Licensure Reference Number 175 NAC 12-006.05(D) Licensure Reference Number 175 NAC 12-006.05(E) Based on record review and interview the facility failed to ensure that the resident/resident representative was informed of the risks, benefits, and alternative treatments for the use of antipsychotic medication (any medication that affects behavior, mood, thoughts, or perception used to manage psychotic disorders) as required for 2 of 2 residents reviewed (Residents 59 and 42). The facility census was 62. Findings are: A. Record review of the facility policy titled Antipsychotic Medication Use dated March 2015 revealed that antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional, psychiatric, social, and environmental causes of behavioral symptoms have been identified and addressed. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. Record review of the Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) dated 4/2/25 for Resident 59 revealed that Resident 59 admitted into the facility on 3/26/25. The MDS revealed that Resident 59 had a Brief Interview for Mental Status (BIMS, a brief screening tool that aids in detecting cognitive impairment) score of 7/15 indicating that the cognitive function of Resident 59 was severely impaired. The MDS revealed that Resident 59 received antipsychotic medications since admission. Record review of the Order Summary (a listing of all current physician orders for the resident) dated 6/26/25 for Resident 59 revealed an order for Seroquel 100 milligrams (an antipsychotic medication) by mouth at bedtime with an order date of 3/26/25. Record review of Resident 59's Medication Administration Record (MAR, a legal record of the medications administered to a patient at a facility by a health care professional) for March 2025 dated 6/26/25 revealed documentation that 100 milligrams of Seroquel were administered on 3/26/25, 3/27/25, 3/28/25, 3/29/25, 3/30/25, and 3/31/25. Record review of the MAR for April 2025 for Resident 59 dated 6/26/25 revealed documentation that Seroquel 100 milligrams was administered daily to Resident 59. Record review of the MAR for May 2025 for Resident 59 dated 6/26/25 revealed documentation that Seroquel 100 milligrams was administered daily to Resident 59. Record review of the MAR for June 2025 for Resident 59 dated 6/26/25 revealed documentation that Seroquel 100 milligrams was administered daily at 8:00 PM to Resident 59 from 6/1/25 through 6/25/25. Record review of the Care Plan dated 6/23/25 for Resident 59 revealed that Resident 59 used psychotropic medications for dementia with psychotic disturbance. Interventions included to administer psychotropic medications as ordered and monitor for side effects and effectiveness. Discuss with the physician and family regarding ongoing need for use of medication. Review behaviors, interventions, and alternate therapies. Monitor for adverse reactions including unsteadiness, frequent falls, and refusal to eat. Record review of the Progress Note for Resident 59 dated 6/6/25 at 8:58 AM revealed that staff have noted that Resident 59 is very sleepy and has been sleeping through meals. A fax was sent to the resident's physician to update on the resident's condition. Record review of the Progress Note for Resident 59 dated 6/6/25 at 11:04 AM revealed that the resident's physician returned the fax and documented that Resident 59 was probably overmedicated. Record review of the electronic health record (EHR) for Resident 59 revealed that it contained no documentation that the resident or family were informed of the risks, benefits, or alternative treatments for the use of the antipsychotic medication Seroquel. Record review of the paper chart medical record for Resident 59 revealed no documentation that the resident or family were informed of the risks, benefits, or alternative treatments for the use of the antipsychotic medication Seroquel. Interview on 6/26/25 at 11:28 AM with the facility Director of Nursing Services (DNS) confirmed that the facility did not have documentation of resident/family education on risks, benefits, or alternate therapy regarding the resident antipsychotic Seroquel use. B. Record review of an admission Record dated 06/23/2025 for Resident 42 revealed an admission date of 05/16/2023, and diagnosis information revealing: -Unspecified dementia, unspecified severity, with other behavioral disturbance (characterized as agitation including verbal and physical aggression). -Bipolar disorder (mental health condition characterized by extreme shifts in mood, energy, and activity levels, causing significant disruptions in daily life). -Personal history of other mental and behavioral disorders. -Anxiety disorder Record review of a Care Plan Report with a revision date of 11/04/2024 for Resident 42 revealed: - Has potential to be verbally aggressive related to dementia, ineffective coping skills, mental /emotional illness, diagnosis (dx) of Bipolar and a history of alcohol abuse. -Impaired cognitive function related to dx of dementia, history of alcohol use in remission, dx of bipolar as evidenced by impaired decision making. -Use of psychotropic medication related to dx and history of Bipolar. -Use of anti-anxiety medications related to anxiety disorder. -Is on hypnotic therapy related to insomnia. -Uses antidepressant medication related to depression. Record review of an Order Summary Report dated 06/23/2025 for Resident 42 revealed: -Ambien 5 milligram (MG) give 1 tablet every bedtime for insomnia, order date 08/30/2024. -Klonopin 0.5 MG give ½ tablet 2 times a day for anxiety disorder, order date 06/05/2025. -Remeron 30 MG give 1 tablet every bedtime for Bipolar, order date 08/30/2024. -Seroquel 25 MG give 1 tablet 2 times a day for Bipolar, order date 08/30/2024. Record review of Resident 42's Medication Administration Record and progress notes for March 2025, April 2025, and June 2025 revealed no missed doses for all scheduled medication administrations. Record review of Resident 42's behavior monitoring and progress notes from dates 02/24/2025 through 06/25/2025 revealed behaviors occurred on several days, the behaviors documented stated: expressed frustration/anger towards others and cursing at others. Interventions documented revealed the behaviors were better or unchanged. Record review of the electronic health record (EHR) for Resident 42 revealed that it contained no documentation that the resident or family were informed of the risks, benefits, or alternative treatments for the use of the antipsychotic medication Seroquel. An interview on 06/25/2025 at 12:08 PM the Minimum Data Set Coordinator (MDSC) confirmed that the facility did not have documentation of resident/family education on risks, benefits, or alternate therapy regarding Resident 42's antipsychotic use.

Licensure Reference Number 175 NAC 12-006.09(D) Based on record review and interview, the facility failed to ensure psychotropic medications had approved indications for use for 2 (Residents 58 and 42) of 5 sampled residents. The facility census was 62. Findings are: A. Record review of a facility policy titled Antipsychotic Medication Use dated March 2015 revealed a Policy Statement of: Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. The Policy Interpretation and Implementation revealed: 1. Resident will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 5. Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. The interdisciplinary team will: a. Complete a PASRR screening (preadmission screening for mentally ill and intellectually disabled individuals), if appropriate; or b. Re-evaluate the use of the antipsychotic medication at the time of admission and/or within two weeks (at the initial MDS assessment) to consider whether or not the medication can be reduced, tapered, or discontinued. c. Based on assessing the resident's symptoms and overall situation, the Physician will determine whether to continue, adjust, or stop existing antipsychotic medication. 6. Antipsychotic medication shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic Statistical Manual of Mental Disorders (current or subsequent editions): a. Schizophrenia; b. Schizo-affective disorder; c. Schizophreniform disorder; d. Delusional disorder; e. Mood disorders (e.g., bipolar, depression with psychotic features, treatment refractory major depression); f. Psychosis in the absence of dementia; g. Medical illness with psychotic symptoms and/or treatment-related psychosis or mania (e.g., high dose steroids); h. Tourette's disorder; i. Huntington's disease; j. Hiccups (not induced by medications) or k. Nausea and vomiting associated with cancer or chemotherapy. 7. Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident or others; AND: i. The symptoms are identified as being due to mania or psychosis; or ii. Behavioral interventions have been attempted and include in the plan of care, except in an emergency. 10. Antipsychotic medications will not be used if the only symptoms are one or more of the following: a. Wandering; b. Poor self-care; c. Restlessness; d. Impaired Memory; e. Mild anxiety; f. Insomnia; g. Inattention or indifference to surroundings; h. Sadness or crying alone that is not related to depression or other psychiatric disorders; i. Fidgeting; j. Nervousness; or k. Uncooperativeness. Record review of an admission Record dated 06/23/2025 for Resident 58 revealed an admission date of 02/17/2025, and diagnosis information revealing: -Neurocognitive disorder with Lewy bodies (a type of progressive dementia (a condition characterized by memory loss and judgment) that leads to a decline in thinking, reasoning and independent function). -Alzheimer's disease (most common form of dementia). -Anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). -Insomnia (sleep disorder where people have difficulty falling asleep, staying asleep, or experience non-restorative sleep, despite having adequate opportunity for sleep). Record review of a Care Plan Report with a revision date of 06/03/2025 for Resident 58 revealed: -Uses antidepressant medication related to insomnia diagnosis and depression diagnosis. -Uses psychotropic medications related to disease process (Lewy body dementia). Record review of an Order Summary Report dated 06/23/2025 for Resident 58 revealed: -Donepezil (used to treat dementia associated with Alzheimer's disease) 5 milligram (MG) 1 tablet by mouth every day for Alzheimer's Disease, order date 04/14/2025. -Mirtazapine (an antidepressant medication used to treat major depressive disorder) 15 MG 1 tablet by mouth every day for depression and insomnia, order date 05/13/2025. -Seroquel (an antipsychotic that treats schizophrenia and bipolar disorder) 25 MG by mouth 2 times a day for dementia related to neurocognitive disorder with Lewy bodies, order date 02/17/2025. Record review of Resident 58's Medication Administration Record for June 2025 revealed no missed doses for scheduled medication administration. Record review of behavior monitoring and progress notes from dates 02/23/2025 through 06/24/2025 revealed behaviors occurred on several days, the behaviors documented stated: sad, tearful, neglecting self, wandering, entering other rooms, pacing, anxious and restless. Interventions documented stated: reapproach, redirection, one on one, and meaningful activities with mixed reviews or improvement and/or no change, unchanged behaviors. An interview on 06/25/2025 at 12:08 PM with the Minimum Data Set Coordinator (MDSC) confirmed that Resident 58 is taking the medication Mirtazapine for depression, yet there is no diagnosis of depression in their medical health record or listed on the active diagnosis sheet for Resident 58. B. Record review of an admission Record dated 06/23/2025 for Resident 42 revealed an admission date of 05/16/2023, and diagnosis information revealing: -Unspecified dementia, unspecified severity, with other behavioral disturbance (characterized as agitation including verbal and physical aggression). -Bipolar disorder (mental health condition characterized by extreme shifts in mood, energy, and activity levels, causing significant disruptions in daily life). -Personal history of other mental and behavioral disorders. -Anxiety disorder Record review of a Care Plan Report with a revision date of 11/04/2024 for Resident 42 revealed: - Has potential to be verbally aggressive related to dementia, ineffective coping skills, mental /emotional illness, diagnosis (dx) of Bipolar and a history of alcohol abuse. -Impaired cognitive function related to dx of dementia, history of alcohol use in remission, dx of bipolar as evidenced by impaired decision making. -Use of psychotropic medication related to dx and history of Bipolar. -Use of anti-anxiety medications related to anxiety disorder. -Is on hypnotic therapy related to insomnia. -Uses antidepressant medication related to depression. Record review of an Order Summary Report dated 06/23/2025 for Resident 42 revealed: -Ambien 5 milligram (MG) give 1 tablet every bedtime for insomnia, order date 08/30/2024. -Klonopin 0.5 MG give ½ tablet 2 times a day for anxiety disorder, order date 06/05/2025. -Remeron 30 MG give 1 tablet every bedtime for Bipolar, order date 08/30/2024. -Seroquel 25 MG give 1 tablet 2 times a day for Bipolar, order date 08/30/2024. Record review of Resident 42's Medication Administration Record for June 2025 revealed no missed doses for scheduled medication administration. Record review of behavior monitoring and progress notes from dates 02/24/2025 through 06/25/2025 revealed behaviors occurred on several days, the behaviors documented stated: expressed frustration/anger towards others and cursing at others. Interventions documented revealed better or unchanged. An interview on 06/25/2025 at 12:08 PM the Minimum Data Set Coordinator (MDSC) confirmed that Resident 42 is taking a medication Ambien for insomnia, yet there is no diagnosis of insomnia in their medical health record or listed on the active diagnosis sheet for Resident 42.

Based on record review and interview the facility failed to notify the ombudsman (a state appointed advocate for residents of nursing homes) of resident discharge for 1 of 1 residents reviewed (Resident 63) as required. The facility census was 62. Findings are: Record review of the facility policy titled Discharge Planning Process dated 5/3/17 revealed that the facility will develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of the resident to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The Discharge Checklist section of the policy revealed that the facility will notify the ombudsman of resident discharge by fax on the date of discharge. Record review of the discharge Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) for Resident 63 dated 4/1/25 revealed that Resident 63 admitted into the facility on 2/28/25. The MDS revealed that Resident 63 had a discharge date of 4/1/25. Interview on 6/25/25 at 10:46 AM with the facility Social Services Director (SSD) revealed that the SSD was unsure if anyone in the facility notifies the ombudsman of resident discharges or transfers. The SSD revealed that they would find out. Interview on 6/25/25 at 11:10 AM with the SSD revealed that the Director of Nursing Services (DNS) is the facility staff that gives notifications of transfers and discharges to the ombudsman. Interview on 6/25/25 at 3:39 PM with the facility Director of Nursing Services (DNS) confirmed that the facility only notifies the ombudsman of resident transfers to the hospital. The DNS confirmed that they do not notify the ombudsman of resident discharges from the facility. The DNS revealed that the DNS documents the facility ombudsman notifications on the Record of Transfers/Discharges form. This surveyor requested the Record of Transfers/Discharges forms from August 2024 to current date. Record review of the provided facility Record of Transfers/Discharges dated from 8/2/24 through 6/23/25 revealed no documentation of ombudsman notification of the discharge of Resident 63. Interview on 6/26/25 at 8:52 AM with the facility DNS confirmed that the facility did not notify the ombudsman of the discharge of Resident 63 on 4/1/25 as required.

Licensure Reference Number 175 NAC 12-006.09(A)(i) Based on record review and interview the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Nebraska Level 1 Form (an initial pre-screening for mental illness and intellectual/developmental disabilities prior to admission) screening was completed prior to resident admission into the facility for 1 of 5 sampled residents (Resident 34). The facility census was 62. Findings are: Record review of the facility policy titled Resident Assessment-Coordination with PASARR Program dated 2/4/22 revealed that the facility coordinates assessments with the preadmission screening and resident review (PASARR) program to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. All applicants to the facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. PASARR Level 1- is the initial prescreening that is completed prior to admission. The facility will only admit individuals with a mental disorder or intellectual disability who the state mental health authority has determined as appropriate for admission. A record of the pre-screening will be maintained in the resident's medical record. Exceptions to the pre-admission screening program include those individuals who are re-admitted directly from a hospital; and individuals who are admitted directly from a hospital and has been certified by the attending physician that the individual is likely to require less than 30 days of nursing facility services. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. Record review of the admission Record for Resident 34 dated 6/24/25 revealed that Resident 34 admitted into the facility on 7/15/24. The admission Record revealed that Resident 34 admitted into the facility from another nursing home and had diagnoses of Post Traumatic Stress Disorder; Anxiety; Depression; and Unspecified Psychosis (a diagnosis given when a person experiences psychotic symptoms like hallucinations or delusions). Record review of the medical record for Resident 34 revealed that it contained a completed Level 1 PASSAR evaluation for Resident 34 dated 5/4/23 (over 14 months prior to admission to the facility). The record did not contain a PASSAR Level 1 screen within 30 days prior to or after the admission to this facility on 7/15/24. Interview on 6/26/25 at 8:52 AM with the facility Social Services Director (SSD) confirmed that the facility did not request a current PASARR level 1 screen for Resident 34 prior to admission as required. The SSD confirmed that the PASARR level 1 dated 5/4/23 was the level 1 evaluation for admission to the nursing home where Resident 34 resided prior to coming to this facility.

Licensure Reference Number 175 NAC 12-006.09(E) Based on record review and interview, the facility failed to review and revise the comprehensive care plan with new interventions after each fall for one (Resident 15) of one resident sampled. The facility census was 62. Findings are: Record review of the facility policy Comprehensive Care Plans dated 10/18/2017 revealed under Policy Explanation and Compliance Guidelines, paragraph 6 that the comprehensive care plan will be prepared by an interdisciplinary team that includes but is not limited to the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of the food and nutrition services staff, the resident and the resident's representative to the extent possible, and other appropriate staff. Alternative interventions will be documented, as needed. Paragraph 10 stated staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Record review of an Incident Report printed 06/24/2025 revealed Resident 15 had an unwitnessed fall on 06/19/2025 and a second unwitnessed fall on 06/23/2025. Record review of the comprehensive care plan for Resident 15 dated 06/24/2025 revealed Resident 15 was at risk for falls. The last update to the care plan related to falls was completed on 05/17/2025. No further interventions or goals had been added for falls since that date. In an interview on 06/24/2025 at 2:40 PM with Registered Nurse (RN)-I who stated that the only persons that update the comprehensive care plans are the Director of Nursing Services (DNS) and the Minimum Data Set Coordinator (MDSC). RN-I was unsure if anyone else had access to update the care plans. In an interview on 06/24/2025 at 2:43 PM with RN-J confirmed that the only people that were able to update the comprehensive care plans or add to the working care plan was the DNS and the MDSC. In an interview on 06/25/2025 at 11:20 AM with DNS who revealed that the only persons that update the care plans are the DNS and MDSC and those are completed either the same day or the day after any fall or infection that is being treated. All other updates are completed as needed with resident assessments or after weekly risk meetings or meetings with staff or family. In an interview on 06/25/2025 at 2:05 PM with MDSC who confirmed that the working care plan and comprehensive care plan had not been updated until that day and not on the same day or the day after the fall incidents had occurred for Resident 15. the MSDC also confirmed that all falls and infections are to be updated on the comprehensive care plans either the same day or the day after the occurrence.

Based on observations, interviews, and record reviews; the facility failed to ensure meals were served within the allotted time frames set forth by the facility staff. This had the potential to affect all residents served from the kitchen. The facility census was 62. Findings were: Record review of the facility policy Serving of Meal Trays copyright date 2000, revealed there was no specific time frame in which meals had to be served but did state that hot foods should be hot when they reached the resident and cold trays should be cold. Record review of the mealtimes posted for the facility stated that lunch will be served at 12:00 PM. Interview on 06/23/2025 at 1:50 PM with Resident 42 who revealed that it isn't uncommon to have to wait an hour to be served for lunch and supper meals. Observation of the noon meal served on 06/24/2025 between the hours of 11:35 AM and 12:50 PM: Frequent observations were made of Cook-A standing and waiting to dish up more meals as Cook-A awaited the dietary staff who were serving meals to return with the meal carts which were used to carry the meals to the tables. At the table and prior to setting the plate on the table for each resident, the dietary staff would ask if the resident wanted any condiments with the meal. Dietary staff also donned gloves and deboned the chicken wings being served at the table while the other plates on the meal cart cooled. -11:35 AM some of the residents were already seated and were visiting with their table mates. -11:45 AM Dietary staff placed desserts and drinks at each table for individual residents. -11:55 AM there were many more seated at their tables in the dining room ready for the meal to be served. Many of the seated residents were eating their desserts and drinking their juices, milk, and water while awaiting the meal and visiting with their table mates. -12:03 PM the service window for meals was opened for the kitchen staff in preparation for the meal to be served. -12:13 PM Cook-A started serving meals. -12:14 PM dietary staff served 4 meals to the first table of 4 residents. -12:18 PM dietary staff served 1 meal to a table of one and 4 meals to a table of 4. -12:24 PM dietary staff served 3 meals to a table of 3 residents. -12:26 PM dietary staff served 2 meals to a table of 2 residents. -12:30 PM two dietary staff served 4 meals to a table with 4 residents, 1 meal to a table with 1 resident, and 2 meals to a table with 2 residents. -12:34 PM dietary staff served 4 meals to a table with 4 residents. -12:35 PM dietary staff served 3 meals to a table with 3 residents. -12:40 PM dietary staff served 4 meals to a table with 4 residents. -12:44 PM dietary staff served 4 meals to a table with 4 residents, and 2 meals to a table with 2 residents. -12:45 PM one resident was removing their clothing protector and was ready to go back to their room. This resident told the Nursing Assistant they were ready to go back to the room when the nursing assistant approached. The nursing assistant (NA) removed the clothing protector from the resident and started to take the resident back to the resident room, but the NA was stopped when told that this table had not yet been served the noon meal. Resident had eaten the dessert and finished the drinks placed before her. -12:47 dietary staff served the last table of four residents their four meals to the table where the resident had tried to leave. -12:52 room trays for 4 residents were prepared and given to nursing staff for meal delivery. Interview on 06/25/2025 at 10:05 AM with Cook-A who stated that the mealtime was long the day before as the staff had to remove the bones from some of the food before it was served. Interview with the Dietary Manager (DM) on 06/25/2025 at 12:35 PM revealed that the staff have been given instructions that all meals must be served within 30 minutes of the time meals begin. Hot meals are to be served hot and cold meals are to be served cold. Temperatures of foods are to be taken prior to meal service to ensure that foods being served are hot enough and follow the food code. The facility does have a policy about food trays, but the required time is not written. However, all personnel are trained to have meals served in 30 minutes. Each table is rotated as to which one gets to be served first. The rotation is with each meal and not a daily rotation. The staff felt this was fair to all residents as to who is served first. At 11:55 AM there were many more seated at their tables in the dining room ready for the meal to be served. Confirmed that taking such a long time to serve meals the day before was not acceptable. Confirmed that dietary staff have to take time to cut up many of the foods prior to setting the foods on the table, or in the case of the day before remove the bones and that takes time. Confirmed the staff are supposed to have all meals delivered and on the tables within 30 minutes. Interview on 6/25/2025 at 2:35 PM with the Facility Administrator who confirmed the mealtimes are 8:00 AM for Breakfast, 12:00 PM for the noon meal, and 6:00 PM for the evening meal.

Licensure Reference Number 175 NAC 12-006.11(A) Based on record review, interview, and observation, the facility failed to ensure that all individuals with beards and moustaches wore beard and moustache coverings, and the facility failed to ensure a safe and effective cleaning routine and process for changing the filtration system of the facility ice machine. This had the potential to affect all residents residing in the facility. The Census was 62. Findings are: A. Record review of the Policy for Hair Nets and Facial Hair last reviewed on 01/20/2026 revealed that everyone working in the dietary department must be cleanly shaved (this does not include eyebrows or eyelashes). The procedure section revealed staff must be clean shaven, no one or two-day growths without wearing a beard guard or mask that covers the whole area. Observation on 06/23/2025 at 8:30 AM revealed the Cook-A who was serving the breakfast meal had on a hair net but did not have a beard and moustache covering in place. Observation on 06/24/2025 at 8:15 AM revealed that Cook-A was not wearing a beard and moustache covering while serving breakfast. Observation on 06/24/2025 at 12:05 PM revealed Cook-A and Cook-B did not have on a beard and moustache covering. Cook-A was serving the noon meal and Cook-B was in the kitchen area. Observation on 06/24/2025 at 12:30 PM revealed Cook-A and Cook-B both stopped working to put on a beard and moustache covering before continuing to work in the kitchen. Interview on 6/24/2025 at 2:05 PM with Cook-B who revealed not wearing beard covering the entire time while working in the kitchen but did stop to put one on. [NAME] B stated that they were a new hire and were still learning. Interview on 06/25/2025 at 10:10 AM with Cook-A confirmed they had not worn a beard and moustache covering at all times while working in the kitchen. B. Observation on 06/24/2025 at 11:10 AM of the facility ice machine which had dates on the four filters. One filter was in a clear (transparent) container, was dark brown in color with small particulates on the filter, and had a date of October 2024 written on the outside of the canister. There were three more filters in blue opaque that had dates written on them. Those dates were 5/13/2019, 7/24/2020, 9/21/2021, 5/26/2022, and 1/13/2023. The area of the ice machines where one can sit a glass or a pitcher to be filled with ice had what looked to be multi colored brown, grey, and white mineral deposits and rust. Interview with the Dietary Manager on 6/24/2025 at 12:35 PM revealed that maintenance is in charge of cleaning and caring for the ice machines located within the facility. Interview on 06/24/2025 at 3:20 PM with Maintenance Personnel (Maint)-F revealed that the ice machines are an enclosed system and must be cleaned thoroughly on a yearly basis. Filters for the 4 filters in the ice machine water line system had to be changed on a regular basis. Maint-F did not have a policy but knew that the lines had to be changed every 6 months for the transparent filter and every year for the other three filters in the system. Maint-F confirmed the filters needed to be changed and the old dates needed to be removed from the filters with an alcohol swab with a new date added. Interview on 06/24/2025 at 3:23 PM with Maint-G confirmed that the filters had to be changed every 6 months for the transparent filter and every year for the opaque blue filters. Maint G confirmed that the filters had not been changed in the 6 month and yearly interval as is required by the staff. Maint-G also revealed not being aware of any written policy related to the filtration system. Interview on 06/24/2025 at 3:40 PM with Maint-F who looked for policies pertaining to the filtration system of the ice machine and that there was no manual found. Interview on 06/24/2025 at 4:15 PM with the facility Administrator (ADMIN) confirmed that the daily cleaning of the ice machines needed to be done by the dietary or housekeeping department. ADMIN further confirmed that the ice machines did have mineral buildup on the service area and that a new base where the cups and pitchers sit to be filled with ice would be ordered because it was starting to rust and didn't look like it could be easily cleaned.

Licensure reference 175 NAC 12-006.05 (21) Based on observation, interviews, and record review, the facility failed to treat for 1 (Resident 24) of 1 sampled residents with dignity by asking them regarding their personal bowel habits while seated at the table in the dining room with their table mates. The facility identified a census is 62. An observation on 04/30/2024 at 12:00 PM while in the dining area, Registered Nurse-A (RN-A) approached Resident 24 while they were seated at their assigned seat for meals. RN-A held a conversation with Resident 24 regarding their bowel habits. This conversation was loud enough for Resident 24 table mates to hear the conversation and this observer to hear across the room. An interview on 05/01/2024 at 1:24 PM with Resident 24, confirmed they would prefer personal bowel habits are kept private. An interview on 05/01/2024 at 3:48 PM with the DON confirmed private conversations regarding bowel habits, should not be occurring in a public space in front of Resident 24 peers. DON further revealed the facility did not have a policy for personal conversations while in public.

Licensure Reference Number 175 NAC 12-006.10A1 Based on observation, record review and interview; the facility staff failed to evaluate 1 (Resident 42) of 3 sampled residents' ability to self-medicate. The facility census was 62. Findings are: A record review of Resident 42's undated Face Sheet revealed an admission date to the facility on 4/17/2023 with diagnoses of congestive heart failure (the heart does not pump blood as well as it should), hypertension (force of the blood against the artery walls is too high), atrial fibrillation (an irregular, often rapid heart rate that causes poor blood flow), vitamin deficiency, and pain. An observation on 5/1/2024 at 8:00 AM during morning medication pass revealed Licensed Practical Nurse (LPN)-A placed the following medications in a medication cup for Resident 42: carvedilol (used to treat high blood pressure and heart failure), cetirizine (used to treat allergies), cholecalciferol (Vitamin D supplement), docusate sodium (used to treat constipation), tramadol (used to treat pain), torsemide (diuretic used for heart failure), probiotic (used for gut health), aspirin (anti-inflammatory used to treat pain and can also be used to thin blood), spironolactone (used to treat high blood pressure and heart failure), and Tylenol (used for pain). An observation on 5/1/2024 at 8:05 AM revealed LPN-A placed the prepared medication cup on the dining room table by Resident 42. Resident 42 pushed them aside towards [gender] drinks. LPN-A went back to the medication cart and continued preparing and passing medications to other residents in the dining room. An observation on 5/1/2024 at 8:10 AM revealed LPN-A left the dining room and Resident 42's medications were still sitting on the table. An interview on 5/1/2024 at 8:50 AM with LPN-A confirmed that [gender] did leave Resident 42's medication cup with the resident and did not visualize [gender] taking the medications. LPN-A stated the pills were still sitting on the table at this time. LPN-A stated [gender] often do this with the alert and oriented residents as there isn't enough time to wait but acknowledged this is not appropriate. LPN-A then took the medication cart and left the dining room again. This surveyor observed Resident 42 take [gender] medications at 9:00 AM. LPN-A was not in the dinning room at this time. An interview on 5/1/2024 at 10:35 AM with the DON (Director of Nursing) confirmed that medications should not be left in the dining room with the resident and should have been observed as taken. An interview on 5/1/2024 at 3:15 PM with the DON confirmed that Resident 42 did not have a Self-Administration of Medication (an assessment used to determine if a resident is safe to self-administer medications without nurse observation) completed. A record review of Resident 42's May 2024 Medication Administration Record (MAR-a document used to indicate what medications were given to the resident) revealed no order from the physician to self-administer medications. A record review of the facility policy Administering Medications revised April 2007 revealed: 12. The individual administering the medication must initial the residents MAR on the appropriate line after giving each medication and before administering the next ones. 18. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. A record review of the facility policy Self-Administration of Drugs reviewed August 2006 revealed: Residents in our facility who wish to self-administer their medications may do so, if it is determined that they are capable of doing so. 3. If the staff determine that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications.

Licensure Reference Number 175 NAC 12-006.09D6 Based on interviews, observations, and record reviews, the facility failed to provide cleaning for 1 (Resident 55) of 1 sampleted residents CPAP equipment. The facility has census of 62. Findings are: Record review of Resident 55's Electronic Medical Administration Record (EMAR, a legal record of the medications administered to a patient at a facility by a health care professional) dated 5/2024 revealed admission date was 10/27/23. Record review of Resident 55's Physician Orders dated 10/27/23 revealed diagnosis of obstructive sleep apnea (adult) (Obstructive Sleep Apnea - a potentially serious sleep disorder in which breathing repeatedly stops and starts), CPAP (Continuous Positive Airway Pressure - a treatment that uses mild air pressure to keep your breathing airways open) CPAP on HS (hour of sleep), off in AM. Record review of MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 3/29/24 revealed in Section C Resident 55's 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 4 indicating Resident 55 was severely congnitively impaired. Record review of Resident 55's Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) revealed diagnosis of OSA and use of CPAP at HS. An observation on 4/29/24 at 10:49 AM revealed CPAP mask was on the bedside table assembled. An observation on 4/29/24 at 3:15 PM revealed CPAP mask equipment was assembled and laying in bedside drawer. The mask had small white specks on the inside of the mask. An observation on 4/30/24 at 11:01 AM revealed CPAP mask was assembled and laying in bedside drawer. There were white specks on inside of the mask. An observation on 5/1/24 at 9:10 AM revealed the CPAP was assembled and laying in bedside drawer with white specks on inside of mask. In an interview on 4/30/24 at 11:10 AM with MA-A revealed that the mask is cleaned in am's and hung it to dry. In an interview on 5/1/24 at 1:35 PM with MA-C revealed that (gender) had not cleaned the CPAP mask and tubing yet today. MA-C said it is to be done at 9 am daily. In an interview on 5/1/24 at 3:25 PM with the DON revealed that the CPAP masks need to be cleaned. Record review of CPAP manufacturer's cleaning instructions undated revealed: -Use Mask Wipes for daily wipe down of your mask, which can be purchased at Snore MD. -Use the MINI CPAP cleaner sold separately at Snore MD to ensure a perfectly clean mask. 3. Gently wash the mask in warm soapy water with a mild liquid detergent. 4. Rinse thoroughly with warm water until all the soap is removed. 5. Let air dry.

Licensure Reference Number 175 NAC 12-006.12E1 Licensure Reference Number 175 NAC 12-006.12E7 Based on observation, interview, and record review; the facility failed to keep a medication cart locked when out of eyesight of a nurse and failed to label and date an eye drops for 1 (Resident 1) of 3 sampled residents. The facility census was 62. Findings are: A. An observation on 5/1/2024 at 7:29 AM revealed an unlocked medication cart on hall 400 with view of a nurse walking into a resident's room further down the hall. An interview on 5/1/2024 at 7:31 AM with Licensed Practical Nurse (LPN)-A confirmed that the medication cart was unlocked and should not have been as it was not within eyesight of [gender]. An interview on 5/1/2024 at 10:35 AM with the Director of Nursing (DON) confirmed a medication cart should not be unlocked when it is out of eyesight of the staff responsible for the cart. A record review of the facility policy Administering Medications revised April 2007 revealed: 9. During administration of medications the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. B. An observation on 5/1/2024 at 7:40 AM during medication pass for Resident 1 revealed a box of Regener-Eyes (an over-the-counter eye drop for dry eyes) with a single bottle in the box. Neither the box or the bottle has a label to indicate who the eye drop is for or directions on how to give the eye drop. The box nor bottle was dated to indicate when the eye drop bottle was opened. An interview on 5/1/2024 at 7:40 AM with the LPN-A revealed neither the box or bottle was dated and should be. An interview on 5/1/2024 at 10:35 AM with the DON revealed a statement that the pharmacy would not label a medication brought in by family but agreed that there should be a label for the eye drops and that it should have been dated to know when the bottle was opened. A record review of Resident 1's April 2024 Medication Administration Record revealed an order for Regener-Eyes, 1 drop to both eyes twice daily for dry eye syndrome initiated 9/28/2023. A record review of the facility policy Labeling of Medication Containers revised April 2007 revealed: All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. 6. Labels for over-the-counter drugs shall include all necessary information, such as: a. The original label, b. The residents name, c. The expiration date when applicable, and d. Directions for use and appropriate accessory/cautionary statements.

Licensure Reference Number 175 NAC 12-006.17B Licensure Reference Number 175 NAC 12-006.17D Based on observation, record review, and interview; the facility failed to perform hand hygiene between residents during medication administration and used bare fingers to pick up a dropped medication on the medication cart and the facility failed to perform hand hygiene according to facility policy during resident care for 3 (Resident 1, 32, 42) of 3 sampled residents. The facility census was 62. Findings are: An observation on 5/1/2024 at 7:29 AM with Licensed Practical Nurse (LPN)-A revealed LPN-A prepareing medications for Resident 1 and entered Resident 1's room. LPN-A obtained warm water for the crushed medications and set up supplies and medications on the bedside table. LPN-A put gloves on and gave Resident 1 their medications per orders through Resident 1's J-tube (soft plastic tube placed through the abdomen into the small intestine). LPN-A then instilled nasal spray into resident's nares and then immediately placed an eye drop into each eye. LPN-A then removed gloves and washed hands at the sink with soap and water for 5 seconds before rinsing hands. LPN-A then went to the next resident's room and knocked on the door, entered the room and asked the resident if they were coming out to breakfast. The resident was not ready at this time. LPN-A continued to take the cart from the 400 hall to the dining room at 8:00 AM. LPN-A began removing medications from Resident 42's individual cassettes for medications. During this process, LPN-A dropped a medication on the cart and picked the pill up with bare fingers and put the medication in the cup with Resident 42's other medications. LPN-A gave Resident 42 the medication cup and returned to the cart and began preparing medications for Resident 32 and then gave Resident 32 their medications. At 8:10 AM LPN-A left the dining room. An interview on 5/1/2024 at 8:50 AM with LPN-A confirmed the facility policy for hand washing is to wash for 20 seconds with soap and water and the 5 seconds [gender] washed after completing Resident 1's medications was not long enough. LPN-A also confirmed that hand hygiene should have been completed with either soap and water or hand sanitizer between residents' administration of medications. LPN-A also confirmed [gender] should not have picked up resident's dropped pill with bare fingers. An interview on 5/1/2024 at 10:35 AM with the Director of Nursing (DON) confirmed that hand hygiene should be completed between residents during administration of medications, 5 seconds is not long enough to wash hands with soap and water and residents' medication should not be picked up with bare fingers. A record review of the facility policy Hand Hygiene dated 12/5/17 revealed: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 5. Hand hygiene technique when using soap and water: c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of hands and fingers, and between fingers, including areas under and around fingernails. 6. Additional considerations: b. The use of gloves does not replace hand washing. Wash hands after removing gloves. A record review of the facility policy Administering Medications revised April 2007 revealed: 14. Staff shall follow established facility infection control procedures (e.gl handwashing, antiseptic technique, gloves, isolation precautions, etc.) when these apply to the administration of medications.

Licensure refernce number 175 NAC 12-006.11E Based on observation, interviews and record review, the facility failed to ensure food safety requirements by not removing dented cans for resident consumption, maintaining correct placement of hairnets while prepping and plating food, preforming hand hygiene for 20 seconds prior to plating residents' food, failure to prevent contamination by improperly holding dining plates while serving the residents meals, and improper storage of the fountain dispenser line. This has the potential to affect 62 residents in the facility. The facility identifies a census of 62 residents. Findings are: A review of the facility policy titled Hand Hygiene undated, revealed .Rub hands together vigorously for at least 20 seconds with soap and water. An interview on 04/30/2024 at 3:26 PM The Dietary Manager (DM) stated the facility does not have a policy for dented or damaged cans. An observation on 4/29/2024 at 9:15 AM in the dry storage area, revealed 2 cans of apple pie filling 112 oz, both with large, dented sides, placed into the shelf for use. An observation on 04/30/2024 at 10:12 AM reveled the 2 cans of apple pie filling 112 oz, with large dented in sides, remain in the dry storage area, ready for use. An observation on 4/29/2024 at 9:15 AM and 4/30/2024 at 2:34 PM, When inspecting the fountain dispenser, the syrup fastener connector (a device that screws on and connects the bag-in-box (a box of liquid drink mix syrup) (BIB) to the syrup pump) was disconnected from the Bag in Box (BIB) juice and was found lying open side down flush with the floor. The opposite side of this line was connected to the syrup pump which pushes the BIB syrup and mixes the BIB syrup with water. After mixed the fluid is available to dispense for use. An observation on 04/30/2024 at 12:10 PM while passing the noon meal plates to residents Dietary Aides (DA)-B and DA-C placed their base of the thumb on to the top portion of the plate. An observation on 05/01/2024 at 11:30 AM DA-A performed hand hygiene. This hand hygiene was preformed for less than 20 seconds prior to plating food onto plates while on the Memory Care Unit (MCU). An observation on 05/01/2024 at 12:15 DA-A had a hair net placed on top of their head with hair out of the net along the side of their head next to their ears, the back of their neck and the front the scalp-bangs area were outside of the hairnet while prepping and plating the noon lunch plates while on the MCU. An Interview on 04/30/2024 at 3:26 PM with DM confirmed the dented cans remained in the dry storage area, shelved for use. The cans should be removed from this area. The cans should not be available for consumption. DM further confirmed that the syrup connector should not be touching the floor. DM also confirmed education has been provided to staff previously, they are aware of proper holding and delivering of resident's meal plates. DM confirmed when delivering meals, the top portion of the plate or cup should not be touched. An interview on 05/01/2024 at 12:43 PM with DA-A confirmed hand hygiene should be performed for 20 second. DA-A confirmed all hair should be placed into the hairnet when preparing and plating food for the residents.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (6) Based on observation, interview, and record review; the facility failed to promote resident dignity with dining by failing to serve each resident seated at the same table before moving on to the next table. This affected 3 (Residents 30, 14, and 45) of 41 residents seated in the facility dining room. The facility identified a census of 62 at the time of survey. Findings are: Observation of the HCU (Health Care Unit) dining room on 6/5/23 at 12:18 PM revealed Residents 30, 14, 45, and 21 were seated at table A in the dining room. DC-B (Dietary Cook) dished a plate of food and walked out to the dining room from the kitchen and placed the plate of food on the table in front of Resident 21. NA-K (Nurse Aide) was seated at a table with Residents 30, 14, 45, and 21. NA-K assisted Resident 21 to start eating. Residents 30, 14, and 45 were not served. At 12:21 PM, table B was served, Residents 22, 40, 36, and 23. Resident 30, who was seated at table A, was observed watching Resident 21 eat their meal. At 12:23 PM, Residents 30, 14, and 45 received their meals. Interview with the DM (Dietary Manager) on 6/7/23 at 2:27 PM revealed all residents seated at the same dining room table were to be served before they moved on to the next table. If it was an assist table, then as long as a nursing staff person was there, they should have served the entire table. Record review of the facility policy Resident Rights dated 2016 revealed the following: the resident has the right to: be treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing his/her individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Record review of Resident 27's Quarterly MDS dated [DATE] revealed an admission date of 11/18/22. Antipsychotic medication was received 7 days of the 7-day MDS look back period. Has a gradual dose reduction (GDR) been attempted was marked no. Physician documented GDR as clinically contraindicated was marked yes with the date listed as 11/18/2022. Record review of Resident 27's Resident Safety Concerns dated 5/25/2023 revealed documentation Resident 27 had an order for Seroquel 100 mg by mouth every day with an order date of 11/18/2022. There was documentation the RP requested the physician review the psychotropic med list. The MD checked there are no medication adjustments recommended for this resident at this time. The Comment (by physician) was blank. Interview with RN-J (Registered Nurse) on 6/6/23 at 3:20 PM confirmed there was no documentation of the clinical rationale for the MD declining the GDR for Resident 27's Seroquel within the medical record. Record Review of the facility policy Tapering Medications and Gradual Dose Reduction dated 2007 revealed the following: within the first year after a resident is admitted on an antipsychotic medication or after the resident has been started on an antipsychotic medication, the staff and practitioner shall attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, the facility shall attempt a GDR at least annually, unless clinically contraindicated. For any individual who is receiving an antipsychotic medication to treat behavioral symptoms related to dementia, the GDR may be considered clinically contraindicated if the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behaviors. LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D5 Based on interview and record review, the facility failed to ensure documentation of clinical rationale for declination of GDRs (Gradual Dose Reduction) for antipsychotic medication (medication used to treat behavioral disorders) for 2 (Residents 16 and 27) of 5 sampled residents. The facility identified a census of 62 at the time of survey. Findings are: A. Record review of Resident 16's Quarterly MDS (Minimum Data Set-a comprehensive assessment used to develop a resident care plan) dated 4/14/2023 revealed an admission date of 8/10/2022. Resident 16 received antipsychotic medication 7 days of the 7-day MDS look back period. Has a gradual dose reduction (GDR) been attempted? was marked no. Physician documented GDR as clinically contraindicated was marked yes with the date physician documented GDR as clinically contraindicated 02/27/2023. Record review of Resident 16's, Resident Safety Concerns worksheet dated 2/27/23 revealed documentation Resident 16 had an order for Seroquel 100 mg by mouth twice a day with an order date of 4/2020. The RP (Registered Pharmacist) had requested the MD (Medical Doctor) review the use of the Seroquel. The MD checked the box next to there are no medication adjustments recommended at this time and the comment (by physician) box was empty. Interview with the DON (Director of Nursing) on 6/8/23 at 11:30 AM confirmed there was no documentation of the clinical rationale for the MD declining the GDR for the Seroquel for Resident 16 within the medical record.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11B Based on observation, interview, and record review; the facility failed to ensure all of the facility residents received 3 meals per day. This affected 1 of 41 residents who were served in the main dining room, Resident 63. The facility identified a census of 62 at the time of survey. Findings are: Record review of the undated facility document Meal Times received from the facility revealed the following: MCU (Memory Care Unit) Breakfast 7:45 AM-Lunch 11:45 AM-Supper 5:45 PM. On the HCU (Health Care Unit) the meal times were listed as 8:00 AM for breakfast-12:00 PM for lunch-and 6:00 PM for supper. Observation of the HCU dining room on 6/5/23 at 12:45 PM revealed DC-B (Dietary Cook) plated 3 plates of food then took the plates of food out to Resident 54, 48 and 51 who were seated in the dining room. Resident 63 was also sitting at the table and did not get served. At 12:50 PM, DC-B closed the meal service window and pulled the pans of food from the steam table. Resident 63 had not been served lunch and was observed watching their table mates eat. At 12:54 PM Resident 63 got up and left the dining room. Resident 63 had not been served lunch. At 12:57 PM the DM (Dietary Manager), DC-B, and DA-E (Dietary Aide) were observed walking out of the kitchen. DC-B and DA-E had containers of food then they clocked out at the time clock and left the unit. Record review of the undated facility policy Meal Pattern and Menu Policy revealed the following: Purpose: To provide nutritionally balanced meals to residents. Menus will be planned to comply with nutritional, esthetic, and budgetary requirements. Policy: A meal pattern will be established in an effort to comply with nutritional requirements of residents while meeting esthetic and budgetary components. Interview with the DM on 6/7/23 at 2:06 PM revealed the staff were supposed to check and make sure all of the residents got fed. Interview with the DM on 6/7/23 at 2:27 PM revealed the facility did not have a policy for making sure everyone was fed.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11A1 Based on observation, interview, and record review; the facility staff failed to follow the menu during meal service for the residents. This affected 16 of the 62 residents who were served the lunch meal, Residents 10, 22, 61, 6, 9, 52, 60, 23, 15, 18, 1, 14, 21, 45, 16, and 40. The facility identified a census of 62 at the time of survey. Findings are: Observation of the facility kitchen on 6/7/23 at 11:32 AM revealed DC-C (Dietary Cook) prepared ground and pureed Salisbury steaks and placed the meat in pans, covered them with foil, and placed them into the convection oven. Observation of the facility kitchen on 6/7/23 at 12:00 PM revealed DA-F (Dietary Aide) opened the convection oven, and scooped ground meat out of the pan into bowls using a blue scoop that was in the pan. DA-F then put the 3 bowls onto a cart with the portable steamers. Interview with DA-F at that time revealed the bowls of meat and the food on the cart was for the residents on the MSU (Memory Support Unit). DA-F then took the cart with the food on it out of the kitchen and down the hall toward the MSU. At 6/7/23 at 12:21 PM DC-C served a blue scoop of ground meat to Resident 9. At 12:25 PM, DC-C dished up a blue scoop of pureed meat and placed it on plates which was then served to Resident 14, 45, and 21. DC-C then continued to serve the ground and pureed meat to the remainder of the resident using the blue scoop. Record review of the facility Diet Spreadsheet Week 4 2023 for Day 25-Wednesday read the following: Lunch: Regular portion size: Salisbury Steak 3 oz; Ground Salisbury steak with gravy #8 dip; pureed Salisbury steak #8 dip. Small portion was listed as 2 ounces of Salisbury steak. Record review of the undated Scoop Sizes for the facility revealed a Dipper Size #8 was 4 ounces, 1/2 cup, gray. A blue dipper was a #16 which was 2.75 ounces. Record review of the Physician's Order List Dietary dated 6/7/23 revealed Residents 10, 22, 61, 6, 9, 52, 60, 23, 15, and 18 had a diet order for ground meat. Residents 1, 14, 21, 45, 16, and 40 had a diet order for a pureed diet. Interview with the DM (Dietary Manager) on 6/7/23 at 2:27 PM revealed the staff were expected to follow the menus and they were shown how to use them.

C. Observation of the dining room on 6/5/23 at 12:08 PM revealed DA-E delivered food from the food cart and stopped to push a resident to their table without sanitizing/changing gloves then continued to deliver food to residents. Observation of the dining room on 6/5/23 at 12:27 PM revealed DA-F touched one resident, then touched another resident with bare hands while at hte table. Observation of dining room on 605/23 at 12:35 PM revealed DA-F cutting residents chicken with no gloves, touching the plate and utensils. Observation of dish washing on 6/5/23 at 08:20 AM revealed dirty fan blowing on clean dishes. Observation of white refrigerator in kitchen on 6/5/23 at 8:20 AM revealed pint size heavy cream expired and freezer with food particles on the bottom. Observation of storage room on 06/05/23 at 08:22 AM revealed multiple boxes on floor including plastic cutlery, foam cups, ready care with one box being opened. Cans on the shelf revealed visible dust on lid surfaces. Observation of the kitchen freezers on 06/05/23 at 08:35 AM revealed unlabeled blue bag on shelf with loose mixed vegetables scattered on the bottom. Observation of the food storage room on 06/05/23 at 08:37 AM revealed open pancake mix with no date of opening and hot and cold cup boxes on the the floor. Observation of the walk in refrigerator on 06/05/23 at 08:42 AM revealed open bag of lettuce with no date of opening. Observation of dish washing on 06/05/23 08:43 AM revealed dirty fan blowing on clean dishes. Observation of ice and water dispenser on 06/05/23 at 08:49 AM revealed rust colored plate with dark colored build up on the bottom and a white build up area around base of water dispenser. Observation of second ice and water dispenser on 06/05/23 at 09:00 AM revealed rust colored plate with dark buildup on the bottom, and a white build up area around base of water dispenser. Observation of storage room on 06/07/23 at 09:18 revealed on the floor oatmeal cream pies and a lid underneath storage shelves, brown and powdered sugar lids were off of containers and the lids on a separate shelf. Boxes if foam cups and plastic cutlery on the floor. Observation of DC-C on 06/07/23 at 9:25 AM revealed opening a can of cream corn without cleaning the dirty lid prior to opening. Observation of DC-C on 06/07/23 at 09:33 AM revealed multiple surfaces touched without changing gloves then checking chicken temperature using their same gloved hand to steady the chicken meat. Observation of DC-C on 06/07/23 at 09:40 AM revealed opening beans without cleaning the dirty lid then pulling the lid out of the beans. Observation of the kitchen on 06/07/23 at 09:54 AM revealed NA-A coming into the kitchen where food was being prepped with no hair net. Observation of kitchen on 06/07/23 at 11:36 AM revealed DA-G putting cereal in bowls for the next day without covering them. DA-G member touched their hair, then put the same gloved hand into one cereal bowl then transferred cereal to another cereal bowl. B. Observation on 6/5/23 at 12:08 PM until 12:45 PM of the facility's Memory Support Unit revealed, NA-H plated meals and did not have a hair restraint on. without wearing a hair restraint. Record review of Food Safety and Consumer Production (2-402.11(A) reveals that, Food employees shall wear hair restraints such as hats. hair coverings or nets, beard restraints and clothing that covers body hair. LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, interview, and record review; the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and food was served and stored in a manner to prevent potential cross contamination. This had the potential to affect all 62 residents who received food from the facility kitchen. The facility identified a census of 62 at the time of survey. Findings are: A. Observation of the facility kitchen on 6/5/23 at 8:28 AM revealed DC-B (Dietary Cook) was serving breakfast to the residents from a steam table in the kitchen in front of a pass-through window. Fans were observed to be blowing on the clean dish area in the back and front dish rooms and blowing towards the steam table where DC-B was serving food to the residents. The fans had dark gray fuzzy material on them. A container of outdated HWC (Heavy Whipping Cream) was in the white refrigerator in the kitchen that outdated 6/2/23. There was also a container of undated opened tomato juice that was in a pitcher and not in the original container and a container of supplement (gallon size pitcher) dated 6/4/23. Gluten free bread was in the freezer of the same white refrigerator/freezer combo. There was a brown and pink substance on the refrigerator shelves and there were food crumbs in the freezer on the bottom shelf. At 8:32 AM the dry storage area/pantry was observed. There were boxes of food items on the floor in the dry storage area. 1 box of Smucker's jelly; 2 boxes of cartons of Ready Care thickened water; 3 boxes of foam cups and a box of plastic cutlery were on the floor. Visible dust and brown debris that looked like dried food particles were on the cans of salmon, tomato sauce, and whole peeled tomatoes. There was a rodent trap under one of the wire shelving units. At 8:35 AM an unidentified blue bag of food-not marked and twisted shut-was not secured or identified in the freezer in the dry storage areas. There were pieces of frozen vegetables (peas and diced carrots) in the bottom of the left-hand side of the upright freezer and debris that appeared to be food crumbs. At 8:37 AM there was an opened paper bag of Krusteaz pancake mix that was approximately half used, and the bag was curled down and secured with a piece of clear scotch type tape on the shelf in the dry storage area. The bag was not marked with the date it was opened and the expiration date was not visible. There was a box of hot or cold insulated bowls sitting on the floor. At 8:39 AM observed the walk-in freezer across the hall from the dry storage pantry. 9 boxes of frozen food were observed on the floor; some were unidentified; there were boxes of fruit, beef burgers, and orange nutr. In the walk in refrigerator, there was a bag of lettuce opened and not dated. It was sealed with a twist tie and had started to decay in the bag/appeared spoiled. At 8:43 AM observed a fan with gray fuzzy material on it that was blowing on dishes in the meal prep area. An 8:44 AM Interview with DA-M (Dietary Aide) confirmed the dishes in that area were clean. When asked where the ice machine was; DA-M walked out to the Assisted Living (ALF) dining room and reported it was the ice machine used for the residents in the skilled area as well. Observation of the ice machine at that time revealed there was a white crust-like material around the spout on the water dispenser and the grate under the ice machine that one would place the pitcher or mug to fill it with ice was corroded with brown rust-like deposits. The black vinyl/rubber coating was eroded on the grate. Observation of the other ice machine in the facility at 9:00 AM revealed the ice machine on 100 was in the same condition as the ice machine on the ALF. Observation of the HCU dining room on 6/7/23 at 8:24 AM revealed DC-C plated food and placed it on a cart with trays and covers then pushed the cart into the dining room. The tray shelf under the steam table had visible dry food crumbs and shredded cheese with other unidentified white soil. DC-C was observed with thick at least 2-inch-long facial hair that was a goatee style moustache and beard. DC-C was not wearing any face covering. DC-C was wearing gloves to scoop the food onto the plates with utensils and was handling the toast and placing it on the plates with the gloved hand after they handled the scoopers, cart handles, plates, and bowls. At 8:32 AM DC-C plated food then placed the food on a 3-tier cart then placed food covers on the plates. DC-C continued to use a gloved hand to place a piece of toast on each plate after they touched the plates, covers, and scoops. DA-E then took food to 4 residents at table 2. DA-E removed the food covers from one plate and placed the cover onto the 2nd shelf of the cart then put the plate in front of the resident. DA-E continued the same process with each of the residents and touched their items to move things around and placed their hand on the table and did not do any hand hygiene in between. DA-E had bare hands. DA-E then pushed the cart back into the kitchen by using touching the cart handle with the bare hands. DC-C then used the gloved hands to grab the handle of the cart that DA-E had handled with their bare hands after handling resident items, serving food, and not doing hand hygiene. DC-C then proceeded to plate more plates of food: DC-C dished the food then put the plate on the cart, picked up a plate cover that DA-E had handled with the bare hands, then put it on the food. DC-C then used the gloved hand to put slices of toast on each plate then filled bowls with hot cereal then put them on top of the plate cover. When DC-C picked up the plates they touched the eating surface with the gloved hands and put the gloved hands inside the bowls to pick them up. DC-C also put a plate against their shirt then put food on it which went out to the residents. DA-E and DA-G then took the carts out to the dining room and handled the cart handles and the covers when they removed them then brought the carts back to the kitchen with the used covers on them then DC-C repeated the meal service process, touching the cart handles, the plate covers with the gloved hands then handling the plates and bowls by the eating surface and using the gloved hand to handle the toast. 41 residents were in the dining room and either received the toast or the hot cereal. At 8:41 AM DC-C continued to handle/reuse the plate covers then put a thumb on plates and in bowls and handle the toast. At 8:47 AM DC-C went to the bread rack and got a loaf of bread from it and put it on the prep table where they were serving. DC-C was still wearing the same gloves they had been wearing when they put the contaminated plate covers on the food. DC-C removed the twist tie and put the gloved hands into the bread, took slices of bread out of the bag and put them in the toaster. DC-C used the same gloved hands to take the toast out of the toaster after it popped up and put the toast on plates of food which then went out to the residents at table 8. At 8:54 AM DC-C was observed using the same gloved hands and re-using the covers and placing the fingers on plates, thumbs in bowls, and serving toast. At 8:56 AM DA-E was observed serving each plate of food to the residents and not doing any hand hygiene. DA-E would rearrange resident items on the table and place their hand on the table when they put the plates of food down in front of the residents. At 8:58 AM Table 10 was served. Observed DA-E placing their thumb on the plates and bowls when they served the plates of food to the residents. All of the residents were observed eating the food either on their own or being fed. 41 residents received a slice of toast or hot cereal (pureed diets). Observation of the facility kitchen on 6/7/23 at 9:15 AM revealed DC-C prepared the noon meal. DC-C was observed with thick at least 2-inch-long facial hair that was a goatee style moustache and beard. DC-C was not wearing any face covering. There was a cart of food on it in the middle of the kitchen with 2 uncovered pitchers of liquid on the cart and 5 bags of frozen chuckwagon corn. DC-C was getting pans ready by putting pan liners in them. DC-C then proceeded to cut open the bags of corn and placed them in the pans, placed a pitcher in the sink then turned the faucet on with the gloved hands and let water run into the pitcher, turned the faucet off with the same gloved hand, then poured the water into the corn. DC-C used the same gloved hands to put foil on the pans then puts them in the oven. 9:18 AM Observation of the walk-in freezer revealed there were 3 new boxes of food on the floor in the freezer in addition to the boxes that were on the floor on 6/5/23. Observation of the pantry revealed lids were off the brown sugar, powdered sugar, and breadcrumbs. There was a lid and a box of oatmeal cream pies on the floor. The top of the cans of food were soiled with dust and brown and white crumbs. There was an unidentified blue bag of unmarked food and a bag of unmarked sausage patties in the freezer. There was soil on the freezer doors that had the appearance of drips and smudges, and the supplement refrigerator was soiled with brown and pink substances and brown crumbs. At 9:19 AM observed the bowl on the stand mixer in the kitchen was not covered and was upright. The stand mixer was gray and there were chips in the paint on the stand mixer above the bowl. At 9:35 AM DC-C took some pieces of chicken out of the oven. DC-C confirmed it was the alternate and DC-C had put them in at 8 AM. DC-C checked the temp then put the pieces in pans, covered them with foil, then placed them back in the oven. At 9:40 AM DC-C pureed creamed corn DC-C had prepared by opening the can and pushing the lid down into the corn to lift it up. DC-C did not clean the can of corn before opening it. DC-C then brought 2 cans of baked beans out of the pantry. The cans had visible soil on them-dust and white/brown flecks. DC-C did not clean the tops and opened the cans with the can opener and put the beans in pans after pushing the lids down into the beans. DC-C then got 2 bags of frozen broccoli out of the freezer and placed them on the cart in the kitchen. At 9:54 AM, NA-A (Nurse Aide), walked through the meal prep area with no hair covering. There was food on the prep table and NA-A walked right by it. Staff were in the kitchen and did not intervene when NA-A walked into the kitchen without hair covering. At 9:57 AM a fan was on and blowing on the clean plate covers. There was a sign on the pass-through door with a reminder to check food temps before meal service that was right in front of the steam table, and it was flapping from the fan blowing on it. The shelving unit the cook was observed taking trays from had visible food crumb debris on it right next to the trays (breadcrumbs, orange debris that appeared to be shredded cheese); The shelf with the pan liners on it under the steam oven was soiled with white and brown debris and gray fuzzy material. The back of the range/oven had gray fuzzy material on it. At 10:12 AM DC-C got 2 boxes of 4-ounce portions of Salisbury (ground beef) steaks out of the walk-in freezer and placed them on the cart and wheeled them out to the kitchen. The cart had visible soil with brown and white substances and tan crumbs on it. DC-C placed the steaks on the griddle using a gloved hand. DC-C then stood over the steaks while DC-C cooked them, and DC-C was not wearing a beard cover. At 11:32 AM DC-C placed 10 steaks into the food processor and ground them and placed the ground meat in a pan and put foil over it. DC-C then used the same food processor and made 6 servings of pureed meat which was moistened with beef broth. DC-C then put the pureed meat in a pan, put foil on it and placed both pans in the convection/steam oven. At 11:36 AM DA-G was observed pouring cereal from a dispenser into bowls. DA-G touched their hair with the gloved hands then continued to put the cereal in bowls. DA-G then put plastic wrap over the bowls of cereal and covered the top of the bowls which were stacked on top of each other. The bottom bowls were not covered and exposed the cereal. DA-G then put the tray with the cereal bowls on it on a shelf. DA-G was observed getting the tray from the stack of trays under the steam table with the soiled shelf. Interview with DA-G at 11:38 AM confirmed the cereal was for the residents for breakfast in the morning. At 12:18 PM observed DC-C pick up baked potatoes with a gloved hand after touching the utensils and the room tray cart. DC-C cut the potatoes in half then added shredded cheese and bacon and placed them on plates then put covers on them. At 12:19 PM DC-C finished the room tray cart. Residents 29, 44, and 7 received the baked potatoes DC-C had handled with the soiled gloved. DC-C then proceeded to serve the baked potatoes to residents or the alternate, baked beans, which DC-C had prepared and served with soiled gloves. Tour of the kitchen with the DM (Dietary Manager) and FA (Facility Administrator) on 6/7/23 at 1:52 PM confirmed the soiled fans were blowing on the clean dishes and across the meal preparation steam table. Interview with the DM at that time revealed the dirty fans should not have been blowing on the clean dishes or on the steam table. The DM confirmed the items in the white refrigerator where the soiled areas were and the outdated HWC and unmarked juice was used for the facility residents and those outdated items should not have been in there/should have been discarded. The DM confirmed it was the supplement refrigerator. The DM and FA observed the soiled shelves, oven/range, and areas of the kitchen that were soiled. The DM confirmed the kitchen was not clean and should have been. The DM and the FA observed the items on the floor in the freezer and the pantry and the DM confirmed they should not be on the floor and the cans should have been cleaned. Interview with the DM and the FA on 6/7/23 at 2:06 PM revealed the FA expressed that the kitchen was expected to be maintained in a clean manner. Interview with the DM on 6/7/23 at 2:27 PM revealed the staff were expected to keep the kitchen clean and carry dishes by the rim or underneath; the staff were expected to change their gloves and do hand hygiene and not use contaminated gloves to serve or handle prepared food or dishes; and the staff were expected to keep their hair covered. Review of the undated diagram How to Handle Dishes & Utensil Safely Sanitation Reminders listed handling the plate and cups by the non-eating surface as a yes and placing hands/fingers on the eating/drinking surface was listed as a no. Review of the undated facility policy Food Storage revealed the following: Food storage areas shall be clean at all times. All foods or food items not requiring refrigeration shall be stored above the floor, on shelves, racks, dollies, or other surfaces which facilitate thorough cleaning, in a ventilated room, not subject to sewage or wastewater backflow or contamination by condensation, leakage, rodents, or vermin. All packaged food, canned foods, or food items stored shall be kept clean and dry at all times. All foods stored in walk-in refrigerators and freezers shall be stored above the floor on shelves, racks, dollies, or other surfaces that facilitate thorough cleaning. Interview with the DON (Director of Nursing) on 6/07/23 at 4:11 PM revealed all of the residents received food from the facility kitchen.

B. Observation of dining room on 06/05/23 12:08 PM revealed staff member (DA-E) with food cart stopped to push a resident to table without changing gloves. Observation of dining room on 06/05/23 12:27 AM revealed staff member (DA-F) touching one resident, then touching another without sanitizing. LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D Based on observation, interview, and record review; the facility staff failed to perform hand hygiene to prevent potential cross contamination during meal service. This had the potential to affect all of the 41 facility residents who ate their meal in the HCU (Health Care Unit) dining room. The facility identified a census of 62 at the time of survey. Findings are: A. Observation of the HCU dining room on 6/05/23 at 12:11 PM revealed DA-E (Dietary Aide) in the HCU dining room served drinks from a cart in the dining room. The drinks were pre-poured and had plastic wrap on them. DA-E was wearing disposable gloves. DA-A remove the plastic wrap then place the drinks in front of the residents at the table. DA-E placed their hand on Resident 19's wheelchair with the gloved hands and touched the handles on the wheelchair then unwrapped and served drinks to Resident 29, Resident 63, and Resident 54. DA-E did not change the gloves or do hand hygiene after touching the wheelchair handles then serving the drinks. At 12:13 PM Resident 29 picked up a bowl that was sitting in front of them on the table with a piece of cake in it and handed it to DA-E who, with the gloved hands, put the bowl of cake on the bottom shelf of the cart with the drinks on it. DA-E removed the gloves and put on another pair of gloves without doing any hand hygiene then passed drinks to Residents 42, 24, 34, 41, and 5. DA-E removed the plastic wrap from each of the drinks and handled the glasses when they placed the drinks in front of the residents. The residents were all observed drinking the drinks on their own and handling the glasses with their bare hands. At 12:16 PM, DA-E placed drinks on the table for Residents 3 and 55. At 12:18 PM DC-B plated a plate of food and walked out of the kitchen to the dining room and placed the plate of food on the table in front of Resident 21 who was seated at a table with 3 other residents, Residents 45, 14, and 30. DC-B went back into the kitchen and did not change their gloves or do any hand hygiene and proceeded to plate food up for the other residents by holding the plate with a thumb on the plate then served each resident. At 12:23 PM, DA-E and DA-D took carts of food from the kitchen DC-B had placed on carts, took the carts from the kitchen out to the dining room and served the food to the residents in the dining room without doing any hand hygiene in between and they wore gloves and did not change them. At 12:27 PM, MA-L (Medication Aide) sat down in between Resident 14 and Resident 45. MA-L grabbed the seat release bar at the top of the wheelchair and adjusted Resident 14's back/head to sit them upright by standing up and placing their hands on the release bar then MA-L sat back down then began to rub Resident 14's chest as Resident 14 was sleeping and would not wake up to eat. (MA-L had previously been observed wheeling Resident 14 into the dining room using the wheelchair handle which was connected to the release bar using their bare hands and they did not clean the surface). MA-L then grabbed a stack of 4-ounce paper cups from the center of the table after MA-L sat back down; placed their fingers inside one of the cups to separate it from the other cups then poured some of Resident 45's juice in the cup and lifted the cup up and Resident 45 drank out of it. MA-L did not do any hand hygiene after they touched Resident 14's wheelchair and clothing before they put their fingers into the cup used to give Resident 45 some juice. At 12:30 PM, DA-E opened a container of sour cream and put it on Resident 28's plate with the food after they handled it with their bare hands. DC-B continued to serve residents in the dining room with the same gloved hands. At 12:45 PM DA-E and DA-D were observed serving plates of food off carts to other residents in the dining room. DC-B plated 3 plates of food then took the plates of food out to Resident 54, 48, and 51. DC-B then went back into the kitchen with the same gloved hands. At 12:46 PM DC-B then picked up a plate by placing their thumb on the plate then took a plate of food to Resident 8 after DC-B put food on it. DC-B then went back to the kitchen and with the same gloved hands picked up another plate with their thumb on the lip of the eating surface of the plate and plated food then put it on a cart. DC-B then plated a serving of spinach and a plate of food for Resident 41 and Resident 3. DA-E then took the cart out of the kitchen and served the food to Residents 41, 3, and 34. All of the residents in the dining room were observed eating from the plates of food dished by DC-B and served by DA-D and DA-E. Observation of the HCU dining room on 06/07/23 at 8:24 AM revealed DC-C plated food and placed it on a cart with trays and covers then pushed the cart into the dining room. DC-C was wearing gloves to scoop the food onto the plates with utensils and was handling the toast and placing it on the plates with the gloved hand after they handled the scoopers, cart handles, plates, and bowls. At 8:32 AM DC-C plated food then placed the food on a 3-tier cart then placed food covers on the plates. DC-C continued to use a gloved hand to place a piece of toast on each plate after they touched the plates, covers, and scoops. DA-E then took food to 4 residents at table 2. DA-E removed the food covers from one plate and placed the cover onto the 2nd shelf of the cart then put the plate in front of the resident. DA-E continued the same process with each of the residents and touched their items to move things around and placed their hand on the table and did not do any hand hygiene in between. DA-E had bare hands. DA-E then pushed the cart back into the kitchen by using touching the cart handle with the bare hands. DC-C then used the gloved hands to grab the handle of the cart that DA-E had handled with their bare hands after handling resident items, serving food, and not doing hand hygiene. DC-C then proceeded to plate more plates of food: DC-C dished the food then put the plate on the cart, picked up a plate cover that DA-E had handled with the bare hands, then put it on the food. DC-C then used the gloved hand to put slices of toast on each plate then filled bowls with hot cereal then put them on top of the plate cover. When DC-C picked up the plates they touched the eating surface with the gloved hands and put the gloved hands inside the bowls to pick them up. DC-C also put a plate against their shirt then put food on it which went out to the residents. DA-E and DA-G then took the carts out to the dining room and handled the cart handles and the covers when they removed them then brought the carts back to the kitchen with the used covers on them then DC-C repeated the meal service process, touching the cart handles, the plate covers with the gloved hands then handling the plates and bowls by the eating surface and using the gloved hand to handle the toast. 41 residents were in the dining room and either received the toast or the hot cereal. At 8:41 AM DC-C continued to handle/reuse the plate covers then put a thumb on plates and in bowls and handle the toast. At 8:47 AM DC-C went to the bread rack and got a loaf of bread from it and put it on the prep table where they were serving. DC-C was still wearing the same gloves they had been wearing when they put the contaminated plate covers on the food. DC-C removed the twist tie and put the gloved hands into the bread, took slices of bread out of the bag and put them in the toaster. DC-C used the same gloved hands to take the toast out of the toaster after it popped up and put the toast on plates of food which then went out to the residents at table 8. At 8:54 AM DC-C was observed using the same gloved hands and re-using the covers and placing the fingers on plates, thumbs in bowls, and serving toast. At 8:56 AM DA-E was observed serving each plate of food to the residents and not doing any hand hygiene. DA-E would rearrange resident items on the table and place their hand on the table when they put the plates of food down in front of the residents. At 8:58 AM Table 10 was served. Observed DA-E placing their thumb on the plates and bowls when they served the plates of food to the residents. All of the residents were observed eating the food either on their own or being fed. 41 residents received a slice of toast or hot cereal (pureed diets). Interview with the DM (Dietary Manager) on 6/7/23 at 2:27 PM revealed the facility staff were expected to change their gloves and perform hand hygiene when the hands were contaminated. Review of the undated facility policy Handwashing/Hand Hygiene revealed the following: This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Employees must wash their hands for at least 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: When coming on duty; when hands are visibly soiled; before and after direct resident contact; before and after eating or handling food; before and after assisting a resident with meals; after handling soiled equipment or utensils; after removing gloves or aprons. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for the following situations: before and after direct contact with residents; after contact with objects in the immediate vicinity of the resident; and after removing gloves. The use of gloves does not replace hand washing/hand hygiene.