dressing, transfers, and toileting. Resident 24 had complaints of shortness of breath and expiratory wheezes were heard throughout the resident's lungs. Resident 24 had complaints of wanting to go home as the resident felt resident was not getting better. Record review of Resident 24's progress note dated 8/3/2022 at 1:11 PM, revealed the facility had received a fax from a provider regarding resident's x-ray results with a recommendation that resident be weight bearing as tolerated in the CAM boot. Also, Resident 24 could do range of motion exercises out of the boot in a controlled environment and complete a repeat x-ray of the left ankle in four weeks. Record review of Resident 24's Progress Note dated 8/8/2022 at 10:11 AM, revealed resident's daughter picked resident up on 8/3/2022 at 5:53 PM. On 8/8/2022 review of Resident 24's discharge paperwork revealed a fax from [NAME] Memorial Health Finance dated 8/8/2022 with an RX Date/time of 9:00 AM had been received by the facility. The fax had a request from the facility for discharge that included discharge orders that included: Resident 24 was discharging home today (8/3/2022), requested current orders be sent to Stockman's Pharmacy, and requests for outpatient Physical and occupational therapy if the family chooses to continue therapy. The faxed request was signed by the provider on 8/8/2022 and was acknowledged with the date of 8/8/2022 and signatures of the ADON (Assistant Director of Nursing) and the DON (Director of Nursing). However, Resident 24 had already been discharged from the facility to home the week prior. Interview with the DON on 8/9/22 at 10:05 AM, confirmed the facility did not have discharge orders signed by the provider and had discharged Resident 24 from the facility to home on 8/3/2022 without an order to do so. Interview with the ADON confirmed the facility did not have discharge orders signed until 8/8/2022 when they had received a fax back from the provider. The ADON disclosed the ADON has faxed the requested orders on 8/3/2022 but did not receive the document back with the physician's signature until 8/8/2022 and Resident 24 was discharged from the facility to home without discharge orders on 8/3/22.

Licensure Reference Number: 175 NAC 12-006.09D Based on record reviews and interview, the facility failed to ensure that non pharmacological interventions were identified and implemented to promote sleep for one current sampled resident (Resident 26) with a diagnosis of insomnia. The facility census was 43 with 12 current sampled residents. Findings are: Review of Resident 26's MAR (Medication Administration Record), dated August 2022, revealed an order for Melatonin (sleep aid) every night. Review of the Care Plan, goal date 9/15/22, revealed that the resident received Melatonin for insomnia. Approach listed was Monitor for side effects such as dizziness, headache, sedation, dizziness, nausea, or tremor. Further review revealed no non pharmacological interventions to promote sleep. Interview with the Director of Nursing on 8/9/22 at 11:00 AM confirmed that non pharmacological interventions should have been identified and implemented to promote sleep to meet the resident's needs.

Reference Number 175 NAC 12-006.09D Based on observations, record review, and interview; the facility failed to monitor side effects of an anticoagulant as bruising was not assessed as ordered for 1 sampled resident (Resident 24). The facility identified a census of 43 at the time of survey. Findings are: Observation in Resident 24's room on 08/2/2022 at 10:56 am, revealed resident had several bruises that were in different shades of healing on bilateral arms, had a large purple bruise on resident's left forearm, and a large purple bruise on the right wrist. Record review of Resident 24's Physician Order Report dated from 7/8/2022 to 8/8/2022, revealed resident was on Xeralto (a blood thinner that can treat and prevent blood clots in conditions such as atrial fibrillation) for unspecified atrial fibrillation (an irregular and rapid heart rhythm that can lead to blood clotting in the heart). Also, there was a treatment order with a start date of 6/14/2022 for Nursing to monitor Resident 24 for signs and symptoms of abnormal bruising or bleeding on each shift (days, evenings, and nights). There were orders for Resident 24 to have skin checks to be completed weekly on Thursdays. Review of Resident 24's record, Licensed Nurse Weekly Skin Assessment dated 6/30/2022, revealed Resident 24 had a softball sized bruise on the right calf, and both arms were covered by large, bruised areas. Progress Note dated 6/30/2022 at 2:03 PM, revealed both of resident's arms were heavily covered by bruising. Review of Resident 24's Licensed Nurse Weekly Skin Assessment dated 7/7/2022, revealed resident continued to have large bruises with several small skin tears to bilateral upper extremities, and a bruise on the back of the right calf. Review of Resident 24's progress note dated 7/7/2022 at 10:00 AM, revealed the nurse documented the weekly skin assessment had been completed, but did not provide details of skin issue findings. Review of Resident 24's Licensed Nurse Weekly Skin Assessment dated 7/14/2022, revealed the nurse documented old bruising on resident's left forearm and indicated the findings in a Progress Note on 7/14/2022 at 8:52 AM. Further review of Resident 24's records, revealed a Licensed Nurse Weekly Skin Assessment was not located for the weekly assessment that was to be completed per order on 7/21/2022. Review of Resident 24's Progress Note dated 7/21/2022 at 11:58 AM, revealed the nurse had documented that the weekly skin assessment had been completed and it was documented that there were no new areas of concern. Review of Resident 24's Progress Note dated 7/28/2022 at 1:39 PM, revealed that a weekly skin assessment had been completed and the resident had redness and excoriation under the breasts. There were no other areas of concern. Review of Resident 24's Wound Management Detail Report dated 7/28/2022 at 3:41 PM, revealed there was not any documentation regarding bruising. Review of the facility's policy for Anticoagulants, dated 5/1/2022, confirmed the facility staff had not followed the policy as staff failed to monitor Resident 24 for adverse consequences associated with anticoagulants (e.g., several bruises on bilateral arms). Interview with the ADON (Assistant Director of Nursing) on 8/8/2022 at 1:37 PM, revealed the facility had changed their process from completing Skin Sheets to Wound Management Reports on 7/25/2022. The ADON explained the previous process was the nurse would complete a Skin Sheet, and the expectation was that the nurse would document a Progress Note to correlate the skin issue findings that were documented on the Skin Sheet. The ADON confirmed documentation regarding Resident 24's skin checks that had been completed on Thursdays was not thorough as it was lacking documentation of resident's bruising and/or following the bruising resident had since admission to the facility. The ADON further confirmed the ADON had checked Progress Notes and weekly Skin sheets from Resident 24's admission to the facility on 6/13/2022 to 8/8/2022 and confirmed there was missing documentation. Interview with the DON (Director of Nursing) on 8/8/2022 at 1:37 PM, confirmed the documentation was not thorough and was lacking information regarding Resident 24's bruising. The DON said there were events on the Wound Management Reports regarding skin tears on Resident 24's elbows and a skin tear on resident's right forearm, but nothing regarding bruises. Interview with the DON on 8/8/2022 at 2:48 PM, again confirmed that there was not accurate and thorough documentation regarding Resident's bruises since being admitted to the facility.

Licensure Reference Number 175 NAC 12.006.14 Based on observation, record review and interview; the facility staff failed to ensure 1 of 1 sampled residents, Resident 10, received routine and emergency dental services. The facility staff identified a census of 43 at the time of survey. Findings are: Interview with Resident 10 on 8/2/2022 at 11:17 AM revealed the resident had concerns of not being able see a dentist because the resident was on Medicaid and there weren't any dentists accepting new Medicaid patients. Resident 10 revealed resident's fillings and teeth were disintegrating and falling out. Record review of Resident 10's, Pioneer Manor Nursing Home Dental Examination form, dated 7/21/2021 revealed this was the last dental examination that had been completed on resident. The Dentist's remarks on the form revealed Resident 10 had two teeth with small fractures on 7/21/2021 and the Dentist documented a recommendation for the teeth to be repaired. The facility's Dental Examination form was noted by the ADON (Assistant Director of Nurses) on 7/21/22021 and by the APRN-NP (Registered Nurse with advanced education-a Registered Nurse with a graduate degree in advance practice nursing) on 7/24/2021. Interview with the DON (Director of Nursing) on 8/9/2022 at 10:16 AM, confirmed Resident 10's last dental examination was completed on 7/21/2021 Interview with the ADON (Assistant Director of Nursing) on 8/9/2022 at 10:16 AM, revealed there were not any dental offices accepting new Medicaid patients in the area. The ADON revealed the facility did not have a Dentist in place for emergency dental care. Interview with the facility Administrator on 8/8/2022 at 10:16 AM, revealed the facility did not have an emergency dental provider including the emergency room. Interview with the ADON on 8/9/2022 at 10:24 AM revealed the ADON had asked Medical Records to document anytime they tried to contact a dental office to get Resident 10 a dental appointment. The ADON confirmed there was not any documentation the facility had attempted to obtain dental care for Resident 10. Interview with the facility Administrator on 8/9/22 at 10:32 AM confirmed the facility staff were not able to locate any documentation showing that they had attempted to get Resident 10 a dental appointment. Interview with Social Services on 8/9/2022 at 10:28 AM revealed Social Services had spoken with Resident 10 and the resident's spouse three months ago and had discussed the issue of not being able to find a dentist that would accept Resident 10 as a patient due to Resident 10's payor source being Medicaid. Social Services revealed the agreement was unless Resident 10's teeth were bothering them, they would wait for CAPWN (Community Action Partnership of Western Nebraska) Dental to get a dental hygienist because they did not have one. Social Services revealed they did not document the conversation that had taken place with Resident 10 and resident's spouse. Record review of the facility policy Dental Care with an effective date of 8/1/2022 revealed there was to be an initial care plan that outlined care for teeth and oral cares. The policy also a letter would be sent to family yearly when an annual dental examination was needed. Observation of Resident 10 on 8/9/22 at 10:40 AM, with the DON and ADON revealed Resident 10 had a broken left upper molar, two bottom right teeth on resident's lower jaw had a thick buildup of a dark brown substance covering the teeth and the back of both teeth were broken. Resident 10 stated resident could feel, Decay when flossing and resident was concerned resident may catch some teeth and pull them out as they were broken and decayed.

175 NAC 12-006.09D7b Based on observations, record reviews and interviews; the facility failed to ensure that 1) interventions were in place to prevent recurrent falls and injuries for one current sampled resident (Resident 15) and 2) oxygen concentrators were turned off while residents were out of the room for three current sampled residents (Residents 24, 88 and 89) to reduce the risk for fire accidents. The facility census was 43 with 12 current sampled residents. Findings are: A. Observation in the hallway, by the nurse's station on 8/3/2022 at 9:46 AM, revealed Resident 15 sitting in a wheelchair (w/c) by the nurse's station. Resident had a visible wound on the right side of resident's forehead that was secured with steri-strips (surgical tape strips that can be used to close wounds). Interview with LPN-A (Licensed Practical Nurse) on 8/3/2022 at 9:46 AM, revealed Resident 15 had a witnessed fall in the dining room on Monday and that the resident had hit the resident's head. Record review of Resident 15's Event Reports, Progress Notes, and current Care Plan revealed that Resident 15 had several falls since the beginning of the year to current date. The facility had documented the following falls for Resident 15: 1. Progress Note completed on 1/10/2022 at 10:19 AM, revealed that Housekeeping heard a loud crash and staff observed Resident 15 laying on resident's right side next to the bed. 2. Progress Note completed on 2/5/2022 at 2:09 AM, revealed that Resident 15 was found crawling on the floor in resident's room. 3. Progress Note entered on 3/1/2022 at 11:50 PM, revealed Resident 15 had been yelling and the fall alarm was signaling. Resident 15 was found laying on resident's right side on the floor with resident's head near the foot of the bed. 4. Progress Note entered on 3/7/2022 at 4:10 AM, revealed that Resident 15 was found on the floor, kneeling by the toilet. 5. Progress Note completed on 4/10/2022 at 8:49 AM, revealed Resident 15 had a witnessed fall as resident had tried to stand up without the w/c being locked and without shoes on. The w/c had rolled back, and Resident 15 had fallen to the floor on resident's buttocks. 6. Progress note completed on 4/11/2022 at 12:27 AM, revealed that Resident 15 had a witnessed fall at 12:06 AM. Resident 15 had fallen out of a w/c at the nurse's station as resident had tried to pick up a bird. 7. Progress Note completed on 5/17/2022 at 3:03 P.M. revealed that Resident 15 had obtained a bruise to the outer portion of resident's left eye while self-transferring during the night. 8. Progress Note completed on 5/23/2022 at 5:12 PM, revealed that Resident 15 was found on the floor as resident had said, to work on resident's w/c. 9. Event Report completed on 6/17/2022 at 2:59 PM, revealed Resident 15 had an unwitnessed fall on 6/12/2022 at 12:45 PM when resident attempted to transfer to another resident's bed. Resident 15 did hit the back of resident's head. 10. Event Report completed on 6/17/2022 at 8:53 AM, revealed that Resident 15 had an unwitnessed fall on 6/16/2022 at 4:26 PM. Resident was laying on the floor at the nurse's station, by the medication room door on Resident's left side. Resident obtained a skin tear on resident's left elbow. 11. Progress Note completed on 6/21/2022 at 12:35 PM, revealed that two Nursing Aides had assisted Resident 15 into the w/c and took resident to the bathroom. Resident had leaned forward to crawl out of the w/c and laid on the floor with both Nursing Aides present. 12. Event Report completed on 7/7/2022 at 4:20 PM, revealed that Resident 15 had an unwitnessed fall on 6/28/2022 at 2:54 PM when resident had rolled out of bed while sleeping. 13. Progress Note completed on 7/20/22 at 9:35 AM, revealed Resident 15 had a witnessed fall when resident was sitting in a w/c by the nurse's station. The Resident had reached for an object on the ground and fell out of the w/c. 14. Event Report completed on 7/25/2022 at 4:31 PM, revealed that Resident 15 had a witnessed fall on 7/20/2022 at 7:20 PM at the Nurse's station. Resident 15 had reached for an object on the ground and fell out of the w/c. 15. Event Report completed on 8/9/2022 at 10:37 AM, revealed Resident 15 had a witnessed fall on 7/31/2022 at 6:01 PM. Resident 15 leaned forward in a w/c and had fallen face first onto the floor. Resident 15 sustained a laceration to resident's forehead. The wound was cleansed with betadine, Vaseline was applied, and the laceration was dressed with steri-strips and non-stick Telfa gauze. Observation by the Nurse's station on 8/8/2022 at 9:20 AM, revealed Resident 15 was sitting in a recliner by the Nurses station. Observation on 8/8/2022 at 09:51 AM, revealed Resident 15 in the same recliner by the nurse's station. Observation on 8/8/2022 at 11:50 AM, revealed Resident 15 sitting in a recliner across from the nurse's station and the resident was fidgeting. Continued observation on 8/8/2022 at 11:53 AM, revealed Resident 15 remained seated in the same recliner by the nurse's station. Resident 15 had leaned forward and was fidgeting (moving arms and leg as though resident wanted to get out of the recliner). Interview with LPN-B on 8/8/22 at 11:53 AM revealed that Resident 15 had been sitting in the recliner by the nurse's station since breakfast. LPN-B revealed that breakfast normally ends in between 9:30-9:45 AM. LPN-B was not sure on the last time Resident 15 had been repositioned or toileted but was going to ask the aide working with the resident. LPN-B asked NA-D (Nursing Assistant) who was working with the resident today and NA-D revealed it was NA-C. NA-C was asked when the last time Resident 15 had been toileted and NA-C replied, Right after breakfast. Observation at the nurse's station on 8/8/2022 at 11:58 AM, revealed NA-C and Restorative assist Resident 15 up out of the recliner and had transferred resident to a w/c. Restorative told the resident, We are going to go to lunch. NA-C told Resident 15 they would take resident to lunch after they took resident to the bathroom. NA-C had taken Resident 15 to the resident's room. Continued observation at 12:00 pm revealed NA-C has transferred Resident 15 from the w/c and onto the toilet. NA-C did not lock the w/c before the transfer and the w/c had rolled out into the Resident's room away from NA-C and the resident. Prior to Resident 15 being transferred to the toilet, the resident told NA-C, I've got to go pee and NA-C replied to the resident, I know you do that's why we came to the bathroom. Observation in Resident 15's room on 8/8/2022 at 2:26 PM, revealed Resident 15 resting in bed with eyes closed. Resident 15's bed was in the lowest position, a body pillow was placed between the resident and the edge of the bed, and a fall mat was laying on the floor next to the resident's bed. Observation in the hallway by the nurse's station on 8/9/2022 at 9:17 AM, revealed Resident 15 in a w/c with the w/c footrests in the down position as resident's feet were directly behind the footrests and were touching the ground. Resident 15 was trying to independently propel the w/c with resident's feet. Resident 15 was observed leaning forward in the w/c as if the resident was attempting to grab something. Nursing staff were present at the nurse's station. Record Review of Resident 15's current Care Plan revealed the facility had put the following fall interventions into place on 6/2/2022: Bed and chair alarms; keep the bed at knee height; monitor Resident 15 every hour when resident is in resident's room; staff will toilet Resident 15 routinely; an edge defining mattress; and a fall mat in place by Resident 15's bed. A fall intervention of Resident 15 was to keep resident's shoes on when up in a w/c was implemented on 4/10/2022. Further record review of Resident 15's Care Plan revealed a problem start date of 6/2/2022 indicated that resident was a high fall risk related to confusion and weakness. Record review of Resident 15's results of the John Hopkins Fall Risk Assessment Tool, completed on 3/2/2022 and 5/31/2022 indicated that resident was a high fall risk. Review of the facility's fall prevention policy with an effective date of 7/30/2019, revealed a section titled High Risk Protocols. Interventions for high-risk protocols included to be provided a sitter if indicated and scheduled ambulation or toileting assistance. Neither of these interventions were implemented on Resident 15's Care Plan. Interview with the ADON (Assistant Director of Nursing) on 8/9/2022 at 3:29 PM, confirmed that the fall interventions care planned for Resident 15 are not preventing the resident's falls. Resident is quick and gets up and moves within minutes. ADON had said the portion of Resident 15's Care Plan that was edited on 6/13/2022 stating, Staff will toilet Resident routinely, meant the standard of every two hours. Licensure Reference Number: NAC 175 12-006.09D7a B. Observations of Resident 24's room on 8/2/22 at 12:40 PM revealed the oxygen concentrator on while the resident was out of the room for lunch. C. Observations of Resident 88's room on 8/2/22 at 12:40 PM, 8/3/22 at 12:20 and on 8/4/22 at 8:10 AM revealed the oxygen concentrator on while the resident was out of the room for meals. D. Observations of Resident 89's room on 8/4/22 at 8:10 AM revealed the oxygen concentrator on while the resident was out of the room for breakfast. Interview with the Administrator on 8/4/22 at 8:10 AM confirmed that the oxygen concentrators were to be turned off while the residents were out of the room to reduce the risk of fire accidents.

Licensure Reference Number: 175 NAC 12-00611B Based on observations, record review and interviews; the facility failed to ensure that meals were served at the posted meal times. The facility census was 43 and most residents were effected by this failure. Findings are: Observations of the dining room on 8/2/22 at 12:00 PM revealed staff passing out drinks and salads for the residents. Further observations revealed that residents who required assistance with their meals were served next. At 12:25 PM, the staff started serving plates for the rest of the residents. Interviews with Resident 30 and one other resident, who requested to remain anonymous, on 8/2/22 at 12:20 PM revealed that the meals were often more than 30 minutes late. Resident 30 stated that they were supposed to be served around 12:00 PM but they will sit and wait for their meal for 30 to 45 minutes. Interview with Resident 10 on 8/8/22 at 2:11 PM revealed ongoing concerns about sitting in the dining room too long waiting for meals. The resident stated was in the dining room before 12:00 PM, the first plate was served at 12:30 PM and their table was served at 1:04 PM. Observations of the dining room on 8/3/22 at 12:30 PM revealed two tables with six residents (Residents 10, 31, 21, 29, 4 and 16) were not served yet. Review of the posted meal times in the dining room revealed that breakfast was at 8:00 AM, lunch at 12:00 PM and supper was at 6:00 PM. Interview with the Administrator on 8/8/22 at 2:30 PM confirmed that meals were not served as posted and in a timely manner. The Administrator confirmed that the residents were waiting too long in the dining room for their meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** License Reference Number 12-006.11D Based on observation, record review, and interview; the facility staff failed to ensure foods were prepared by methods that conserve the food's nutritive value and were served at palatable temperatures. The facility staff also failed to follow recipes. This had the potential to affect all 43 residents who resided in the facility. The facility identified a census of 43. The sample size was 12. Findings are: A. Observation in the kitchen of meal preparation of breakfast on 8/4/2022 at 8:20 AM, revealed there were three plates of pureed food sitting on the ledge of the stove (they did have foil covering them). Dietary Aide-N revealed Dietary Aide-N had prepared the plates of pureed food at 7:50 AM. Dietary Aide-N was getting ready to serve the plates of pureed food until asked if the food was still warm. Dietary Aide-N then replied, I temp the food to make sure they are still warm and had checked the temperature of pureed eggs on one out of three plates and had verbalized the temperature was 120 degrees F. Dietary Aide-N had then checked the temperature of the toast on that same pureed plate of food and had reported the temperature was 104.7 degrees F. Dietary Aide-N explained Dietary Aide-N waits 15 seconds for the thermometer to read the temperature. Dietary Aide-N Did not document the food temperatures on the Hot Food Temperature Log. Dietary Aide-N had only checked the temperature of the one plate of pureed food. Dietary Aide-N had placed the plate of pureed food (the one she checked the temp on) in the microwave for 30 seconds and had rechecked the temperature of the toast which was 130.8 degrees F. Dietary Aide-N was asked if Dietary Aide-N would normally recheck the temperature of the pureed eggs on the plate and Dietary-N replied, Yeah, I will. Dietary [NAME]-N then rechecked the pureed egg temperature on that plate and the result was 121.4 degrees F. Dietary Aide-N had microwaved the other two plates but did not recheck the food temperatures on them. Observation on 8/4/2022 at 8:20 AM, revealed the Hot Food Temperature Logs had areas of missing documentation. Dietary Aide-N had said Dietary Aide-N did check the temperatures of the food that was prepared for breakfast this morning but had forgotten to write the temperatures on the log. B. Observation in the kitchen during meal preparation for lunch on 8/4/22 at 10:23 AM, revealed Dietary Aide-N at the prepping counter (across from the stove). Dietary Aide-N, had said they didn't know the portion sizes or the temperatures for food. Dietary Aide-N disclosed Dietary Aide-N was making a hash brown casserole and said, The recipe book is not available, so I looked up my own recipe online and wrote it down. I don't have measurements. The ingredients per the recipe Dietary Aide-N had revealed, included: Sour cream, cream of chicken, cheese, has browns, no added salt, and cheese on top. Dietary Aide-N had said, I put the oven temperature to 350 degrees F and the recipe says to cook it for 45-55 minutes, but that's not correct, I cook it until it starts bubbling. Dietary Aide-N had said the ham is precooked, so it just needs to be warmed up. Observation in the kitchen on 8/4/2022 at 10:50 AM, revealed the Housekeeping Supervisor had the recipe book in the Housekeeping Supervisor's office. The Housekeeping Supervisor had revealed there was a recipe for hash brown casserole in the recipe book. Dietary Aide-N had not followed the recipe in the facility's recipe book. The Housekeeping Supervisor had given the recipe book to Dietary Aide-N with it opened to the page with the chicken fried steak recipe as that was the next food item Dietary Aide-N was going to prepare. Continued observation in the kitchen on 8/4/2022 at 10:54 AM, revealed Dietary Aide-N had looked at the chicken fried steak recipe, then filled an electric skillet with oil, had added salt and pepper to a bowl of flour, and closed the recipe book. The recipe also called for milk, but it was not added. The directions on the recipe were to beat 6 eggs, but Dietary Aide-N had poured an entire carton of liquid eggs into a bowl. Interview on 8/4/2022 at 10:50 AM with the Consulting RD (Registered Dietician), revealed the carton of liquid eggs contained approximately 14 eggs. The Consulting RD confirmed that Dietary Aide-N had not followed the hashbrown casserole or the chicken fried steak recipes. Further interview with the Consulting RD confirmed there were several areas of missing documentation on the Hot Food Temperature Logs. Continued observation of meal preparation revealed Dietary Aide-N had cut the chicken fried steak with scissors to, Make sure it's done before holding them in the oven. Dietary Aide-N had re-checked the ham and hashbrown casserole temperature and reported a temperature of a 157 degrees F for the ham and a temperature of 153 degrees F for the hashbrown casserole. Interview with the Administrator on 8/4/2022 at 9:58 AM, confirmed that all residents eat food from the kitchen.

Reference Number 12-006.11E Based on observation, interview, and record review, the facility failed to ensure the kitchen's equipment was kept clean, food was served and stored at temperatures to prevent foodborne illness, and failed to ensure staff performed hand hygiene or change gloves to prevent cross contamination. This had the potential to affect 43 of 43 residents who resided at the facility. The facility identified a census of 43. Sample size was 12. Findings are: A. Initial tour of the kitchen on 8/1/2022 at 1:01 PM, revealed the following findings: -The bottom shelf of the prep table (by the stove) was dirty with debris and had pots stored face down on it; -the stove had buildup of food and dark brown substances covering the surface; the back splash of the stove and the shelf directly above it had dried debris/areas of a dark brown substance/grease on it; -dust/debris build up was present on the all slits of the oven vent; -all of the yellow thermometers stored in a white container on the prep table shelf (directly across from the stove) were dirty as they were covered with a grayish-black residue and a couple of the caps had dried food/debris on them; -the refrigerator in the back part of the kitchen had a clear plastic container with a white substance in it that was not dated; -there was a small plastic bag that contained a package of opened slices of cheese that had mold covering it with an open/use date of 7/8/22 and an expiration date was July 16, 2022; -the D. Door refrigerator temperature was 49 degrees F; -all three prep counters were dirty with food/debris; -the refrigerator in the main area of the kitchen had a package of veggie burgers that had been opened, but no received/open/expiration dates were written on the package; -there was a container of pasta salad that had a large amount of water sitting on the lid and had a date of 7/27/22 written on the container; -there was a clear container with a green lid of cooked meat that was undated; -the refrigerator temperature in the main part of the kitchen was 78.5 degrees F and products in the refrigerator were slightly warm to the touch (Cheese, packages of bacon, Gallon of milk, several cartons of liquid scrambled eggs, BBQ sauce and other sauces, Gallon jugs of salad dressing, a package of ribs, container of meat, container of pasta salad, whipped topping, butter, veggie burgers, etc.). -Continued observation revealed there was an opened package of vanilla pudding mix without an open/received/used date; -a package of opened Oreo cookies that were exposed to air as the package was not completely sealed; there was an unopened container of Best Choice frosting that had a received date of 12/2021, but had expired on 4/12/22; -all three deep freezers had a thick layer of ice and frost build up covering the walls of the freezers; -a large swamp cooler was running and faced the stove and had dust/debris on the blades; -the wall and door to the fuse box behind the prep table where the blenders and mixer sat, were dirty with dark brown in color splashes or areas that had debris covering the area; -there was a flyswatter laying on the table by the mixer; -the telephone above the counter with the blenders and mixer was dirty with residue build up; and -the entire kitchen floor was dirty with dried food and other debris. Further initial tour of the kitchen on 8/1/2022 at 1:01 PM, revealed the food temperature log had missing documentation from July 20th-July 31st. Interview with Dietary Aide-E on 8/1/2022 at 1:39 PM, confirmed the temperature of the front refrigerator in the main part of the kitchen was at 78.5 degrees F and the D. Door refrigerator in the back part of the kitchen had a temperature of 49 degrees F. Dietary Aide-E said the temperatures of the refrigerators should usually be in-between 40-43 degrees F. Dietary Aide-E did not think they had a refrigerator temperature log. Interview with the Administrator on 8/1/2022 at 1:55 PM, confirmed the refrigerator (in the main part of the kitchen) had an elevated temperature of 78.5 degrees F. The Administrator had moved the refrigerator away from the wall and the temperature fluctuated between 55-58-degrees F. The Administrator had provided a Daily Refrigerator Log for the refrigerator in the main part of the kitchen. The Daily Refrigerator Log for the month of July 2022 had documented temperatures above 41 degrees F for 30 out of 31 days. The Daily Refrigerator Log log for the D. Door refrigerator had documented temperatures over 41 degrees F for 24 out of 31 days the month of July 2022. It was also confirmed there were several temperatures that had not been documented for the months of January 2022 to June 2022. Observation of the kitchen on 8/4/22 at 8:07 AM, revealed the following findings: -The bottom shelf of the prep counter directly behind/across from the stove continued to have debris on it and clean pots were lying face down on the shelf; -the metal cart sitting in-between the refrigerator and vegetable sink with cutting boards, knives, scissors, a plastic container of cereal, a container of dried onions, a container of parmesan cheese, etc. continued to have debris on it and a couple of pairs of scissors and metal potato masher were resting directly on the cart; -there was buildup of a brown in color substance on the floor around the dishwashing station as well as a large dead black bug was laying on the floor directly under the dishwashing/rinsing sink; -the kitchen floor continued to be dirty with buildup and debris; -there was a blue serving cart on wheels sitting next to the salad prepping table and was dirty with residue and build up around the edges on all three shelves of the cart; -the yellow food thermometers remained dirty with a grayish-black buildup covering the outer portion of the thermometers and the caps had debris on them; and -the white plastic container that held the thermometers was dirty and had debris in it. -There was a red sanitizing bucket sitting in between clean pots on the bottom shelf of the prep counter directly behind/across from the stove. Interview with Dietary Aide-N on 8/4/2022 at 8:17 AM, revealed the blue cart on wheels was used during lunch times for salads and fruit. B. Observation of the kitchen on 8/4/2022 at 8:20 AM, revealed Dietary Aide-N had uncovered three plates of pureed food that were sitting on the ledge of the stove. Interview with Dietary Aide-N on 8/4/2022 at 8:20 AM, revealed Dietary Aide-N had prepared three plates of pureed food at 7:50 AM and was getting ready to serve the plates of food until asked if the food was still warm. Dietary Aide-N said, I temp the food to make sure they are still warm. Dietary Aide-N checked the temperature of pureed eggs on one out of three plates and verbalized the temperature was 120 degrees F. Dietary Aide-N then checked the temperature of pureed toast on the same plate and reported the temperature was 104.7 degrees F. Dietary Aide-N reported Dietary Aide-N waits 15 seconds before reading the thermometer temperature. Observation on 8/4/2022 at 8:20 AM, revealed Dietary Aide-N did not write the food temperature results down on the Hot Food Temperature Log and had only checked the temperature of one plate. Continued observation of the kitchen on 8/4/2022 at 8:20 AM revealed Dietary Aide-N had placed a plate of pureed food (Dietary Aide-N had previously checked the temperature) in the microwave for 30 seconds. Dietary Aide-N rechecked the temperature of the toast which was 130.8 degrees F and had rechecked temperature of the eggs on the same plate which was 121.4 degrees F. Dietary Aide-N then microwaved the other two plates of pureed food but did not recheck the food temperatures after being microwaved. At 8:29 AM, dietary staff had taken the three plates of pureed food and served them to the residents. The food temperature logs were incomplete as there were areas of missing documentation. The stove continued to be dirty with residue down the front of it; thick black residue build up was on the inside of the oven doors; there was residue/grease buildup on the ledges of the bottom drawers of the ovens; dust remained in the slits of the hood vent; the shelf above the stove was dirty with debris; the top oven the stove was dirty with buildup; there was large amounts of dust inside of/behind the knobs on the stove. Interview with Dietary Aide-N on 8/4/2022 at 8:29 AM, confirmed there were several meals that had missing food temperature documentation. Dietary Aide-N had reported Dietary Aide-N had checked food temperatures prepared for breakfast but had forgotten to write the temperatures on the log. Interview with Maintenance Manager on 8/4/22 at 8:38 AM, confirmed stove vents and stove knobs had a buildup of dust, the stove had a buildup of grease and debris and other substances all over it as well as the shelf above the stove. Maintenance Manager also confirmed the kitchen floor was dirty with residue build up and debris; there was a package of expired, moldy cheese in the D. Door refrigerator; and there was an expired container of vanilla frosting on the shelf. Interview with Consulting RD (Registered Dietician) on 8/4/2022 at 9:44 AM, confirmed that the sanitizing bucket filled with liquid was sitting on the bottom shelf of the prepping table (that is directly behind/across from the stove) and was sitting in-between clean pots and pans. Consulting RD confirmed that the sanitizing bucket should not be there. The RD also confirmed the thermometers, the thermometer covers, and the white container holding the thermometers were dirty with residue/debris; the kitchen floor was dirty with residue build up and debris; the prepping counters in the kitchen were dirty with debris; the Hot Food Temperature Log had missing documentation; the oven was dirty with thick black build up; the stove was dirty with debris/dried food/and buildup of residue; the shelf above the stove was dirty with debris; the left oven did not work; and there was dust build up in/behind the knobs of the stove and in the slits of the stove hood vent. Interview with the Administrator on 8/4/2022 at 9:58 AM, confirmed that all residents eat food from the kitchen. Further interview with the Administrator revealed there was missing documentation for temperatures and sanitizer concentration percentages on the Dish Machine Temperature and Sanitizer Logs from January 2022 to June 2022; the kitchen cleaning schedule document was blank, and the facility did not have a completed food receiving log. Review of the facility Policy and Procedure Manual, Food Temperatures, with a copyright of 2021; revealed temperatures of all food items will be taken and properly recorded prior to service of each meal. All hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees F. Cooking temperatures must be reached and maintained according to regulations, laws, and standard recipes while cooking. Hot food items may not fall below 135 degrees F after cooking unless it is an item which was to be rapidly cooled to below 41 degrees F and reheated to at least 165 degrees F (for a minimum of 15 seconds) prior to serving. Caution should be taken to avoid serving food and liquids at temperatures that are too hot to avoid the risk of burns. All cold food items must be stored at a temperature of 41 degrees F or below. Microwave cooking and reheating food, rotate and stir foods during the cooking process so that all parts of the food are heated to a temperature of at least 165 degrees F. Allow time for the microwaved/reheated food to stand for 2 minutes after cooking, so the food is heated throughout. Under the section taking accurate temperature, revealed temperatures are to be taken with a clean, rinsed, and airdried thermometer. A temperature record for recording the temperatures is needed. Review of the facility Policy and Procedure Manual, Food storage, with a copyright of 2021; revealed food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination on cross contamination. Food should be dated as it is placed on the shelves if required by state regulation. All containers or storage bags must be legible and accurately labeled and dated. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. All refrigerator units should be kept clean and in good working condition at all times. Time/temperature control for safety (TCS) must be maintained at or below 41 degrees F unless otherwise specified by law. Temperatures of refrigerators should be between 35 to 39 degrees. Review of the facility Policy and Procedure Manual, Employee Sanitary Practices, with a copyright of 2021; revealed staff were to wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food. Staff to wash hands before handling food, sing hand-washing procedures. Use utensils to handle food, avoiding bare hand contact with food. Disposable gloves are a single use item and should be discarded after each use. Hands must be washed prior to using gloves and after removing gloves. Avoid touching mouth or face while preparing food (and wash hands if contaminated). Review of the facility Policy and Procedure Manual, General Sanitation of the Kitchen, with a copyright of 2021; revealed cleaning and sanitation tasks for the kitchen will be outlined in a written cleaning schedule. C. Observation of the kitchen on 8/1/2022 at 1:01 PM, revealed Dietary Aide-E had most of their ponytail hanging out from underneath the hairnet. Observation of the kitchen on 8/1/2022 at 1:01 PM, revealed Dietary Aide-J with a surgical mask resting under Dietary Aide-J's nose and only covering Dietary Aide-J's mouth. Observation of the kitchen on 08/01/22 at 1:52 PM, revealed Dietary Aide-J with a surgical mask resting on Dietary Aide-J's chin and not covering the nose or mouth. At 1:55 PM, Dietary Aide-J had taken the surgical mask off, walked through the end of the dining room, and exited the facility. Observation in the kitchen on 8/2/2022 at 8:40 AM, revealed Dietary Aide-E in the kitchen with a face shield resting on the top of Dietary Aide-E's head, a surgical mask was resting under Dietary Aide-E's chin and not covering the mouth or nose. Dietary Aide-E's ponytail was not secured in the hair net as the full ponytail was hanging out of it while cooking. Observation of the kitchen on 8/2/2022 at 11:54 AM during meal service, revealed Dietary Aide-E in the kitchen at the stove with a ponytail that was not secured within the hairnet as most of the ponytail was hanging down Dietary Aide-E's back. Observation of the kitchen on 8/2/2022 at 12:06 PM, revealed Dietary Aide-F had messed with Dietary Aide-F's hair net with bare hands and then placed it back on. Dietary Aide- F had several strands of hair that hung down each side of Dietary Aide-F's face as they were not secured within the hair net. Dietary Aide-F washed hands at the kitchen handwashing station for 15 seconds versus 20 seconds. Observation of the kitchen on 8/2/2022 at 12:09 PM, revealed Dietary Aide-E had adjusted own surgical mask twice with gloves on. Dietary Aide-E did not change the gloves and did not perform hand hygiene prior to touching cooking utensils, cookware on the stove, resident's plates of food, and a slice of bread. Dietary Aide-E had not changed out the gloves and did not perform hand hygiene. Observation of the kitchen on 8/2/2022 at 12:13 PM, revealed Dietary Aide-G had applied gloves and then had touched and adjusted Dietary Aide-G's goggles. Dietary Aide-G did not change the gloves and did not perform hand hygiene. Observation of the kitchen on 8/2/2022 at 12:15 PM, revealed Dietary Aide-G had taken a resident's meal card and a marker with the same gloves on since 12:13 PM. Dietary Aide-G had exited the kitchen and into the back hallway to nursing. Dietary Aide-G had gone to a resident's room and re-entered the kitchen at 12:19 PM with the same gloves on. Dietary Aide-G did not change out the gloves or perform hand hygiene prior to touching resident's plates and delivering to the residents. Observation in the dining room on 8/2/22 at 12:22 PM, revealed NA-H was at the kitchen door getting a resident's plate when NA-H had scratched NA-H's head and did not perform hand hygiene prior to taking a plate and serving it to a resident. Observation of the kitchen on 8/2/2022 at 12:32 PM, revealed Dietary Aide-I touching own pants and badge with Dietary Aide-I's bare hands while waiting for a resident's plate. Dietary Aide-I did not perform hand hygiene prior to taking the resident's plate and serving it to the resident. No hand hygiene was performed upon Dietary Aide-I's return to the kitchen. Observation in the dining room on 8/2/2022 at 12:37 PM, revealed Dietary Aide-I still had not performed hand hygiene prior to retrieving coffee cups from a cabinet by the Beverage Bar. Dietary Aide-I had filled the cups and served them to residents. No hand hygiene was performed after serving the coffee. Observation in the dining room on 8/2/2022 at 12:39 PM, revealed Dietary Aide-I had placed Dietary Aide-I's bare hands both handles of a resident's walker while asking the resident what they would like to eat. Dietary Aide-I did not perform hand hygiene prior to retrieving a coffee cup from the cabinet next to the Beverage Bar. Dietary Aide-I had filled the coffee cup and served it to a resident. Dietary Aide-I continued to not perform hand hygiene. Dietary Aide-I entered the kitchen to retrieve butter that a resident had requested, and Dietary Aide-I retrieved the butter from the refrigerator. Dietary Aide-I continued to without the benefit of hand hygiene. Interview with the Administrator on 8/9/2022 at 10:01 AM confirmed the kitchen's PPE policy is the same as the facilities COVID (2019 Novel Coronavirus) PPE policy. The Administrator said the expectation for the kitchen staff was the same as all other employees who worked in the facility which included wearing a face shield/goggles and a surgical mask. The Administrator verified not all staff have followed the PPE policy. Review of the facility's, Infection Prevention and Control policy revised on 7/7/2020, revealed under the Hand Hygiene protocol section stated that all staff shall wash their hands when coming on duty, between resident contacts, after handling contaminated objects, after PPE removal, before/after eating, toileting, and before going off duty. Under the section, Staff referral to treatment centers/services, revealed staff shall use PPE according to established facility policy governing the use of PPE. Review of the facilities COVID 19 (Coronavirus) policy and procedure with an effective date of 5/16/2022, revealed that the facility would comply with the Center of Disease Control (CDC) and State Department of Health (DOH) guidelines regarding awareness and the prevention of the spread of COVID-19. Under section, Screening for visitors and staff, revealed the facility would screen them for signs or symptoms of the Coronavirus upon entrance to the facility. As well as staff would be monitored for compliance with hand hygiene and compliance with standard and transmission-based precautions. Under the section, Additional precautions, revealed staff would always utilize source control (mask) and goggles/face shield where there is substantial (orange) or high (red) community transmission during sustained resident interactions (within 6 feet greater than 15 minutes).

License Reference Number 175 NAC 12.006.17B Based on observations, interviews, and record review, the facility staff failed to prevent the potential spread of COVID 19 (2019 Novel Coronavirus) by not screening Daycare staff and by staff not wearing personal protective equipment (PPE) as indicated. This had the potential to affect all 43 residents who resided in the facility. The facility Identified a census of 43 residents at the time of survey. The sample size was 12. Findings are: Observation in the nursing hallway (Golden Rod) on 8/2/2022 at 2:55 PM, revealed NA-K (Nurse Aide) exiting a resident's room with a surgical mask down under NA-K's nose and only covering the mouth. NA-K then walked through the hallway and past the nurse's station where residents were sitting. Observation at the Nurses station on 8/2/2022 at 2:56 PM, revealed Social Services had a surgical mask resting under Social Services nose and was by residents who were sitting at the nurse's station. Observation by the Nurse's station on 8/2/2022 at 2:57 PM, revealed Housekeeping Supervisor with a surgical mask down under Housekeeping Supervisor's chin, exposing the nose and mouth as Housekeeping Supervisor stood by resident's across from the nurse's station. Observation at the nurse's station on 8/3/2022 at 9:43 AM, revealed NA-L sitting at the nurse's station with a surgical mask under NA-L's nose and only covering the mouth. Residents were sitting by the nurse's station. Continued observation at the nurse's station on 8/3/2022 at 10:09 AM, revealed NA-L sitting at the nurse's station with a surgical mask resting under NA-L's chin, exposing the mouth and nose as residents were sitting near the nurse's station. Observation in the hallway by the nurse's station on 8/3/2022 at 3:37 PM, revealed Activities had pulled Activities' surgical mask down, exposing their nose and mouth while speaking close to a resident's face. Observation at the nurse's station on 8/3/2022 at 4:08 PM, revealed RN-M (Registered Nurse) standing at a mediation cart that was parked next to the nurse's station. RN-M had a surgical mask resting under RN-M's chin, exposing the nose as RN-M had been speaking with another staff member. Residents were sitting around by the nurse's station. Observation in the kitchen on 8/4/2022 at 11:26 AM, revealed Daycare had entered the kitchen to pick up the daycare's meals. Daycare was not wearing a hairnet, a face shield/goggles, or a mask while in the kitchen. Interview with Daycare on 8/4/2022 at 11:26 AM, confirmed that Daycare had not been screened for COVID 19 symptoms at the door prior to entering the facility/kitchen. Daycare had said the daycare staff, Just comes in the back door (pointed to the door closest to the kitchen). Daycare reported that the only time the daycare staff have had to wear PPE (personal protective equipment) and be screened at the door was when the facility had been in the red zone. Daycare explained dietary staff would meet daycare staff at the door with food when the facility had been in the red zone. Otherwise, we just come in and pick it up. Observation upon entrance to the facility through the front door on 8/9/2022 at 9:14 AM, revealed the Administrator had performed the COVID 19 screening process as Dietary Aide-N had stood next to the Administrator and was not wearing the required PPE as a surgical mask was observed resting under Dietary Aide-N's nose and Dietary Aide-N was not wearing a face shield/goggles. Residents were passing by in the hallway within proximity. Observation in the hallway by the nurse's station on 8/9/2022 at 9:33 AM, revealed NA-D had walked through the hallway, past the nurse's station, to the laundry room with NA-D's surgical mask resting under NA-D's nose and a pair of goggles were resting on the top of NA-D's head. Continued observation revealed NA-D has exited a resident's room in the Golden Rod hallway with goggles resting on NA-D's head and a surgical mask resting under their nose. NA-D continued to enter and exit resident's rooms on the Golden Rod hallway with goggles resting on the top of NA-D's head. NA-D had placed footrests on an occupied wheelchair without goggles on as they continued to sit on the top of NA-D's head. Observation at the Nurses station on 9/9/2022 at 9:38 AM, reveled NA-O was seen exiting a resident's room and walking down Meadowlark hallway, towards the nurse's station with a surgical mask resting under NA-O's nose. NA-O had stood next to a resident with a surgical mask not covering NA-O's nose. Interview with the Administrator on 8/9/2022 at 10:01 AM confirmed all staff were expected to follow the facility's COVID 19 PPE policy and were to wear a face shield/goggles, and a surgical mask. The Administrator verified not all staff were following the facilities PPE policy. Review of the facility's COVID 19 policy and procedure with an effective date of 5/16/2022, revealed that the facility would comply with the Center of Disease Control (CDC) and State Department of Health (DOH) guidelines regarding awareness and the prevention of the spread of COVID-19. Under section, Screening for visitors and staff, revealed the facility would screen them for signs or symptoms of the coronavirus upon entrance to the facility. As well as staff would be monitored for compliance with hand hygiene and employee compliance with standard and transmission-based precautions. Under the section, Additional precautions, revealed staff would always utilize source control (mask), goggles/face shield will be utilized where there is substantial (orange) or high (red) community transmission during sustained resident interactions (within 6 feet greater than 15 minutes).

License Reference Number 175 NAC 12-006.18B Based on observation, record review and interview; the facility staff failed to ensure equipment was in working order as 1) the refrigerator temperature was 78.5 degrees F and 2) the left side of the oven was not in working order. This had a potential to affect all 43 residents who resided at the facility. The facility identified a census of 43 residents at the time of survey. The sample size was 12. Findings are: Initial tour of the kitchen on 8/1/2022 at 1:01 PM, revealed the refrigerator temperature in the main part of the kitchen was 78.5 degrees F. The D. Door refrigerator temperature was 49 degrees F. Interview with Dietary Aide-E on 8/1/2022 at 1:39 PM, confirmed the temperature of the front refrigerator in the main part of the kitchen was at 78.5 degrees F and the D. Door refrigerator in the back part of the kitchen had a temperature of 49 degrees F. Dietary Aide-E said the temperatures of the refrigerators should usually be in-between 40-43 degrees F. Dietary Aide-E did not think they had a refrigerator temperature log. Interview with the Administrator on 8/1/2022 at 1:55 PM, confirmed the refrigerator (in the main part of the kitchen) had an elevated temperature of 78.5 degrees F. The Administrator had moved the refrigerator away from the wall and the temperature fluctuated between 55-58-degrees F. The Administrator had provided a Daily Refrigerator Log for the refrigerator in the main part of the kitchen. The Daily Refrigerator Log for the month of July 2022 had documented temperatures above 41 degrees F for 30 out of 31 days. The Daily Refrigerator Log log for the D. Door refrigerator had documented temperatures over 41 degrees F for 24 out of 31 days the month of July 2022. It was also confirmed there were several temperatures that had not been documented for the months of January 2022 to June 2022. Observation in the kitchen on 8/4/2022 at 10:23 AM, revealed there were two small ovens in the kitchen. Dietary Aide-N had prepared ham and a hashbrown casserole. Dietary Aide-N had to put each of the food items in the right side of the oven and had to rotate them. Interview with Dietary Aide-N on 8/4/2022 at 10:23 AM, revealed that the left oven was not in working order, so the facility only had one side of the oven to work with. Interview with the Consulting RD (Registered Dietician) on 8/4/2022 at 10:50 AM, confirmed the left side of the oven was not in working order. Interview with the Administrator on 8/4/2022 at 9:58 AM, confirmed that all residents eat food from the kitchen. Review of the facility Policy and Procedure Manual, Food storage, with a copyright of 2021; revealed all refrigerator units should be kept clean and in good working condition at all times. Time/temperature control for safety (TCS) must be maintained at or below 41 degrees F unless otherwise specified by law. Temperatures of refrigerators should be between 35 to 39 degrees.