**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09H Based on observation, interview, and record review, the facility failed to cleanse the resident's wounds prior to applying treatment and failed to cleanse another wound in a circular motion from the center of the wound outward for 1 (Resident 9) of 4 sampled residents. The facility census was 63. Findings are: A record review of the NursingEducation.org's article Nurse Insights: What Are the Best Practices for Wound Care in Nursing? dated 01/18/2024 revealed the best practice for cleaning a wound is to clean around the wound using the prescribed solution. This is done by gently wiping in a circular motion from the center of the wound outward. https://nursingeducation.org/insights/wound-care/ A record review of Resident 9's Clinical Census dated 02/11/2025 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 9's Medical Diagnosis list dated 02/11/2025 revealed the resident had diagnoses of Non-pressure chronic (long term) ulcer (wound) on the right foot, Non-pressure chronic (long term) ulcer (wound) on the left foot, Type 2 Diabetes Mellitus (uncontrolled blood sugar), Abnormal coagulation (blood clotting), and Venous insufficiency (poor blood flow in the veins). A record review of Resident 9's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 12/31/2024 revealed the resident had a Brief Interview for mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15/15 which indicated the resident was cognitively intact. The resident was independent for most activities of daily living (ADLs) except bathing and eating. The resident had diabetic ulcers and was receiving wound care. A record review of Resident 9's Care Plan with an admission date of 11/08/2022 revealed the resident had a focus area for actual impairment to skin integrity (condition of the skin's barrier) and interventions that included to avoid scratching and keep body parts from excessive moisture, educate on causes, encourage good nutrition and hydration, and treatments as ordered by the provider. A record review of Resident 9's Physician's Orders dated 02/11/2025 revealed on 05/01/2024 the provider ordered wound care to the right plantar (sole of the foot). The order was to apply a double layer of Therabond (a [NAME] plated wound dressing) moistened with tap water and cover with Mepilex (a foam absorbent dressing) on Mondays, Wednesdays, and Fridays. Mupirocin (an antibiotic ointment used to treat skin infections) ointment 2 percent (%) ointment, apply to open areas on the legs daily with dressing changes. A record review of the facility's Resident Listing Report dated 12/27/2024 through 01/16/2025 revealed on 01/16/2025 Resident 9 had a right plantar wound that was 1 centimeter (cm) long, 0.8 cm wide, and had no depth. A record review of the facility's Weekly Skin Observation Tool dated 02/07/2025 revealed Resident 9 had a diabetic right plantar wound the was 1.5 cm long, 0.8 cm wide, and had no depth. The wound bed had granulation (reddish connective tissue on the surface of a healing wound). The wound drainage was serosanguinous (thin, watery, pale, red/pink drainage) and there was 25% dressing saturation. The resident was seeing a wound care provider for this wound. In an observation on 02/10/2025 at 12:00 PM revealed Licensed Practical Nurse (LPN)-A performed hand hygiene (cleaning), donned (put on) a gown and gloves, and took a 4 inch by 4 inch (4x4) dressing that was soaked in wound wash and cleansed the right plantar wound by rubbing from toes to mid-foot across the wound multiple times. The observation did not reveal LPN-A used a circular motion specific to the wound when cleansing the right planter wound. LPN-A took a dry 4x4 and rubbed around and between the resident's toes on the right foot, then from toes to mid-foot over the right planter wound to dry the wound. The observation did not reveal LPN-A used a clean, dry, 4x4 when drying the right plantar wound after drying the toes. LPN-A then doffed (removed) gloves, performed hand hygiene, applied new gloves, removed a piece of Therabond that was soaking in a cup of water, folded, applied to the right plantar wound and applied Mepilex over the wound. LPN-A doffed gloves, performed hand hygiene, donned new gloves, applied a small amount of Mupirocin to LPN-A's gloved right fingers, and rubbed across all 5 wounds multiple times on the shin (front part) of the left leg. The observation did not reveal LPN-A treated each of the 5 scabbed wounds separately on the shin of the left lower leg or cleansed prior to Mupirocin being applied. LPN-A then doffed gloves, performed hand hygiene, donned gloves, applied a small amount of Mupirocin LPN-A's gloved right fingers, and applied to a scabbed area on the resident's right medial malleolus (bony projection on each side of the ankle). The observation did not reveal the wound on the right medial malleolus was cleansed prior to the treatment being applied. LPN-A doffed gown and gloves and disposed of all supplies without further concern. In an interview on 02/10/2025 at 12:00 PM, LPN-A confirmed LPN-A did not cleanse the wounds due to the resident had a shower that morning. LPN-A confirmed LPN-A cleansed the right plantar wound in an up and down motion and should have done a circular motion from the center of the wound out. In an interview on 02/10/2025 at 3:47 PM, the Assistant Director of Nursing (ADON) confirmed LPN-A should have cleansed and treated Resident 9's wounds per best practice and should not have dried the wound on the right plantar with the same 4x4 used to dry around the toes.

Based on interview and record review the facility failed to ensure behavior monitoring was completed to support the use of multiple psychotropic medications (drugs that affect the brain and nervous system, influencing mood and behavior) for one (Resident 17) of two sampled residents. The facility identified a census of 63. Findings are: A record review of the facility policy titled Charting (Behaviors) with a last revision date of 1/20 revealed the following guidance related to the documentation of resident behaviors: Procedure: 1. All staff are responsible for the documentation of any observed behaviors. a. Nursing Assistants should document behaviors in the POC (Point of Care) system under the specific resident. b. Nurses and members of the Inter-disciplinary team (IDT) should document daily behaviors in PCC: i. Create a note under the Behavior category. This should include details of the behavior and the attempted interventions, including the outcome of those interventions. 1. New interventions need to be tried and documented. Non-pharmacological interventions should always be tried first. A record review of the admission Record printed on 2/6/25 revealed Resident 17 had been admitted into the facility on 4/19/17 with a primary diagnosis of right above the knee amputation. A record review of the Significant Change Minimum Data Set (MDS, completed when a resident has had an improvement or a decline in 2 areas of activities of daily living (ADL's)) dated 12/13/24, Section C revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 13/15 which indicated Resident 17 was cognitively intact. A record review of the Medication Administration Record (MAR) dated February 2025 revealed Resident 17 was taking the following psychotropic medications that affect mood and behaviors: -Buspirone (a medication used to treat anxiety disorder) 5 milligrams (mg) one tablet by mouth three times daily (TID) for anxiety disorder. -Duloxetine (a medication used to treat depression, anxiety and chronic muscle pain) 60 mg by mouth daily for major depressive disorder. -Lexapro (a medication used to treat depression and anxiety disorder) 20 mg by mouth daily at bedtime for major depressive disorder. -Lamictal (a medication used to treat seizures and bipolar disorder) 100 mg by mouth daily for bipolar disorder. -Ativan (a medication used to treat anxiety and seizure disorders) 1 mg by mouth every bedtime for anxiety. -Ativan 0.5 mg every 6 hours as needed (PRN) for anxiety. A record review of a document titled admission Medication Regimen Review dated 8/29/24 for Resident 17 contained the following guidance: Residents receiving psychoactive medications should have ongoing behavior monitoring, diagnosis, target behaviors identified, and side effect monitoring. Med(s) to be monitored: Buspirone, Lexapro, Ativan, Duloxetine, and Trazadone. A record review of a document titled Note to Attending Physician/Prescriber dated 7/26/24 revealed a request for a dose reduction of the psychotropic medications for Resident 17 was declined by the physician with a note stating no gradual dose reduction (GDR) due to psychiatric instability, which would support the need for monitoring and documentation of behaviors. An interview on 2/6/25 at 2:08 PM with the Assistant Director of Nursing (ADON) revealed that the facility's process related to behavior documentation was that the nurse aides (NAs) would document the behavior in the Point Click Care (PCC), (the facility's electronic medical record system) Task charting (where a check list of behaviors that the staff can choose from is documented along with all Activities of Daily Living (ADL's)) and then were to report the behaviors to the charge nurse to document in the Progress Notes for that resident, to include interventions provided and effectiveness of the interventions. A record review of the Task: Behavior charting covering the prior 30 days (1/12/25 through 2/9/25), revealed Resident 17 had displayed wandering behavior on 1/18/25, 2/1/25, 2/8/25, and 2/9/25, with no correlating Progress Note. An interview on 2/10/25 at 1:22 PM with the ADON, after review of the Task: Behavior charting covering the prior 30 days and the correlating Progress Notes, confirmed that the charting did not relay details of the behaviors to explain what wandering looked like for Resident 17 and did not relay any interventions or redirections provided for Resident 17, and should have. The interview with the ADON also confirmed that the behavior documentation for Resident 17 did not support the use of the 6 psychotropic medications currently being used. An interview on 2/11/25 at 7:00 AM with Medication Aide (MA)-R confirmed that the NA's will document resident behaviors in the PCC Task charting and then report those behaviors to the Charge Nurse to documents further details in the Progress Notes. An interview on 2/11/25 at 7:04 AM with Registered Nurse (RN)-D confirmed that the process related to behavior charting was that the NA's would document the type of behavior displayed in the PCC Task charting and report the behavior to the Charge Nurse to documents further details and interventions in the Progress Notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05(S) Licensure Reference Number 175 NAC 12-006.19(A) Based on observation, interview, and review; the facility failed to ensure that the food and beverages were not served to residents with disposable dishware and cutlery to protect the residents' rights to be treated with dignity and to preserve a homelike environment. This affected the 25 facility residents who received their meals in their rooms. The facility census was 63. Findings are: A record review of the Resident Rights policy, dated 9/2019 revealed the facility would make every effort to assist each resident in exercising their rights to ensure that the resident was always treated with respect, kindness, and dignity. A record review of the facility's Resident Handbook, dated January 2024 revealed Resident Rights were included and the residents had the right to be treated with consideration, respect, dignity, and reasonable accommodation of one's needs and preferences. A record review of the facility's undated Residents who eat in their room list revealed the highlighted residents were residents who ate in their rooms, for a total of 25 residents. The list included residents who resided in room [ROOM NUMBER]-2, 103-2, 105-2, 107-2, 108-2, 109-1, 110-1, 111-1, 113-1, 113-2, 115-2, 202-2, 203-1, 207-1, 207-2, 208-2, 209-1, 209-2, 214-1, 301, 303, 304-2, 307-1, and 311-1. An observation on 02/06/2025 at 12:46 PM revealed room trays were being delivered to residents' rooms with the food and beverages in Styrofoam containers and packs of plastic utensils. An observation on 02/11/2025 at 1:02 PM revealed room trays were being delivered to residents' rooms with the food and beverages in Styrofoam containers and packs of plastic utensils. In an interview on 02/06/2025 at 2:11 PM, the Dietary Manager (DM) confirmed resident room trays were always served in Styrofoam containers. In an interview on 02/10/2025 at 3:47 PM, the facility's Administrator confirmed that food and beverages delivered to the resident's room were served in Styrofoam containers and per the regulation should not have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05(S) Licensure Reference Number 175 NAC 12-006.19(A) Based on observation, interview, and review, the facility failed to ensure that comfortable sound levels were maintained in the facility to protect the residents' right to be treated with consideration, respect, and the choices of the residents. The facility census was 63. Findings are: A record review of the Resident Rights policy dated 9/2019 revealed the facility would make every effort to assist each resident in exercising their rights to ensure that the resident is always treated with respect, kindness, and dignity. A record review of the facility's Resident Handbook dated January 2024 revealed Resident Rights were included and the residents had the right to be treated with consideration, respect, dignity, and reasonable accommodation of one's needs and preferences. A record review of the un-named Resident 36 complaint dated 02/10/2025 revealed the resident was admitted to the facility on [DATE] and around the date of 08/04/2024 the resident complained to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) that Resident 52's music in the lobby was too loud. A record review of the following residents' Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to develop a resident's care plan) revealed: -Resident 52's 11/19/2024 MDS revealed a Brief Interview for mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) of 15/15, which indicated the resident was cognitively intact. -Resident 54's MDS dated [DATE] revealed a BIMS score of 8/15, which indicated the resident had moderately impaired cognition. -Resident 218 did not have a MDS but their 02/09/2025 Skilled Evaluation revealed the resident was alert and oriented x 3. -Resident 31's 12/24/2025 MDS revealed a BIMS score of 15/15, which indicated the resident was cognitively intact. -Resident 58's 11/26/2024 MDS revealed a BIMS of 14/15, which indicated the resident was cognitively intact. -Resident 42's 12/10/2024 MDS revealed a BIMS of 13/15, which indicated the resident was cognitively intact. -Resident 16's 10/22/2024 MDS revealed a BIMS of 13/15, which indicated the resident was cognitively intact. -Resident 36's 10/22/2024 MDS revealed a BIMS of 15/15, which indicated the resident was cognitively intact. An observation on 02/06/2025 from 7:00 AM through 9:53 AM revealed there was very loud music playing that could be heard upon entering the front door of the facility. The music was located in the sitting area across from the nurse's station where all 3 halls came together and could clearly be heard at the far end of all 3 hallways that contained resident rooms. An observation on 02/06/2025 at 7:11 AM revealed the following: -room [ROOM NUMBER] had the door open and a resident sleeping in bed 1. -room [ROOM NUMBER] had the door closed and a resident in bed 1 was trying to sleep. -rooms [ROOM NUMBERS] had the door closed and residents in bed trying to sleep. -room [ROOM NUMBER] had the door open and a resident sleeping in the recliner. -room [ROOM NUMBER] had the door open and a resident in bed 1 attempting to sleep in bed. -room [ROOM NUMBER] had the door closed and a resident was trying to sleep. -room [ROOM NUMBER] had the door open and a resident in bed 2 was trying to sleep. -room [ROOM NUMBER] had the door closed and the residents were trying to sleep. -room [ROOM NUMBER] had the door open and a resident in bed 1 was trying to sleep. -room [ROOM NUMBER] had the door open and a resident in bed 2 was trying to sleep. -rooms [ROOM NUMBER] had the room doors closed and residents trying to sleep. -room [ROOM NUMBER] had the door open and a resident in bed 2 was sleeping. -room [ROOM NUMBER] bed 1 and 2 had residents in bed trying to sleep. -room [ROOM NUMBER] had the door open and a resident in bed 2 had the lights off but was awake. Further observation on 02/06/2025 at 9:53 AM revealed Residents 52 and 54 were in the sitting area across from the nurse's station where all 3 halls came together. Resident 52 was singing with the music into a microphone and Resident 54 was unintelligibly (unable to understand) also singing in the microphone. An observation on 02/10/2025 from 7:05 AM through 9:37 AM revealed there was very loud music playing that could be heard upon entering the front door of the facility. The music was located in the sitting area across from the nurse's station where all 3 halls came together and could clearly be heard at the far end of all 3 hallways which contained resident rooms. At 9:07 AM, Resident 52 had a microphone in hand and was singing to the song. At 9:37 AM, Resident 54 was unintelligibly singing into the microphone. An observation on 02/10/2025 at 7:50 AM revealed the following: -room [ROOM NUMBER]'s door was closed and had a sign on the door that revealed do not disturb. I prefer to be left alone from: 9pm - 8 am. -room [ROOM NUMBER]'s door was open and a resident sleeping in bed 1. -room [ROOM NUMBER]'s door was closed. -room [ROOM NUMBER], 303, and 304 had the doors closed. -room [ROOM NUMBER] had the door closed and the resident laying in bed attempting to sleep. -room [ROOM NUMBER]'s door was closed, and the resident was lying in bed attempting to sleep. -room [ROOM NUMBER]'s door was closed, and the residents were in bed trying to sleep. An observation beginning on 02/11/2025 at 6:48 AM revealed the music in the sitting area was turned to a reasonable level and by 6:56 AM the volume had gradually increased to a very loud level that could be heard at the far end of all 3 halls. At 9:38 AM, Resident 54 was unintelligibly singing in the microphone and 9:42 AM, Resident 52 was singing into the microphone. In an interview 02/06/2025 at 7:21 AM, the Assistant Director of Nursing (ADON) was at the nurse's station and confirmed the music was playing very loudly. The ADON confirmed the resident playing the music was Resident 52 but that Resident 52 does not play the music that loud everyday and that only 1 resident has complained about it. In an interview on 02/06/2025 at 7:55 AM, Resident 218 in room [ROOM NUMBER] confirmed the loud music did bother the resident and the resident had to try and keep the door to their room closed due to the noise. In an interview on 02/06/2025 at 7:57 AM, Resident 31 in room [ROOM NUMBER] confirmed that when the music was that loud in the mornings, it did disturb the resident and made it hard to sleep. In an interview on 02/06/2025 at 8:02 AM, Resident 42 in room [ROOM NUMBER] confirmed the loud music did disturb the resident and the resident could not sleep in due to the noise. In an interview on 02/06/2025 at 8:36 AM, Resident 16 in room [ROOM NUMBER] confirmed their room door was kept closed as soon as their roommate left because the loud music drove this resident nuts. Resident 16 stated they had tried to speak to Resident 52 about it and Resident 52 said the resident can play the music as loud as the resident wants if it was after 6 AM. Resident 16 confirmed Resident 54's singing was horrible. Resident 16 confirmed the resident had talked to the administration about it and nothing had been done about it. Resident 16 confirmed the music would be fine if it were quieter, but it was way too loud. Resident 16 confirmed the resident was unable to keep their room door shut until their roommate, Resident 23, had been gotten up and taken out of the room due to the roommate had seizures and the staff wanted the door left open. In an interview on 02/10/2025 at 9:28 AM, Resident 36 in room [ROOM NUMBER] confirmed the resident wanted to sleep in but the music was too loud, especially when the door was open. The resident confirmed the resident complained about the music noise level to the administration when the resident moved in to the facility and nothing was done about it. The resident confirmed the resident does not like when Resident 54 just yells in the microphone. Resident 36 confirmed the resident just keeps their room door closed and turns up their television to try and drown it out. In an interview on 02/10/2025 at 10:47 AM, the ADON confirmed Resident 36 had complained about the loud music but did not want to complete a grievance form. The ADON was unaware of another resident complaining about the loud music. In an interview on 02/10/2025 at 3:47 PM, the facility's Administrator confirmed that the music was played too loudly early in the mornings.

Licensure Reference Number 175 NAC 12-006.11(E) Licensure Reference Number 175 NAC 12-006.18(B) Based on observation, interview, and record review, the facility failed to ensure the final cooking temperatures (temps) of the food were obtained to prevent the potential for foodborne illness. The facility also failed to ensure the dishwashing machine temps were greater than 120 degrees Fahrenheit (F) during the wash and rinse cycles, the ceiling fan and light covers were free from debris, and food temperatures were taken following microwaving food to prevent the potential for foodborne illness. This had the potential to affect all residents in the facility that consumed food from the kitchen. The facility census was 63. Findings are: In an interview on 02/11/2025 at 2:11 PM, the facility's Administrator confirmed there was only 1 resident in the facility that did not consume (eat) food from the kitchen. A. A record review of the United States Department of Agriculture's (USDA) Safe Minimum Internal Temperature Chart dated 05/11/2020 revealed that safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. [NAME] all food to the following minimum temperatures as measured with a food thermometer before removing food from the heat source. • Beef, Pork, Veal & Lamb Steaks, chops, roasts 145 degrees F • Ground Meats 160 degrees F • Ground Poultry 165 degrees F • Ham, fresh or smoked (uncooked) 145 degrees F • Fully Cooked Ham (to reheat) USDA inspected 140 others 165 degrees F • All Poultry 165 degrees F • Eggs 160 degrees F • Fish & Shellfish 145 degrees F • Leftovers 165 degrees F • Casseroles 165 degrees F https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/safe-temperature-chart A record review of the facility's Steam Table Temperature Log sheets dated 12/09/2024 - 02/09/2025 revealed there was 1 meat, 1 starch, 1 vegetable, and 1 dessert row on the log sheet, it did not reveal areas to record temperatures of the the mechanically altered diets such as puree (blended to a pudding-like consistency) and mechanical soft (blended to a easy to eat consistency). The log sheets did reveal the following: • 12/09/2024 there were no dinner cooking or holding temps recorded. • 12/10/2024 through 12/13/2024 there were no dinner hold temps recorded. • 12/14/2024 through 12/15/2024 there were no cooking or holding temps recorded for any meals. • 12/16/2024 through 12/19/2024 there were no dinner hold temps recorded. • 12/18/2024 there were no lunch holding temps recorded. • 12/20/2024 there were no dinner cooking or holding temps recorded. • 12/21/2024 through 12/22/2024 there were no cooking or holding temps recorded for any meals. • 12/23/2024 through 12/24/2024 there were no dinner cooking or holding temps recorded. • 12/25/2024 through 12/26/2024 there were no cooking or holding temps recorded for any meals. • 12/27/2024 there were no dinner cooking or holding temps recorded. • 12/28/2024 through 12/29/2024 there were no cooking or holding temps recorded for any meals. • 12/30/2024 the only dinner temp recorded was a vegetable cooking temp. • 12/31/2024 there were no lunch holding temp or dinner cooking or holding temps recorded. • 01/01/2025 through 01/03/2025 there were no dinner cooking or holding temps recorded. • 01/04/2025 through 01/05/2025 there were no cooking or holding temps recorded for any meals. • 01/06/2025 there were no dinner holding temps recorded. • 01/07/2025 through 01/08/2025 there were no lunch or dinner holding temps recorded. • 01/09/2025 through 01/10/2025 there were no dinner holding temps recorded. • 01/11/2025 through 01/12/2025 there were no cooking or holding temps recorded for any meals. • 01/13/2025 through 01/17/2025 there were no dinner holding temps recorded. • 01/15/2025 there were no lunch holding temps recorded. • 01/18/2025 through 01/19/2025 there were no cooking or holding temps recorded for any meals. • 01/20/2025 through 01/24/2025 there were no dinner holding temps recorded. • 01/25/2025 through 01/26/2025 there were no cooking or holding temps recorded for any meals. • 01/27/2025 through 01/31/2025 there were no dinner holding temps recorded. • 02/01/2025 through 02/02/2025 there were no cooking or holding temps recorded for any meals. • 02/06/2025 there were no cooking temps recorded. A record review of the facility's undated, un-named menus for 02/02/2024 through 02/15/2025 revealed there was a meat dish prepared for the noon and main meals everyday except the main meal on 02/05/2025 was vegetable chili. An observation on 02/06/2025 from 9:14 AM through 12:38 AM revealed the facility Cook-B prepared the lunch meal that included Beef Stroganoff, Sauteed Zucchini, Noodles, and Pineapple Upside Down Cake. Following the meal preparation, Cook-B pureed the meal items and placed in a small steam pan which was then placed on the steam table, and then blended the mechanical soft and placed in a medium sized steam pan which was then placed on the steam table. The Beef Stroganoff, and the Sauteed Zucchini were removed from the oven and placed on the steam table. The noodles were prepared on the stove in batches through the meal service and dumped in a large steam pan on the steam table. At 11:08 AM Cook-B started plating the food and the Dietary Aides (DA) delivered the food to the residents in the Dining Room. Once the residents in the Dining Room were all served, at 11:58 PM, Cook-B temped the main pan of Beef Stroganoff, Sauteed Zucchini, and Noodles and recorded on the Steam Table Temperature Log. The observation did not reveal final cooking temps were taken from the main menu items, the pureed items, or the mechanical soft items prior to being served to the residents to ensure the food items were at a safe serving temperature. In an interview on 02/06/2024 at 12:00 PM, Cook-B confirmed Cook-B did not check the final cooking temperature of any of the food items prior to being served to the residents and should have. In an interview on 02/06/2025 at 2:11 PM, the Dietary Manager (DM) confirmed that Cook-B should have temped the final cooking temperatures of all food prior to serving the food to the residents to ensure it was safe to consume. B. A record review of the facility's Cleaning (Dishes) policy dated 7/2018 revealed the staff was to check temperature during the dishwashing procedures to determine if wash and rinse temperatures were being maintained and that a wetting agent and chemical sanitizer was being dispensed. A record review of the Jackson Hot Water Sanitizing Upright Door Dishmachine Installation And (&) Operation Manual dated 07/10/2006 for model ES-2000HT INTL, page number 2, revealed the wash minimum temperature was 150 degrees F and the rinse minimum temperature was 180 degrees F. A record review of the undated, un-named ECOLAB sticker on the side of the dish sanitizer revealed Minimum (min) wash temp 120 degrees F, Min rinse temp 120 degrees F, Recommended Incoming water temperature was 140 degrees F. Min chlorine was 50 parts per million (ppm). An observation on 02/06/2025 from 10:20 AM to 12:38 PM revealed Cook-B completed pureed the Pineapple Upside Down Cake in the Robot Coupe blender and used a scoop to put a measured amount in 3 bowls. Cook-A then took the blender container and blade to the 3-campartment sink and sprayed it out. Cook-A placed the container parts and blade on a plastic rack and placed into the dish machine, pressed the button to start, and walked back into the kitchen. The observation revealed the wash temp only reached 78 degrees F, and the rinse temperature only reached 108 degrees F. An observation of the undated, un-named ECOLAB sticker on the side of the dish sanitizer revealed Minimum (min) wash temp 120 degrees F, Min rinse temp 120 degrees F, Recommended Incoming water temperature was 140 degrees F. Min chlorine was 50 parts per million (ppm). Cook-B then returned to the dishwashing room to get the blender parts, washed hands, returned to the food prep area and put the blender together. Cook-B then put 6 scoops of the Sauteed Zucchini in the blender and pureed, then scooped into a medium sized steam pan. Cook-B took the blender container and parts to the dishroom and sprayed out, placed the container and parts on a plastic rack, placed into the dishwasher, started the dishwasher and went back to the kitchen. The observation revealed the wash temp only reached 92 degrees F, and the rinse temperature reached 121 degrees F. An observation on 02/05/2025 at 7:40 AM revealed a sign on the front of the dishwashing machine that revealed: dish machine must be between 120-140. If temp not reading between 120-140 must run machine until it reaches a min of 120. In an interview on 02/06/2025 at 2:11 PM, the DM confirmed that Cook-B should have watched and ensured the dishwashing machine reached a temperature of at least 120 degrees F. C. A record review of the facility's Cleaning & Sanitization policy dated 1/08 revealed the staff would ensure a clean and sanitary environment for the preparation and storage of food by regular cleaning and maintaining kitchen surfaces. An observation on 02/05/2025 at 7:40 AM with the DM revealed the 6 black metal light covers above the drink station of the kitchen with a moderate amount of a gray fuzzy substance on them. An observation on 02/06/2025 at 12:38 PM with the DM revealed the ceiling fan above the dishwashing machine had a moderate amount of a gray fuzzy substance on it and the fan was running. In an interview on 02/05/2025 at 7:40 AM, the DM confirmed the 6 black metal light covers above the drink station of the kitchen with a moderate amount of a gray fuzzy substance on them and they should have been clean. In an interview on 02/06/2025 at 12:38 PM, the DM confirmed the ceiling fan above the dishwashing machine had a moderate amount of a gray fuzzy substance on it and the fan should have been clean. D. A record review of the Nebraska Food Code dated 07/21/2016 revealed Ready to Eat foods that had been processed and packaged in a food processing plant shall be heated to a temperature of at least 135 degrees F. An observation on 2/6/2025 at 11:33 AM revealed Cook-B opened a can of Campbell's soup and poured into a bowl. Cook-F then placed the bowl of soup in the microwave for 1 minute. When the microwave alerted it was done, Cook-B took the bowl of soup out of the microwave and served directly to the Resident 4 without temping the bowl of soup. An observation on 2/6/2025 at 11:41 AM revealed DA-C opened a can of Campbell's soup and poured into a bowl. DA-C then placed the bowl of soup in the microwave for 1 minute. When the microwave alerted it was done, DA-C took the bowl of soup out of the microwave and served directly to the Resident 24 without temping the bowl of soup. In an interview on 02/06/2025 at 12:00 PM, Cook-B confirmed Cook-B and DA-C microwaved soup and delivered directly to residents without temping and should have to ensure the food was safe to eat. In an interview on 02/06/2025 at 2:11 PM, the DM confirmed Cook-B and DA-C should have temped the food after microwaving and before delivering to the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.18B Licensure Reference Number 175 NAC 12-006.18D The facility failed to ensure infection control measures were followed related to lack of signage indicating Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) and the Personal Protective Equipment (PPE) required for cares on Residents 10,15, 24 , and 52, the storage of respiratory equipment for Residents 10, 15, 24, 25 and 52, mask cleaning for Resident 1's PAP, perform hand hygiene between glove changes and wear eye protection during catheter cares on Resident 52, and failed to carry clean linens away from the body to prevent the potential for cross contamination. The facility identified a census of 63. Findings are: A. An interview on 02/06/25 at 10:10 AM with Nurse Aide (NA)-O revealed that residents in EBP were identified by a yellow dot sticker on their name plate outside the room. When questioned how (gender) knew which PPE was to be worn with each resident, NA-O answered, well I know that Resident 15 has a catheter so I would wear a gown and gloves when emptying (gender) catheter. When questioned how visitors know that PPE they need to wear, NA-O was unable to answer this. An interview on 02/06/25 at 10:50 AM with Licensed Practical Nurse (LPN)-P confirmed that EBP signage was not posted in the room and voiced that only the PPE supplies needed to care for that patient were placed into the yellow bag hanging in each EBP room. When questioned how visitors knew what PPE was necessary for resident in EBP, LPN-P voiced that visitors did not come down to resident rooms and visited in the lobby or solarium area. An interview on 2/06/25 at 12:35 PM with the Assistant Director of Nursing (ADON) confirmed that visitors do go to the resident rooms. A record review of the facility policy titled Infection Control (Enhanced Barrier Precautions) dated 5/2024 contained the following guidance: Procedures: 1. Appropriate signage for type of precaution will be posted on room door. B. An observation on 2/06/25 at 10:53 AM revealed NA-O carrying a stack of linens into a resident room while carrying linens up against (gender) body. An interview on 2/06/25 at 10:54 AM with LPN-P confirmed that staff were to carry linens away from their body and not up against their chest. An observation on 2/06/25 at 11:27 AM revealed Medication Aide (MA) -M carrying a stack of linens into a resident room while carrying linens up against (gender) body. An interview on 2/06/25 at 11:27 AM with MA-M confirmed that linens should not be delivered to resident rooms while being held against staff's body. MA-M confirmed that linens where to be carried in a bag and away from the body. An interview on 2/6/25 at 1:21 PM with the facility Assistant Director of Nursing (ADON) confirmed that linens were to be carried away from staff's body and not up against clothing and that EBP signs should be posted in the resident rooms to indicate what PPE should be used with cares. A record review of the facility policy titled Laundry (Linen Pass) with a revision dated of 4/18 revealed it did not contain any guidance related to carrying linens and touching against the body. E) A record of the facility's All Nurses Respiratory Equipment Change/Storage notification dated 2/7/25 revealed oxygen nasal cannulas (a tube that fits in the nose to deliver oxygen), masks on the concentrators (a machine used to purify oxygen), and portable canisters must be rolled up and placed in their bag on the concentrator, or portable on their wheelchair or walker when they are not using them. A record review of Resident 25's Clinical Census dated 02/10/2025 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 25's Medical Diagnosis dated 02/11/2025 revealed the resident had diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Shortness of breath, Obstructive Sleep Apnea (OSA), History of Pneumonia, and Morbid Obesity (severely overweight). A record review of Resident 25's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 12/03/2024 revealed the resident had a Brief Interview for mental Status (BIMS)(a score of a residents cognitive abilities) of 15 which indicated the resident was cognitively aware. The resident required setup or clean-up assistance with eating and oral hygiene (cleaning), partial/moderate assistance with person hygiene, substantial/maximal assistance with upper body dressing, and was dependent on staff for toileting, bathing, lower body dressing, and footwear. The resident was on oxygen therapy while a resident. A record review of Resident 25's Transition Orders And Information For The Continuation Of Patient Care dated 12/30/2021 revealed an oxygen order for 2-4 liter per minute (L/M). An observation on 02/05/2025 at 2:50 PM revealed Resident 25 was not in the resident's room and the oxygen nasal cannula was draped over the concentrator and the prongs that go in the nose were touching the floor. An observation on 02/10/2025 at 11:28 AM with Licensed Practical Nurse (LPN)-A revealed Resident 25's wheelchair was located in the hallway with the oxygen nasal cannula draped over the arm of the wheelchair and the nasal prongs that go in the resident's nose were touching the tire and wheel of the wheelchair 1 inch from the floor. There was a bag that the nasal cannula should have been placed in attached to the handle of the wheelchair. In an interview on 02/10/2025 at 11:28 AM, LPN-A confirmed Resident 25's nasal cannula was draped over the arm and touching the wheel and tire of the wheelchair and should not have been. C) Record review of Resident 52's admission record dated 2/6/25 revealed admission was 10/6/22. Observation on 2/5/25 at 3:06 PM revealed Resident 52's catheter tubing had slight cloudy urine. Record review of Resident 52's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 11/29/24 revealed: -Section C: BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) was 15. -Section G: Maximum assist with toileting hygiene. -Section H: indwelling catheter Record review of Resident 52's Physician Orders dated 2/10/25 revealed: -Change suprapubic catheter every 30 days. -Acetic Acid Solution 0.25 %, use as directed to flush suprapubic catheter as needed, flush liquid 60 milliliters saline as needed. -Bacitracin ointment 500/gram, apply topically to suprapubic site twice daily. Record review of Resident 52's Medical diagnosis dated 2/6/25 revealed: Pyuria, Obstructive and Reflux uropathy, Poor urinary stream, Personal history of (corrected) Hypospadias, and Retention of urine. Observation on 2/10/25 at 10:22 AM with RN-D performing suprapubic (SP) catheter cares with Resident #52. RN-D donned gown and 3 pairs of gloves without washing hands prior. RN-D removed the old SP catheter dressing. RN-D then removed the top pair of gloves and threw into trash without hand hygiene. RN-D cleansed SP catheter insertion site with an alcohol wipe, then wiped the skin surrounding the catheter where the tape and dressing was with a skin prep. RN-D removed the top set of gloves, then donned another pair over the top of the existing pair and applied Bacitracin ointment 500 gram at SP catheter site. RN-D applied a split gauze around catheter tubing and secured with paper tape. RN-D took off top pair of gloves and put on a new pair of gloves with no hand hygiene. RN-D cleansed the catheter tubing that was exposed with alcohol wipes from outside of the new dressing. RN-D removed the top gloves and flushed the catheter with Acetic Acid Solution 0.25%. RN-D did not wear goggles or a face shield during the catheter flush. RN-D attached the catheter to the catheter strap and doffed gloves. RN-D performed hand hygiene x 20 seconds. Interview with Resident 52 on 2/10/25 at 10:34 AM revealed that the staff do not clean the catheter tubing very often. Interview on 2/10/25 at 11:00 AM with the Assistant Director of Nursing confirmed that the RN should have cleaned the catheter tubing prior to applying the dressing, wear only 1 pair of gloves at a time, change gloves and preform hand hygiene when removing the gloves, and to wear goggles/shield when flushing the catheter. Record review of Indwelling Catheter Policy dated 1/20 revealed: Sunrise will assist each individual admitted to this facility with the right to become involved in their own care and to provide the services to reach their highest possible practicable, physical and psychosocial level they so choose. And indwelling catheter is not used unless there is valid medical justification for catheterization and the catheter is to be discontinued as soon as clinically warranted. Because of the risk of substantial complications with the use of indwelling urinary catheters, they should be reserved primarily for short term decompression of acute urinary retention. Sunrise Country Manor will refer the Lippincott Manual for insertion, ongoing care and removal protocols. protocols. Record review of Hand Hygiene Policy undated revealed: -Wet hands with water; -Apply enough soap to cover all hand surfaces; -Rub hands palm to palm; -Write palm over left dorsum 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; -Rinse hands with water; -Dry hands thoroughly with a single use towel; -Used towel to turn off faucet; -Your hands are now safe. Your 5 moments for hand hygiene: -Before touching a patient. -Before clean/aseptic procedure. -After body fluid exposure risk. -After touching a patient. -After touching patient surroundings. Hand hygiene and medical glove use: -The use of gloves does not replace the need for cleaning your hands. -Hand hygiene must be performed when appropriate, regardless of the indication for glove use. -Remove gloves to perform hand hygiene, when an indication occurs while wearing gloves. -Discard gloves after each task and clean your hands. Gloves may carry germs. -Wear gloves only when indicated according to standard and contact precautions; otherwise they become a major risk for germ transmission. Record review of Enhanced Barrier Precautions education dated 1/14/25 revealed: -Used for anyone with (MDRO's) colonized multidrug resistant organisms. -Used with anyone who has a device: central line, urinary catheter, feeding tube, tracheostomy. -Between standard and contact precautions. Use only when performing high contact resident care. -Includes perform hand hygiene and includes a gown and gloves with high contact care delivery. -Dressing, showering, transferring, providing hygiene, changing linens, changing briefs or toileting. Record review of Infection Control (Precautions) Policy dated/revised 4/24 revealed: -It is the policy of Sunrise Country Manor to provide a safe and sanitary environment for residents, visitors and employees. Standard precautions will be practiced by all staff and should be used for all resident cares at all times. Sunrise Country Manor follows the guidance for Standard and Transmission-based precautions and intensified interventions as recommended by the APIC manual Infection Preventionist guide to long term care, as well as by the Centers for Disease Control. -Standard Precautions are Based on the principle that blood, all body fluids and secretions, excretions, (not including sweat), non-intact skin or lesions, and mucous membranes may contain transmissible infectious organisms. Standard precautions included hand hygiene and use of gloves, gown, mask and eye protection or face shield, depending on the anticipated exposure. Refer to the Facilities Policy on Personal protective Equipment. Standard precautions also include safe injection practices. -Hand Hygiene: Perform hand hygiene with soap and water when hands are visibly soiled. Unless hands are visibly soiled, an alcohol based hand rub is preferred over soap and water in most clinical situations. Refer to visual guidance provided by World Health Organization on how to hand rub or how to hand wash and how to hand wash. Clean your hands using an alcohol based hand rub or wash. With soap and water for the following clinical indications: -Before and after having direct contact with the patient (taking a pulse or blood pressure, performing physical examination, lifting the patient in bed). -Before performing an aseptic task. Example placing an indwelling device or handling invasive medical devices. -Before moving from work on a soiled body site to a clean body site on the same patient. -After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings or contaminated surfaces. -If hands will be moving from a contaminated body site to a clean body site during patient care. -Immediately after glove removal. Gloves: For contact with blood, body fluids, secretions, excretions, and contaminated items; for touching mucous membranes or non-intact skin: for contact with intact skin when infection risks are identified. 3. Change gloves during patient care if the gloves will move from a contaminated body site example peroneal area to a clean body site example face. 4. Remove gloves after contact with a patient and or the surrounding environment. Including medical equipment using proper technique to prevent hand contamination. Mask Rye Protection and Face Shields: During procedures likely to generate splashes or sprays of Blood or body fluids or the splatter of debris. D) Record review of Resident 1's admission records dated 2/6/25 admission was 12/9/22. Interview with Resident 1 on 2/5/25 at 12:50 PM revealed that resident changes the oxygen (O2) when [gender] thinks it needs changed. Resident 1 stated the CPAP (Continuous Positive Airway Pressure -a treatment that uses mild air pressure to keep your breathing airways open) mask it is not cleaned much. Record review of Resident 1's Physician Orders dated 2/10/25 revealed: -Weekly CPAP/Bi-Level/Auto PAP cleaning, hand wash mask, nasal pillows, and tubing with dawn dish soap and water, Rinse thoroughly, air dry. -Oxygen 3 Liters, titrate with activity to keep sats above 90%. -Oxygen nasal cannula/mask, replace nasal cannula/mask weekly -Oxygen tubing, replace oxygen tubing every 28 days. -Daily CPAP/Bi-level/auto pap cleaning, wipe mask with damp cloth to remove debris. Empty chamber, fill chamber with soapy warm water and shake vigorously, rinse, air dry. - Distilled water add distilled water per manufacture recommendations to BiPAP and humidifier. Record review of Resident 1's Medical diagnosis dated 2/6/25 revealed: Chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, chronic diastolic (congestive) heart failure, and obstructive sleep apnea. Record review of Resident 1's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 11/12/24 revealed: -Section C: BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) was 15. - Behavior present for inattention. -Section E: delusions, rejection of care 4 to 6 days. -Section G: dependent for oral hygiene and toileting hygiene -moderate assist with bathing -independent with upper body dressing, lower body dressing, footwear, personal hygiene, repositioning and transfers. -Section O: O2, Non-invasive Mechanical Ventilator Observation on 2/5/25 at 12:50 PM Resident 1's O2 concentrator revealed: 4 liters and the O2 tubing is not dated. O2 tubing that is in an open sack on top of the concentrator dated 1/2024. The CPAP mask was lying on the bed unused, and had many whitish specks of debris inside the mask and the outside of the mask has yellow-light tannish hard debris on the plastic of the mask. The CPAP tubing was light yellowish approximately 10 inches down the tubing from the mask. The O2 tubing that resident 1 is using is hardened from the cannula to around the ears. Observation on 2/6/25 at 9:20 AM Resident 1's O2 concentrator revealed: 4 liters and the O2 tubing is not dated. O2 tubing that is in an open sack on top of the concentrator dated 1/2024. The CPAP mask was lying on the bed unused, and had many whitish specks of debris inside the mask and the outside of the mask has yellow-light tannish hard debris on the plastic of the mask. The CPAP tubing was light yellowish approximately 10 inches down the tubing from the mask. The O2 tubing that resident 1 is using is hardened from the cannula to around the ears. Interview on 2/6/25 at 10:45 AM with RN-D confirmed that the inside of CPAP mask had whitish dry substance, and the outside has yellow-light tannish debris on the plastic mold of mask and approximately 10 inches of tubing from the mask was light yellow. The O2 tubing was hard from nares to around ears and I will change it. RN-D said the CPAP gets cleaned weekly on night shift and we should be wiping it clean every day, and I didn't. Interview on 2/6/25 at 11:20 AM with the Assistant Director of Nursing revealed that the staff should be cleaning the CPAP mask every day and weekly cleaning with soap and water, CPAP mask must be placed in a storage bag, date the O2 tubing, and change the O2 cannula weekly. Record review of Respiratory Care Policy dated 2/20 revealed: Respiratory care service at Sunrise Country Manor (i.e. oxygen therapy, breathing exercises, CPAP/BiPAP, nebulizers/metered dose inhalers, tracheostomy cares) will be provided with a physician's order consistent with professional standards of practice. -Cleaning Schedule: Mask, nasal pillows, and tubing-wipe daily with damp cloth or alcohol-free mask wipe. Headgear, mask, and tubing - wash weekly in a mixture of warm water and small amount of liquid dishwashing detergent or baby shampoo. Rinse thoroughly, air dry and reassemble. Documentation received titled All Nursing Staff- Oxygen, CPAP/BiPAP, Nebulizers dated 5/1/24 revealed: -If a resident wears oxygen continuously, when you get them up in the morning, after you complete their morning cares, have the med aide or the nurse unhook their tubing from the concentrator and roll it up or hook it up to the portable. -If the resident does not wear the oxygen continuously, take the cannula/mask off and roll it up and put the cannula/mask/tubing in the oxygen storage bag that is attached to the oxygen concentrator. Turn the oxygen concentrator off. -If you walk into their room, and their oxygen tubing is not in the oxygen storage bag, please roll it up and place it in the bag. -The CPAP/BiPAP mask must be placed in the storage bag. -Date tubing's on oxygen, and nebulizers when changed.

Licensure Reference Number 175 NAC 12-006.09D2b Based on record review, observation, and interview; the facility failed to monitor a pressure ulcer for 1 (Resident 4) of 3 sampled residents. The facility staff identified a census of 61. Findings are: Record review of Resident 4's face sheet revealed the resident admitted to the facility 11/30/2020. Record review of a late entry progress note for Resident 4 by Registered Nurse (RN)-J revealed the following Late entry for 2/24, treatment completed to right leg lotion applied, noticed a large piece of lose dry skin hanging from the heal. assessing the area there is a 5 cm x 5 cm purple mushy area on his heal. Applied a merplix to protect the heal. Fax to MD and skin assessment done today. Record review of a fax cover sheet dated 2/26/2024 to Resident 4's practitioner revealed Resident 4 Has a fluid filled area 5.0 Centimeters (CM) X 5.0 CM to the right heel, Possible Pressure related. The facility staff requested a treatment order for the right heel. Record review of a returned fax with the sent date of 2/26/24 revealed the Family Nurse Practitioner (FNP) signed the requested order and faxed back to the facility on 3/26/24. The order was received 30 days after the Resident 4 initially had a fluid filled blister identified on the right heel. Record review of Resident 4's Braden score (is a standardized, evidence-based assessment tool commonly used in health care to assess and document a resident's risk for developing pressure injuries) assessed on 2/26/24 revealed the score was 15. A Braden score of 15 is considered a moderate risk for potentially developing a pressure wound. Record review of Resident 4's Advanced Practice Registered Nurse-H's (APRN-H) encounter dated 4/18/2024 revealed Resident 4 had the right heel pressure ulcer listed as a stage 3 (STAGE III Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed.) The APRN-H assessed the measurements as L: (Length) 2.0 cm (Centimeters), W: (Width) 2.0 cm, D: (Depth) 0.1 cm. The ARPN described the wound with 100% granulation tissue (Granulation tissue is new connective tissue and microscopic blood vessels that form on the surface of a wound during the healing process) and moderate (Serosanguineous) sero/sang drainage with an odor. Record review of an encounter sheet for Resident 4 dated 5/9/2024 by APRN-H revealed the measurements for the right heel were L: 3.2 cm by W:3.2 cm, D: 0.1 cm, and granulation tissue is 25% with slough (dead tissue, cream or yellow in color) at 75% of the wound bed. The drainage from the wound was documented as moderate sero/sang with an odor, and peri wound (the area around the wound) as macerated (softening and breakdown of the skin as a result of prolonged exposure to moisture). The encounter sheet dated 4/18-2024 revealed Resident 4's APRN-H identified evidence of infection and wound status as having decline. Record review of a fax cover sheet for Resident 4 dated 5/16/24 reveled APRN-H diagnosed Resident 4 with a wound infection and to start Metronidazole (an anti-biotic medication) 500 milligrams (mg) ,twice a day for 7 days. Observation on 5/21/24 at 7:15 AM of dressing change to Resident 4's right heel completed by Registered Nurse-E (RN-E) revealed RN-E removed the dressing. Further observation revealed the dressing was saturated with sero/sang fluid. The area around the wound was macerated and approximate measurements were 3.0 CM by 3.0 CM. RN-E completed the dressing change as ordered to Resident 4's right heel. Interview on 5/21/24 at 11:30 AM was conducted with the Director of Nursing (DON). During the interview the DON verified there were not measurements for Resident 4's right heel wound from 4/18-5/9/24. The DON revealed the staff nurses should measure the wounds weekly when they are completing the weekly skin observation. The DON confirmed that the facility was not following the skin policy and procedure. The DON confirms the wound deteriorated when the wound nurse did not round at the facility. Interview on 5/21/24 at 11:30 AM with the Assistant Director of Nursing (ADON) revealed that the nurse's taking care of the Resident 4, should have been measuring the wound and notifying the practitioner if the wound was declining. The ADON confirms the wound deteriorated when the wound nurse did not round at the facility. Interview on 5/21/24 with Licensed Practical Nurse-F (LPN-F) reveals that LPN-F rounded with the wound nurse weekly. LPN-F verified the wound nurse had not been at the facility between 4/19-5/8/24. LPN-F confirmed the wound deteriorated when the wound nurse did not round at the facility. Record review of the facility's skin policy and procedure dated 1/20 reveled that residents will receive care consistent with professional standards of practice, to prevent pressure ulcers and do not develop pressure ulcers unless clinically unavoidable. Resident with pressure ulcers will receive necessary treatments and services to promote healing, prevent infection and prevent new ulcers from developing. Procedure of this policy confirms that the nursing staff will follow procedures if skin integrity issues that are noted. The nursing staff will obtain measurements for each skin integrity issue, update the responsible party, update the provider, and obtain orders.

Licensure Reference Number 175 NAC 12-006.18 Based on observation, interview and record review; the facility failed to maintain equipment and personal property in good condition as evidenced by: dried light beige-colored streaks on top of and down the front of a dresser, dried light beige-colored areas on the base of a tube feeding pole, and grey substance build up on a bed side tray, suction machine, nebulizer machine and CD player for 1 (Resident 6) of 1 sampled residents. The facility census was 66. Findings are: An observation on 3/28/24 at 8:06 AM of Resident 6's room revealed the following: dried light beige-colored streaks on top of and down the front of a dresser, dried light beige-colored areas on the base of the tube feeding pole, and grey substance build up on a bed side tray, suction machine, nebulizer machine and CD player. An observation on 4/1/24 at 8:52 AM of Resident 6's room revealed the following: dried light beige-colored streaks on top of and down the front of a dresser, dried light beige-colored areas on the base of the tube feeding pole, and grey substance build up on a bed side tray, suction machine, nebulizer machine and CD player. Review of the paper titled Resident 6 Tube Feeding, undated, revealed that nurses are to wipe off the TF (tube feeding) pump and pole with disinfecting wipes when the TF/water bag is changed. In an interview on 4/1/24 at 8:38 AM with Nursing Assistant (NA)-A revealed that housekeeping is to clean the dresser and dust the bed side tray, suction machine, nebulizer machine and CD player and nurses are to clean the tube feeding pole. NA-A confirmed the presence of the dried light beige-colored streaks on top of and down the front of a dresser, dried light beige-colored areas on the base of the tube feeding pole, and the grey substance build up on a bed side tray, suction machine, nebulizer machine and CD player. In an interview on 4/01/24 at 8:40 AM with Licensed Practical Nurse (LPN)-B confirmed that nurses are to clean the tube feeding pole and it had not been cleaned. In an interview on 4/1/24 at 8:46 AM with Housekeeper (HSKP)-C revealed that there is no set schedule or documentation for when resident rooms are to be cleaned. HSKP-C confirmed the presence of light beige-colored streaks on top of and down the front of the dresser and the dust on the bed side tray, suction machine, nebulizer machine and CD player. HSKP-C further confirmed that the dresser, bed side tray, suction machine, nebulizer machine and CD player had not been cleaned recently. In an interview on 4/1/24 at 12:54 PM the Assistant Director of Nursing (ADON) confirmed that there is no policy regarding the cleaning of personal property or equipment.

**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 (MI), Intellectual or Developmental Disabilities (IDD) or condition related to Intellectual or Developmental Disabilities (RC) as defined by Medicaid) for 1 (Resident 7) of 1 sampled resident. The facility census was 66. Findings are: Review of Resident 7's admission record revealed that [gender] admitted to the facility on [DATE]. Review of Resident 7's PASARR Level 2 Outcome-Notification of NF (nursing facility), dated 4/4/17, revealed that Resident 7 met the PASARR criteria for a Level 2 evaluation for MI. Review of Resident 7's Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care), dated 11/14/23, revealed that the question at A1500: 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 Resident Assessment Instrument (RAI) Manual v1.17.1, dated October 2019, 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 4/2/24 at 10:17 AM the MDS Coordinator confirmed that the question at A1500 should have been marked yes due to Resident 7 having a MI. An interview on 4/2/24 at 12:01 PM the Assistant Director of Nursing confirmed that the facility had no policy related to coding of the MDS.

Licensure Reference Number 175 NAC 12-006.09A Based on record review and interview; the facility failed to ensure a new 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 (MI), Intellectual or Developmental Disabilities (IDD) or condition related to Intellectual or Developmental Disabilities (RC) as defined by Medicaid) screen was completed related to a new mental health diagnosis for 1 (Resident 59) of 1 sampled resident. The facility census was 66. Findings are: Review of Resident 59's admission Record, dated 3/27/24, revealed a new diagnosis of Unspecified Psychosis not due to a Substance or known Physiological Condition (a mental disorder characterized by a disconnection from reality with an unknown cause) was added on 10/10/23. Review of Resident 59's PASARR-Notice of Level 1 Screening Outcome, dated 3/30/23, revealed that Resident 59 had no signs of serious MI, IDD, or a related condition and that no further clinical review or onsite evaluation was needed. Review of Resident 59's electronic health record (EHR) revealed no other completed PASARR screens. An interview on 3/28/24 at 4:00 PM, the Business Office Manager (BOM) confirmed that a Level 2 PASARR screen should have been completed and had not been after the new mental health diagnosis was added on 10/10/23. An interview on 4/1/24 at 12:58 PM the Assistant Director of Nursing (ADON) revealed that there is no policy regarding when a new PASARR screen should be completed. The ADON confirmed that there should be new PASARR screen completed when a new mental health diagnosis is added to a resident's diagnosis list.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.09C 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 reflected the care needs of Resident 2. This affected 1 of 1 sampled resident. The facility census was 66. Findings are: A record review of Resident 2's Face Sheet, dated 4/1/24, revealed that Resident 2 admitted on [DATE]. A review of Resident 2's diagnosis list, dated 4/1/24 revealed the following diagnoses: Chronic Diastolic (congestive) Heart Failure (when the left ventricle of the heart stiffens and cannot relax properly between heartbeats, preventing the heart from filling with blood between beats), Chronic Obstructive Pulmonary Disease (a group of lung conditions that damage the airways and make it hard to breathe), Chronic Respiratory Failure with Hypoxia (when there is not enough oxygen in the blood stream), and Obstructive Sleep Apnea (Adult) (when the throat muscles relax and block the airway). A review of Resident 2's Minimum Data Set (MDS-a federally mandated assessment tool that measures the health, cognitive, psychosocial, and functional status of nursing home residents. The MDS used by a nursing home to identify problems and determine qualification of Medicare and Medicaid benefit) dated 2/2/24 revealed that the resident required oxygen therapy. A review on 4/1/24 1:45 PM of Resident 2 CCP, dated 12/23/23, revealed no resident centered respiratory care plan. An interview with the Assistant Director of Nursing (ADON) on 4/1/24 at 1:56 PM confirmed that there was not a respiratory care plan in place for Resident 2 and should have been. Is there a policy on Care Plans?

Licensure Reference Number 175 NAC 12-006.04C2 Based on interview and record review; the facility failed to ensure a Registered Nurse (RN) was present in the facility for at least 8 consecutive hours on 3/9/24 and 3/24/24, which had the potential to affect all residents. The facility census was 66. Findings are: Review of the nursing schedule, dated 3/9/24, revealed that there was no RN present in the facility for at least 8 consecutive hours. Review of the nursing schedule, dated 3/24/24, revealed that there was no RN present in the facility for at least 8 consecutive hours. In an interview on 4/2/24 at 11:55 the Assistant Director of Nursing (ADON) confirmed that there was no RN present in the facility for at least 8 consecutive hours and that there should have been one.

Licensure Reference Number 175 NAC 12-006.12E7 Based on observations, interview and record review, the facility failed to ensure multiuse medications were appropriately labeled with the date opened in accordance with currently accepted professional principles for 2 (Resident 9 and 61) of 4 sampled residents. The facility census was 66. Findings are: A review of the facilities Pharmacy and Medication Policy and Procedure dated 3/18/18 revealed there is no instruction regarding dating and initialing opened multiuse medications. An observation on 4/1/24 at 8:18 AM of hallway 100 medication cart revealed the following: -An undated open bottle of Novolog insulin (a rapid acting insulin that helps to lower blood sugar) for Resident 9 An interview on 4/1/24 at 8:59 AM with Registered Nurse (RN)-K confirmed that all multiuse medications are to be dated when opened, and Resident 9s' insulin was not and should have been. An observation on 4/1/24 at 8:36 AM of hallway 200 medication cart revealed the following: -An undated open bottle of eye drops for Resident 61 An interview on 4/1/24 at 8:48 AM, Medication Aide (MA)-J confirmed that all multiuse medications are to be dated when opened, and Resident 61's eye drops were not and should have been. An interview on 4/1/24 at 12:59 PM, the Assistant Director of Nursing (ADON) confirmed that all multiuse medications are to be dated when opened. Do we know when it was last delivered? Did the medication specify it needed an open date or when to discard the medication after opening? Was thes medications administered to the residnet?

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** D. A record review of the facility's Equipment Sanitation (Oxygen) policy dated 5/23 revealed that the staff should wipe off oxygen concentrators with a clean damp cloth for cleansing, replace oxygen cannula and masks weekly and replace oxygen tubing once per month. A record review of facility's Respiratory Care policy dated 10/13 revealed that the facility will follow the guidelines provided by vendor Northwest Respiratory Service regarding use and cleaning of CPAP/BIPAP (Continuous Positive Airway Pressure/Bilevel (varied) Positive Airway Pressure) (a machine that is used to treat sleep apnea or obstructive sleep apnea) equipment. The following information was revealed in the Northwest Respiratory Service Manual referenced on page 27, labeled Cleaning your CPAP/Bi-Level Equipment: cleaning of the CPAP/BIPAP mask should be completed daily with damp cloth or alcohol wipe. Also, that weekly mask and tubing cleaning of headgear, mask and tubing with soap and water then air dry. A record review of facility's Respiratory Care policy dated 10/13 revealed that the facility will follow the guidelines provided by vendor Northwest Respiratory Service regarding use and cleaning of nebulizer (a medication delivery device that produces a fine mist for inhalation into lungs) equipment. The following information was found in the Northwest Respiratory Service Manual on page 22 and labeled Cleaning Your Nebulizer: the nebulizer should be disassembled and rinsed with warm water daily and then after allowing to air dry. A weekly disinfection of the nebulizer is to be completed with 1:3-part white distilled vinegar to water, and every 2 weeks the nebulizer is to be replaced with a new one. A record review of Resident 2's Face Sheet, dated 4/1/24, revealed that Resident 2 admitted on [DATE]. A review of Resident 2's Physician Orders dated 3/28/24 revealed the following: replace nebulizer set weekly, label new set with the date every Friday night shift, cleanse nebulizer and rinse after each use, replace oxygen nasal cannula weekly, and oxygen tubing every 28 days. A review of March 2024 Treatment Administration Record (TAR) revealed on 3/22/24 the nebulizer was not replaced due to equipment not available, and that nebulizer cleaning was not on the TAR. Further review revealed that there was no mention of the CPAP or the cleaning schedule on the TAR. An observation on 3/27/24 at 9:46 AM of Resident 2's room revealed: the nebulizer treatment equipment was without a date of last change marked, the mask was discovered with debris, the CPAP tubing and mask had a yellowish tint and debris covering the coils on the inside of the tubing, and the water reservoir was empty with brownish film on the inside. An observation 03/28/24 on 10:46 AM of Resident 2's room revealed: the nebulizer treatment equipment remained undated. The nebulizer mask continued to have debris, and the CPAP tubing as well as mask have a yellowish tint and debris lining the coils on the inside of the tubing. The water reservoir remained empty with brownish film on the inside of the container. A bottle of distilled water dated 11/14 was found located on the floor in front of the bedside table. An interview on 3/28/24 at 10:48 AM, Resident 2 revealed that the resident puts the CPAP on without assistance from staff at night, as well as throughout the day. Resident 2 also revealed that the CPAP tubing and mask had not been changed since before admission date. An observation on 4/1/24 at 10:00 AM of Resident 2's room revealed that the nebulizer tubing was dated and initialed, the CPAP tubing and mask continued to have debris on inner part of tubing and the tubing was a discolored yellowish appearance. The mask had a smeared, oily substance on the inside of the mask. The water reservoir on the CPAP machine was dry with a brownish film on the inside. An interview on 4/1/24 at 10:15 AM, the ADON confirmed the discoloration and debris in Resident 2's CPAP tubing, and that all the respiratory supplies should be cleaned, changed, and dated per policy. An interview on 04/01/24 at 10:25 AM, the DON confirmed that there was no mention of Resident 2's CPAP cleaning on the TAR. Licensure Reference Number 175 NAC 12-006.09D6(7), 175 NAC 12-006.17B, 175 NAC 12-006.17D Based on observation, record review and interview; the facility failed to perform hand hygiene upon entering resident's room, after emptying a used bed pan, before setting up resident's meal tray in room, and prior to exiting the resident's room for Resident 3 and failed to ensure cleaning and storage of respiratory equipment was done in a manner to prevent potential cross-contamination for Resident 2, Resident 13, and Resident 19. The facility census was 66. How many sampled? Findings are: A. An observation on 3/28/2024 at 1:08 PM in Resident 3's room revealed NA-D (Nursing Assistant) knock and enter the resident's room with lunch meal in hands. NA-D put the food down on the resident's bedside table, put gloves on, and removed a used bed pan from the resident's bed and emptied it in the bathroom. NA-D came out of the bathroom, removed [gender] gloves and put new gloves on and proceeded to set up the resident's lunch directly on her bed per resident's request. NA-D was headed to the door and asked the resident if she was good and removed [gender] gloves. NA-D took some used Styrofoam cups off her bedside table and emptied them in the bathroom sink, turned the light on and left the room. Observed NA-D go into the hopper room (a separate room to dispose of dirty items and clean dirty equipment) to dispose of the cups and came out of the hopper room and picked up another room tray off a medication cart and delivered to another resident's room and set their meal up for them. NA-D then went to the dining room. No hand hygiene was observed to be performed during this time. An interview on 3/28/2024 at 1:18 PM with NA-D when asked of when [gender] would perform hand hygiene, NA-D revealed as [gender] looked down the hallway and said after the bed pan was emptied before setting the resident's lunch up and after removing dirty gloves. NA-D also confirmed that hand hygiene should have been done when entering the resident's room and prior to leaving the room as there was increased risk of cross contamination when other tasks were completed without doing any hand hygiene. An interview on 3/28/2024 at 1:20 PM with the ADON (Assistant Director of Nursing) revealed NA-D should have performed hand hygiene upon entering the resident's room, after emptying the used bed pan before setting up the resident's lunch and upon exiting the resident's room. The ADON further confirmed that hand hygiene needs to be performed any time gloves are removed and was not done and should have been done. ADON further revealed there was no specific policies for hand hygiene and glove usage, but does have policies for Nursing Assistant Procedures. A record review of the facility policy Nursing Assistant Procedures last revised 4/2018 which had attached procedures from the Nebraska Health Care Association dated 2019 revealed how to wash hands, how to change gloves, and how to handle soiled equipment. Review of the handwashing procedure states to rub all surfaces of the hands continuously for at least 20 seconds, rinse, and dry hands. Review of the procedure for handling soiled equipment stated to wash and dry hands thoroughly, apply gloves, hold, and carry soiled equipment away from clothing, clean soiled equipment (bedpan, urinal, etc.) with cold water and appropriate disinfectant per facility policy, remove gloves and dispose in proper container, wash and dry hands thoroughly, and return cleaned equipment to appropriate storage area. There was no information on when to perform hand hygiene or when to exchange gloves. B. A record review of the document titled admission Record printed on 3/28/24 revealed that the facility had admitted Resident 13 on 6/19/20 with a primary diagnosis of a TBI (Traumatic Brain Injury). A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 2/22/24, Section C revealed no 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 for Resident 13. The record review revealed Section C did contain the following questions related to cognitive patterns: C0700 Seems or appears to recall after 5 minutes with an answer of 1. Memory problem. C1000 Made decisions regarding tasks of daily life with an answer of 3. Severely impaired. An observation on 03/27/24 at 8:31 AM revealed Resident 13 was noted to have a bag hanging on the oxygen (o2) concentrator (which is a machine that takes air from your surroundings, extract oxygen and filter it into a purified oxygen for you to breathe) which was next to the heater and the bag was melted down one side. The observation revealed o2 tubing attached to the portable tank on the w/c (wheelchair) was not stored in the bag attached to the w/c. The nasal cannula (a device that delivers oxygen throught a tube and into your nose) was noted to be touching the outside of the bag and was not being used to store the oxygen tubing which was attached to the portable tank. The observation revealed a bag of candy in the bag provided for oxygen tubing storage. An observation on 3/28/24 at 10:37 AM revealed Resident 13 to be sitting in the hallway outside of the dining room and did not have oxygen on. When asked why (gender) did not have o2 on, the facility Administrator then directed MA-G to retrieve Resident 13's nasal cannula from (gender) room. MA-G returned with oxygen tubing and allowed the connector (the piece of oxygen tubing that connects to either the oxygen conentrator or portable tank) end to fall onto the floor while applying the cannula and then connected the connector end that had touched the floor to the portable tank. An observation on 3/28/24 at 10:46 AM revealed Resident 13's oxygen tubing which was still connected to the concentrator was being stored in the melted bag. An interview with RN-H on 3/28/24 at 10:47 AM after observation of the tubing attached to Resident 13's concentrator, confirmed the bag had melted and tubing was still being stored in the melted bag and confirmed that the bag should be changed. The interview with RN-H confirmed that the facility policy was to change oxygen tubing once weekly and store in the blue bag on the back of the wheelchair and the clear bag attached to the concentrators. A record review of the facility policy titled Equipment Sanitation (Oxygen) dated 2/20, reads as follows: Care of Cannula/Mask: Replace cannula/mask weekly. Care of tubing: Replace oxygen tubing once per month. C. A record review of the document title admission Record printed on 3/28/24 revealed Resident 19 had been admitted into the facility on 3/9/18 with a primary diagnosis of Bacteremia (bacteria in the blood) and a secondary diagnosis of acute and chronic respiratroy failure (an acute exacerbation or decompensation of chronic respiratory failure recognized by worsening symptoms and increasing treatment needs). A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 1/30/24, Section C revealed no 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 for Resident 19. The record review revealed Section C did contain the following questions related to cognitive patterns: C0700 Seems or appears to recall after 5 minutes with an answer of 1. Memory problem. C1000 Made decisions regarding tasks of daily life with an answer of 1. Modified independence - some difficulty in new situations only. An observation on 03/27/24 at 2:50 PM revealed Resident 19's CPAP (continuous positive airway pressure - a machine that provides air at a pressure just high enough to prevent the collapse of your airway, often used to treat sleep apnea) mask to be attached to the tubing and draped over the nightstand, no bag present for storage of the mask and the mask was noted to be lying face down touching the nightstand. An observation on 03/28/24 at 8:56 AM revealed Resident 19's CPAP on nightstand, undated, with the mask still attached to tubing and resting face down touching the nightstand. An interview on 03/28/24 at 10:55 AM with RN-H when questioned regarding process for respiratory equipment cleaning and storage, voiced I wiped out (gender) CPAP mask with one of theses this morning, pointing to a container of disinfectant wipes. When asked if the equipment was taken apart, cleaned and dried, RN-H voiced night shift is to clean/soak them. During an interview on 03/28/24 at 10:55 AM with RN-H present, Resident 19 voiced that the CPAP mask had not been cleaned or soaked on the night shift. An observation on 04/01/24 at 2:19 PM revealed Resident 19's CPAP mask to still be attached to the tubing and draped over nightstand with face mask touching the nightstand. An interview with LPN-I on 04/01/24 at 2:19 PM after an observation of the CPAP equipment confirmed that Resident 19's CPAP mask and tubing was not being stored per facility expectations. LPN-I further confirmed that the mask and tubing was to be stored in a bag. A record review of the facility policy titled Respiratory Care and dated 10/13, regarding the cleaning and storage of respiratory equipment, revealed it follows the guidance from Northwest Respiratory (the respiratory supply vendor for the facility) which was on pages 27-28 of the Northwest Respiratory Services guide provided to the facility: -Northwest Respiratory Services guide, page 27, titled Cleaning your CPAP/Bi-Level Equipment read as follows: Daily Cleaning 2. Wipe the portion of the mask that comes in contact with your skin with a damp cloth or alcohol-free wipe. This removes most skin oil from the mask. 3. Empty any remaining water from the humidifier chamber. 4. Fill the chamber with soapy water and shake vigorously. 5. Rinse the chamber with clean water. 6. Air dry. The record review of the undated Northwest Respiratory Services guide, page 27, titled Cleaning your CPAP/Bi-Level Equipment revealed it did not contain guidance related to the storage of equipment once cleaned.

C. Review of Resident 59's Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care), dated 3/5/24, revealed the following: -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 3 indicating the resident was severly cognitively impaired. -a diagnosis of Dementia without Behavioral Disturbance (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). -is independent with eating An observation on 3/28/24 at 8:03 AM revealed Resident 59 sitting on [gender] bed with a bed side tray placed in front of [gender] with Styrofoam container on it. Resident 59 opened the container and revealed meatloaf, sweet potatoes and a mix of carrots, cauliflower, and broccoli inside it. An interview on 3/28/24 at 8:03 AM Resident 59 confirmed that it was meatloaf, sweet potatoes and a mix of cauliflower, carrots and broccoli in the Styrofoam container. An interview on 3/28/24 at 8:17 AM with Medication Aide (MA)-J revealed that the Styrofoam container contained the meal from the previous evening. MA-J confirmed that the container should not have been on Resident 59's bed side tray still. Review of the facility policy, Dining (Room Trays), dated 1/2020, revealed the following: -3. The nursing assistant is expected to monitor room trays by returning to the resident's room in a timely manner to check on the resident. Licensure Reference Number175 NAC 12-006.11E Based on observation, interview and record review, the facility failed to prevent the potential for food borne illness related to low dishwasher temps. This had the potential to affect 65 of 66 residents who receive food from the kitchen. The facility failed to monitor remvoal of room trays this affected Resident 59. The facility identified a census of 66. Findings are: An observation on 03/27/24 at 07:45 AM revealed that facility dishwasher was a hot water and chemical sanitization system. The observation revealed a dishwasher temperature for the wash cycle that read 100 degrees F. The observation revealed that the face of the temperature dial on the dishwasher read 120 degrees F. The observation revealed a rinse temperature of 110 degrees F. The observation of the dishwasher temperatures during the wash and the rinse cycles was observed and verified by the CDM and confirmed to not be meeting sanitization requirements on 03/27/24 at 7:55 AM. An observation on 3/27/24 at 2:10 PM, accompanied by Cook-B, revealed a dishwasher temperature of 110 degrees on the wash cycle and 130 degrees on the rinse cycle. An interview on 3/27/24 at 2:10 PM with the CDM, confirmed that the facility had had no food borne illnesses within the facility. During the observation on 3/27/24 at 2:10 PM, Cook-B, reported that the DM had placed a call to ECO-Lab (a company that provide services systems that specialize in treatment, purification, cleaning, and hygiene of water sanitization appliances). A second run of the dishwasher wash cycle revealed a temperature of 118 degrees F. An interview on 3/27/24 at 3:10 PM the CDM revealed that Eco-Lab had been in the building and stated that the booster to the dishwasher was throwing error codes and that the booster had been reset. A record review of the document titled ECOLAB, Extra Service Request dated 3/27/24 at 3:51 PM revealed the following information: -Request Description: not reaching temperature. -Service Comments: Reset booster heater and consistently started getting the right temperature. An observation on 3/28/24 at 9:55 PM accompanied by the CDM, revealed a dishwasher temperature of 110 degrees on the wash cycle and 120 degrees on the rinse cycle after 2 cycles runs. An observation on 4/1/24 at 10:48 AM, during meal preparation with Cook-F, revealed a dishwasher temp of 120 degrees during the wash cycle and 138 degrees during the rinse cycle. The observation on 4/1/24 at 10:48 AM, revealed a sign taped onto the dishwasher directing all staff to run the dishwashing cycle two times to ensure it met required temperatures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 175 NAC 12-006.09D3(5) Based on record review and interview, the facility failed to assess and treat Resident 67 for constipation. This affected 1 of 1 sampled residents for constipation. The facility census was 65. Findings are: A review of Resident 67's Electronic Health Record (EHR) revealed that the resident was admitted on [DATE] and had diagnoses of Slow Transit Constipation (waste moves through the large intestine more slowly than usual, leading to constipation) and Diverticulosis (a condition in which there are small pouches or pockets in the wall or lining of any portion of the digestive tract, which can lead to constipation.) Record review of Resident 67's active Physician's Orders as of 5/11/23 revealed the following orders for bowel medications: - Docusate Sodium (a stool softener) 100 mg (milligrams) tablets, 1 tablet by mouth in the evening, and 2 tablets by mouth in the morning. - Polyethylene glycol (a laxative) powder, mix 17 gm (gram) in 4 ounces juice/water and take by mouth daily. - Bisacodyl (a laxative) 10 mg suppository (a form of medication given rectally) on day 2 of no bowel movement (BM), insert 1 suppository rectally as needed for constipation. - Enema Ready To Use (a type of medication given rectally to stimulate a BM) on day 3 of no BM, use 1 enema rectally as needed for constipation. - Milk of Magnesia (MOM-a laxative) on day 1 of no BM 30 mL (milliliters) by mouth as needed for constipation. A review of Resident 67's documentation of bowel BM consistency from 4/17/23 to 5/16/23 revealed the resident had no BMs charted for 4/17, 4/18, 4/24 through 4/28 (5 days), 5/1, 5/3 through 5/8 (6 days), 5/6, and 5/11 through 5/16/23 at 4:23 AM (6 days). A review of the resident's Medication Administration Record (MAR) for 4/23 revealed the resident was not documented as receiving any of the as needed bowel medications from 4/24 through 4/28. A review of the resident's MAR for May 2023 printed 5/15/23 revealed the resident had not received any of the as needed bowel medications from 5/3 through 5/8, and from 5/11 through the morning of 5/15. A review of the facility's Bowel Care Policy last approved 1/20 revealed the following: -If the resident has as needed bowel care orders, follow as prescribed. -If the resident has not had a bowel movement in 2 full days, by the morning of the 4th day, by the evening of the 4th day, and by morning of the 5th day, a bowel assessment should be performed. During the initial interview with Resident 67 on 5/10/23 at 1:05 PM, the resident revealed that sometimes they go long enough between BMs that it is painful. During an interview on 05/16/23 at 2:37 PM the Director of Nursing (DON) confirmed that no as needed bowel medications had been given from 4/24 through 4/28, from 5/3 through 5/8, and from 5/11 through the time of the interview. The DON further confirmed that there was no documentation that bowel assessments had been done per the facility's policy.

175 NAC 12-006.11D Based on observations and interviews, the facility failed to ensure food was palatable which affected 4 residents (Resident 15, Resident 33, Resident 37, Resident 53) of 4 sampled residents who eat in their room. The facility census was 65. Findings are: Interview on 5/10/23 at 11:31 AM, Resident 15 revealed the room trays were delivered in Styrofoam containers and were not hot. Resident 15 revealed the food felt refrigerator like temperatures. Interview on 5/10/23 at 12:05 PM, Resident 33 revealed when the room tray is delivered the food is cold. Interview on 5/10/23 at 2:26 PM, Resident 37 revealed the food is terrible and cold when the food is delivered to Resident 37 in their room. Interview on 5/10/23 at 2:43 PM Resident 53 revealed the food is cold when they eat in their room and the flavor is hit and miss. A review of the Diet Type Report provided by the facility and printed 5/8/23 revealed that there are 3 residents who do not take anything in by mouth. Observation of test tray provided by facility on 5/15/23 at 12:55 PM revealed that the test tray was brought to the conference room by the Dietary Manager (DM) in a Styrofoam container after all resident room trays were delivered. Food temperatures were obtained by the DM using the facility's thermometer as follows: -Sloppy Joes were 131.7 degrees F. -French fries were 116 degrees F. Interview on 5/15/23 at 12:55 PM, the DM confirmed that the French fries and Sloppy Joes were not at a high enough temperature. On 5/15/23 at 1:00 PM, a taste test revealed that the French fries were cold, and the Sloppy Joes were cold and bland. Interview on 5/15/23 at 1:10 PM, the DM confirmed that the Sloppy Joes were bland.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on observation, interview and record review, the facility failed to ensure sufficient staffing to respond to call lights in a timely manner. The sample size was 5. The facility census was 64. FINDINGS ARE: During a record review of the facility grievance reports titled Customer Complaint Written Response and dated 11/2/22, Resident 6 had complained about the weekend call light response time being long. An interview with the facility Administrator on 1/4/22 at 10:02 AM revealed that the facility was unable to run a call light log due to the system being old. The Administrator revealed that the call light response times were monitored by audits and reviewing the cameras if needed. During the interview, when requesting to view the call light audits, the Administrator revealed the facility didn't have any call light audits. A record review of the call light audits received from the facility Social Worker (SW) revealed a call light audit had been completed one time monthly for the last 6 months. During an interview on 1/4/22 at 01:26 PM with Resident 4 and roommate Resident 5, both residents voiced experiencing long call light response times and Resident 5 voiced it's pretty slow and it depends on who is working and if it is shift change. During the interview, Resident 5 then turned on the call light and voiced just watch, the time was 01:31 PM. The interview with Residents 4 and 5 on 1/4/22 revealed that no staff had entered the room to respond to the call light as of 02:09 PM. A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 12/27/22, section C revealed Resident 4 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) of 11. A record review of the MDS dated [DATE], section C revealed Resident 5 had a BIMS score of 12. An interview on 1/4/23 at 02:29 PM with Resident 7 revealed feeling that call light response times vary and are bad during the nighttime. Resident 7 voiced it depends upon who is working and voiced (gender) had spoken with the SW regarding the call light response times. A record review of the MDS dated [DATE], section C revealed Resident 7 had a BIMS score of 15.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.12 LICENSURE REFERENCE NUMBER 175 NAC 12-006.12A Based on observation and record review, the facility failed to ensure medications were available to residents when ordered. The sample size was 5. The facility census was 64. FINDINGS ARE: A. An observation on 1/4/23 at 08:55 AM of a morning medication pass completed by Medication Aide (MA)-D, while administering medications to Resident 4, revealed 2 medications were unavailable to give. MA-D revealed that Resident 4's Lexapro (an antidepressant medication) and Torsemide (a medication used to reduce extra fluid in the body caused by conditions such as heart failure, kidney disease, and can lessen symptoms such as shortness of breath) were not available to give to the resident. A record review of the admission record dated 12/20/22 for Resident 4, revealed the following diagnoses's present upon admission; Major Depressive Disorder, Essential Hypertension, Atherosclerotic Heart Disease and Shortness of Breath. During an interview on 1/4/23 at 08:55 AM with MA-D, it was revealed that the Lexapro for Resident 4 had been re-ordered but had not come in yet and the Torsemide had not been re-ordered yet. A record review of the MAR dated December 2022 revealed that on December 20, 2022 the following medications had been listed as med unavailable and not given to Resident 4; -Levothyroxine (a thyroid supplement) -Genteal drops (eye drops used for dry, burning eyes) -Dorzolamide drops (eye drops used to treat increased pressure in the eye -Flonase (a nose spray used to treat allergy symptoms) -Mirapex (a medication used to improve the ability to move and decrease shakiness) -Midodrine (a medication used to treat low blood pressure when standing) -Metoprolol (a medication used to treat high blood pressure) -Eliquis (a prescription blood thinner) -Seroquel (a medication used to treat certain mental/mood disorders) -Latanoprost (an eye drop used to decreased the pressure of the eye) A record review of the MAR dated December 2022 revealed that on December 21, 2022 the following medications had been listed as med unavailable and not given to Resident 4; - Dorzolamide drops -Flonase -Genteal -Latanoprost A record review of the MAR dated December 2022 revealed that on December 22, 2022 the following medications had been listed as med unavailable and not given to Resident 4; -Dorzolamide drops (AM and PM doses) -Flonase -Genteal -Latanoprost -Spiriva (a medication used to open the airways and aide in better breathing) A record review of the MAR dated December 2022 revealed that on December 23, 2022, the following medications had been listed as med unavailable and not given to Resident 4; -Spiriva (a medication used to open the airways and aide in better breathing) A record review of the MAR dated December 2022 revealed that on December 26, 2022 the following medications had been listed as med unavailable and not given to Resident 4; -Dorzolamide drops A record review of the MAR dated January 2023 revealed that on 1/3/23 the following medications had been listed as med unavailable and not given to Resident 4; -Dorzolamide drops -Flonase -Genteal -Seroquel -Spiriva B. During an interview on 1/4/23 at 09:17 AM while observing a medication pass for Resident 3, completed by MA-E, MA-E revealed that medications were often unavailable and that it was not uncommon. A record review of the admission record dated 08/09/2021 for Resident 3, revealed the following diagnoses's present upon admission; Paranoid Schizophrenia (a mental disorder), Diabetes Mellitus, Hyperlipidemia, Heart Disease, Pneumonia, Anxiety Disorder, Hypertension and Prostate neoplasm. A record review of the MAR dated January 2023 revealed that on 1/1/23 the following medication had been listed as med unavailable and not given to Resident 3; -Victoza (an injectable medication used to treat high blood sugars) A record review of the MAR dated January 2023 revealed that on 1/2/23 the following medication had been listed as med unavailable and not given to Resident 3; -Glipizide (a medication used to lower blood sugars) A record review of the MAR dated January 2023 revealed that on 1/3/23 the following medications had been listed as med unavailable and not given to Resident 3; -Glipizide -Victoza -Hydrocort (an oral medication used to treat a number of different conditions, such as inflammation, severe allergies, adrenal problems, arthritis, asthma, breathing problems and cancer) A record review of the MAR dated December 2022 revealed that on 12/30/22 the following medication had been listed as med unavailable and not given to Resident 3; -Perphenazine (a medication used for treatment of behavior problems in older adults with dementia). A record review of the MAR dated December 2022 revealed that on 12/31/22 the following medication had been listed as med unavailable and not given to Resident 3; Perphenazine A record review of the MAR dated October 2022 revealed that on 10/11/22 the following medication had been listed as med unavailable and not given to Resident 3; -Hydrocort A record review of the MAR dated October 2022 revealed that on 10/14/22 the following medication had been listed as med unavailable and not given to Resident 3; -Seroquel C. During a record review of the facility grievance reports titled Customer Complaint Written Response and dated 12/31/22, revealed that Resident 7 had complained that the scheduled Melatonin (an over-the-counter medication that aides in sleep) had been signed out as being given but had not been given. A record review of the Medication Administration Record (MAR) dated December 2022 revealed that on December 01, 2022 the following medications had been listed as med unavailable and not given to Resident 7; -Atorvastatin (a medication used to treat high cholesterol) A record review of the MAR dated December 2022 revealed that on December 06, 2022 the following medications had been listed as med unavailable and not given to Resident 7; -Zanaflex (used to treat muscle spasms) A record review of the MAR dated December 2022 revealed that on December 11, 2022 the following medications had been listed as med unavailable and not given to Resident 7; -Miralax (used to treat constipation) A record review of the MAR dated December 2022 revealed that on December 26, 2022 the following medications had been listed as med unavailable and not given to Resident 7; -Linzess (a medication used to treat Irritable Bowel Syndrome) A record review of the MAR dated November 2022 revealed that on 11/30/22 the following medications had been listed as med unavailable and not given to Resident 7; Zanaflex A record review of the MAR dated November 2022 revealed that on 11/25/22 and 11/26/22 the following medications had been listed as med unavailable and not given to Resident 7; -Dakins solution (used to prevent and treat skin infections) A record review of the MAR dated October 2022 revealed that on 10/18/22 the following medications had been listed as med unavailable and not given to Resident 7; -Linzess A record review of the MAR dated November 2022 revealed that on 11/30/22 the following medications had been listed as med unavailable and not given to Resident 7; -Nystatin (used to treat fungal infections of the skin) AM and PM doses E. A record review of the admission record dated 03/01/2022 for Resident 1, revealed the following diagnoses's present upon admission; Disorientation, Unspecified Mood Disorder, Hypertension, Dementia with Behavioral Disturbances, Bipolar Disease, Unspecified Psychosis, Aortic Valve Stenosis, and Anxiety Disorder. A record review of the MAR dated January 2023 revealed that on 1/1/23 the following medications had been listed as med unavailable and not given to Resident 1; -Atorvastatin (a medication used to lower bad cholesterol) -Seroquel -Haldol (used to treat certain mental/mood disorders) -Hydroxyz HCL (an antihistamine medication which also helps control anxiety) A record review of the MAR dated December 2022 revealed that on 12/5/22 the following medications had been listed as med unavailable and not given to Resident 1; -Aspirin A record review of the MAR dated December 2022 revealed that on 12/9/22 the following medications had been listed as med unavailable and not given to Resident 1; -Zyprexa (used to treat certain mental/mood conditions such as schizophrenia and bipolar disorder) A record review of the MAR dated December 2022 revealed that on 12/12/22 and 12/13/22 the following medications had been listed as med unavailable and not given to Resident 1; -Aricept (used to treat confusion, Dementia and Alzheimer's Disease) A record review of the MAR dated December 2022 revealed that on 12/30/22 the following medications had been listed as med unavailable and not given to Resident 1; -Haldol A record review of the MAR dated December 2022 revealed that on 12/18/22, 12/19/22, 12/30/22 and 12/31/22, the following medications had been listed as med unavailable and not given to Resident 1; -Hydro/APAP (a narcotic medication used to treat severe pain) A record review of the MAR dated November 2022 revealed that on 11/14/22 the following medications had been listed as med unavailable and not given to Resident 1; Trazadone (a medication used to treat depression and decrease anxiety and insomnia) -Zyprexa A record review of the MAR dated November 2022 revealed that on 11/22/22 the following medications had been listed as med unavailable and not given to Resident 1; -Lexapro A record review of the MAR dated November 2022 revealed that on 11/23/22 the following medications had been listed as med unavailable and not given to Resident 1; -Lexapro -Vitamin D -Atorvastatin