**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09 Based on record review and interview, the facility failed to ensure that neurological checks (a series of physical tests that assess the nervous system to monitor for brain injury after a fall) were completed to monitor 1 of 3 residents reviewed (Resident 2) after an unwitnessed fall. This had the potential for resident change in condition to not be identified. The facility census was 32. Findings are: Record review of the undated facility procedure Falls and Neurological Assessments revealed that for unwitnessed falls the policy for required neurological checks to be conducted every 15 minutes x 4, every 30 minutes x 2, every hour x 2, every 2 hours x 2, every 4 hours x 2, then every shift for 72 hours. A set of vital signs (blood pressure, pulse, respirations, temperature) is required for each neurological check. Record review of the admission Record dated 10/7/24 for Resident 2 revealed that Resident 2 admitted into the facility on [DATE]. Record review of the Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) for Resident 2 dated 7/28/24 revealed that Resident 2 had 1 fall with major injury since the previous assessment. Record review of the progress note dated 7/18/24 at 6:35 AM for Resident 2 revealed that a neighbor of Resident 2 pressed the call light to alert staff that a loud noise was heard coming from Resident 2's room. Staff observed Resident 2 sitting on their bottom in front of the bathroom sink. Resident 2 was assessed. It was noted that urine was all over the bathroom floor. Resident 2 stated that the resident stood from the toilet and slid down on their butt. Record review of the medical record for Resident 2 revealed no neurological checks were completed for Resident 2 following the resident's unwitnessed fall that occurred on 7/18/24. Interview on 10/7/24 at 3:14 PM with Registered Nurse-B (RN-B) revealed that neurological checks were to be done for all unwitnessed falls and witnessed falls with head injury. Interview on 10/7/24 at 4:29 PM with the facility Minimum Data Set Coordinator (MDSC) (a facility nurse that utilizes a mandatory comprehensive assessment tool for care planning) confirmed that no neurological checks were completed for Resident 2 after the resident's fall on 7/18/24. Interview on 10/7/24 at 4:42 PM with the facility Director of Nursing (DON) confirmed that neurological checks were expected to be completed for all unwitnessed resident falls to monitor the resident for a change in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference NUmber 175 NAC 12-006.09D3 Based on Interview and record review the facility failed to ensure the facility bowel management program was followed for 1 (Resident 30) of 1 sampled residents. This affected 1 resident (Resident 30). The facility census was 31. Findings are: A record review of the facility Bowel Management Program which is not a dated document, revealed the following Bowel Movement (BM) protocol: -If no BM, on second day: prune juice breakfast and PRN (as needed) lunch. -If no BM end of day 2: MOM (milk of magnesia - a medication to induce a BM). -May use judgement. May try two doses of MOM and then if no results. -If no BM by last night rounds (04:00 AM to 05:00 AM) of day 3: suppository. A record review of the Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities to help nursing home staff identify health problems) dated 4/25/2024 for Resident 30 revealed a Brief Interview for Mental Status (BIMS, a brief screening tool that aides in the detection of cognitive impairment) score of 5 indicating severe cognitive impairment. Resident 30 takes antipsychotic (medications are generally used to treat the symptoms of schizophrenia and other psychotic disorders) and an antianxiety (medications used to treat symptoms of anxiety, such as feelings of fear, dread, uneasiness, and muscle tightness, that may occur as a reaction to stress) medication. The MDS also revealed a diagnosis for Non-Alzheimer's Dementia (several diseases such as Lewy body dementia, vascular or multi-infarct dementia; mixed dementia; frontotemporal dementia such as Pick's disease; and dementia related to stroke, Parkinson's or Creutzfeldt-[NAME] diseases.) There is no indication in the MDS that the resident has a diagnosis of constipation. A record review of the Care Plan dated and last revised on 1/24/2024 for Resident 30 revealed a diagnosis of Constipation had been added to Resident 30's Care Plan but had not been addressed in the care plan for interventions, treatments, and expected outcomes. The Care Plan revealed that Resident 30 is cognitively impaired. A record review of the Care Plan last revised on and dated 5/2/2024 for Resident 30 revealed no interventions in place for Resident 30's constipation. A record review of the Physician Orders for Resident 30 revealed an order for Senna-S 8.6/5 mg (milligrams) one tablet daily for constipation which had a start date of 11/16/2023. There is also an order for Milk of Magnesia (MOM, milk of magnesia - a medication to induce a BM) to be given PRN (as needed) for constipation and an order for Bisacolax Suppository (a medication that aides in the relief of constipation) 10 mg to be given PRN with a start date of 11/16/2023 for constipation. A record review of the Follow Up Question reports for April 2024 revealed Resident 30 did not have a BM through the following dates: -On April 1 Resident 30 had a BM. No further BM was documented until April 4. -On April 6 Resident 30 had a BM. No further BM was documented untilApril 9. -On April 9 Resident 30 had a BM. No further BM was documented until April 12. -On April 12 Resident 30 had a BM. No further BM was documented until April 15. -On April 26 Resident 30 had a BM. No further BM was documented until April 30. A record review of the Medication Administration Record for the month of April 2024 revealed Resident 30 received MOM on the following dates: -April 29 on day two per the facility bowel protocol. -April 30 on day three per the facility bowel protocol. A record review of the Follow Up Question reports for the month of May 2024 revealed Resident 30 did not have a BM through the following dates: -On April 30 Resident 30 had a BM. No further BM was documented until May 5. -On May 12 Resident 30 had a BM. No further BM was documented until May 16. -On May 16 Resident 30 had a BM. No further BM was documented until May 20. A record review of the Medication Administration Record for the month of May 2024 revealed Resident 30 received MOM, and Bisacolax suppositories on the following dates: -May 2, day two, per the facility bowel protocol, Resident 30 should have received MOM and didn't. -May 3, day three, Resident 30 recieved MOM. -May 4, day four, Resident 30 recieved MOM. -May 5, day five, Resident 30 received a suppository at 5:00 AM. -May 16, day four Resident 30 received MOM. -May 20, day four, Resident 30 received a suppository at 5:00 AM. -May 24, day two, Resident 30 received MOM. -May 29, day four, Resident 30 received MOM. A record review of Resident 30's Physician Orders dated 5/22/2024 revealed an order to increase the Senna-S 8.6/5 mg to two tablets every morning. A record review of the Follow Up Question reports for June 2024 revealed Resident 30 did not have a BM through the following dates: -On June 5 Resident 30 had a BM. No further BM was documented until June 8. A record review of the Medication Administration Record for the month of June 2024 revealed the resident had not received any PRN medications for constipation whereas according to policy Resident 30 should have received MOM on June 5 and June 6. A record review of the Health Status Notes during the months of April 2024, May 2024, and June 2024 in the Progress notes show that the issues of constipation were not addressed except on the date of 5/21/2024 when the staff had asked the Physician for an order to increase the Senna-S for constipation issues. This order was received and started on 5/22/2024. In an interview on 6/26/24 at 10:40 AM with Registered Nurse-D (RN-D) explains how the facility nurses use the BM Protocol. Night nurses fill out the form so the day shift nurses are able to start the protocol at breakfast as needed. Night nurses fill out who has not had a BM in the last 2 days and then we start the protocol and follow it until we have results. Sometimes the nurses will ask the Nurses' Aides that are working with the patients if they have forgotten to chart any BM's. If they have forgotten or not gotten a BM in the charts, the Nurses' Aides are to enter them right away. The example given was that if a resident had a BM on Sunday, and there was no BM on Monday, then on Tuesday the resident would receive prune juice with meals. Tuesday night if there was still no BM, the resident would receive an ordered dose of MOM. Finally on Wednesday if the resident remained constipated with no results staff are able to give another dose of MOM or give a suppository. Confirmed how to use the BOWEL program, how the staff documents, and that there was no MOM or SUPP done when should have been per the facility policy and procedure. In an interview on 6/26/2024 at 10:55 with Assistant Director of Nursing (ADON). The ADON stated that the BM's are reviewed by the night shift nurses who then fill out the paperwork for the Bowel Protocol. Confirmed that by looking through the MARS and then looking through the BM's that have been charted that this resident should have received multiple different doses of medications on days the facility Bowel program required medication. On these dates and times, no medications were charted. The ADON also confirmed that the Interdisciplinary team reviews the Bowel habits of the residents every week during the risk management assessment. After increasing the Senna in May, the resident has had fewer issues with constipation. Confirmed the facility staff were not following bowel program as the facility policy and procedure directs staff. Confirmed that the information is not contained on the comprehensive patient centered care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Review of a facility policy titled Catheter Care Procedure dated 06/12/2023 revealed to cleanse area by the catheter (which is a tube inserted into the bladder to drain urine) insertion site with a clean wipe. Then, to clean the catheter tubing with alcohol wipes and wiping area closest to the resident body first then away from the body. In an observation completed on 6/26/2024 at 8:21 AM Medication Aide-E (MA-E) was providing catheter cares to Resident 26 while [gender] was lying in the bed. MA-E had gloves on both of [gender] hands and removed a disposable wipe from the package. MA-E dispensed from a plastic pump bottle 2 pumps of a white foam onto the disposable wipe. MA-E then used the disposable wipe to wipe around the tip and down the shaft towards the abdomen of Resident 26's penis. MA-E then used the wipe starting at the tip of the penis to wipe down the catheter tubing away from the resident's body approximately 4 inches down the catheter tubing. MA-E repeated this action using the same section of the disposable cloth 3 times. MA-E then disposed of the cloth into a trash bag. In an interview on 6/26/2024 at 8:50 AM with MA-E, confirmed that a different section of the cloth should have been used for each wipe of the catheter tubing. In an interview on 6/27/2024 at 9:30 AM with the Assistant Director of Nursing (ADON), confirmed the facility policy was to cleanse the catheter tubing with an alcohol wipe not a disposable wipe. C. Review of a facility policy titled Wound Care dated 01/2002 revealed: -Establish a clean field, place all items to be used during procedure on the clean field. -Wash and dry your hands thoroughly. -Loosen tape and remove old dressing, pull the glove over the dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. -Wash tissue around the wound with antiseptic or soap and water. -Be certain all clean items are on the clean field. Review of a facility policy titled Hand Washing for all Healthcare Workers dated 08/01/2011 revealed under procedure using friction, wash entire surface of hands for 20 seconds. In an observation on 6/26/2024 at 11:21 AM the following was observed during wound care being completed by the facility Infection Control Coordinator (ICC): -The ICC placed a clear plastic medication cup with a piece of white material in it, a pair of silver scissors, a roll of white tape, and an open package containing a dark gray foam material on Resident 12's bedside table. The bedside table was not sanitized or did not contain a barrier prior to ICC placing the wound supplies on the table. -The ICC removed the dressing from Resident 12's right foot. The ICC examined the dressing then placed the removed dressing on top of the scissors laying on the bedside table. -The ICC removed their gloves and performed hand hygiene with soap and water in the resident's bathroom for 5 seconds. -The ICC then placed on gloves on both hands and utilized a white moist cloth and rubbed up and down on Resident 12's right foot wound. -The ICC then used the scissors and cut a piece of the gray foam dressing and placed the gray foam over the wound on Resident 12's right foot. The ICC did not cleanse the scissors prior to cutting the material and placing it over the wound after contaminating the scissors with the removed dressing being placed on top of the scissors. -The ICC removed their gloves and performed hand hygiene with soap and water in the resident's bathroom for 7 seconds. In an interview on 6/26/2024 at 12:10 PM with the ICC, confirmed [gender] did not provide a clean field or sanitize the bedside table prior to placing the wound care items on top of it. The ICC confirmed [gender] placed the removed, soiled dressing on top of the scissors and used the scissors to cut the new dressing material and did not sanitize or clean the scissors prior. The ICC confirmed [gender] did not complete 20 seconds of hand washing. Licensure Reference Number 175NAC 1-005.06(A) Licensure Reference Number 175NAC 1-005.06(D) Licensure Reference Number 175NAC 1-005.06(F) Based on record review and interview the facility failed to ensure that the policy for infection control was reviewed and updated annually. This had the potential for the policy to not include current and up to date recommendations for infection control. This had the potential to affect all facility residents. The facility failed to complete catheter and wound cares cares for Resident 26 in a manner to prevent cross contamination. The facility census was 31. Findings are: A. Record review of the Facility assessment dated [DATE] revealed that the services and care offered included Infection Prevention and control. Identification and containment of infections, and prevention of infections. A facility must include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program. Record review of the facility Infection Policy dated 7/2007 revealed that all staff engaged in direct patient care shall be instructed in correct techniques and be familiar with the facility's established infection control policies and procedures. The policy had no documentation of annual review. Interview on 6/26/24 at 4:55 PM with the facility Social Services Director (SSD) confirmed that the facility Infection Policy had not been reviewed and updated annually as required to ensure it was up to date with current infection control standards.

Licensure Reference Number 175NAC 12-006.05(21) Based on observation, record review, and interview the facility failed to ensure that staff served meals in a manner to maintain resident dignity for 1 resident (Resident 8). The facility census was 31. Findings are: Record review of the facility Resident Rights dated 2016 revealed that the resident has the right to a dignified existence and be treated with respect and dignity that promotes his or her quality of life, recognizing his/her individuality. The facility must provide equal access to quality of care. Observation on 5/22/23 at 12:04 PM in the main dining room revealed that Dietary Aide-B (DA-B) delivered a meal to Resident 27. Resident 8 (the tablemate of Resident 27) sat at the table and was not served a meal. DA-B delivered a meal to Resident 16 at another table. Resident 16 was alone at their table. Dietary Aide-A (DA-A) delivered a meal to Resident 12 at another table. Resident 12 was alone at their table. DA-A delivered a meal to Resident 25 at another table. Resident 25 was alone at their table. Resident 8 still had not been served a meal. Resident 8 watched as their tablemate (Resident 27) continued to eat their meal. The time was now 12:14 PM. DA-A returned to the dining room with a second helping of ribs for Resident 13. Resident 8 still had not received a meal. Resident 8 continued to watch their tablemate (Resident 27) eat their meal. DA-A asked Resident 8 if they wanted more coffee. Resident 8 refused. Observation on 5/22/23 at 12:18 PM in the main dining room revealed that Resident 27 was finished eating and had consumed 100% of their meal. Resident 8 (tablemate of Resident 27) still had not been served. Resident 8 revealed that they were still waiting for their meal. Interview on 5/22/23 at 12:19 PM with Dietary Cook-C (DC-C) revealed that they were not sure if Resident 8 was going to be a room tray or come to the dining room. DA-A told DC-C that Resident 8 was out in the dining room. Observation on 5/22/23 at 12:20 PM in the facility kitchen revealed that DC-C plated food for Resident 8. DA-A delivered the plate of food to Resident 8. This was 16 minutes after Resident 8's tablemate (Resident 27) had been served. Interview on 5/25/23 at 8:38 AM with the facility Registered Dietitian (RD) confirmed that the expectation is that all residents at a table should be served the meal before serving the next table for resident dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D1c Based on observations, interviews, and record review; the facility failed to ensure 1 (Resident 5) of 2 sampled residents was assisted with ADLs (Activities of Daily Living-dressing, grooming, toileting, bathing) and had the means to obtain assistance if needed. The facility identified a census of 31. Findings are: Record review of the Minimum Data Set (MDS) (a federally mandated assessment used to develop a resident's plan of care) dated 5/4/2023 revealed Resident 5 was admitted on [DATE] with a diagnosis of Schizoaffective Disorder (a mental health disorder) and Section G indicated the resident required extensive assistance with 2 staff members for all Activities of Daily Living (ADL). Record review of Resident 5's Care Plan with a revision date 1/20/23 revealed Resident 5 with a self care deficit problem with an intervention to check and change before/after meals and PRN (as needed) and needs total assistance with bed mobility, transfers, showers, locomotion, dressing, personal hygiene and toileting. Observation on 5/22/23 at 11:22 AM revealed Resident 5 in the wheelchair in the resident's room with a strong odor of bowel incontinence, the call light was located on the floor behind Resident 5, hanging on the oxygen concentrator resting on the floor, out of Resident 5's reach. Resident 5 reached out and asked for help after placing a hand down the soiled brief. Observation on 5/23/23 at 8:00 AM revealed Resident 5 lying in bed flat on the residents back, the call light was located hanging over the oxygen concentrator on the floor, out of Resident 5's reach. Observation on 5/23/23 at 10:25 AM revealed Resident 5 lying in bed in the same position as Resident 5 was in at 8:00 AM, the resident remained in night gown, and the call light was located hanging over the oxygen concentrator on the floor, out of Resident 5's reach. A continuous observation on 5/23/23 from 1:30 PM to 4:10 PM revealed Nurse Aide (NA-I) walked into the residents room at 3:15 PM, and coming out of the room in less than 3 seconds. Nurse Aid (NA-I) did not enter any other rooms on that wing. No other staff member entered the Resident 5's room during this observation period. Staff members were observed gathering in the nurse's office for long periods of time with the door closed during the continuous observation. A continuous observation on 5/24/23 from 8:20 AM to 10:25 AM revealed that at 8:20 AM Resident 5 was in bed in the resident's room with gown on, the call light was located hanging off of the nightstand out of the residents reach. At 9:25 AM an observation revealed staff entering Resident 5's room to provide AM cares, the resident was left in the same position. Observation on 5/24/23 at 2:00 PM revealed that Resident 5 understood the call light use but was not able to manipulate to push the button. Interview with Registered Nurse (RN- H) on 5/24/23 at 2:05 PM revealed the nurse was unsure of who was responsible for determining the type of call light that a resident would use, and that all residents received routine rounding. The interview also revealed that routine rounding meant every two hours and before and after meals. Interview with the Minimum Data Set Coordinator (MDSC) on 5/24/23 at 2:25 PM confirmed that Resident 5 would be able to use a call light and that everyone should have a call light available. A record review of ADL documentation for bowel and bladder incontinence and checking Resident 5 revealed: *5/11/2023 there were 5 episodes of documentation in a 24-hour time period. *5/13/2023 there were 3 episodes of documentation in a 24-hour time period. *5/14/2023 there were 5 episodes of documentation in a 24-hour time period. *5/15/2023 there were 4 episodes of documentation in a 24-hour time period. *5/16/2023 there were 4 episodes of documentation in a 24-hour time period. *5/17/2023 there were 5 episodes of documentation in a 24-hour time period. *5/19/2023 there were 5 episodes of documentation in a 24-hour time period. *5/23/2023 there were 3 episodes of documentation in a 24-hour time period. Interview with the MDS Nurse (MDSC) on 5/24/23 at 9:15 AM confirmed there was no other documentation available for ADL/incontinence cares. The interview also confirmed that check and change routinely indicated that a resident would be checked and changed before and after meals and every 2 hours. A policy review of AM Resident Cares last revised on 11/19/2022 and HS Cares last revised on 1/6/2011 revealed toileting was to be offered with AM and HS cares. Routine rounding and incontinence cares were not addressed in either policy. Interview with the Assistant Director of Nursing (ADON) on 05/24/2023 at 3:25 PM confirmed there was no toileting/ADL policy other than a bowel management policy, and there was no policy for routine rounding.

Licensure Reference Number 175NAC 12-006.18B Based on observation, record review, and interview the facility failed to ensure that it maintained the cleanliness of facility lighting fixtures. This affected 24 residents that resided on the 200 hallway. The facility census was 31. Findings are: Record review of the facility admission Packet Nursing Home Accommodation Rates for 2022-2023 revealed that the facility daily rate includes laundry and housekeeping services. Record review of the undated facility Resident Handbook revealed that the maintenance staff is responsible for the general care and maintenance of the nursing home. Record review of the facility Resident Rights dated 2016 revealed that the resident has the right to a safe, clean, comfortable, and homelike environment. The nursing facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Observation on 5/24/23 at 8:46 AM in the facility 200 hallway between the great room and the west nurses station revealed that 9 of 9 ceiling lights had dead insects laying in the light covers. The 2 ceiling lights at the 200 hallway west exit both had dead insects laying in the light covers. 8 of 8 ceiling lights in the 200 north hall had dead insects laying in the light covers. 9 of 9 ceiling lights on the 200 south hall had dead insects laying in the light covers. Observation on 5/25/23 between 10:31 AM and 10:47 AM on the facility 200 hallway with the facility Maintenance Supervisor (MS) confirmed that the ceiling lights in the 200 hallways had dead insects in the light covers. The MS revealed that they would look for documentation of scheduled maintenance of the lights that had been performed. Record review of the facility housekeeping checklist titled Procedure for Care of Resident Rooms and Restrooms dated 10/18/07 revealed that lights (halls, rooms, and bathrooms) were scheduled to be cleaned monthly. Interview on 5/25/23 at 11:21 AM with the Maintenance Supervisor (MS) confirmed that housekeeping is scheduled to clean hall lights monthly and monitor them in between. The MS confirmed that this had not been done as the longest tenured housekeeping staff has been here about 6 months and was unaware of this task.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Record review of the facility Resident Rights dated 2016 revealed the section titled Planning and Implementing Care. The policy revealed that the resident has the right to be informed of and participate in his or her treatment, including the right to be fully informed in a language that he or she can understand of his or her total health status, including but not limited to his or her medical condition. The resident has the right to participate in the development and implementation of his or her person-centered plan of care. The resident has the right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings, and the right to request revisions to the person-centered plan of care. The resident has the right to participate in establishing the expected goals and outcomes of care and any other factors related to the effectiveness of the plan of care. The resident has the right to be informed in advance of changes to the plan of care. The resident has the right to see the care plan, including the right to sign after significant changes to the plan of care. The resident has the right to be informed, in advance, of the care to be furnished and the type of caregiver or professional that will furnish care. The facility will facilitate the inclusion of the resident and/or representative in the planning process. Record review of the admission Record dated 5/23/23 for Resident 33 revealed that Resident 33 admitted into the facility on 1/3/23. Diagnoses included severe dementia with agitation, anemia (a lack of red blood cells in the body that leads to reduced oxygen flow to the body's organs), and abnormal weight loss. Record review of the Interim Care Plan for Resident 33 dated 1/3/23 revealed that it contained no documentation of review of the interim care plan with the resident/resident representative. It contained no documentation of a written summary of the interim care plan being provided to the resident or resident representative. Record review of the medical record for Resident 33 revealed no documentation that a review of the interim care plan with the resident/resident representative was completed. It contained no documentation of a written summary of the interim care plan being provided to the resident or resident representative. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 1/9/23 for Resident 33 revealed that it was the admission comprehensive assessment for Resident 33. Record review of the Plan of Care progress note for Resident 33 dated 1/12/23 (9 days after Resident 33 admitted into the facility) at 9:58 AM revealed that the initial care plan meeting was held today. C. Record review of the admission Record for Resident 34 dated 5/23/23 revealed that Resident 34 admitted into the facility on 1/30/23. Diagnoses included a fracture of the left femur (upper leg bone), depression, and anxiety. Record review of the Interim Care Plan for Resident 34 dated 1/30/23 revealed that it contained no documentation of review of the interim care plan with the resident/resident representative. It contained no documentation of a written summary of the interim care plan being provided to the resident or resident representative. Record review of the medical record for Resident 34 revealed no documentation that a review of the interim care plan with the resident/resident representative was completed. It contained no documentation of a written summary of the interim care plan being provided to the resident or resident representative. Record review of the Minimum Data Set (MDS) dated [DATE] for Resident 34 revealed that it was the admission comprehensive assessment for Resident 34. Record review of the Plan of Care progress note for Resident 34 dated 2/23/23 revealed that the initial care plan meeting scheduled for 2/16/23 (17 days after Resident 34 admitted into the facility) was canceled due to weather. The care plan team reviewed the resident level of care on 2/23/23 (24 days after Resident 34 admitted into the facility). Interview on 5/24/23 at 3:26 PM with the facility Assistant Director of Nursing (ADON) confirmed that the facility was unable to find any documentation that the baseline care plan was reviewed with the resident or resident representative for Residents 30, 33, and 34. Interview with the ADON (Assistant Director of Nursing) on 5/24/23 at 3:52 PM confirmed there was no documentation a written summary of the baseline care plan had been provided to Residents 30, 33, and 34 and/or the resident representatives or that the baseline care plan had been reviewed with the residents or their representatives. The ADON revealed we have not been doing that. The ADON revealed the facility did not have a policy for reviewing the baseline care plan with the residents and/or resident representatives and providing them with a written summary. LICENSURE REFERENCE NUMBER 175NAC 12-006.09C1a Based on record review and interview, the facility failed to ensure that a review of the baseline (interim) care plan (a written plan required to be developed within 48 hours of admission detailing the instructions needed to provide initial effective and person-centered quality care for a resident) was reviewed with the resident/resident representative and failed to ensure that the resident/resident representative was provided a written summary of the baseline care plan as required for 3 of 3 sampled residents (Residents 30, 33, and 34). This prevented the resident/resident representative from identifying additional areas of care required by the resident. The facility census was 31. Findings are: A. Review of Resident 30's quarterly MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) dated 3/9/2023 revealed an admission date of 1/3/2023. Resident 30 had no BIMS (Brief Interview for Mental Status) score as Resident 30 was rarely/never understood. Resident 30's staff assessment for mental status indicated short term and long term memory problems, severely impaired cognitive skills for daily decision making, and disorganized thinking that was present that did not fluctuate. Review of Resident 30's Care Plan dated 1/4/2023 revealed Resident 30 had a Guardian (a legal guardian is a person who is given authority by a court to act on behalf of a ward and/or to take responsibility for meeting the needs of a ward. Wards are unable to take care of themselves, either due to incapacity or because they are minors). Review of Resident 30's Progress Notes dated 1/3/2023 to 5/25/23 revealed no documentation the baseline care plan was reviewed with Resident 30's personal representative or that a written summary of the baseline care plan was provided to the personal representative. Review of Resident 30's Baseline Care Plan dated 1/3/23 revealed no documentation that is was reviewed with Resident 30 or their personal representative or that a written summary had been provided to them.

Licensure Reference Number 175NAC 12-006.11E Based on observation, record review, and interview; the facility failed to ensure that staff did not handle foods with the bare hands to prevent the potential for cross contamination and foodborne illness. This affected 14 residents (Residents 8, 19, 13, 23, 17, 28, 20, 12, 30, 14, 24, 2, 4, and 10). The facility census was 31. Findings are: A. Record review of the Nebraska Food Code dated 7/21/16 section 81-2,272.10* (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 5/22/23 at 12:20 PM in the facility kitchen revealed that Dietary Cook-C (DC-C) reached into the package of dinner rolls with the bare hand and removed a dinner roll. DC-C placed the dinner roll on the plate of food on the steam table. Dietary Aide-A (DA-A) delivered the plate of food to Resident 8. Observation on 5/22/23 at 12:20 PM in the facility dining room revealed that Resident 8 picked up the dinner roll from the plate of food. Resident 8 tore the dinner roll in half and buttered the dinner roll. Resident 8 began to take bites of the dinner roll. Interview on 5/25/23 at 8:38 AM with the facility Registered Dietitian (RD) confirmed that bare hands should not be used to handle ready to eat foods. The RD confirmed that gloves or utensils should be used to handle ready to eat foods. The RD was unsure if the facility had a policy. The RD confirmed that the facility is expected to follow the national and state food codes. B. Observation on 5/23/23 at 8:10 AM in the facility kitchen revealed that Dietary Aide-D (DA-D) brought 2 menus into the kitchen and placed them on the shelf of the steam table for Dietary Cook-C (DC-C). DA-D told DC-C that Resident 19 requested a fried egg. DC-C cracked an unpasteurized egg into the frying pan on the stove. DC-C continued to cook the egg to hard yolk consistency and then placed it on a plate. DC-C reached into the loaf of bread package and removed two pieces of bread with the bare hand. DC-C placed them into the toaster. DC-C placed the toast on the plate with the fried egg for Resident 19. Observation on 5/23/23 at 8:22 AM in the main dining room revealed that Resident 19 had eaten half of the toast. C. Observation on 5/24/23 at 11:55 AM in the facility kitchen revealed that Dietary Cook-C (DC-C) plated a meal for Resident 12. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 12. Dietary Aide-A (DA-A) told DC-C that Resident 12 was not in the dining room yet. DC-C placed a sheet of foil over the plate for Resident 12 and placed it into the food warmer. DC-C plated a meal for Resident 13. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 13. DA-A took the meal to Resident 13. DC-C plated a meal for Resident 23. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 23. DC-C plated a meal for Resident 17. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 17. DC-C plated a meal for Resident 28. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 28. DC-C put a plate cover over the plate. DC-C plated a meal for Resident 20. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 20. DC-C put a plate cover over the plate. DC-C placed plate warmers and covers on the cart for East hallway resident meals. DA-A told DC-C that Resident 12 was now in the dining room. DC-C removed the foil covered plate from the food warmer and placed it on the shelf above the steam table. DA-A delivered the plate to Resident 12. The plate contained the dinner roll that DC-C had placed on it with the bare hand. DC-C plated a meal for Resident 8. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 8. DC-C plated a meal for Resident 30. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 30 and sat the plate on the cart for East hallway resident meals. DC-C plated a meal for Resident 14. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 14 and sat the plate on the cart for East hallway resident meals. DC-C plated a meal for Resident 24. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 24. DC-C used the bare left hand to reposition the dinner roll on the plate. DC-C sat the plate on the cart for East hallway resident meals. DC-C plated a meal for Resident 19. Resident 19 was in the main dining room. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 19. DC-C plated a meal for Resident 2. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 2 and sat the plate on the cart for East hallway resident meals. DC-C plated a meal for Resident 4. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 4 and sat the plate on the cart for East hallway resident meals. DC-C plated a meal for Resident 10. DC-C reached into the package of dinner rolls with the bare right hand and picked up the dinner roll with the bare right hand. DC-C sat the dinner roll on the plate for Resident 10 and sat the plate on the cart for East hallway resident meals. DA-A pushed the cart of East hallway resident meals out of the kitchen. D. Observation of the facility east unit dining room on 5/22/23 at 12:35 PM revealed MA-E (Medication Aide) sat down next to Resident 24 who was seated at the dining room table and began to feed Resident 24. There was a dinner roll on Resident 24's plate with the other food items. MA-E picked up the roll with their bare hand then put it back onto the plate with the food. MA-E then proceeded to feed Resident 24 the food that was on the plate with the roll MA-E had handled with their bare hand. MA-E then opened the roll and buttered it and fed it to Resident 24.

B. Record review of the undated facility policy titled Emptying the Urinary Drainage Bag revealed that the purpose was to keep the inside of the drainage bag sterile to prevent infection. All catheter drainage bags will be emptied following the proper procedure to prevent contamination of the drain system. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 3/30/23 for Resident 27 revealed that Resident 27 had an admission date of 12/7/21. The MDS revealed that Resident 27 had an indwelling urinary catheter. Observation on 5/23/23 at 10:42 AM in the room of Resident 27 revealed that the resident was in the bed curled up on their left side. The urinary catheter drainage bag sat on the floor under the bed. The urinary catheter bag was folded in half. Observation on 5/24/23 at 10:32 AM in the room of Resident 27 revealed that the resident was in bed. The bed was in low position. The urinary catheter drainage bag was flat on the floor underneath the bed. Observation on 5/25/23 at 9:37 AM at the room of Resident 27 revealed that Nurse Aide-F (NA-F) pulled the mechanical total body lift (a mechanical assistive device used to transfer a resident with difficulty standing up on their own) out of the resident's room. Nurse Aide-G (NA-G) exited the resident room with a soiled garbage bag. Resident 27 was in bed. The bed was in low position and the urinary catheter drainage bag was touching the floor. Interview on 5/25/23 at 9:40 AM with NA-G revealed that staff try to prevent resident urinary tract infections by offering drinks and performing correct catheter care. NA-G revealed that when Resident 27 is in bed the catheter drainage bag is hung from the bed rail. NA-G revealed that the catheter drainage bag should not be touching the floor. Interview on 5/25/23 at 10:09 AM with the facility Assistant Director of Nursing (ADON) confirmed that urinary catheter drainage bags should not be touching the floor due to potential for contamination and infection. Licensure Reference Number 175NAC 12-006.17D Licensure Reference Number 175NAC 12-006.17 Based on observation, record review, and interview; the facility staff failed to perform hand hygiene (hand washing using soap and water or an alcohol-based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection and food-borne illness among patients and health care personnel) during dining which affected 6 of 6 residents who were served food on the east unit, (Residents 10, 2, 24, 30, 4, 14); and the facility failed to maintain urinary catheters (a flexible plastic hollow tube inserted into the bladder to continuously drain urine into a drainage collection bag) to prevent the potential for cross contamination for 1 of 1 sampled residents (Resident 27). The facility census was 31. Findings are: A. Record review of the facility policy titled Hand Washing Procedure dated 8/27/08 revealed that the purpose was to control infection and reduce transmission of organisms. Hand washing should be performed before and after handling residents and after touching dirty areas or utensils. Procedure: Turn on water and wet hands well. Apply soap and work up lather. Using friction, wash entire surface of hands for 20 seconds. Give special attention between fingers, under nails and around wrists. Rinse with hands lowered to allow soiled water to drain from wrists to fingers. Do not touch sink with your hands. Dry hands well. Use new clean dry disposable hand towel to turn off faucet. Observation of the facility east unit dining room on 5/22/23 at 12:16 PM revealed MA-E (Medication Aide) moistened washcloths under the faucet of water in the sink in the dining room then assisted residents with washing their hands and faces. Residents 10, 2, and 4 washed their own faces and hands after MA-E gave them a wet washcloth then MA-E placed the soiled washcloths into a receptacle. MA-E assisted Residents 14, 24, and 30 with washing their faces and hands using the wet washcloths then placing the soiled washcloths into a receptacle. MA-E was observed touching the residents' hands and faces as MA-E was washing them with the wet washcloths. At 12:26 PM MA-E washed their hands for 5 seconds at the sink in the dining room, rinsed their hands under running water, turned the faucet off with their bare hands, then dried their hands with paper towels. There was a cart in the dining room with 6 plates of prepared food that were in insulated plate warmers. MA-E used their thumb to push the plate out of the bottom of the insulated warmer by touching the top of the lip of the plate then took the plates of food to the 6 residents who were seated in the dining room, Residents 10, 2, 24, 30, 4, and 14. All 6 residents were then observed eating the food off the plates that MA-E had handled without performing hand hygiene as required. Interview with the RD (Registered Dietitian) on 5/25/23 at 8:38 AM revealed the facility staff were expected to perform hand hygiene during meal service.

Licensure Reference Number 175NAC 12-006.04D2 Based on record review and interview the facility failed to ensure that it had a Dietary Manager (DM) that held the required credentials for the position. This affected 29 residents that received meals from the facility kitchen. The facility census was 31. Findings are: Record review of the undated facility Resident Handbook revealed that the Dietary Supervisor (Dietary Manager) and Registered Dietitian are responsible for selecting nutritious meals and that they manage all special diets and offer recommendations for the use of nutritional supplements. Food consumed by residents must be prepared in a licensed kitchen. Record review of the undated facility Licensed Staff list revealed that the facility Dietary Supervisor (Dietary Manager) had no certification number. Interview on 5/25/23 at 8:38 AM with the facility Registered Dietitian (RD) confirmed that the RD is normally in the facility one day a week on Thursdays and can also do some work remotely. The RD confirmed that the RD does not work full-time in the facility. The RD confirmed that the facility Dietary Manager (DM) is not certified as a dietary manager and is taking the certification class. The RD revealed that the DM has been taking the class off and on. The RD revealed that the DM started the class sometime in 2020. The RD revealed that the DM is somewhere in the middle of the class work at this time.