Licensure Reference Number 175 NAC 12-006.04(H) Based on record reviews and interviews, the facility failed to have qualified dietary staff working in the kitchen. This had the potential to affect all residents who reside in the facility. The facility census was 75. Findings are: A record review of the employee list revealed that SR-A had not been an employee of the facility. A record review of the Dietary Aide job description with a copyright date of 2023 revealed: Required Qualifications: -15 years or older, working towards GED, and or High School diploma -As a condition of employment, completes all assigned training and skills competency. An interview on 4/7/25 at 11:30 AM with the Dietary Manager (DM) confirmed that SR-A was (genders) child. DM confirmed that SR-A was in the kitchen on 3/29/25 helping peel potatoes due to being short-staff in the kitchen. DM confirmed that SR-A was not qualified to be working in the kitchen and should not have been working in the kitchen. An interview on 4/8/25 at 1:30 PM with the Administrator confirmed that (gender) had not been aware of SR-A working in the kitchen. The Administrator confirmed that SR-A was not an employee of the facility and should not have been working in the kitchen.

Licensure Reference Number 175 NAC 12-006.04 (E) Findings are: Based on record review and interview, the facility failed to notify the State Agency of a change in the Director of Nursing position within the required 5 days. This failure had the potential to affect all the residents residing in the facility. The facility census was 75. A record review of the Change of Administrator of Director of Nursing Notification form revealed that the Director of Nursing was changed on 11/8/24 and the notice to the State agency was received on 1/15/25. A interview on 4/8/25 at 1:30 PM with the Administrator confirmed that the Notification of a change in the Director of Nursing was not sent to the State Agency in the required time frame and the notification should have been.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to report an allegation of abuse for 1 (Resident 1) of 3 sampled residents. The facility census was 64. Findings are: A record review of the facility Abuse Policy and Procedures, revised January 2025, revealed the following: -Key points to remember: Remember that ALL allegations of abuse, neglect, or misappropriation must be reported even if made by a resident who has a cognitive impairment. An allegation is a claim or assertion that someone has done something wrong, typically one made without proof. -Investigations: Allegations will be investigated and reported to the Department of Health and Human Services (DHHS). -VII/ Reporting/Response: report all alleged violations, reasonable suspicion of a crime, and all substantiated incidents to the state agency and to all other agencies as required within the prescribed time limits, and take all necessary corrective actions depending on the results of the investigation; alleged violation includes mistreatment, neglect, misappropriation of the resident's property (exploitation), involuntary seclusion, or physical, mental, verbal, or sexual abuse. Record review of Resident 1's Progress Note (PN) dated 12/30/2024 with a time identified as 6:47 AM revealed a Nursing Assistant (NA) reported to the day shift staff that Resident 1 was difficult to arouse during the night. Further review of Resident 1's PN dated 12/30/2024 revealed facility staff reported to the nurse Resident 1 complained about a [gender] at 4:00 AM was hitting and pounding [gender] chest and woke [gender] up saying that [gender] can't get up at anytime until day shift people wake [gender] up. According to Resident 1's PN dated 12/30/2024 the nurse went in to assess and visit with Resident regarding [gender] statement. Resident was unable to verbalize details of the incident. A review of the provided facility reported investigations to the state agency revealed no staff to resident allegations of abuse investigations had been completed during December 2024. In an interview on 1/15/25 at 12:30 PM, the Director of Nursing (DON) revealed [gender] was made aware of the allegation of abuse Resident 1 had made on 12/30/24. The DON further revealed [gender] had completed an investigation of the allegation of abuse in which the allegation was deemed to be unfounded. The DON confirmed [gender] had not submitted a report to the required State Agency on the allegation of abuse on Resident 1 and should have.

Licensure Reference Number 175 NAC 12-006.05(B) Based on record review and interview, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN, a required notice of the cost of continuing to receive skilled services) and the Notice of Medicare Non-Coverage (NOMNC-a required notice allowing the resident to appeal the facility decision to end Medicare Part A coverage) were provided to Resident 3 and Resident 44 or their representatives to notify them of charges for non-covered care items and services prior to a change in Medicare A coverage. This affected 2 of 3 residents sampled for Advance Beneficiary Notification. The facility census was 61. Findings are: A. A record review of the SNF [Skilled Nursing Facility] Beneficiary Protection Notification Review form for Resident 3 revealed a Last Covered Day (LCD) for Medicare Part A services of 10/05/2024. A review of the SNF ABN for Resident 3 revealed a resident signature dated 10/07/2024. An interview on 12/03/2024 at 3:48 PM with the Social Services Director (SSD) confirmed that the SNF ABN and NOMNC were not signed within the required time frame prior to the LCD for Resident 3. B. A record review of the SNF Beneficiary Protection Notification Review form for Resident 44 revealed an LCD for Medicare Part A services of 11/03/2024. A review of the SNF ABN for Resident 44 revealed a resident signature dated 11/07/2024. An interview on 12/03/2024 at 3:09 PM with the SSD confirmed that the SNF ABN and NOMNC were not signed within the required time frame prior to the LCD for Resident 44.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview, the facility failed to report a suspected allegation of abuse to the state agency within the required time frame after a allegation was made and failed to report the follow-up investigation in the required 5 working days for 1 (Resident #53) out of 16 sampled residents. The facility census was 61. The findings are: A record review of the Christian Homes abuse policy and procedures revised January 2024 revealed the following: -If the alleged abuser is a staff member: -If possible and reasonably safe to do so, ask for the employee's written statement -Allegations will be investigated and reported to the state. -The Administrator or the Director of Nursing will be responsible for ensuring the investigation and timely reporting to DHHS. Allegations will be investigated and reported to the Department of Health and Human Services. A record review of admission Record revealed Residents #53 was admitted on [DATE] with the diagnosis of Atrial Fibrillation(a heart condition that causes the upper chambers of the heart to beat irregularly and often very fast), Unspecified Psychosis not due to a substance or known physiological condition (a medical classification for psychosis symptoms that don't meet the criteria for a specific psychotic disorder), Depression (mental health condition that can impact a person's thoughts, feelings, behavior, and sense of well-being) , Hypothyroidism(thyroid gland doesn't produce enough thyroid hormone), Menieres disease (a chronic inner ear disorder that causes vertigo, tinnitus, hearing loss, and a feeling of fullness in the ear), Unspecified Convulsions (rapid involuntary muscle contractions), Chronic Kidney Disease(a condition where the kidneys are damaged and can't filter blood properly), hearing loss. A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated Oct. 7th, 2024 revealed a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored 0-15, the higher the score, the higher the cognitive function) score of 13 indicating cognitively intact. An interview on 12/3/24 at 10:12 AM with Family Member I revealed Resident # 53 had called Family Member I around the middle part of June 2024, and told the Family Member I that NA-H had been rubbing up against them in the bath house making Resident # 53 feel uncomfortable. Family Member I confirmed that they had called the facility to talk to the Assistant Director of Nursing (ADON) regarding what Resident # 53 had told Family Member I. A record review of the working schedule indicated that Nursing Assistant (NA)-H worked June 19, 2024 and worked June 22, 2024 a double shift 6:00 AM until 10:00 PM. An Interview on 12/03/24 at 11:30 AM was conducted with Licensed Practical Nurse (LPN)-F. During the interview LPN-F confirmed the facility staff were aware of the allegation of NA-H rubbing up against Resident #53 making Resident #53 uncomfortable. A record review of the facility reportable incidents revealed no report of the alleged abuse between Resident # 53 and NA-H in the last 6 months. A interview on 12/03/2024 at 11:45 AM was conducted with the Assistant Director of Nursing (ADON). During the interview the ADON confirmed Family Member I had reported Resident #53 had reported NA-H had rubbed up against Resident #53. The ADON confirmed a the allegation had not been reported to the required state agency and a investigation conducted and submitted to the state agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.02(H) The facility staff failed to investigate an alleged incident of abuse for 1 (Resident 53) out of 16 sampled residents. The facility census was 61. The findings are: A record review of the Christian Homes abuse policy and procedures revised January 2024 If the alleged abuser is a staff member: -If possible and reasonably safe to do so, ask for the employee's written statement -Allegations will be investigated and reported to the state. -For allegations which do not involve a physical danger to the resident, the neighborhood charge nurse will consider the case and decide on one of the following options 1) to place the employee under the supervision of a supervisor or other staff member in the same or another section of the nursing home or to place in nonresident duties 2) to suspend and send the employee home ,pending further investigation. The Administrator or the Director of Nursing will be responsible for ensuring the investigation and timely reporting to Department of Health and Human Services. Allegations will be investigated and reported to the Department of Health and human Services. A Record Review of admission record revealed Residents# 53 was admitted on [DATE] with the diagnosis of Atrial Fibrillation (a heart condition that causes the upper chambers of the heart to beat irregularly and often very fast), Unspecified Psychosis not due to a substance or known physiological condition (a medical classification for psychosis symptoms that don't meet the criteria for a specific psychotic disorder), Depression (a mental health condition that can impact a person's thoughts, feelings, behavior, and sense of well-being), Hypothyroidism( thyroid gland doesn't produce enough thyroid hormone), Meniere's disease (a chronic inner ear disorder that causes vertigo, tinnitus, hearing loss, and a feeling of fullness in the ear), Unspecified Convulsions(rapid involuntary muscle contractions), Chronic Kidney Disease(a condition where the kidneys are damaged and can't filter blood properly), and Hearing loss. A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated Oct. 7th, 2024 revealed a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored 0-15, the higher the score, the higher the cognitive function) score of 13 indicating cognitively intact. An interview on 12/3/24 at 10:12 AM with Family Member I confirmed Resident # 53 had called Family Member I around the middle part of June 2024, and told the Family Member I that NA-H had been rubbing up against them in the bath house making Resident # 53 feel uncomfortable. Family Member I confirmed that they had called the facility to talk to the Assistant Director of nursing (ADON) regarding what Resident # 53's allegation. An Interview on 12/3/24 at 09:30 AM with Medication aide (MA)-G confirmed Resident # 53 informed MA-G of what had taken place with NA-H and how Resident # 53 felt uncomfortable with NA-H. MA-G reported Resident # 53 concerns of alleged abuse to the Licensed Practical Nurse (LPN)-F. An Interview on 12/03/24 at 11:30 AM with LPN-F confirmed they did bring it up in risk management the following Monday. LPN-F confirmed that the facility was already aware of the alleged abuse. A record review of the facility reportable incidents revealed no report of the alleged abuse between Resident # 53 and NA-H in the last 6 months. An Interview on 12/03/24 at 11:45 AM with the ADON confirmed a investigation had not been conducted for the allegation NA-H had rubbed up against Resident #53 making Resident #53 uncomfortable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09B Based on record review and interview; the facility failed to ensure the Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) reflected a Level II PASARR (Preadmission Screening and Resident Review -that is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. Level 2 screening is triggered by evidence of a serious mental illness (SMI), Intellectual/Developmental Disabilities (ID/DD) or condition related to Intellectual or Developmental Disabilities (RC) as defined by Medicaid) for one (Resident 1) and failed to code the use of an antibiotic for one (Resident 35) of 16 sampled residents. The facility census was 61. Findings are: Review of the facility MDS and Comprehensive Care Plan policy, revised [DATE], revealed the following: -MDS: 3. All MDSs will be completed according to the CMS (Centers for Medicare and Medicaid Services) Resident Assessment Instrument (RAI) Manual. A. Review of Resident 1's PASARR Level 2 Outcome-Notification of NF (nursing facility), dated 1/5/17, revealed that Resident 1 met the PASARR criteria for a Level 2 evaluation for ID and SMI. Review of Resident 1's MDS, dated [DATE], revealed the following: -Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, was marked No. Review of the MDS 3.0 RAI Manual v1.19.1, dated October 2024, revealed the following: -Code yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition An interview on 12/4/24 at 01:58 PM the MDS Consultant confirmed that Resident 1 did have a PASARR Level 2 evaluation for ID and SMI and that the MDS should have been marked yes. B. Review of Resident 35's October 2024 electronic Medication Administration Record (eMAR) revealed a new order received on 10/18/24 for Rifaximin (an antibiotic that works mainly in the digestive tract) 550 milligrams (mg) by mouth two times a day. Further review revealed that Resident 35 received the medication as ordered. Review of Resident 35's MDS, dated [DATE], revealed that that under the column Is taking, antibiotic was unchecked. Review of the MDS 3.0 RAI Manual v1.19.1, dated October 2024, revealed the following: -Antibiotic: Check if an antibiotic medication was taken by the resident at any time during the 7-day look-back period. An interview on 12/4/24 at 01:52 PM the MDS Consultant confirmed that antibiotic should have been checked as taken on Resident 35's MDS and was not checked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(E)(i) Based on interview and record review, the facility failed to develop and implement a resident-centered comprehensive care plan (CCP-a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) that accurately reflected the care needs of the resident for 2 (Residents 3 and 35) of 16 sampled residents. The facility census was 61. Findings are: A. Review of Resident 35's admission Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care), dated /21/23, revealed Resident 35 took the following classifications of medications: antidepressant (used to treat depression), antianxiety (used to treat anxiety) and anticoagulant (used to prevent/reduce blood clots). A review of Resident 35's CCP, dated 12/3/24, revealed no resident-centered care plan related to antidepressant, antianxiety and anticoagulant use. In an interview on 12/4/24 at 1:52 PM, the MDS Consultant confirmed that there was no care plan related to Resident 35's previously listed medication uses and that there should have been one. Review of the facility MDS and Comprehensive Care Plan policy, revised [DATE], revealed the following: MDS: -The comprehensive care plan may include the following areas/services as appropriate, but not limited to, to attain and maintain residents' highest level of functioning: e. Medication Management f. Mood and Behavior B. A record review of Resident 3's admission Record printed 12/04/2024 revealed the resident was admitted on [DATE] and had diagnoses of heart failure, chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), chronic kidney disease, high blood pressure, neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems), and a history of infection with a multi-drug resistant organism (MDRO). A record review of Resident 3's Quarterly MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS- a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 15, indicating they were cognitively intact. During an interview on 12/03/2024 at 10:10 AM Resident 3 revealed they had had a fall, but did not remember the exact date. The resident stated they had dropped a piece of food, and fallen out of the recliner while reaching for it. Resident 3 stated they had not been hurt. A record review of the Incidents by Incident Type list dated 12/03/2024 revealed Resident 3 had an unwitnessed fall on 09/08/2024. A review of Resident 3's Progress Notes revealed a note from 09/08/2024 at 9:37 PM that stated the resident had been observed on the floor, complained of right hip, leg, arm and elbow pain, and went to the emergency room (ER). A follow-up note from 09/09/2024 at 1:56 AM stated the resident had returned and had no fractures. A record review of a Fall Risk Evaluation dated 07/31/2024 revealed that Resident 3 was at risk for falls. A review of Resident 3's CCP revealed a focus initiated 09/17/2024 that stated the resident was at risk for falls. The care plan did not address Resident 3's actual fall from 09/08/2024. In an interview on 12/05/2024 at 2:13 PM, the Assistant Director of Nursing (ADON) confirmed that Resident 3 had been identified as at risk for falls on 07/31/2024, but the care plan for falls had not been initiated until after the fall occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B). A record review of the admission record for Resident # 2 printed on [DATE]rd 2024 revealed that Resident # 2 was admitted to the facility on [DATE] and had diagnoses of Major Depressive Disorder(a serious mental health condition that can significantly impact how a person feels, thinks, and functions in daily life), Generalized Anxiety Disorder( a mental health condition that causes people to experience excessive and persistent anxiety and worry about everyday things), Essential Hypertension(a type of high blood pressure that occurs without a clear cause), and Benign Prostatic Hyperplasia without lower Urinary Tract Symptoms(a non-cancerous condition that causes the prostate gland to enlarge). A record review of the Quarterly MDS dated [DATE] revealed in Section C , Resident # 2 had a BIMS (Brief interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 15 indicating cognitive intact. A record review of the Progress note dated 8/18/24 revealed Resident # 2 had fallen in their room with abrasions noted to the left temple. A record review of Resident #2's CCP dated 9/19/24 revealed the fall that had taken place on 8/18/24 had not been addressed on Resident #2's CCP. An interview on 12/3/24 at 10:00 AM with the Assisted Director of Nursing (ADON) confirmed Resident #2 fall occurred on 8/18/24. The ADON further confirmed Resident #2's CCP had not been updated related to the fall. C). A record review of Resident # 62 admission Record with the printed date of 12/4/24 revealed Resident # 62 was admitted to the facility on [DATE] with the diagnosis of, Infection and Inflammatory reaction due to Cardiac Valve Prosthesis (infection that occurs on a surgically implanted heart valve, causing inflammation around the valve due to bacterial or fungal growth on the prosthetic material) , Obstructive Sleep Apnea(a common sleep disorder that occurs when the upper airway becomes blocked or narrows during sleep, interrupting breathing), Type 2 Diabetes Mellitus Without Complications (closely manages their type 2 diabetes, they can reduce their risk of developing any complications), Cervicalgia (neck pain), Acute Kidney Failure (a sudden decline in kidney function). Observation on 12/02/24 at 3:43 PM revealed the C-Pap(CPAP (Continuous Positive Airway Pressure, that keep the airway open by blowing pressurized air into it) tubing and nasal cannula were hanging off of Resident #62's tray table. Observation on 12/03/24 at 10:44 AM revealed the C-Pap machine remained on Resident #62's tray table. Observation on 12/04/24 at 9:19 AM revealed the C-Pap tubing and nasal cannula was hanging off Resident #62's tray table. A record review of the Clinical Physician Orders with the printed dated of 12/4/24 for Resident #62 revealed a order with a start date of 11/1/24 for the C-PAP per home settings. A record review of the CCP dated 9/19/24 revealed Resident #62's CCP did not address Resident # 62 usage of the C-PAP. An interview on 12/4/24 at 12:59 PM with the ADON confirmed that Resident # 62 does use the C-PAP and the C-PAP was not on Resident #62's CCP. Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on observation, record review, and interview, the facility failed to revise the Comprehensive Care Plan to include the current use of a Positive Airway Pressure device for Resident 14 and Resident 62, and failed to revise the Comprehensive Care Plan for Resident 2 related to falls. This affected 3 of 16 residents reviewed for care plan revision. The facility census was 61. Findings are: A. A record review of Resident 14's admission Record printed 12/04/2024 revealed Resident 14 was admitted to the facility on [DATE] and had diagnoses of dementia (a term for several diseases that affect memory, thinking, and the ability to perform daily activities), leukemia (a type of cancer involving the blood), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), high blood pressure, irregular heartbeat, and obstructive sleep apnea (a common sleep disorder that occurs when the upper airway becomes blocked or narrows during sleep, interrupting breathing). A record review of Resident 14's Quarterly Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) dated 10/30/2024 revealed that in Section O Special Treatments, Procedures, and Programs, question G1 Non-invasive Mechanical Ventilator, was marked under column b While a Resident. This category included both a BiPAP (Bilevel Positive Airway Pressure) and CPAP (Continuous Positive Airway Pressure), which are two kinds of breathing machines that keep the airway open by blowing pressurized air into it. A record review of Resident 14's Order Summary Report printed 12/04/2024 revealed Resident 14 had an order to wear a BiPAP at night and remove it in the morning with an order date of 09/07/2023. A record review of Resident 14's Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) with revealed the use of a BiPAP was not addressed. An interview on 12/05/2024 at 2:13 PM with the Assistant Director of Nursing (ADON) confirmed that Resident 14 did use a BiPAP, and that it was not addressed on Resident 14's CCP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. A record review of Resident # 62 admission Record with the printed date of 12/4/24 revealed Resident # 62 was admitted to the facility on [DATE] with the diagnosis of, Infection and Inflammatory reaction due to Cardiac Valve Prosthesis (infection that occurs on a surgically implanted heart valve, causing inflammation around the valve due to bacterial or fungal growth on the prosthetic material) , Obstructive Sleep Apnea(a common sleep disorder that occurs when the upper airway becomes blocked or narrows during sleep, interrupting breathing), Type 2 Diabetes Mellitus Without Complications (closely manages their type 2 diabetes, they can reduce their risk of developing any complications), Cervicalgia (neck pain), Acute Kidney Failure (a sudden decline in kidney function). An observation on 12/02/24 at 3:43 PM of the C-Pap(CPAP (Continuous Positive Airway Pressure, that keep the airway open by blowing pressurized air into it tubing) tubing and nasal cannula hang off the tray table with water in the chamber. An observation on 12/03/24 at 10:44 AM of Resident #62's C-Pap machine revealed water in the water chambers. An observation on 12/04/24 at 9:19 AM of Resident #62's C-Pap machine revealed water was in the water chamber. A record review of the Clinical Physician orders with the printed date of 12/4/24 record revealed an order to Empty and was CPAP Humidity Reservoir every Am with Antibacterial Dish Soap and water. Rinse Thoroughly and air dry. An interview on 12/04/24 at 10:34 AM with the ADON confirmed that the C-Pap humidity reservoir had not been cleaned and it should of been cleaned daily. A record review of undated CPAP/BIPAP cleaning revealed the following: Policy: It is the policy of the facility to clean CPAP/BIPAP equipment in accordance with current CDC guidelines and manufacturer recommendations in order to prevent the occurrence or spread of infection: -1) CPAP/BIPAP equipment may vary from manufacturer. Common equipment includes the machine, tubing, masks, headgear/straps/disposable/non disposable filters and humidifier chamber. -2 If humidification if required, distilled or sterile water will be used to fill he humidifier chamber. Empty the chamber completely after each use and wipe dry. -3 Clean mask frame daily after use with CPAP cleaning wipes or soap and water. Dry well, Cover with plastic bag or completely enclosed in machine storage when not in use. Licensure Reference Number 175 NAC 12-006.18(B), 175 NAC 12-006.18(D) Based on observations, record reviews and interviews, the facility failed to implement Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes. EBP involves wearing a gown and gloves during high-contact resident care activities, such as personal hygiene, transferring, and care of indwelling medical devices such as catheters, for residents known to be colonized or infected with a MDRO as well as residents at increased risk of MDRO acquisition [for example, residents with wounds or indwelling medical devices]) and ensure hand hygiene was performed in a manner to prevent cross contamination during catheter cares for 1 Resident (Resident 3) of 2 residents sampled for catheter cares, and the facility failed to ensure the mask and water chamber for a Continuous Positive Airway Pressure (CPAP-a machine that keeps the airway open by blowing pressurized air into it) device were cleaned after use to prevent the potential for respiratory infections for 1 Resident (Resident 62) of 3 residents sampled for PAP device use. The facility census was 61. Findings are: A. A record review of Resident 3's admission Record printed 12/04/2024 revealed the resident was admitted on [DATE] and had diagnoses of heart failure, chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), chronic kidney disease, high blood pressure, neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems), and a history of infection with a multi-drug resistant organism (MDRO). A record review of Resident 3's Order Summary Report printed 12/04/2024 revealed the resident had an order for a Foley catheter (a flexible tube that drains urine from the bladder into a collection bag outside the body) with an order date of 08/18/2024. Further review revealed the resident had an order dated 08/18/2024 for staff to wear a gown and gloves when changing the catheter due to the resident's history of an MDRO. A record review of Resident 3's Quarterly Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) dated 11/25/2024 revealed in in Section H Bladder and Bowel question H0100A was marked for an indwelling catheter. Further review of the MDS revealed the resident had a Brief Interview for Mental Status (BIMS- a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 15, indicating they were cognitively intact. An interview on 12/03/2024 at 10:21 AM with Resident 3 revealed the resident had had a catheter for at least five years. Resident 3 stated that staff wore gloves when changing and emptying the catheter and when performing catheter and peri cares (the process of washing the genital and anal regions), but they did not wear gowns during those procedures. An observation on 12/03/2024 at 10:21 AM revealed Resident 3 had an indwelling catheter. There was no signage indicating the resident required EBP and no gowns available in the resident's room. An observation on 12/03/2024 at 3:40 PM revealed no signage for EBP and no gowns available in the resident's room. An observation on 12/04/2024 from 6:56 AM to 7:22 AM of peri cares and catheter cares revealed the following: -At 6:56 AM, Nursing Assistant (NA) A entered the room, did not perform hand hygiene, and put gloves on. The NA then turned off the call light, used their radio to call for further assistance, and assisted Resident 3 to put on makeup and jewelry while they waited for assistance. The NA did not put on a gown. -At 7:05 AM, Medication Aide (MA) B entered the room, did not perform hand hygiene, and put gloves on. The MA did not put on a gown. -At 7:09 AM, without performing hand hygiene, changing gloves, or putting on gowns, NA A and MA B raised Resident 3 up from the commode using the full lift. Resident 3 had had a bowel movement (BM), so NA A used peri wipes to wipe the resident's peri anal area. Resident 3 was transferred to bed using the full lift. NA A removed their gloves and, without performing hand hygiene, got a washcloth wet and put on new gloves. MA B changed their gloves without performing hand hygiene and used the wet washcloth to wipe the catheter tubing, then the labia (folds of skin around the vaginal opening), and then applied barrier cream to the labia. -At 7:16 AM both NA A and MA B washed their hands with soap and water. -At 7:20 AM NA A emptied the bedside commode of the BM. -At 7:22 AM Resident 3 was transferred to the wheelchair by NA A and MA B using the full lift. NA A did not perform hand hygiene between emptying the commode and assisting with the resident transfer. NA A and MA B did not wear gowns throughout the procedures of transferring the resident, performing peri-cares, or performing catheter cares. A record review of the facility's Hand Hygiene policy implemented 07/11/2023 revealed the following: 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table, and, 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. A record review of the undated Hand Hygiene Table attached to the Hand Hygiene policy revealed conditions when hand hygiene should be performed included after handling contaminated objects; before applying and after removing personal protective equipment (PPE), including gloves; before performing resident care procedures; and when, during resident care, moving from a contaminated body site to a clean body site. A record review of the facility's Personal Protective Equipment policy implemented 07/11/2023 revealed that gloves should be changed, and hand hygiene should be performed between clean and dirty tasks and when moving from one body part to another. A record Review of the facility's Enhanced barrier Precautions policy implemented 07/11/2023 revealed the following statements: Enhanced Barrier Precautions refer to the use of gown and gloves for use during catheter changes or straight catheterization for residents known to be colonized or infected with a MDRO. and High contact resident care activities include catheter changes and straight catheterization. There was no mention in the policy of other high contact resident care activities, such as transferring, providing hygiene, assisting with toileting, wound care, or catheter cares. A record review of a note provided by the facility on 12/02/2024 revealed Christian Homes has no one on transmission based precautions at this time. A record review of Resident 3's Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) revealed a focus initiated 11/06/2024 that stated the resident required EBP due to catheter use, and had an intervention dated 11/06/2024 to Maintain enhanced barrier precaution as indicated when providing care to catheter. In an interview on 12/05/2024 at 1:06 PM the Assistant Director of Nursing (ADON) confirmed their policy for EBP did not address emptying catheters, wound care, personal hygiene, or performing peri cares or catheter cares and that they had not implemented EBP with activities other than catheter changes or straight catheterization. The ADON further confirmed that PPE was not readily available in the resident's room, but was available in the storeroom. The ADON confirmed that Resident 3 should be in EBP due to the presence of the indwelling catheter. The ADON further confirmed that NA A should have performed hand hygiene prior to providing care, when changing gloves, and when going from the peri-anal cares to perineal cares.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** E. A record Review of admission record revealed Residents# 53 was admitted to the facility on [DATE] with the diagnosis of Atrial Fibrillation(a heart condition that causes the upper chambers of the heart to beat irregularly and often very fast), Unspecified Psychosis not due to a substance or known physiological condition (a medical classification for psychosis symptoms that don't meet the criteria for a specific psychotic disorder), Depression (mental health condition that can impact a person's thoughts, feelings, behavior, and sense of well-being) , Hypothyroidism(thyroid gland doesn't produce enough thyroid hormone), Menieres disease (a chronic inner ear disorder that causes vertigo, tinnitus, hearing loss, and a feeling of fullness in the ear), Unspecified Convulsions (rapid involuntary muscle contractions), Chronic Kidney Disease (a condition where the kidneys are damaged and can't filter blood properly), hearing loss. A record review of the Clinical Physician Orders printed 12/3/24 revealed an order with a start date of 10/26/24 for Ativan(slowing activity in the brain to allow for relaxation) 0.5 mg every 2 hours as need for Anxiety (a feeling of fear, dread, and uneasiness) by expressed by resident/seizure activity. There is no stop date noted in the order. An interview on 12/3/24 at 2:30 PM with the ADON confirmed the PRN (as needed) Ativan order should of had a stop date on it and it did not. F. A record review of the admission record for Resident # 55 revealed Resident # 55 was admitted to the facility on [DATE] with the diagnosis of : Moderate Protein-Calorie Malnutrition ( a condition that occurs when the body doesn't get enough calories or nutrients, such as vitamins and minerals, to be healthy), Anemia (a blood disorder that occurs when your body doesn't produce enough healthy red blood cells, or your red blood cells don't function properly), Dementia in other Disease classified elsewhere, mild with other Behavioral Disturbance (a person is presenting signs and symptoms of dementia and has a dementia diagnosis, but they lack any symptoms of behavioral disturbances) , Dementia in other Diseases Classified elsewhere Severe, with Anxiety ( person is experiencing symptoms of dementia, which is not directly caused by a known primary dementia disease, but is likely a secondary symptom of another medical condition, and the severity of the dementia is not specified, while also showing significant symptoms of anxiety) , Depression( a persistent feeling of sadness and loss of interest and can interfere with your daily living), Unspecified Mental Disorder due to Known Physiological Condition( when various physical diseases or conditions create some form of mental health issue), Generalized Anxiety Disorder (a mental health condition that causes people to experience excessive and persistent anxiety and worry about everyday things), Alzheimer's Disease with Late Onset (the most common form of Alzheimer's disease, usually appearing after age [AGE]) , Palliative Care ( a medical specialty that helps people with serious illnesses manage their symptoms, cope with stress, and improve their quality of life). A record review of the clinical Physician orders with the printed date of 12/3/24 revealed an order for Buspirone HCL (used to treat anxiety disorders or in the short-term treatment of symptoms of anxiety) 10 mg every 24 hours as needed for Anxiety with the start date of 11/6/24 and no stop date for the Buspirone. An interview on 12/04/24 at 12:58 PM with the ADON confirmed that Buspirone should not be an PRN (as needed) order and that the Buspirone PRN should have a stop date and did not. Licensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview, the facility failed to identify specific target behaviors for the use of an antidepressant (used to treat depression) medication for 5 (Residents 3, 35, 37, 44, 55), antianxiety (used to treat anxiety) medication for 2 (Residents 35 and 55) and an antipsychotic (used to treat psychosis) for 2 (Residents 44 and 55) of 5 residents reviewed for psychotropic (group of medications used to treat mental health disorders) medication use. The facility census was 61. Findings are: Review of the facility Psychotropic Medication Policy and Procedure, dated August 2018, revealed the following: -The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, medical, and/or behavioral interventions, as well as psychopharmacological medications can be utilized to meet the needs of the individual resident. -Nursing: will monitor for the presence of target behaviors daily, charting by exception (i.e. charting only when the behaviors are present). A record review of the facility Psychotropic Medication Policy and Procedure dated August 2018 revealed the following: -Primary Care Physicians, PA or APN: 1. Documents rationale and diagnosis for use and identifies target symptoms. 2. Orders for PRN psychotropic medications will be time limited (i.e., times 2 weeks) and only for specific clearly documented circumstances. Nursing: 1. Monitors psychotropic drug use daily noting any adverse effects such as increased somnolence or functional decline. 2. Will monitor for the presence of target behaviors on a daily basis charting by exception(i.e. charting only when the behaviors are present). A. Review of Resident 35's current medication orders, dated 12/3/24, revealed the following orders: -Bupropion (antidepressant) 150 milligrams (mg) by mouth in the evening for depression -Bupropion 300mg by mouth one time a day for depression -Cymbalta (antidepressant) Delayed Release 60 mg by mouth two times a day for depression -Buspirone (antianxiety) 30 mg by mouth two times a day for anxiety Review of Resident 35's Comprehensive Care Plan (CCP--a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) revealed no care plan related to Resident 35's psychotropic medication uses or any identification of targeted behaviors for the use of Resident 35's antidepressant and antianxiety medications. In an interview on 12/4/24 at 9:21 AM, Medication Aide (MA)-C revealed that targeted behaviors would be on the care plan. In an interview on 12/4/24 at 9:30 AM, Registered Nurse (RN)-D revealed they were unaware of the behaviors that were to be monitored related to Resident 35's psychotropic medication use. In an interview on 12/4/24 at 11:22 AM, the Assistant Director of Nursing (ADON) was unable to find any documentation in Resident 35's electronic health record (EHR) that identified the targeted behaviors for Resident 35's antidepressant and antianxiety medication use. The ADON confirmed that targeted behaviors needed to be identified for psychotropic medications so that they can be monitored for effectiveness of the medications. B. Review of Resident 37's current medication orders, dated 12/3/24, revealed the following order: -Sertraline (antidepressant) 100 mg by mouth in the evening related to depression Review of Resident 37's CCP revealed no identification of targeted behaviors for the use of Resident 37's antidepressant. In an interview on 12/4/24 at 9:21 AM MA-C revealed that targeted behaviors would be on the care plan. In an interview on 12/4/24 at 9:30 AM, RN-D revealed they were unaware of the behaviors that were to be monitored related to Resident 37's psychotropic medication use In an interview on 12/4/24 at 11:22 AM, the ADON was unable to find any documentation in Resident 37's EHR that identified the targeted behaviors for Resident 37's antidepressant medication use. The ADON confirmed that targeted behaviors needed to be identified for psychotropic medications so that they can be monitored for effectiveness of the medications. C. Review of Resident 44's current medication orders, dated 12/3/24, revealed the following: -Sertraline 75 mg by mouth in the evening related to depression -Quetiapine (antipsychotic) 25 mg by mouth at bedtime related to Alzheimer's disease Review of Resident 44's CCP revealed no identification of targeted behaviors for the use of Resident 44's antidepressant and antipsychotic medications. In an interview on 12/4/24 at 9:21 AM MA-C revealed that targeted behaviors would be on the care plan. In an interview on 12/4/24 at 9:30 AM, RN-D revealed they were unaware of the behaviors that were to be monitored related to Resident 44's psychotropic medication use In an interview on 12/4/24 at 11:22 AM, the ADON was unable to find any documentation in Resident 44's EHR that identified the targeted behaviors for Resident 44's antidepressant and antipsychotic medication use. The ADON confirmed that targeted behaviors needed to be identified for psychotropic medications so that they can be monitored for effectiveness of the medications. D. A record review of Resident 3's admission Record printed 12/04/2024 revealed the resident was admitted on [DATE] and had diagnoses of heart failure, chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), chronic kidney disease, high blood pressure, depression, and Post-Traumatic Stress Disorder (PTSD, disorder that develops in some people who have experienced a shocking, scary, or dangerous event). A record review of Resident 3's Order Summary Report printed 12/04/2024 revealed the resident had an order for sertraline (an antidepressant) for depression. A record review of Resident 3's CCP revealed a care plan focus initiated 09/17/2024 that stated the resident uses psychotropic medications and is at risk for complications. There were no target behaviors listed in the care plan goal or interventions. Further review of the CCP revealed no mention of target behaviors. In an interview on 12/05/2024 at 12:02 PM the ADON confirmed there were no target behaviors identified in the CCP for Resident 3.

Licensure Reference Number NAC 12-006.05(6) Based on record reivew, observations, and interviews, the facility failed to ensure the catheter drainage bag was covered to protect 1 (Resident 15) of 3 sampled residents for dignity. The census was 51. Findings are: A review of a facility policy dated 04/05/2023 titled Catheter Care revealed: - It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care, maintain their dignity and privacy when indwelling catheters are in use. - Privacy bags will be available and catheter drainage bags will be covered at all times while in use. An observation on 1/29/24 at 11:50 AM revealed, Resident 15 was in their room sitting in [gender] recliner chair. Resident 15's catheter drainage bag was uncovered and hooked onto their recliner chair. An observation on 01/29/24 at 12:48 PM revelaed, that Resident 15 was in their recliner chair finishing the noon meal. Resident 15's catheter drainage bag was uncovered and hooked on to the recliner chair. The uncovered catheter drainage bag was visible from the doorway of the resident's room. An observation on 01/29/24 at 4:03 PM revealed, that Resident 15's catheter drainage bag was uncovered, and hooked onto side of the recliner chair. An interview on 01/29/24 at 4:03 PM with Resident 15 revealed that [gender] prefered to keep the catheter drainage bag covered at all times, even when in [gender] room alone. An interview on 01/30/2024 at 1:24 PM with Nursing Aide-A revealed, that catheter drainage bags are to be covered at all times, unless the resident refused. An interview on 1/31/2024 at 7:31 AM with Licensed Practical Nurse-A confirmed it is not the facility practice to leave the catheter drainage bag outside of a privacy bag. The catheter drainage bag should have been placed into a privacy bag unless the resident refused.

Licensure Reference Number 175 NAC 12-006.17 Based on record review, observations, and interviews, the facility failed to ensure C-PAP (CPAP or continuous positive airway pressure, is a respiratory therapy intervention used to provide a patent airway during periods of sleep apnea. It requires a machine that generates by a machine, delivered through a tube into a mask that fits over the nose or mouth), mask and tubing was cleaned after use to prevent the spread of infection that affected 2 (Resident # 156 and #1) of 2 sampled residents. The facility census was 51 at time of survey. Findings are: A. A record review of the CPAP/BIPAP cleaning policy last revised on 4/5/23 revealed, under the policy explanation and compliance guidelines section 6) Clean mask frame daily after use with CPAP cleaning wipe or soap and water, and dry well. 7) weekly cleaning activities a) wash headgear/straps in warm, soapy water and air dry, b) wash tubing with warm, soapy water, soak in 50% vinegar and water for 30 minutes minimum, rinse and allow to air dry. A record review of the Physician Diagnosis dated 01/11/2017 revealed, that Resident #1 had a diagnosis of obstructive sleep apnea. A record review of the Pocket Care Plan (PCP a care plan on paper which addresses residents individualized needs that staff can carry in the pocket for reference) dated 11/29/23 for Resident #1 revealed that Resident #1 has a C-pap for sleep apnea, and staff are to document how long that Resident #1 uses the C-pap at night through the next quarter. An observation on 01/30/24 at 9:54 AM revealed, that Resident #1's C-Pap tubing was draped across the tray table with the face mask still attached to the C-pap tubing. The face mask was laying on the tray table. An observation on 01/30/24 at 12:14 PM revealed that Resident #1's C-Pap tubing was draped across the tray table with face mask still attached to the C-Pap tubing. The face mask was laying on the tray table. An interview on 01/30/24 at 12:59 PM with Registered Nurse (RN)-B confirmed that the mask was not cleaned because the mask and tubing was still attached and laying across the tray table. RN-B further revealed that the CPAP mask and tubing is suppose to be cleaned every day and the water chamber is to be washed daily and the placed on a clean barrier to air dry. An interview on 01/30/24 at 1:07 PM with the Director of Nursing (DON) confirmed that Resident #1's C-Pap mask and water chambers had not been cleaned and the C-Pap mask and water chambers should be cleaned daily. DON confirmed that Resident #1 does wear the C-Pap for several hours nightly. B. A record review on 1/30/24 in Physician Diagnosis dated 01/22/2024 revealed that Resident # 156 had a diagnosis of Sleep Apnea. A record review on 1/30/24 of MAR for the month of January 2024 revealed, that Resident # 156 wore the C-Pap nightly. A record review on 01/30/2024 in the MAR for the month of January 2023 revealed, an order to clean the CPAP mask and tubing weekly An observation on 01/29/24 at 11:25 AM revealed, that Resident # 156's C-Pap tubing was draped across the tray table with the face mask still attached to the C-pap tubing. The face mask was laying on the tray table. An observation on 01/30/24 at 9:01 AM revealed, that Resident # 156's C-Pap tubing was draped across the tray table with the face mask still attached to the C-pap tubing. The face mask was laying on the tray table. An observation on 01/30/24 at 12:15 PM revealed, that Resident #156's C-Pap tubing was draped across the tray table with the face mask still attached to the C-pap tubing. The face mask was laying on the tray table. An interview on 01/30/24 at 9:02 AM with Resident # 156 revealed, that Resident # 156 does wear the C-Pap every night. Resident # 156 further revealed, that [gender] is not aware of staff cleaning the C-Pap mask. Resident # 156 also revealed, that staff do change the water in the C-Pap machine chambers nightly before [gender] puts the C-Pap mask on. An interview on 01/30/24 at 12:59 PM with RN-B confirmed that the mask was not cleaned because the mask and tubing was still attached and laying across the tray table. RN-B further revealed that the CPAP mask and tubing is suppose to be cleaned every day and the water chamber is to be washed daily and the placed on a clean barrier to air dry. An interview on 01/30/24 at 1:07 PM with the DON confirmed that the C-Pap mask and water chambers had not been cleaned and the C-Pap mask and water chambers should be cleaned daily. The DON also confirmed that Resident # 156 does wear the C-Pap nightly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.04C3a(5) Based on record review and interview, the facility failed to ensure that the resident care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) included interventions to prevent identified risk of infection for 1 resident (Resident 50) of 1 resident reviewed. The facility census was 54. Findings are: Record review of the facility policy titled Comprehensive Care Plans dated 5/22/22 revealed that it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident. The care planning process will include an assessment of the resident's strengths and needs. The comprehensive care plan will describe resident specific interventions that reflect the resident's needs and preferences. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly assessment. A copy of the signed care plan will be placed on the chart. Record review of the Face Sheet dated 3/2/23 for Resident 50 revealed that Resident 50 admitted into the facility on 6/1/22. Record review of the care plan dated 1/13/23 for Resident 50 revealed that the staff assists the resident with toileting hygiene (cleaning the private areas after toileting). The care plan contained no documentation that Resident 50 had a risk of urinary tract infection (UTI) or interventions to prevent urinary tract infection. Record review of the undated Hospitalizations for Resident 50 revealed that Resident 50 was hospitalized from [DATE]-[DATE]; 12/13/22-12/14/22; 12/20/22-12/23/22; and 12/27/22-1/4/22. Record review of the nurse's note dated 9/7/22 at 1:53 PM revealed that Resident 50 was in the bathroom and didn't think they could stand. Resident 50's words were clear but made no sense. The physician was notified, and an order was received to transfer the resident to the emergency room. Record review of the nurse's note dated 9/7/22 at 7:27 PM revealed that the nurse spoke with the hospital and Resident 50 was admitted to the hospital with a urinary tract infection (UTI). Record review of the nurse's note dated 9/9/22 at 11:06 AM revealed that Resident 50 returned to the facility from the hospital. Record review of the nurse's note dated 11/25/22 at 3:14 PM revealed that the MDS Quarterly Nursing Assessment was performed on 11/23/22. The note revealed that Resident 50 toilets on the resident's schedule and staff assist the resident with peri care (cleaning of the private areas). Record review of the nurse's note dated 12/13/22 at 5:05 PM revealed that Resident 50 complained of not feeling right in the head after breakfast. Resident 50 had unresponsive episodes and the ambulance was called to transport the resident to the emergency room. The emergency room called the facility to notify them that Resident 50 was being kept at the hospital with a diagnosis of UTI. Record review of the nurse's note dated 12/14/22 at 1:49 PM revealed that Resident 50 was resting in the recliner after lunch. Resident 50 was back in the facility. Record review of the nurse's note dated 12/20/22 at 3:30 PM revealed that Resident 50 fell in the bathroom. An ambulance was called, and Resident 50 was transported to the emergency room. The nurse called the emergency room for an update on the condition of Resident 50. Resident 50 was being admitted for a white blood cell count (WBC) of 14 (Normal WBC range is 4.5-11. A WBC result greater than 11 indicates the body is fighting an infection). Record review of the nurse's note dated 12/23/22 at 1:28 PM revealed that Resident 50 returned to the facility from the hospital. Record review of the nurse's note dated 12/27/22 at 12:16 AM revealed that Resident 50 had a seizure and was transferred to the emergency room. Record review of the nurse's note dated 1/4/23 at 2:58 PM revealed that Resident 50 returned to the facility from the hospital. Record review of the Minimum Data Set Assessment (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 12/20/22 documented that Resident 50 had a UTI in the last 30 days. The MDS documented that Resident 50 had received an antibiotic for 6 of the 7 days of the assessment look-back period. Record review of the MDS dated [DATE] for Resident 50 documented that Resident 50 had a UTI in the last 30 days. The MDS documented that Resident 50 had received an antibiotic for 2 of the 7 days of the assessment look-back period. Record review of the MDS dated [DATE] documented that Resident 50 had received an antibiotic for 6 of the 7 days of the assessment look-back period. Interview on 3/2/23 at 11:43 AM with Registered Nurse-G (RN-G) revealed that the pocket care plan (A sheet listing the resident names and specific care plan interventions for each resident. The pocket care plan is used by floor staff to guide them in the care needs of each resident) and the comprehensive care plan for Resident 50 contained no care guidance for the prevention of urinary tract infections for Resident 50. RN-G confirmed that Resident 50 had experienced UTI's while in the facility. Interview on 3/2/23 at 1:10 PM with the facility Director of Nursing (DON) confirmed that Resident 50 has had urinary tract infections along with other health issues leading to hospitalizations. The DON confirmed that the comprehensive care plan is developed and revised by assessments including the MDS. The DON confirmed that the care plan for Resident 50 did not contain interventions for prevention and monitoring for urinary tract infection for Resident 50. The DON confirmed that the care plan would be expected to include interventions for the prevention of UTI's for Resident 50.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observation, interview, and record review; the facility failed to implement interventions to prevent complications related to edema (swelling) for 1 of 1 sampled residents, Resident 19. The facility identified a census of 54 at the time of survey. Findings are: Review of Resident 19's quarterly MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) dated 11/30/22 revealed an admission date of 8/25/2020. Resident 19 had a BIMS (Brief Interview for Mental Status) score of 5 which indicated severe cognitive impairment. Resident 19 required extensive assistance from staff for transfers and locomotion. Observation of Resident 19 on 2/27/23 at 12:01 PM revealed Resident 19 was sitting in their room in their wheelchair. Resident 19's legs were down and their feet were on the floor. Resident 19 had decorative crew type socks on that were cutting into their legs and leaving deep indentations in their legs just below mid shin. Resident 19's legs and ankles were swollen. Observation of Resident 19 on 2/28/23 at 8:20 AM revealed Resident 19 was observed sitting in the dining room eating breakfast. Resident 19 was wearing white crew style socks that were cutting into their legs and leaving deep indentations in their legs. Resident 19's lower legs and ankles were swollen. Observation of Resident 19 on 3/02/23 at 7:35 AM revealed Resident 19 was sitting in the dining room in their wheelchair. Resident 19's lower legs and ankles were swollen and Resident 19 was wearing crew style white socks. Review of Resident 19's Care Plan dated 12/6/22 revealed no documentation of the edema or management of including not putting socks on that cut into their legs. Interview with the DON (Director of Nursing) on 3/02/23 at 11:06 AM revealed the nurses should have been monitoring the edema in Resident 19's legs. The DON revealed they thought Resident 19 had edema wear. The DON had LPN-A (Licensed Practical Nurse) bring up Resident 19's pocket care plan on the computer and look at it and there was no documentation of TED hose, edema wear, or what type of socks the staff should be applying to keep them from cutting into Resident 19's legs. Interview with the DON on 3/02/23 at 11:33 AM revealed the staff tried to use TED stockings (TED stockings were an abbreviation for thromboembolism-deterrent. They are stockings designed and worn to support the venous and lymphatic drainage of the leg, which means when you are recovering in bed these stockings will help stop blood clots from forming. If you are non-ambulatory then the gradient compression is combined with the actual muscle pump effect of your calf, these two things work together to help circulate blood and lymph fluid through your legs) to manage Resident 19's edema 8/25/20 through 4/23/21 but Resident 19 refused to wear them. The DON did not find any documentation Resident 19 had been evaluated for an alternative to the TED hose such as edema wear. The DON revealed the it was a concern Resident 19 was wearing socks 2 days in a row that were cutting into Resident 19's legs.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E Based on observation, interview, and record review; the facility failed to ensure oxygen concentrators were turned off when they were not in use in the resident room which created an oxygen rich environment which would support combustion and a potential accident hazard for 1 of 1 sampled residents, Resident 18. The facility identified a census of 54 at the time of survey. Findings are: Review of Resident 18's quarterly MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) dated 1/11/23 revealed an admission date of 6/11/21. Resident 18 had a BIMS (Brief Interview for Mental Status) score of 4 which indicated severe cognitive impairment. Resident 18 required extensive assistance from staff for transfers and locomotion. Oxygen was used while a resident. Observation of Resident 18's room on 2/27/23 at 9:52 AM, 2/28/23 at 8:22 AM, and 2/28/23 at 12:51 PM revealed Resident 18 was not in their room and the oxygen concentrator (an oxygen concentrator is a type of oxygen delivery device that draws in air from the surroundings, removes nitrogen and other gasses and delivers purified oxygen to the user. Oxygen concentrators deliver oxygen continuously (at a steady rate) and need to be plugged into an electrical outlet to operate) was on. Interview with the FA (Facility administrator) on 3/02/23 at 11:12 AM confirmed the facility staff were not to leave the oxygen concentrators on in the resident rooms when they were not in use. Review of the facility policy Oxygen Safety dated 2021 revealed the following: Turn off oxygen cylinders when not in use.

Licensure Reference Number 175NAC 12-006.11E Based on observation, record review, and interview; the facility failed to ensure documentation of high temperature sanitation dishwasher (a dishwasher that uses superheated water in the final rinse to kill food-borne bacteria to sanitize dishes) temperatures for each meal to prevent the potential for food-borne illness. This had the potential to affect 53 resident that ate food served by the facility kitchen. The facility census was 54. Findings are: Record review of the Nebraska Food Code dated 7/21/16 section 4-501.15 revealed that ware washing (dishwashing) machines shall be operated in accordance with the machine's data plate and other manufacturer's instructions. Record review of the Manufacturer's Instructions dated November 2021 for model AM15 Select Dishwashers revealed that the AM15 dishwasher can operate in one of two modes: Hot water sanitizing mode or a chemical sanitizing mode. The instructions revealed that the operating temperatures for hot water sanitizing are a minimum wash temperature of 150 degrees Fahrenheit and a minimum rinse temperature of 180 degrees Fahrenheit. Observation on 3/2/23 at 12:35 PM in the facility kitchen revealed that the dishwasher data plate documented the dishwasher as model number AM15. Interview on 3/2/23 at 8:55 AM with Dietary Cook-E (DC-E) revealed that the facility dishwasher is a high temperature dishwasher and has a heat booster to sanitize dishware. DC-E revealed that the facility does not use chemical sanitization for facility dishes. Interview on 3/2/23 at 12:52 PM with Dietary Staff-F (DS-F) confirmed that the facility dishwasher sanitizes by high temperature and not by chemical sanitization. DS-F revealed that the dishwasher displays the wash temperature and the rinse temperature. DS-F revealed that the wash and rinse temperatures are required to be recorded for each meal. Observation on 3/2/23 at 8:02 AM in the facility kitchen dishwashing room revealed that a Dish Machine Monthly Temperature Record hung on a clipboard on the wall. Record review on 3/2/23 at 8:02 AM of the February 2023 Dish Machine Monthly Temperature Record hanging on the clipboard in the facility kitchen dishwashing room revealed that the last recorded temperature was the 2/28/23 breakfast wash temperature of 150 degrees Fahrenheit. No breakfast final rinse temperature was documented on 2/28/23. There were no wash temperatures or rinse temperatures documented for the dinner and supper dishes for 2/28/23. No wash or rinse temperatures were recorded for the 3/1/23 breakfast, lunch, or dinner dishes or for the 3/2/23 breakfast dishes. Interview on 3/2/23 at 10:23 AM with Dietary Cook-E (DC-E) revealed that the monthly dishwasher temperature logs are usually reviewed and changed out by the Registered Dietitian or the Dietary Manager. Interview on 3/2/23 at 2:09 PM with Dietary Staff-B (DS-B) confirmed that it is the facility expectation that the facility dishwasher wash and rinse temperatures are documented for each meal on the Dish Machine Monthly Temperature Record to ensure that dishes are sanitized at the required temperature.