Based on interviews, observation, and record reviews, the facility failed to follow policy and procedures for constipation management and prevention. This affected 1 of 2 residents sampled (Resident 31). The stated facility census was 53. Record review of the facility Bowel and Bladder Management Standard updated on 04/18/2024 defined constipation as difficulty in passing stools or incomplete or infrequent passage of hard stool. The standard states that the care plan should contain the appropriate interventions based upon the interventions for potential risks. Record Review of the Elimination Protocol dated 6/2024 gave specific nursing instructions to review the elimination records of residents and interventions for bowel management and documentation. -Small bowel movements did not count towards the daily elimination. -Day 2; After 48-hour period without a bowel movement (BM); offer 4 ounces of prune juice or natural laxative of resident's choice. The intervention must be recorded in the column below (on the paper). -Day 3; Day shift without a BM; Give 30 milliliters (ml) of milk of magnesia or Miralax (both are medications to relieve constipation) (or medication ordered by their physician) in the morning on the 6 AM to 2 PM shift. Assess bowel sounds, then palpate and document assessment results. Document findings and medication in the Medication Administration Record (MAR). Record in the intervention column on the daily Elimination Protocol sheet. Communicate interventions/results to the oncoming shift for further action if no BM. -Day 3; Evening/Night shift without a BM; Evening/Night charge nurse to assess bowel sounds, palpate and document assessment results before suppository administration. If No Bowel Sounds for the day, call the physician immediately. Give Dulcolax suppository, as ordered, at a time agreeable to the resident. Document on the MAR. Communicate interventions/results to oncoming shift for further action if no BM. Record in Intervention column of the daily Elimination Protocol sheet. -Day 4; All shifts without a BM; If interventions have not been successful; Contact the physician. Advance to enema as ordered and continue with bowel assessments each shift until resolved. Record review of the Minimum Data Set (MDS, part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes to assist in care plans) dated 09/26/2024 revealed that Resident 31 received hospice care, had a BIMS (Brief Interview for Mental Status assessment, which is used to categorize a patient's cognitive impairment) score of 10, meaning moderate cognitive impairment, was continent of bowel, was not on a bowel program, and had diagnoses for Parkinson's disorder, paraplegia, progressive neurological disorder, and difficulty walking. Resident 31 received scheduled and as needed opioid (narcotic) (pain medications). Record review of the Care Plan (a document that outlines a patient's care, including the goals, activities, and who will be involved in care of the resident) revised on 7/12/2024 revealed a potential for alteration in bowel elimination related to narcotic medications, bowels would be managed without complications through the next review date of December 2024, and nursing staff would administer medications per the physician's orders, follow the facility bowel management protocol, and report complications related to bowel elimination. Record review of the Hospice Plan of Care (a document that outlines a patient's care, including the goals, activities, and who will be involved in the resident care) updated on 10/16/2024 revealed that Resident 31 and a family member both verbalized understanding of the risk factors of care that increased the risk of constipation and measures used by Hospice staff to prevent constipation. Interview on 10/28/2024 at 12:20 PM with the family member of Resident 31 revealed that constipation has been an issue. The family member also stated that Resident 31 had gradually become weaker and now received Hospice cares. Interview on 10/28/24 at 1:18 PM with Resident 31 stated I am still having issues with constipation. Resident 31 uses a walker all the time now and no longer walks. Observation on 10/29/2024 at 12:25 when Resident 31 was served a meal there was no prune juice on the food tray. Record review of the Physician Orders printed on 10/29/2024 revealed orders for Milk of Magnesia (400 milligrams (mg)/5 milliliters (ml)) 30 ML daily for constipation, docusate sodium (a medication that works as a stool softener)100 mg capsule 1 capsule twice a day for bowel regulation, bisacodyl suppository (a medication for constipation) 10 mg as needed for constipation, and prune juice 4 ounces (oz) as needed for bowel regulation. Record review of a Bowel Movements (BM) in a 30 day look back period printed on 10/29/2024 for bowel history of Resident 31 revealed the following: -09/30/24; no BM, -10/01/24; no BM, -10/02/24; Resident 31 had a BM, -10/03/24; Resident 31 had a BM, -10/04/24; no BM, -10/05/24; no BM, -10/06/24: Resident 31 had four small BMs, -10/07/24; Resident 31 had a BM, -10/08/24; no BM, -10/09/24; Resident 31 had a BM, -10/10/24; Resident 31 had a small BM, -10/11/24; Resident 31 had a BM, -10/12/24; Resident 31 had a BM, -10/13/24; Resident 31 had a BM, -10/14/24; no BM, -10/15/24; no BM, -10/16/24; Resident 31 had a BM, -10/17/24; no BM, -10/18/24; no BM, -10/19/24; Resident 31 had a BM, -10/20/24; no BM, -10/21/24; no BM, -10/22/24; no BM, -10/23/24; Resident 31 had a BM, -10/24/24; no BM, -10/25/24; no BM, -10/26/24; no BM, -10/27/24; no BM, -10/28/24; Resident 31 had a BM, -10/29/24 no BM. Record review of the October 2024 MAR/TAR (medication administration record/treatment administration record) for Resident 31 revealed no documented administration of prune juice. The MAR/TAR also revealed Resident 31 received a new order for milk of magnesia 400 milligrams (mg)/5 milliliters (ml) and administered 30 ml daily for constipation with a start date of 9/28/2024. Resident 31 received Dulcolax sodium capsules 100 mg twice daily for constipation. Resident 31 received a bisacodyl suppository 10 mg on October 2, 11, 13, 16, 19, 23, and 27 for constipation. There was no documented suppository given on 10/26/24. Record review of the medical records for Resident 31 did not reveal any physician communication with the physician about constipation. Interview with LPN-F (Licensed Practical Nurse-F) on 10/30/24 at 11:40 AM: Spoke about the Elimination Protocol on day 2, residents get whatever is ordered which is usually prune juice. On day 3 we give the resident milk of magnesia, or the physician ordered medication, if there are still no results. The nurse charts the medication on the MAR/TAR and then follows up throughout the shift. If the resident has had no results, the nursing staff will give this information to the oncoming staff for the next shift. On day four of no BM, staff nurses will give the resident a suppository after we assess the resident bowel sounds, and double check with our nurses' aides to be certain there was not a BM that didn't get charted so we do not give something unnecessarily. The nurse then has to write a nursing progress note. If there are no bowel sounds or if the resident complains of abdominal pain if no BM for several days or if the stuff we are doing simply is not working, we have to call the doctor. We also will reach out when necessary to see if the physician wants to have anything else specifically added to the orders. The nurse will not usually call the doctor unless the resident is having pain or there are no bowel sounds, which is not exactly what the elimination protocol says to do. Interview with the DON (Director of Nursing) on 10/30/2024 at 02:40 PM who confirmed that the bowel and elimination protocols for management and prevention were not followed as written for residents who have constipation.

Licensure Reference Number 175NAC 12-006.09(H)(vi)(3)(d) Based on observation, record review, and interviews, the facility failed to follow the manufacturer's instructions for insulin administration for 1 of 2 residents observed (Resident 24) to prevent the potential for hypoglycemic reaction. The facility census was 53. Findings are: Record review of the Fiasp FlexTouch (insulin aspart injection) (a fast acting insulin) product insert (manufacturer's instructions for use) dated 09/2022 revealed the section titled Dosage and Administration. Item 2.2 Route of Administration Instructions revealed the instructions to inject Fiasp at the start of a meal or within 20 minutes after starting a meal. Record review of the admission Record for Resident 24 dated 10/29/24 revealed that Resident 24 admitted into the facility on 3/11/24. Diagnoses included diabetes. Record review of the Care Plan dated 10/28/24 for Resident 24 revealed that Resident 24 has the potential for abnormal blood sugars related to diabetes. Interventions included to monitor blood sugar and administer insulin as ordered. Report any signs and symptoms of hypoglycemia (low blood sugar): sweating tremor, high heart rate, paleness, nervousness, confusion, slurred speech, lack of coordination to the charge nurse. Record review of the Order Summary Report (a listing of all physician orders for a specific resident) for Resident 24 dated 10/29/24 revealed a physician order for Fiasp insulin injection before meals. Observation on 10/29/24 at 11:51 AM in the room of Resident 24 revealed that Resident 24 sat in a wheelchair. Registered Nurse-H (RN-H) confirmed the blood sugar reading of 258 for Resident 24. RN-H confirmed that the physician order for Fiasp insulin for Resident 24 was to receive 6 units of insulin to be given for a blood sugar reading of 258. RN-H removed a Fiasp Insulin pen from the medication cart. RN-H applied the needle to the pen and turned the dial to 2 units and pushed the plunger to prime the needle. RN-H turned the dial on the insulin pen to the ordered 6 units of insulin. RN-H entered the room of Resident 24 and administered the insulin into the right upper arm of Resident 24. The time was 11:53 AM. RN-H did not offer Resident 24 a snack or juice. RN-H provided no instructions to Resident 24. Resident 24 was assisted to the dining room by an unidentified staff member and placed at a table in the dining room. Observation on 10/29/24 at 12:00 PM in the facility dining room revealed Resident 24 seated in the wheelchair at a dining room table with a cup of coffee and a glass of dark brown liquid. Resident 24 revealed that the glass contained diet coke. Interview on 10/29/24 at 12:07 PM with Dietary Aide-I (DA-I) confirmed that Resident 24 received diet coke and coffee. Observation on 10/29/24 from 12:00 PM to 12:27 PM in the dining room revealed that Resident 24 received no caloric intake and only had the cup of coffee and glass of diet coke available for consumption. Observation on 10/29/24 at 12:27 PM in the dining room revealed that Dietary Aide-J (DA-J) delivered a plate with a hot dog on a bun to Resident 24. Resident 24 told DA-J it was not what the resident ordered. DA-J carried the plate back to the kitchen. DC-J returned to Resident 24 at 12:30 PM with a menu and clarified what Resident 24 wanted for lunch. Resident 24 remained at the table with only the cup of coffee and glass of diet coke. Resident 24 had consumed approximately 1/4 of the diet coke. Observation on 10/29/24 at 12:39 PM in the dining room revealed that DA-J carried a plate of food to Resident 24. The plate contained a hamburger on a bun, potato salad, and a bowl of mandarin oranges. DA-J sat the plate on the table in front of Resident 24. Resident 24 immediately took a couple of bites of the hamburger. This was 46 minutes after RN-H administered the fast acting insulin to Resident 24. Resident 24 had not received any caloric intake for 46 minutes after the fast acting insulin was administered. Record review of the Treatment Administration Record (TAR, a legal record of the administration of scheduled treatments or performance of other scheduled medical tasks for a resident by a health care professional such as a licensed nurse) for Resident 24 dated 10/29/24 revealed that RN-H documented the administration of the 6 units of Fiasp insulin for Resident 24 occurred at 11:51 AM (48 minutes before Resident 24 received any caloric intake). Interview on 10/30/24 at 4:12 PM with Registered Nurse-K (RN-K) revealed that the nurse is expected to ensure that a resident receiving fast acting insulin receives nutrition (caloric intake) within 15 minutes of administration. RN-K revealed that RN-K administers fast acting insulin just before the resident goes to the dining room to get nutrition. RN-K revealed that staff should let dietary know that the diabetic is in the dining room. RN-K confirmed that no juice or snack is given from the treatment cart after insulin administration to a resident. Interview on 10/30/24 at 4:38 PM with the facility Director of Nursing (DON) confirmed that residents receiving fast acting insulin are required to receive nutrition with caloric value within 15 minutes of the insulin administration to prevent complications of low blood sugar. The DON confirmed that the coffee and diet Coke provided to Resident 24 did not have caloric value. Interview on 10/31/24 at 9:38 AM with Registered Nurse-H (RN-H) revealed that RN-H ensures a resident receives something with caloric value after insulin administration by telling them to get a cup of juice when they get to the dining room. RN-H revealed that if the resident appeared to need immediate caloric intake the RN-H would get them their meal in the dining room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 1-005.06 Licensure Reference Number 175NAC 12-006.18 Based on observation, interview, and record review; the facility failed to ensure that oxygen administration supplies were monitored and replaced for 1 of 1 residents observed (Resident 41) to prevent the potential for respiratory infection. The facility census was 53. Findings are: Record review of the facility document titled Facility Assessment dated 8/8/24 revealed that resident care needs include infection prevention and control. Specific care practices include identification and containment of infections and prevention of infections. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 41 dated 10/3/24 revealed that Resident 41 admitted into the facility on [DATE]. The MDS revealed that Resident 41 receives oxygen therapy while a resident in the facility. Record review of the Care Plan dated 10/28/24 for Resident 41 revealed that Resident 41 has altered respiratory function and requires oxygen. The care plan lacked interventions to replace the oxygen administration tubing and nasal cannula (a small, flexible tube that contains two open prongs intended to sit just inside your nostrils to provide supplemental oxygen therapy to people who have lower oxygen levels) for Resident 41. Record review of the Order Summary Report (a listing of all physician orders for a resident) for Resident 41 dated 11/1/24 revealed that it contained a physician's order for oxygen at 2 to 4 liters per minute to be given by nasal cannula. The Order Summary lacked interventions to replace the oxygen tubing and nasal cannula for Resident 41. Record review of the Medication Administration Records (MAR, a legal record of the medications administered to a patient at a facility by a health care professional) and Treatment Administration Records (TAR, a legal record of the administration of scheduled treatments or performance of other scheduled medical tasks for a resident by a health care professional such as a licensed nurse) for Resident 41 for the months of February 2024-September 2024 dated 10/30/24 revealed that Resident 41 received oxygen daily. The MARs and TARs lacked interventions to replace the oxygen tubing and nasal cannula for Resident 41. Observation on 10/28/24 at 12:24 PM in the room of Resident 41 revealed a light blue oxygen concentrator (a medical device that concentrates the oxygen from room air and delivers it to a patient needing supplemental oxygen) with oxygen tubing and a nasal cannula in an undated blue infection control pouch. A humidification bottle with a 10/31/27 manufacturer outdate had no opened date on the bottle. There was no date on the oxygen tubing or the nasal cannula. Observation on 10/29/24 at 7:39 AM in the room of Resident 41 revealed that Resident 41 was in bed as Registered Nurse-H (RN-H) administered medications to Resident 41. The nasal cannula was in place on Resident 41 and had no date on it. The humidification bottle had no open date documented on it. The oxygen tubing had no date documented on it. The oxygen concentrator was operating and the oxygen flow rate was set at 2 liters per minute. Observation on 10/30/24 at 8:05 AM in the room of Resident 41 with the facility Director of Nursing (DON) revealed that the oxygen tubing was connected to the oxygen concentrator and the tubing had not been dated, the humidification bottle was not dated, and the blue infection control pouch was not dated. Interview on 10/30/24 at 8:05 AM with the facility DON confirmed that the oxygen tubing, cannula, and infection control pouch of Resident 41 were not dated. The DON confirmed that the humidification bottle is not dated with an open date. The DON revealed that oxygen tubing, nasal cannula, and infection control pouches were expected to be changed (replaced) weekly on Thursday nights by the night shift. The DON confirmed that the oxygen tubing and cannula are expected to be changed out weekly. The DON revealed that the weekly changing of the oxygen administration supplies is documented on the monthly cleaning schedule with staff initials to document completion. The DON revealed that the staff are not dating the oxygen supplies when it is changed out. The DON revealed that the DON observed that the oxygen supplies were set out to know that the oxygen supplies were being changed out. Record review of the untitled and undated monthly cleaning log provided by the DON revealed that it contained the instructions for Thursdays: Change out all respiratory bags, tubings including nebulizer masks and mouthpieces- infection control bags (on concentrators, portable tanks- change bags on wheelchairs). The log contained a box to initial completion of changing the respiratory administration supplies on the date it was performed. The monthly cleaning log did not list the residents receiving oxygen. Interview on 10/30/24 at 8:10 AM with the DON confirmed that there is not a cleaning schedule log for individual residents. The cleaning log is for all residents receiving oxygen on the hall and is documented as a whole. The DON revealed that there is one monthly cleaning log for the 400 hall and one monthly cleaning log for the 300 hall. The DON confirmed that there is no individual resident documentation that the oxygen supplies were changed out weekly for each specific resident as required. Interview on 10/30/24 at 4:28 PM with the DON confirmed the facility had no documentation of individual resident oxygen being replaced for any residents. The DON confirmed that the facility had no documentation that the oxygen supplies were replaced weekly as required for Resident 41.

Licensure Reference Number: 12-006.05 21 Based on observation, interview and record review; the facility failed to ensure residents remained covered to protect resident dignity and failed to assist residents in a dignified manner for 1 resident (Resident 44). Census was 53. Findings Are: Observation on 09/12/22 at 10:15 AM revealed Resident #44 was sitting in the wheelchair with the lift pad underneath and the straps still pulled between the legs and without a brief on. Resident #44 had a blanket at the knees, fully exposed. Observation on 9/12/22 at 12:10 PM revealed three coffee cups served with pureed food with straws and no beverages were served to Resident #44. NA (Nursing Assistant)-K was assisting the resident to eat without talking to the resident and without taking any breaks between drinks of food. No fluid drinks were offered. NA-K repeatedly touched the end of the straw to place it in the resident's mouth. Interview with MA-P on 9/14/22 at 4:45 PM revealed residents have the right to be covered and not exposed, at all times. Interview with MA (Medication Aide)-P on 9/14/22 at 4:50 PM revealed when assisting a nonverbal resident to eat it is best to talk with the resident and ask them what they like the taste of, and if they want more of something. Even if a resident cannot talk a person will still be able to tell what is needed. Talk with them, not at them. Record review of the facility policy titled Getting To Know Us Resident Policies dated 12/2020 revealed the section titled Resident Rights. The Resident Rights section revealed: All residents have the right to a dignified existence, self-determination, and communication inside and outside the facility. The facility wants to ensure that residents are treated with dignity and respect in all interactions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C. Record review of the facility policy titled Baseline Care Plan (BCP) Guidelines dated 03/2021 revealed that the baseline care plan is to be completed per state guidelines (within 24 hours in Nebraska). An Interdisciplinary Team member/members (a group of health care professionals with various areas of expertise who work together toward the goals of the resident) will review the baseline care plan summary with the resident/representative prior to the completion of the Comprehensive Care Plan (the written interdisciplinary comprehensive care plan detailing how to provide quality care for a resident. The Comprehensive Care Plan must be completed within 7 days of completion of the resident's comprehensive assessment). The signed Care Plan Acknowledgement Form is to be scanned into the resident's electronic health record to verify that the baseline care plan review was done with the resident/resident representative. The policy revealed that the only reason that the baseline care plan summary would not be reviewed and signed by the resident/resident representative would be due to an unplanned discharge. If the resident/representative prefers not to have a copy of the baseline care plan, document in the progress notes that a copy of the BCP was offered to the resident/representative and the copies were declined. Record review of the admission Record dated 9/13/22 for Resident 41 revealed that Resident 41 admitted into the facility on 8/9/22. Diagnoses included right sided hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body following a stroke); prostate cancer; and malnutrition. The admission Record revealed that Resident 41 had a power of attorney for healthcare (a resident representative). Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 8/12/22 for Resident 41 revealed that it was the admission assessment (a comprehensive assessment) for Resident 41. Record review of the Baseline Care Plan for Resident 41 revealed that the baseline care plan was completed on 8/9/22. Record review of the Care Plan Acknowledgement Form for Resident 41 revealed that the type of care plan was not identified. The reason for discussion or viewing of the care plan was left blank. The form contained the signature of the resident representative for Resident 41 with a date of 8/17/22. The form contained the signature of the facility Social Services Director (SSD). The Care Plan Acknowledgement Form did not contain documentation that a baseline care plan review with the resident/resident representative occurred. Record review of the progress note dated 8/17/22 at 3:24 PM for Resident 41 revealed that a care plan meeting took place with the Interdisciplinary Team and the resident's child. The progress note contained no documentation that a review of the baseline care plan summary was completed with the resident/resident representative. The progress note contained no documentation that a copy of the baseline care plan was provided to the resident/resident representative or if a copy of the baseline care plan was offered and refused. Interview on 9/15/22 at 2:30 PM with the facility Minimum Data Set Coordinator (MDSC) (a facility nurse that utilizes a mandatory comprehensive assessment tool for care planning) confirmed that the resident's baseline care plan is initiated on admission to the facility. The MDSC confirmed that during the initial care plan meeting the resident/resident representative are to be provided with a copy of the baseline care plan. The MDSC revealed that you always find out things during the meeting with the resident/resident representative that require the care plan to be fine-tuned. The MDSC confirmed that the resident/resident representative sign the Care Plan Acknowledgement form. The MDSC confirmed that a progress note documenting that a copy of the baseline care plan was provided to the resident/resident representative is to be completed. LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1a Based on record review and interview, the facility failed to ensure a written summary of the baseline care plan (a written plan required to be developed within 24 to 48 hours of admission detailing the instructions needed to provide initial effective and person-centered quality care for a resident) was provided to the resident/resident representative within the required timeframe for 3 residents (Residents 31, 46, and 41) of 7 residents reviewed. This prevented the resident/resident representative from identifying additional care concerns for inclusion in the care plan. The facility census was 53. Findings are: A. Review of Resident 31's admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 8/3/2022 revealed an admission date of 7/27/2022. The CAA (Care Area Assessment) completion date and care plan completion date was 8/5/2022. Review of Resident 31's Baseline Care Plan dated 7/27/2022 revealed no documentation a written summary was offered to Resident 31 and/or their PR (Personal Representative). The signature line for resident or PR acknowledgement of the baseline care plan was blank. Review of Resident 31's Initial Care Plan revealed a date initiated of 8/05/2022. Review of Resident 31's Progress Notes dated 8/10/2022 revealed the IDT (Interdisciplinary Team-the facility team responsible for the development of the care plan) met for the initial care team meeting with the resident. The Baseline care plan and copy of orders was declined which was 5 days after the completion of the CAA and initial care plan. There was no documentation a written summary of the baseline care plan was offered to Resident 31 or their PR prior to the completion of the initial care plan. B. Review of Resident 46's admission MDS dated [DATE] revealed an admission date of 4/7/22. The CAA completion date and Care Plan completion date was 4/27/22. Review of Resident 46's Baseline Care Plan dated 4/7/22 revealed the resident and representative signature area was blank. Review of Resident 46's Initial Care Plan revealed it was initiated 4/8/22. Review of Resident 46's Baseline Care Plan Acknowledgement Form dated 5/4/22 revealed the baseline and Initial care plan was marked and signed by Resident 46 and their PR on 5/4/22, 7 days after the Care Plan completion date, 27 days after the admission date, and 26 days after the initial care plan was initiated. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 dated October 2019 revealed the care plan completion date (item V0200C2) must be either later than or the same date as the CAA completion date (item V0200B2), but no later than 7 calendar days after the CAA completion date. Review of the facility policy Baseline Care (BCP) Guidelines dated 3/2021 revealed the baseline care plan was to be completed per state guidelines. An IDT member (s) will review the baseline care plan summary with the resident/representative prior to the completion of the Comprehensive Care Plan (7 days from when MDS is signed).

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observation, interview, and record review; the facility failed to ensure Resident 40 was offered pain medication prior to potentially painful procedures. This affected 1 of 1 sampled residents. The facility identified a census of 53 at the time of survey. Findings are: Review of Resident 40's SCSA (Significant Change in Status) MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 8/1/22 revealed an admission date of 12/10/2021. Resident 40 had a BIMS (Brief Interview for Mental Status) score of 15 which indicated Resident 40 was cognitively intact. Resident 40 required extensive assistance from staff with ADLs (Activities of Daily Living including bed mobility, transfer, toilet use, dressing, bathing, and personal hygiene). Resident 40 had an indwelling urinary catheter (a tube inserted into and left in the bladder to drain urine). Resident 40 had pain occasionally rated at a 6 on a 0-10 pain scale, with 10 being the worst pain. Resident 40 had pressure ulcers present that were not present upon admission. Observation of Resident 40 on 9/14/22 at 12:28 PM revealed Resident 40 was lying in bed in their room. RN-F (Registered Nurse) and NA-H (Nurse Aide) were in the room. RN-F reported Resident 40 did not like to lay down due to issues with pain. Resident 40 had a urethral (the tubular passage through which urine is discharged from the bladder to the exterior of the body) urinary catheter. Resident 40's perineum (an area between the thighs that marks the approximate lower boundary of the pelvis and is occupied by the urinary and genital ducts and rectum), urinary meatus (external urinary opening) and groins were very red. RN-F used a wet washcloth to wipe Resident 40's urinary meatus and perineum. The washcloth had a rough surface and Resident 40 hollered out in pain ouch and oh and winced when RN-F wiped Resident 40. RN-F then dried Resident 40's meatus and perineum with a hand towel which also had a rough surface and after RN-F wiped Resident 40, there was bright red bloody drainage on the towel. Resident 40 hollered out in pain and winced when RN-F dried Resident 40's perineum and meatus with the hand towel. NA-H then took pre-moistened wipes and wiped Resident 40's groins. Resident 40 winced every time NA-H wiped Resident 40's groins. Resident 40 was observed writhing and squirming around in bed and complaining of pain while Resident 40 was lying in bed. NA-H then assisted Resident 40 to roll over to their left side in bed and Resident 40 winced and hollered out in pain. There were numerous open areas on Resident 40's coccyx (tailbone) and sacrum (the large, triangle-shaped bone in the lower spine that forms part of the pelvis). RN-F removed a dressing from a package and applied it to the open areas on Resident 40's sacrum and coccyx. RN-F and NA-H assisted Resident 40 to roll back over in bed onto their back and Resident 40 hollered out in pain ouch and oh. MA-Q (Medication Aide) then brought a bottle of nystatin (a medicated powder used to treat rashes caused by yeast) powder and RN-F sprinkled it onto Resident 40's red groin areas. RN-F rubbed the powder onto Resident 40's groin area and Resident 40 hollered out with pain. NA-H revealed Resident 40 did not like to lay down in bed because it caused Resident 40 discomfort. Review of Resident 40's MAR (Medication Administration Record) for September 2022 revealed order for acetaminophen (Tylenol pain reliever) 650 mg at bedtime and every 4 hours as needed for pain. There was no documentation any acetaminophen was administered to Resident 40 for pain before Resident 40 was assisted into bed and catheter care, pressure ulcer care, and perineal care were provided. The last documentation the acetaminophen was administered was at 9:00 PM on 9/13/2022, over 15 hours prior to the procedures. Interview with Resident 40 on 9/15/22 at 9:50 AM revealed Resident 40 did not like to lay down in bed as it caused them pain. Resident 40 revealed it hurt to lay down in bed and they had slept in their recliner for 20 years. Interview with the DON (Director of Nursing) on 9/15/22 at 9:00 AM confirmed Resident 40 did not like to lay down in bed and often refused perineal care which resulted in pressure ulcers and a sore perineal area. The DON revealed the staff should have used a soft wipe instead of the washcloth when they cleaned Resident 40 and they should have offered Resident 40 something for pain prior to the procedure. Review of the facility Skin and Wound Management Standard dated 4/2019 revealed the following: Pain related to pressure ulcers should be consistently assessed and addressed for all residents with pressure ulcers.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, interview, and record review; the facility failed to maintain a medication error rate below 5% with 2 medication errors out of 37 opportunities which resulted in a medication error rate of 5.41%. This affected 2 of 6 residents observed, Residents 25 and 18. The facility identified a census of 53 at the time of survey. Findings are: A. Observation of Resident 25 on 9/14/22 at 9:27 AM revealed LPN-G (Licensed Practical Nurse) prepared medications to administer to Resident 25 via PEG tube (A PEG (percutaneous endoscopic gastrostomy) feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall). LPN-G poured medication into a medication cup to the 10 ml (milliliter) mark on the cup from a bottle labeled acetaminophen 160 mg (milligrams) per 5 ml; administer 10.15 ml (325 mg) per PEG tube TID (three times a day). The medication cup had hash marks every 5 ml after the 10 ml mark and did not have marks to measure .10 ml or .05 ml. LPN-G did not draw up the .15 ml using a syringe after they poured the 10 ml in order to ensure the exact amount of acetaminophen was administered which resulted in 1 medication error. LPN-G then administered the acetaminophen to Resident 25 via PEG tube. B. Observation of Resident 18 on 9/14/22 at 11:16 AM revealed LPN-G dialed 2 units on a Novolog insulin pen holding the pen sideways, pushed the plunger on the pen, then dialed 20 units on the insulin pen. The instructions on the insulin pen read administer 20 units before meals. LPN-G then took the cap off the insulin pen and put a needle on the pen then administered the insulin to Resident 18. LPN-G did not prime the insulin pen after the needle was attached to the insulin pen to ensure it was primed which resulted in 1 medication error for not ensuring the ordered dose of insulin was administered. Review of the facility policy Prefilled Insulin Pen Competency dated 1/2020 revealed the following: Attach the capped needle onto the end of the pen by turning it clockwise until tight. To prime the pen, make sure the arrow is in the center of the dose window. Pull the dose knob out in the direction of the arrow until a 0 is seen. Turn the dose knob clockwise until the number 2 is seen. Hold the pen with the needle pointing straight up, tapping the clear cartridge holder so any air bubbles collect near the top. Push the injection button completely using thumb. Keep pressing and continue to hold the injection button firmly. A stream of insulin should come out the tip of the needle. Interview with the DON (Director of Nursing) on 9/15/22 at 4:23 PM confirmed LPN-G should have attached the needle to the insulin pen before priming to ensure the ordered amount of insulin was administered and LPN-G should have measured the exact amount of acetaminophen liquid.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E LICENSURE REFERENCE NUMBER 175 NAC 12-006.11C Based on observation, interview, and record review; the facility failed to ensure staff served meals to residents in a manner to prevent potential cross-contamination and the facility failed to ensure potentially hazardous foods were cooked to prevent the potential for food-borne illness. This affected 4 residents (Residents 44, 30, 32, and 33). The facility identified a census of 53 at the time of survey. Findings are: A. Observation on 9/12/22 at 11:50 AM revealed DA (Dietary Aid)-E putting a thumb on each plate as the plates were being served. Observation on 9/12/22 at 11:55 AM revealed AD (Activities Director) with a thumb on each dessert plate as the plates were being served. Observation on 9/12/22 at 12:00 PM revealed DC (Dietary Cook)-L with a thumb on each dessert plate as they were being set in the window to be served to the residents. Observation on 9/12/22 at 12:00 PM revealed DC-M with a thumb on each plate as they were being filled with food and then set in the window to be served to the residents. Observation on 9/12/22 at 12:10 PM revealed three coffee cups served with pureed food with straws. No beverages are served to Resident 44. NA (Nursing Assistant)-K was repeatedly touching the end of the straw with an un-gloved hand to place food in Resident 44's mouth. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: 3-301.11 Preventing Contamination by employees 81-2,272.10*(Replaces 2013 Food Code 3-301.11 (B), (C), (D) and (E) Preventing Contamination from Hands). 1. Food employees shall wash hands as specified in the Nebraska Pure Food Act. 2. Food employees shall be trained to wash hands 3. Except when washing fruits and vegetables, food employees shall minimize bare hand and arm contact with exposed food. This may be accomplished with the use of suitable utensils such as deli tissue, spatulas, tongs, single use gloves, or dispensing equipment. 4. Food employees not serving highly susceptible populations may contact exposed ready-to-eat food with their bare hands if they have washed their hand as specified in the act prior to handling the food. B. Observation on 9/12/22 at 9:43 AM of eggs in both refrigerators revealed there were no pasteurized (treated with mild heat to eliminate pathogens and extend shelf life) eggs in the facility. Interview on 09/12/22 at 9:45 AM with the DM (Dietary Manager) revealed there were no pasteurized eggs in the facility at this time. The farm fresh eggs that were in the facility were used for baking and used for the residents sometimes if there is no pasteurized. Observation on 9/13/22 at 8:15 AM revealed Resident #30 had ordered an over-easy egg with bacon and toast and was dipping the toast in the runny egg. Resident #30 ate 100% of the breakfast. Observation on 9/13/22 at 8:15 AM revealed Resident #32 ordered one over-easy egg and toast and was dipping the toast in the runny egg. Resident #32 ate 100% of the breakfast. Observation on 9/13/22 at 8:16 in the kitchen revealed a container full of eggs from the refrigerator sitting next to the stove. The eggs had no pasteurized stamping on them and one had multiple cracks in it. These were the eggs used for the made-to-order eggs for the residents breakfast. Interview on 9/13/22 at 8:30 AM with DC (Dietary Cook)-M confirmed that the eggs used for breakfast were not pasteurized. DC-M stated that the eggs do not have a P stamped on them like pasteurized eggs usually do and the package does not say pasteurized on it. Observation on 9/13/22 at 9:30 Resident #23 had ordered two over-easy soft eggs served with toast, sausage with gravy and oatmeal. Resident #23 ate one egg and everything else that was ordered for breakfast. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food serve sanitation practices, revealed the following: 3-202.13 Shell Eggs A. Egg Products shall be obtained pasteurized. D. Observation on 9/13/22 at 8:10 AM in the facility [NAME] Dining Room revealed that Resident 32 sat at a table. The plate on the table had soft cooked eggs. Resident 32 poked the yoke of an egg with a fork and dipped a half slice of toast into the runny egg yolk and took a bite of the toast. Observation on 9/13/22 at 8:10 AM in the facility [NAME] Dining Room revealed that Resident 30 sat at the table with Resident 32. Resident 30 had a plate with soft cooked eggs on the table in front of the resident. Resident 30 poked the yolk of an egg with a fork and the yoke ran over the white of the egg. Observation on 9/13/22 at 8:33 AM in the [NAME] Dining Room revealed that Resident 32 ate all of the breakfast meal. Observation on 9/13/22 at 8:33 AM in the [NAME] Dining Room revealed that Resident 30 ate all of the breakfast meal. Interview on 9/13/22 at 8:33 AM with Resident 32 confirmed that the resident ate all of the breakfast meal and enjoyed the eggs. Interview on 9/13/22 at 8:33 AM with Resident 30 confirmed that the resident ate all of the breakfast meal. C. Interview with the PDC (People Development Coordinator) who oversaw the dietary department on 9/15/22 at 11:30 AM revealed the facility staff were expected to carry plates of food from the bottom and not touch drinking surfaces of the straws and glasses. The PDC revealed the facility had been having issues with obtaining pasteurized eggs. The PDC confirmed the staff should not have been serving soft cooked/undercooked eggs to the residents that were not pasteurized. Review of the facility policy Proper Ways to Serve Food dated 2008 revealed a diagram showing a thumb on the plate was wrong and carrying a glass, or touching the drinking surface with the hands, and handling utensils by the use surface was wrong. Review of the undated untitled facility policy revealed the following: The purpose of this policy is to ensure all products made and/or served in this facility containing eggs or egg products are made by utilizing proper sanitation, food handling practices, and pasteurized shell eggs or liquid pasteurized eggs to prevent the outbreak of foodborne illnesses. Guidelines: Pasteurized shell eggs or liquid pasteurized eggs will be utilized for requests for undercooked eggs. All unpasteurized eggs will be cooked until yolks and whites are firm.

D. 09/13/22 01:20 PM Observation on 9/13/22 at 1:20 PM revealed Resident #28 was having a dressing change on a small healing pressure ulcer. RN (Registered Nurse)-N was in the room with two aids who were helping to reposition the resident. The aids assisted the resident to roll onto the left side and RN-N applied gloves after doing hand hygiene with ABHS (Anti-Bacterial Hand Sanitizer) and undid the brief on the right side and observed the area on the inner top right buttock. RN-N was interviewed and said the resident came back to the facility with the these skin issues. Rolling the dirty brief on itself and toward the left hip of the resident, RN-N then removed the gloves and did ABHS and donned a new set of gloves and applied Calazinc cream (prevents and relieves skin irritation associated with wet, cracked skin) to the pressure area and removed the gloves then obtained a new brief and opened and applied gloves, rolled, tucked and removed the old brief and replaced it with the new one. RN-N used a wipe over and over to peri area and applied the brief. Both the aids removed their gloves and washed with soap and water and left the room. RN-N removed gloves and emptied the trash then proceeded to wash with soap and water. Observation on 9/13/22 at 1:30 PM revealed NA (Nursing Assistant)-O washed hands for 15 seconds. Observation on 9/13/22 at 1:40 PM revealed RN-N washed hands for 8 seconds. Review of the facility Hand Hygiene Competency dated 12/2019 revealed the following: Hand Hygiene Using Antimicrobial Soap and Water: Check for paper towels before staring the hand hygiene procedure. Turn on the water and wet the hands. Apply the soap. Using friction, rub hands together. Clean under and around nails/jewelry and between fingers. Wash up onto wrists. Lather and rub hands together for a full 20 seconds. While positioning hands lower than wrists, rinse hands well under warm water without touching the inside of the sink or the faucet to hands. (These areas are always considered soiled.) Do not shut off the water. Leave it running. Dry hands well with paper towels. When finished drying hands, discard the paper towel and take a clean paper towel to shut off the water faucet. Discard the paper towel. When to wash hands: Before eating and drinking; before each resident contact, after sneezing, coughing or blowing your nose; after using the restroom; after touching a resident or handling their belongings; whenever hands are soiled; after any contact with body fluids; after handling contaminated items (linens/garbage/briefs, etc.); before and after gloving; whenever indicated. Hand Hygiene Using Hand Sanitizer: When can hand sanitizer be used: Hands should be free of dirt or organic material. If visibly soiled, use soap and water. Duration of entire procedure: 20 to 30 seconds. If carrying hand sanitizer in you pocket, apply sanitizer to your hand then immediately place the bottle back in your pocket with your free hand. Your pocket and the hand sanitizer bottle are considered dirty. Examples: before/after direct contact with resident.; preparing or handling medications; after contact with resident's intact skin; after contact with inanimate objects, such as medical equipment in resident's room or vicinity; after removing gloves or between changing gloves. Procedure; How to Hand Rub: apply a palmful of the product in a cupped hand, covering all surfaces. Rub hands palm to palm. Right palm over left dorsum (back of hand) with interlaced fingers and vice versa. Palm to palm with fingers interlaced. Backs of fingers to opposing palms with fingers interlocked. Rotational rubbing of left thumb clasped in right palm and vice versa. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa. Once dry, your hands are safe. E. Record review of the undated facility document titled Clean Linen revealed that only those with clean hands may access clean linen. Record review of the facility policy titled Hand Hygiene Competency dated 12/2019 revealed the section titled Hand Hygiene Using Hand Sanitizer (alcohol-based hand rub (ABHR)). The section revealed that the duration of the entire procedure is 20-30 seconds. The procedure revealed that a palmful of the product should be applied to the cupped hand. Interview on 9/15/22 at 1:48 PM with the Infection Preventionist (IP) confirmed that the use of hand sanitizer is included in the Hand Hygiene Competency and that staff are expected to follow the steps of the competency. Observation on 9/14/22 at 9:47 AM on the facility [NAME] Hall revealed that Laundry Assistant-B (LA-B) removed a pair of pants on a hanger from the laundry cart. LA-B carried them into the room of Resident 4. LA-B exited the room of Resident 4 and did not 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 among patients and health care personnel). LA-B pulled the laundry cart down the hallway towards the nurse's station. LA-B placed a small amount of alcohol-based hand rub (ABHR) on the tip of the hand and rubbed the hands together for 5 seconds. LA-B removed clothing on hangers and a folded laundry item from inside the laundry cart. LA-B carried the clothing into the room of Resident 45. LA-B exited the room of Resident 45 carrying used empty clothes hangers and hung them on the rack inside of the laundry cart. LA-B did not perform hand hygiene. LA-B removed clothing on hangers and folded laundry from inside of the laundry cart. LA-B carried the clothing into the room of Resident 47. LA-B exited the room of Resident 47 carrying used empty clothes hangers and hung them on the rack inside of the laundry cart. LA-B did not perform hand hygiene. LA-B removed clothing on hangers from inside the laundry cart and carried them into the room of Resident 40. LA-B exited the room of Resident 40 carrying used empty clothes hangers and hung them on the rack inside of the laundry cart. LA-B applied a small amount of ABHR to a hand and rubbed the hands together for 3 seconds. LA-B removed clothing on hangers from inside the laundry cart. LA-B carried the clothing into the room of Resident 32. LA-B exited the room of Resident 32 carrying used empty clothes hangers. LA-B grabbed additional empty used clothes hangers that were on the handrail outside the room of Resident 154. LA-B carried the used empty clothes hangers to the laundry cart and hung them on the rack inside of the laundry cart. LA-B applied ABHR to a hand and rubbed the hands together for 10 seconds. Interview on 9/15/22 at 9:19 AM with the facility Director of Nursing (DON) confirmed that when utilizing alcohol-based hand rub (ABHR) the staff are to place a palmful of the sanitizer on the palm of the hand and wet the entire hands. The DON confirmed that the staff are to rub the hands with the ABHR until dry. The DON confirmed that staff are expected to perform hand hygiene after exiting the resident's room including during laundry delivery. F. Record review of the undated facility document titled Clean Linen revealed that only those with clean hands may access clean linen. Clean linen will be held away from the employee's uniform. Observation on 9/14/22 at 9:47 AM on the [NAME] Hall revealed that Laundry Assistant-B (LA-B) removed a pair of pants on a hanger from the laundry cart. LA-B held the hanger up at head level with the pants resting against LA-B's shirt as LA-B carried them into the room of Resident 4. LA-B exited the room of Resident 4. LA-B pulled the laundry cart down the hallway towards the nurse's station. LA-B removed clothing on hangers and a folded laundry item from inside the laundry cart. LA-B held the folded laundry item against LA-B's shirt. LA-B carried the clothing into the room of Resident 45 with the folded laundry held against LA-B's shirt. LA-B exited the resident's room carrying used empty clothes hangers and hung them on the rack inside of the laundry cart. LA-B removed clothing on hangers and folded laundry from inside of the laundry cart. LA-B carried the clothing into the room of Resident 47 with the folded laundry held against LA-B's shirt. LA-B exited the room of Resident 47 carrying used empty clothes hangers and hung them on the rack inside of the laundry cart. Interview on 9/15/22 at 9:19 AM with the facility Director of Nursing (DON) confirmed that staff are to keep clean laundry from touching their uniform. The DON confirmed that the DON saw the staff delivering laundry with the clean laundry against their uniform. The DON revealed that the DON corrected it. LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D LICENSURE REFERENCE NUMBER 175 NAC 12-006.18C1 Based on observation, interview, and record review; the facility failed to prevent potential cross contamination by failing 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 among patients and health care personnel) for 20 seconds, failing to perform hand hygiene before donning and after doffing gloves during medication administration for 1 of 5 residents observed (Resident 25); failing to perform hand hygiene, change gloves, and cleanse a wound before applying a dressing for 4 of 4 residents observed (Residents 25, 40, 155 and 28); failing to perform hand hygiene and change gloves during catheter care for 1 of 1 residents observed (Resident 40), failing to perform hand hygiene between going in and out of resident rooms which affected 4 residents (Residents 45, 47, 40, and 32); and failing to ensure laundry delivery was conducted to prevent the potential for cross-contamination which affected 3 residents (Residents 4, 45, and 47). The facility identified a census of 53 at the time of survey. Findings are: A. Observation of LPN-G (Licensed Practical Nurse) on 9/14/22 at 9:27 AM revealed they prepared medications to administer to Resident 25 via PEG tube (A PEG (percutaneous endoscopic gastrostomy) feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall). LPN-G crushed each medication and mixed them with water separately. LPN-G had gloves on when LPN-G pushed the pills out of the bubble packs. LPN-G removed the gloves and did not do hand hygiene before LPN-G poured each pill into the pill crusher pouches and poured them into the medication cups. As LPN-G was preparing the medications, LPN-G donned a pair of gloves, removed 1 glove and then put another glove on the same hand without doing hand hygiene in between. LPN-G then put each cup of medication into a bin. LPN-G removed the gloves and did hand hygiene with ABHR (alcohol based hand rub) then took the bin into Resident 25's room and put a paper towel down on the table and put the bin on top of it. LPN-G then went into the bathroom and turned the water on. LPN-G put soap onto their hands from the dispenser on the wall and lathered them for 2 seconds. LPN-G then rubbed their hands together under running water for 20 seconds. The soap was no longer visible after 2 seconds. LPN-G turned the faucet off with a paper towel and donned gloves. Resident 25 was in bed. LPN-G removed the glove from their right hand then without doing hand hygiene, LPN-G used that hand to touch the bed control to raise the bed and head of the bed then LPN-G donned a new glove on that hand without doing any hand hygiene. LPN-G exposed Resident 25's abdomen by pulling the blanket and top sheet down and pulling Resident 25's gown up and handled the PEG tube with the gloved hands. The tube was inserted into Resident 25's abdomen through the skin. LPN-G inserted a 30 ml (milliliter) syringe into the PEG tube and aspirated the stomach contents. LPN-G then put the syringe into the PEG tube port and flushed the tube via gravity with water. LPN-G poured each medication into the tube and flushed the tube with water via gravity in between. LPN-G then poured water into the tube and put the Jevity nutritional formula into the tube, poured more water in and removed the syringe and put the cap into the port. At 9:51 AM, LPN-G removed the gloves and donned a new pair without doing hand hygiene. LPN-G opened a toothette (a stick with a swab sponge on it used to do oral care) and poured some mouthwash into an emesis basin. LPN-G dipped the toothette into the mouthwash and did oral care by swabbing Resident 25's mouth. LPN-G put the basin on the stand and removed their gloves and donned new gloves without doing hand hygiene. The PEG tube dressing supplies were observed lying on the counter of the built in dresser in front of the stereo. LPN-G removed the soiled drain sponge and silver dressing from around the PEG tube site on Resident 25's abdomen. There was serous drainage on the dressings. LPN-G then used the same gloved hands and picked up a gauze sponge off the counter, opened the package, took the sponge out of the package, picked up a bottle of wound cleanser and sprayed the wound cleanser on the sponge and cleaned around the site which LPN-G did twice by handling the bottle of wound cleanser and the gauze sponges with the soiled gloves. LPN-G then got a pair of scissors out of the bathroom and cut the silver dressing after opening the package and taking the dressing out of the package by handling it with the same gloved hands. LPN-G laid the silver dressing on Resident 25's gown. Using the same gloved hands, LPN-G opened a package of cotton swabs, picked up a tube of Calmoseptine (medicated) ointment and squeezed some onto the swabs. LPN-G then swabbed the area around the PEG tube under the flange with the Calmoseptine ointment. LPN-G touched the flange and the PEG tube with the same gloved hands. Using the same gloved hands, LPN-G picked up the dressing off of Resident 25's hospital gown, cut a slit in it with the scissors that were laying on the counter and not on a barrier, and placed it around the PEG tube insertion site in Resident 25's stomach under the flange. Using the same gloved hands LPN-G opened a package of drain sponges, used the same gloved hands to handle the drain sponge and placed it over the silver dressing under the flange of the PEG tube. LPN-G then removed their right glove and held it in their left hand, used the right hand to take a permanent marker out of their pocket, and wrote the date on the drain sponge. LPN-G used the same ungloved hand to reposition the PEG tube and cover Resident 25 up with the blanket/sheet. LPN-G did not do any hand hygiene after LPN-G removed the glove. LPN-G then removed the glove on the left hand and used their right hand to lower the bed by handling the control with their bare hand. LPN-G did not do any hand hygiene after LPN-G removed the other glove. LPN-G then put the opened silver dressing back into the drawer in the bathroom and used their right hand to take a permanent marker out of their pocket and marked on the bottle of Jevity that was sitting on the bathroom counter. LPN-G then went back out into Resident 25's room and picked up the bin with all of the used cups, took it into the bathroom, and rinsed the cups in the sink and put them on a towel in the bathroom. LPN-G then put the bin on the bathroom counter and did not clean it. LPN-G then washed their hands for 10 seconds under running water. There were no paper towels, so LPN-G used one of the hand towels that was on the bar in the bathroom to dry their hands. LPN-G then took the trash out of the can by handling the bag and put it on the floor. LPN-G pulled a trash can liner out of the can and put the towel in it and tied it and laid it on the floor. LPN-G then pulled up a trash can liner with their bare hands, tied a knot in it, and used it to line the trash can. LPN-G used their elbow to open the room door. LPN-G then did hand hygiene with ABHR. LPN-G put on 1 glove and took a disinfectant wipe out of a container on the cart and cleaned the table the medications were on in Resident 25's room but did not clean the scissors or the counter with the dressing supplies on it. LPN-G then removed the glove with the wipe in it and put the same glove back on and took the emesis basin with the mouthwash in it into the bathroom and rinsed it out in the sink. LPN-G then removed the glove, and without doing hand hygiene, took the bottle of Jevity formula off the bathroom counter and put it on top of the treatment cart and took the trash and linen bags out of the room and down the hall. Review of the facility policy Lippincott procedures-Enteral feeding tube exit site care, gastrostomy and jejunostomy dated 9/15/22 revealed the following: Remove and discard your gloves, perform hand hygiene, put on a new pair of gloves. Completing the procedure: Remove and discard your gloves. Perform hand hygiene. B. Observation of Resident 40 on 9/14/22 at 12:28 PM revealed Resident 40 was resting in bed on their back with their pants down. Resident 40 had an indwelling urinary catheter (a tube inserted and left in the bladder to drain urine). RN-F (Registered Nurse) donned gloves and used a wet washcloth to wipe the front of Resident 40's perineum (an area between the thighs that marks the approximate lower boundary of the pelvis and is occupied by the urinary and genital ducts and rectum), including the catheter insertion site at the urinary meatus (external urinary opening). RN-F then removed their gloves and put another pair on. RN-F did not do hand hygiene between glove changes. RN-F then dried Resident 40's perineum with a hand towel and there was blood on it. RN-F took off their gloves and put new ones on without doing any hand hygiene. NA-H (Nurse Aide) assisted Resident 40 to roll over in bed onto their side exposing their backside. RN-F took a Mepilex (a type of dressing) sacral (the large, triangle-shaped bone in the lower spine that forms part of the pelvis) dressing out of the package. Resident 40 had numerous open areas on their sacrum and coccyx (tailbone) and there was thick white paste like cream on the entire area. RN-F did not clean Resident 40's open areas, backside/bottom area or wipe the cream residue off. RN-F put the dressing on over the cream residue and did not wash Resident 40. RN-F took the gloves off and put on a new pair without doing hand hygiene. RN-F and NA-H helped Resident 40 roll back over onto their back. RN-F sprinkled medicated powder onto Resident 40's groin areas. RN-F rubbed the powder onto the groin areas. RN-F removed their gloves and put on a new pair and did not do hand hygiene in between. RN-F and NA-H then put a brief (a type of incontinent product) on Resident 40 and repositioned Resident 40 by touching Resident 40's body and linens. With the same gloved hands, RN-F got a graduate, paper towel, and alcohol wipe out of the bathroom, placed the graduate on the floor on the towel and emptied the catheter bag into the graduate. RN-F wiped the spout before putting the drain tube back into the holder on the catheter bag. RN-F then took the graduate into the bathroom and emptied it. Review of Resident 40's TAR (Treatment Administration Record) for September 2022 revealed documentation the zinc paste and skin barrier had been applied to Resident 40's open areas on buttocks and surrounding skin at 8:00 AM on 9/14/22 and the treatments had been discontinued on 9/14/2022. Review of Resident 40's Progress Notes revealed documentation Resident 40 was treated for a UTI (Urinary Tract Infection) on 3/20/22 when Resident 40 was taken to the hospital emergency room due to abdominal pain, and again on 8/17/22. On 9/14/22, the MD (Medical Doctor) ordered the Sacral Mepilex dressing to buttocks and to discontinue the zinc paste and aloe-vesta cream. On 8/8/22 it was documented the pressure areas on the coccyx showed no improvement. The areas measured: upper right buttock 1.5 cm (centimeters) x (by) 1.7 cm. Under that pressure area there was another area that measured 2.8 cm x 2 cm. On the left buttock there was a .2 cm x .2 cm open area. On 7/6/2022 it was documented Resident 40 had an open area to the right buttock measuring .5 cm x .6 cm. On 4/5/2022 it was documented Resident 40 had a 0.5 x 0.5 cm circular open area to the left buttock. Interview with the DON (Director of Nursing) on 9/15/22 at 9:00 AM revealed the staff should have cleaned the open areas on Resident 40's coccyx and sacrum before applying the dressing. C. Observation of Resident 155 on 9/13/22 at 1:11 PM revealed Resident 155 was resting in bed. MA-I (Medication Aide) and MA-J were in the room and both of them donned gloves. MA-I wiped Resident 155's perineum front side with a pre-moistened wipe. MA-I and MA-J then pulled a brief up over Resident 155's perineum and fastened it. MA-I took the trash out of the can by Resident 155's bed that had the soiled wipes in it and took the trash and the soiled linen into the bathroom. MA-I put the bag of trash onto the bathroom counter next to the sink. MA-I then removed their gloves and washed their hands in the bathroom sink for 7 seconds. MA-I then walked out into Resident 155's room and took a liner out of the trash can and pulled it up in the can. MA-J then went into the bathroom and washed their hands for 7 seconds and used their bare hand to turn off the faucet. MA-J then went out into Resident 155's room and moved Resident 155's eye glasses that were laying on the counter. MA-I put the linen into a trash bag they had taken out of the trash can and tied it. MA-I picked the trash bag up off the bathroom counter and walked out into Resident 155's room with both bags and touched the bed control with the same hands they had used to handle the trash bags and lowered the bed. Interview with the DON on 9/15/22 at 9:02 AM revealed the expectation was for staff to wash hands a full 20 seconds and do hand hygiene before donning and after doffing gloves. The DON revealed the staff should use enough hand sanitizer to completely wet their skin and rub their hands together until dry. The DON revealed gloves were not to be used in place of hand hygiene and should have been changed when they are soiled. Review of the facility Donning and Doffing Competency dated 3/2021 revealed the following. Donning (putting on the equipment): Perform hand hygiene. Put on gloves. Doffing (taking off the gear): Remove gloves. Perform hand hygiene. Review of the facility Hand Hygiene Competency dated 12/2019 revealed the following: Hand Hygiene Using Antimicrobial Soap and Water: Check for paper towels before starting hand hygiene procedure. Turn on water and wet hands. Apply soap. Using friction, rub hands together. Clean under and around nails/jewelry and between fingers. Wash up onto wrists. Lather and rub hands together for a full 20 seconds. While positioning hands lower than wrists, rinse hands well under warm water without touching the inside of the sink or the faucet to hands. (These areas are always considered soiled.) Do not shut off water. Leave it running. Dry hands well with paper towels. When finished drying hands, discard paper towel and use a clean paper towel to shut off water faucet. Discard paper towel. When to wash hands: Before eating and drinking; before each resident contact; after sneezing, coughing or blowing your nose; after using the restroom; after touching a resident or handling their belongings; whenever hands are soiled; after any contact with body fluids; after handling contaminated items (linens/garbage/briefs, etc.); before and after gloving; whenever indicated. Hand Hygiene Using Hand Sanitizer: When can hand sanitizer be used: Hands should be free of dirt or organic material. If visibly soiled, use soap and water. Duration of entire procedure: 20 to 30 seconds. If carrying hand sanitizer in your pocket, apply sanitizer to your hand then immediately place the bottle back in your pocket with your free hand. Your pocket and the hand sanitizer bottle are considered dirty. Examples: before/after direct contact with resident; preparing or handling medications; after contact with resident's intact skin; after contact with inanimate objects, such as medical equipment in resident' room or vicinity; after removing gloves or between changing gloves. Procedure: How to Hand Rub: apply a palmful of the product in a cupped hand, covering all surfaces. Rub hands palm to palm. Right palm over left dorsum (back of hand) with interlaced fingers and vice versa. Palm to palm with fingers interlaced. Backs of fingers to opposing palms with fingers interlocked. Rotational rubbing of left thumb clasped in right palm and vice versa. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa. Once dry, your hands are safe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that staff testing for Covid-19 was completed as required for 3 of 3 sampled staff to prevent the spread of Covid-19. The facility census was 53. Findings are: A. Record review of the facility policy titled Covid-19 Vaccine Mandate Policy and Procedure dated 11/18/21 revealed that the facility will implement additional precautions to mitigate (prevent or reduce) the transmission and spread of Covid-19 for all staff who are not fully vaccinated for Covid-19 including but not limited to: regular testing two times per week. Interview on 9/15/22 at 1:48 PM with the Infection Preventionist (IP) confirmed that the facility follows the Covid-19 Vaccine Mandate Policy and Procedure dated 11/18/21. The IP confirmed that routine Covid-19 testing is performed on staff that are unvaccinated against Covid-19 and staff that are not up to date for Covid-19 vaccination. The IP confirmed that the definition of staff that are not up to date are staff that have not received all of the current recommended Covid-19 boosters. The IP confirmed that the expectation for staff that are unvaccinated against Covid-19 and for staff that are not up to date for Covid-19 vaccination is for them to be tested two times per week. The IP revealed that a staff list is used to monitor that staff are tested as expected for Covid-19. The IP revealed that staff requiring Covid-19 testing know that the scheduled testing for Covid-19 is on Monday and Thursday each week. The IP revealed that the staff requiring Covid-19 testing make sure they come in to test on Monday and Thursday or make sure that they are tested before their next work shift to make sure they are tested two times per week. Record review of the undated Covid-19 Staff Vaccination Status provided by the facility revealed that Dietary Aide-E (DA-E) received the primary Covid-19 vaccination but had not received the recommended booster vaccination. DA-E was not up to date for Covid-19 vaccination. DA-E was required to test for Covid-19 two times per week. Interview on 9/14/22 at 11:32 AM with DA-E confirmed that DA-E was vaccinated for Covid-19 but had not received any Covid-19 booster vaccinations. DA-E confirmed that DA-E was required to test two times per week for Covid-19. DA-E confirmed that DA-E tested positive for Covid-19 on 8/13/22. Record review of the facility [NAME] BinaxNOW Covid-19 Ag Card Internal Controls and Testing Logs (a form for recording test results for Covid-19 point of care rapid tests) dated from 6/30/22 through 9/14/22 revealed that DA-E had no documented testing between 6/30/22 and 7/12/22. DA-E was tested for Covid-19 on 7/12/22 (negative result); 7/14/22 (negative result); 7/21/22 (negative result) (7 days after previous test); 7/28/22 (negative result) (7 days after previous test); 8/1/22 (negative result); 8/4/22 (negative result); and 8/11/22 (negative result) (7 days after previous test). Record review of the undated Timecard for DA-E revealed that between 7/1/22 and 7/11/22 DA-E worked on 7/1/22, 7/2/22, 7/3/22, 7/4/22, 7/5/22, 7/6/22, 7/9/22, 7/10/22, and 7/11/22 and was available for Covid-19 testing. DA-E was not tested for Covid-19 two times per week as required the week of 7/4/22. Record review of the undated Timecard for DA-E revealed that between 7/11/22 and 7/25/22, DA-E worked on 7/11/22, 7/12/22, 7/13/22, 7/14/22, 7/15/22, 7/17/22, 7/19/22, 7/21/22, 7/22/22, 7/23/22, 7/24/22, and 7/25/22 and was available for Covid-19 testing. DA-E was not tested for Covid-19 two times per week as required during the week of 7/18/22. Record review of the undated Timecard for DA-E revealed that between 7/21/22 and 8/1/22 DA-E worked on 7/21/22, 7/22/22, 7/23/22, 7/24/22, 7/25/22, 7/26/22, 7/27/22, and 7/28/22 and was available for Covid-19 testing. DA-E was not tested for Covid-19 two times per week as required during the week of 7/25/22. Record review of the undated Timecard for DA-E revealed that between 8/1/22 and 8/12/22 DA-E worked on 8/5/22, 8/6/22, 8/7/22, 8/10/22, 8/11/22, and 8/12/22 and was available for Covid-19 testing. DA-E was not tested for Covid-19 two times per week as required the week of 8/8/22. Interview on 9/14/22 at 7:36 AM with the Facility Administrator (FA) confirmed that the expectation for staff requiring to be tested for Covid-19 is that they are tested two times per week. B. Record review of the undated Covid-19 Staff Vaccination Status provided by the facility revealed that Medication Aide-D (MA-D) received the primary Covid-19 vaccination but had not received the recommended booster vaccination. MA-D was not up to date for Covid-19 vaccination. MA-D was required to test for Covid-19 two times per week. Interview on 9/14/22 at 11:19 AM with MA-D confirmed that MA-D was vaccinated for Covid-19 but had not received any Covid-19 booster vaccinations. MA-D confirmed that MA-D was to be tested two times per week for Covid-19. MA-D confirmed that MA-D tested positive for Covid-19 at home on 8/20/22. MA-D revealed that MA-D returned to the facility for Covid-19 testing on 8/25/22 and tested positive for Covid-19. Record review of the facility [NAME] BinaxNOW Covid-19 Ag Card Internal Controls and Testing Logs dated from 6/30/22 through 9/14/22 revealed that MA-D was tested for Covid-19 on 7/5/22 (negative result); 7/11/22 (negative result); 7/14/22 (negative result); 7/18/22 (negative result); 7/21/22 (negative result); 7/25/22 (negative result); 8/1/22 (negative result) (7 days after the previous test); 8/5/22 (negative result); 8/11/22 (negative result); 8/15/22 (negative result); 8/18/22 (negative result); 8/25/22 (positive result); 8/28/22 (negative result); 9/9/22 (negative result). Record review of the undated Timecard for MA-D revealed that between 7/4/22 and 7/14/22 MA-D worked on 7/4/22, 7/5/22, 7/6/22, 7/8/22, 7/9/22, 7/10/22, 7/11/22, 7/12/22, 7/13/22, and 7/14/22 and was available for Covid-19 testing. MA-D was not tested for Covid-19 two times per week as required the week of 7/4/22. Record review of the undated Timecard for MA-D revealed that between 7/25/22 and 8/1/22 MA-D worked on 7/27/22 and 7/28/22 and was available for Covid-19 testing. MA-D was not tested for Covid-19 two times per week as required the week of 7/25/22. Record review of the undated Timecard for MA-D revealed that between 8/1/22 and 8/15/22 MA-D worked on 8/1/22, 8/2/22, 8/3/22, 8/5/22, 8/6/22, 8/7/22, 8/8/22, 8/9/22, 8/10/22, 8/12/22, and 8/15/22 and was available for Covid-19 testing. MA-D was not tested for Covid-19 two times per week as required the week of 8/8/22. C. Record review of the undated Covid-19 Staff Vaccination Status provided by the facility revealed that Nursing Assistant-C (NA-C) received the primary Covid-19 vaccination but had not received the recommended booster vaccination. NA-C was not up to date for Covid-19 vaccination. NA-C was required to test for Covid-19 two times per week. Record review of the facility [NAME] BinaxNOW Covid-19 Ag Card Internal Controls and Testing Logs dated from 6/30/22 through 9/14/22 revealed that NA-C was tested for Covid-19 on 6/30/22 (negative result); 7/8/22 (negative result) (8 days after the previous test); 7/14/22 (negative result); 7/19/22 (negative result); 7/21/22 (negative result); 7/25/22 (negative result); 7/28/22 (negative result); 8/1/22 (negative result); 8/2/22 (negative result); 8/8/22 (negative result); 8/19/22 (positive result). 8/22/22 (positive result); 8/25/22 (positive result); and 8/26/22 (negative result). Record review of the undated Timecard for NA-C revealed that between 8/8/22 and 8/19/22 NA-C worked on 8/8/22, 8/9/22, 8/10/22, 8/11/22, and 8/12/22 and was available for Covid-19 testing. NA-C was not tested for Covid-19 two times per week as required the week of 8/8/22.