**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.04(B)(ii)Licensure Reference Number 175 NAC 12-006.04(B)(ii)(1) Based on record review and interview, the facility failed to ensure 2 of 5 sampled nurse aides (NA) completed the required 12 hours of ongoing training annually and failed to ensure 5 of 5 sampled NAs had completed 4 hours of Alzheimer's care and dementia care training annually. This had the potential to affect all residents who reside within the facility. The facility census was 42. Findings Are: A record review of a facility document [NAME] Care Center Employee Hire and Release Dates dated 9/7/2025 revealed the following:-NA-C was hired on 6/25/2024,-NA-D was hired on 5/9/2024,-NA-E was hired on 8/10/2023,-NA-F was hired on 7/17/2023, and -NA-G was hired on 7/10/2019. A.A record review of a facility provided document Employee Training Tracker for NA-F for the timeframe of 7/10/2024-7/10/2025 revealed NA-F had completed 8 hours of ongoing training. A record review of a facility provided document Employee Training Tracker for NA-G for the timeframe of 7/17/2024-7/17/2025 revealed NA-G had completed 1 hour of ongoing training. An interview on 9/9/2025 at 9:55 AM with the Director of Nursing (DON) confirmed NA-F and NA-G had not completed the required 12 hours of ongoing training annually. B.A record review of a facility provided document Employee Training Tracker for NA-C for the timeframe of 6/25/2024 through 6/25/2025 revealed NA-C had not completed any Alzheimer's care or dementia care training. A record review of a facility provided document Employee Training Tracker for NA-D for the timeframe of 5/9/2024 through 5/9/2025 revealed NA-D had not completed any Alzheimer's care or dementia care training. A record review of a facility provided document Employee Training Tracker for NA-E for the timeframe of 8/10/2024 through 8/10/2025 revealed NA-E had not completed any Alzheimer's care or dementia care training. A record review of a facility provided document Employee Training Tracker for NA-F for the timeframe of 7/17/2024 through 7/17/2025 revealed NA-F had not completed any Alzheimer's care or dementia care training. A record review of a facility provided document Employee Training Tracker for NA-G for the timeframe of 7/10/2024 through 7/10/2025 revealed NA-G had not completed any Alzheimer's care or dementia care training. An interview on 9/9/2025 at 9:55 AM with the Director of Nursing (DON) confirmed NA-C, NA-D, NA-E, NA-F, and NA-G had not completed the required 4 hours of Alzheimer's care and dementia care training annually.

Licensure Reference Number 175 12-006.02(H) Based on record review and interviews, the facility failed to report an allegation of abuse as per regulatory requirements. This had the potential to affect all residents. The facility identified a census of 45. Findings Are: A record review of the facility's undated Abuse Policy revealed the following: External Reporting: -Intitial reporting of allegations: If an incident or allegation is considered reportable the Administratior or designee will make initial (immediate or within 24 hours) report to the State Agency. A follow up investigation will be submitted to the State Agency within 5 working days. A record review of an Investigative Summary that concluded on 04/28/2025 revealed no documented evidence of abuse allegations being reported to the State Agency. The investigation revealed that the Director of Nursing (DON) was notified on 4/25/25 of an event that occurred on 4/19/25 regarding allegations of abuse from LPN-E to Resident 4 and Resident 3. The investigation revealed that LPN-E was observed speaking firmly to Resident 4 and said a curse word to Resident 3 after Resident 3 said the same curse word to LPN-E. The summary went on to detail interviews with two staff in which one recalled hearing LPN-E talking loudly to Resident 4 and it made them come out of the bath house. The other staff denied that LPN-E was verbally abusing residents and that LPN-E was educating Resident 4 to quit being rude/mean to staff. That staff member denied that LPN-E said a curse word to Resident 3 but rather told them not to say that. The DON detailed a phone call to LPN-E who denied verbally abusing Resident 3 and 4 and stated they were sternly educating them not to talk rudely/bad to the staff. The DON revealed that LPN-E was educated that if they were talking/yelling at the residents that they needed to slow down and have more patience with them and talk to them with respect. An interview with the Director of Nursing (DON) on 06/16/2025 at 2:30 PM revealed they were aware of a incident involving a nurse and a resident that occurred on 04/19/2025. The DON stated they were aware that LPN-E has had numerous complaints lodged against them in the past and thought perhaps it was LPN-E 's personality. The DON confirmed that LPN- E is their sibling and stated because of that fact, all disciplinary action taken on LPN-E went through the administrator. The DON went on to reveal that they were made aware of the 04/19/2025 incident on 04/25/2025 by the former nursing home administrator (FNHA) who instructed them to investigate the allegations. The DON stated they performed several interviews and all said nothing happened. The DON stated they turned their documented finding to the FNHA for review. The DON confirmed the allegations of abuse were not reported to the State Agency and stated it was not reported because nothing happened. An interview with the Nursing Home Administrator (NHA) on 06/16/2025 at 4:30 PM revealed that at present there is no documentation for the investigation that the DON stated took place on 04/25/2025 but they would continue to look. The NHA confirmed that the incident had not been reported to the State Agency, and it should have been.

Based on record review and interviews, the facility failed to implement policies and procedures to prevent the potential for further abuse to occur during the investigation of abuse allegations. This had the potential to affect all residents. The facility identified a census of 45. Findings Are: A record review of an undated facility Abuse Policy revealed no documented evidence regarding procedures for how residents would be protected from further abuse while allegations of abuse were investigated, as per regulatory requirements. The policy revealed the facility was to include how the residents were protected in the report to the State Agency. A record review of an Investigative Summary dated 4/25/25 revealed no documented evidence of how residents were protected during investigative process. The summary describes the Director of Nursing's (DON) interviews with staff and effected residents regarding an incident that occurred on 4/19/2025 involving Licensed Practical Nurse (LPN-E) and Residents 3 and 4. The DON further revealed that LPN-E was called on the phone regarding the incident and was questioned. The date and times of these interviews was not observed on the summary. The summary concluded by saying that LPN-E was educated that when they are talking/yelling at residents they needed to slow down and have more patience with them and talk to them with respect. An interview with Nurse Aide (NA)-A, on 06/16/2025 at 12:30 PM revealed NA-A had concerns involving an incident they witnessed in April 2025. NA-A stated they were giving a bath down the 300 hall, with the water running when they heard their nurse, LPN-E yelling at a resident clear down the hall, NA-A stated that even the resident they were bathing heard it and asked what was going on. NA-A further revealed they heard LPN-E yelling at a resident that they needed to respect the staff. NA-A confirmed they reported their concerns to the registered nurse on shift who stated they had heard it too and would take care of it. An interview with the Director of Nursing (DON) on 06/16/2025 at 2:30 PM revealed they were aware of a incident involving a nurse and a resident that occurred on 04/19/2025. The DON stated that on 4/25/2025 they performed several interviews and all said nothing happened. The DON stated they turned their documented findings to the Nursing Home Administrator (NHA) for review. The DON confirmed the alleged employee had not been suspended during the investigation because nothing happened. An interview with the Nursing Home Administrator (NHA) on 06/16/2025 at 4:30 PM revealed that at present there is no documentation for the investigation that the DON stated took place on 04/25/2025 but they would continue to look.The NHA stated they would look into whether or not the employee was suspended during the course of the investigation. An interview with NHA on 06/16/2025 at 5:15 PM revealed that they were able to find the investigation summary and stated they reached out to the staff who were interviewed on 04/25/2025 to re-obtain their statements. The NHA presented three statements from employees that were dated 06/16/2025 and further presented the investigation summary. The NHA states according to the schedule LPN-E was not scheduled to work from 04/25/2025 through 04/28/2025 and confirmed this was the facility's original schedule and that LPN-E was not formerly placed on suspension pending the investigation.

Licensure Reference Number 175 12-006.02(H) Based on record review and interviews, the facility failed to protect residents from further potential abuse during an investigation of alleged violations of abuse as per regulatory requirements. This had the potential to affect all residents. The facility identified a census of 45. Findings Are: A record review of a facility undated Abuse Policy revealed the following: The facility must include the following investigative components- -Have evidence that all investigative components have been thoroghly investigated. -Prevent further abuse, neglect, exploitation, or mistreatment while the investigation is in progress. An interview with the Director of Nursing (DON) on 06/16/2025 at 2:30 PM revealed they were aware of an incident involving a nurse and a resident that occurred on 04/19/2025. The DON stated they were aware that LPN -E has had numerous complaints lodged against them in the past and thought perhaps it was LPN-E ' s personality. The DON confirmed that LPN-E is their sibling and stated because of that fact, all disciplinary action taken on LPN-E went through the Former Nursing Home Administrator (FNHA). The DON went on to reveal that they were made aware of the 04/19/2025 incident on 04/25/2025 by the FNHA who instructed them to investigate the allegations. The DON stated they performed several interviews and all said nothing happened. The DON stated they turned their documented finding to the FNHA for review. The DON confirmed the alleged employee had not been suspended during the investigation because nothing happened. Regarding access to residents, the DON revealed that while on shift LPN-E had the potential to provide care for all residents in the building but was formerly assigned to half the building. An interview with the Nursing Home Administrator (NHA) on 06/16/2025 at 4:30 PM revealed that at present there is no documentation for the investigation that the DON stated took place on 04/25/2025 but they would continue to look. An interview with NHA on 06/16/2025 at 5:15 PM revealed that they were able to find the investigation summary and stated they reached out to the staff who were interviewed on 04/25/2025 to re-obtain their statements. The NHA presented three statements from employees that were dated 06/16/2025 and further presented the investigation summary. The NHA stated that according to the schedule LPN-E was not scheduled to work from 04/25/2025 through 04/28/2025 and confirmed this was the facility's original schedule and that LPN-E was not placed on suspension pending the investigation.

Licensure Reference Number 175 NAC 12-006.09 Based on record review and interview; the facility failed to monitor 1 (Resident 2) of 2 sampled resident's blood pressure while the resident was taking medications used to treat hypertension (elevated blood pressure). The facility census was 43. The Findings Are: A record review of a facility document provided by the Director of Nursing (DON) titled admission Check Off List revealed that if a resident was taking a blood pressure medication, staff must put an order in for weekly vital signs and medications must have parameters. A record review of Resident 2's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning), dated 6/27/24 revealed Resident 2 had a diagnosis of hypertension. A record review of Resident 2's Physician's Orders revealed the following medications: -Amlodipine Besylate (a calcium channel blocker used to treat high blood pressure and chest pain) 5 milligrams (MG) twice a day for blood pressure management and angina symptoms. -Lisinopril (an ACE inhibitor used to treat high blood pressure and heart failure) 5 MG once a day for blood pressure management. A record review of the Vitals section of Resident 2's electronic medical records (EMR) revealed the following blood pressures: -On 2/15/2024 at 2:49 AM a blood pressure of 110/60. -On 2/15/2024 at 9:43 AM a blood pressure of 121/60. -On 2/15/2024 at 10:36 PM a blood pressure of 118/64. -On 2/16/2024 at 12:36 PM a blood pressure of 124/68. -On 2/16/2024 at 11:06 PM a blood pressure of 118/62. -On 2/17/2024 at 2:22 PM a blood pressure of 124/64. -On 2/17/2024 at 10:27 PM a blood pressure of 118/74. -On 2/18/2024 at 9:00 AM a blood pressure of 114/76. -On 2/18/2024 at 9:55 PM a blood pressure of 118/72. -On 2/19/2024 at 10:24 AM a blood pressure of 124/64. -On 2/20/2024 at 1:24 AM a blood pressure of 111/60. -On 2/20/2024 at 10:33 AM a blood pressure of 114/67. -On 2/20/2024 at 9:48 PM a blood pressure of 116/70. -On 2/24/2024 at 7:01 AM a blood pressure of 122/78. A record review of Resident 2's Progress Note dated 2/29/24 revealed a blood pressure of 47/34. The progress note also revealed the resident was admitted to the hospital on this date. A record review of Resident 2's paper Physician's Order sheet in Resident 2's hard chart (a binder containing medical records on paper) dated 3/22/24 revealed a blood pressure of 122/78. A record review of Resident 2's hard chart revealed a document faxed to Resident 2's primary care provider (PCP) dated 3/23/24 regarding the resident having a fall, revealed a blood pressure of 106/54. A record review of the Vitals section of Resident 2's EMR (electronicl medical record) dated 3/23/2024 revealed a blood pressure of 97/62. A record review of Resident 2's paper Physician's Order sheet in Resident 2's hard chart dated 5/23/24 revealed a blood pressure of 97/62. A record review of Resident 2's PCP documentation in their hard chart dated 6/18/24 revealed a blood pressure of 123/78. A record review of the Vitals section of Resident 2's EMR revealed the following blood pressures: -On 6/18/2024 at 11:48 PM a blood pressure of 92/70. -On 6/19/2024 at 8:44 AM a blood pressure of 125/81. -On 6/20/2024 at 12:59 AM a blood pressure of 92/72. -On 6/20/2024 at 9:07 AM a blood pressure of 116/78. -On 6/20/2024 at 11:57 PM a blood pressure of 120/65. -On 6/21/2024 at 10:39 AM a blood pressure of 134/66. -On 6/21/2024 at 11:50 PM a blood pressure of 118/70. -On 6/22/2024 at 9:55 AM a blood pressure of 122/67. -On 6/22/2024 at 11:41 PM a blood pressure of 126/68. -On 6/23/2024 at 2:29 PM a blood pressure of 113/65. -On 6/24/2024 at 1:00 AM a blood pressure of 112/75. -On 6/24/2024 at 12:31 PM a blood pressure of 101/70. -On 6/24/2024 at 11:27 PM a blood pressure of 83/52. -On 6/25/2024 at 7:46 AM a blood pressure of 100/55. A record review of Resident 2's Progress Notes revealed the following blood pressures: -On 7/9/24 a blood pressure of 70/42. -On 7/29/24 a blood pressure of 133/94. A record review of Resident 2's paper Physician's Order sheet in Resident 2's hard chart dated 7/30/24 revealed a blood pressure of 100/55. A record review conducted on 8/13/24 of Resident 2's EMR and hard chart revealed there were no additional blood pressure readings in the prior 6 months. An interview on 8/13/24 at 8:36 AM with the Director of Nursing (DON) confirmed that if a resident was taking a blood pressure medication, the facility obtained a blood pressure at least weekly unless the resident's provider ordered it more frequently. The DON confirmed that Resident 2 did not have an order for a weekly blood pressure and should have since Resident 2 was taking blood pressure medications. The DON also confirmed that Resident 2 had not had their blood pressure checked on a weekly basis. A follow up interview on 8/13/24 at 9:15 AM with the DON confirmed that no order had been implemented for weekly vital signs for Resident 2 per the requirements of the facility's admission Check Off List document.

Licensure Reference 12-006.12(A)(vi) Based on record reviews and an interview; the facility failed to ensure the pharmacist had identified irregularities during their monthly medication regimen review (MRR, a monthly review of a resident's medications by a licensed pharmacist to minimize or prevent adverse consequences or to prevent residents from receiving unnecessary medications) for 1 (Resident 37) of 5 sampled residents. The facility identified a census of 43. Findings are: A record review of a facility policy Medication Regimen Reviews with a last revised date of April 2007, revealed no information regarding identifying irregularities regarding regulatory requirements. A record review of an admission Record indicated the facility admitted Resident 37 on 12/26/2023 with an admitting diagnosis of dementia, Alzheimer's disease, and Major Depressive Disorder. A record review of Resident 37's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) with an Assessment Reference Date of 7/28/2024 revealed Resident 37 had a Brief Interview for Mental Status score of 4/15, which indicated Resident 37 had severe cognitive impairment. A record review of Resident 37's Order Summary revealed an order for PRN (as needed) Ativan with a start date of 2/7/2024 and did not have a stop date. A record review of Resident 37's Monthly Medication Regimen Reviews revealed the following: - 3/2024 - No irregularities identified by the pharmacist - 4/2024 - No irregularities identified by the pharmacist - 5/2024 - No irregularities identified by the pharmacist - 7/2024 - No irregularities identified by the pharmacist - 8/2024 - No irregularities identified by the pharmacist An interview on 8/12/2024 at 9:05 AM with the Pharmacist confirmed an irregularity of Resident 37's Ativan without a stop date should have been identified.

Licensure Reference 175 NAC 12-006.09(H)(vi) Based on record reviews and interview; the facility failed to ensure a PRN (as needed) psychotropic medication (a medication to treat mental illnesses) had a stop date for 1 (Resident 37) of 5 sampled residents. The facility identified a census of 43. Findings are: A record review of a facility policy Use of Psychotropic Medications with a last reviewed date of 1/1/2024 revealed the following: - PRN orders for all psychotropics drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days.) - If the attending physician believes that is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. A record review of an admission Record indicated the facility admitted Resident 37 on 12/26/2023 with an admitting diagnosis of dementia, Alzheimer's disease, and Major Depressive Disorder. A record review of Resident 37's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) with an Assessment Reference Date of 7/28/2024 revealed Resident 37 had a Brief Interview for Mental Status score of 4/15, which indicated Resident 37 had severe cognitive impairment. A record review of Resident 37's Order Summary revealed an order for PRN Ativan with a start date of 2/7/2024 and did not have stop date. An interview on 8/12/2024 at 8:36 AM with the Director of Nursing confirmed Resident 37's PRN Ativan order did not have a stop date and confirmed it should have a duration or stop date for use.

B. A record review of an undated facility policy Infection Control - Enhanced Barrier Precautions - Personal Protective Equipment (PPE) of a gown and gloves are required during urinary catheter care. A record review of a facility policy Handwashing/Hand Hygiene with a last revised date of August 2014 revealed alcohol-based hand rub should be used after removing gloves. An observation on 8/12/2024 at 2:50 PM of Nurse Aide (NA) - D provide urinary catheter cares to Resident 40. NA-D performed hand hygiene then donned (put on) a pair of gloves. NA-D then removed [gender] gloves, drew the curtain for privacy and explained the procedure to Resident 40. No hand hygiene was performed after NA-D removed their gloves. NA-D then applied a new pair of gloves and a gown. NA-D tied their gown around the back of [gender] neck, touching [gender] hair. NA-D then removed gloves without performing hand hygiene after. NA-D then removed a paper towel inside a graduate cylinder, placing the paper towel in the trash can, touching [gender] glove to the trashcan. NA-D proceeded to catheter cares, during the cares, NA-D's gown began to fall off, exposing [gender] clothes to the urinary catheter care area. NA-D removed [gender] gloves without performing hand hygiene and retied [gender] gown in the back, finishing catheter cares. An interview on 8/12/2024 at 3:01 PM with NA-D confirmed hand hygiene should be completed between changing of gloves and confirmed contamination of their clothes and urinary catheter area due to gown not being donned properly. C. An observation on 8/8/2024 at 11:15 AM of Registered Nurse (RN) - A preparing to administer insulin to Resident 12. RN-A donned gloves then touched the computer lid to close it, knocked on the door, and used the door handle to open the door, contaminating [gender] gloves. RN-A then administered insulin to Resident 12 without first changing the contaminated gloves. An interview on 8/8/2024 at 11:20 AM with RN-A confirmed touching door handles and other dirty surfaces would contaminate their gloves. Licensure Reference Number 175 NAC 12-006.18 Based on observations, interviews, and record review; the facility failed to utilize enhanced barrier precautions as required when assisting with personal cares for Residents 3 and 40, and failed to ensure staff did not continue to utilize gloves after they were contaminated during medication administration for Resident 12. The facility census was 43. The Findings Are: A. A record review of an undated facility policy Infection Control-Enhanced Barrier Precautions revealed that the facility would implement enhanced barrier precautions (EBP) during high-contact resident care activities when caring for residents that had an increased risk for acquiring a multi-drug resistant organism, such as residents with wounds. The policy stated that high contact care activities included dressing, transferring, changing briefs, and wound care. Personal protective equipment of a gown and gloves were required for all staff performing the high contact care activities. A record review of Resident 3's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning), dated 7/29/24 revealed Resident 3 had a stage 4 (Full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer to their right buttock and was dependent on staff for toileting hygiene, dressing, bed mobility, and transfers. A record review of Resident 3's Care Plan revealed Resident 3 was on EBP due to having a suprapubic urinary catheter and a wound. The Care Plan stated to follow standard of practice for EBP and that instructions & supplies were outside of the resident's room. An observation on 8/12/24 at 3:40 PM revealed Centers for Disease Control (CDC) EBP signage outside Resident 3's room doorway and hanging above Resident 3's bed. Nurse Aide (NA)-F was standing next to Resident 3's bed wearing gloves and holding Resident 3, so the resident was positioned on their left side while RN-A performed wound care to Resident 3's pressure ulcer on their right buttock. NA-F then assisted Registered Nurse (RN)-A to apply a new incontinence brief and reposition the resident in their bed after the cares were completed. A record review of the CDC's EBP signage revealed that providers and staff must wear gloves and a gown for high-contact resident care activities. The signage included dressing, transferring, providing hygiene, changing briefs, and wound care in the list of high-contact resident care activities. An interview on 8/12/24 at 4:03 PM with NA-F confirmed that NA-F did not wear a gown while assisting with Resident 3's cares. NA-F confirmed that they were aware Resident 3 was on EBP, but NA-F stated they did not think they needed to wear a gown when assisting with Resident 3's cares.

LICENSURE REFERENCE NUMBER NAC 175 12-006.11(E) Based on observations, interviews, and record review; the facility failed to ensure foods were date-marked or labeled with their common names and failed to dispose of or consume foods within seven days as required to prevent the potential for food-borne illness. This had the potential to affect all 43 residents who resided within the facility and were served out of the kitchen. Findings are: A. A record review of the 2017 Nebraska Food Code revealed in section 3-602.11(C)(1) and (2) that bulk foods which are available for consumer self-dispensing shall be prominently labeled with the manufacturer's or processor's label that was provided with the food or a card, sign, or other method of notification that includes the required information. An observation on 8/7/24 from 7:40 AM to 7:55 AM during the initial kitchen tour revealed the following: -In the greater kitchen area, four large plastic bins with open lids, labeled only with paper taped on each lid reading, thick-it, cornstarch, flour, and sugar. -In the dry storage room, four sealed plastic bags containing a red liquid approximately one gallon each with a handwritten date in black marker on each bag. None of the bags had a label indicating what the red liquid was. An interview on 8/7/2024 at 9:55 AM with the Certified Dietary Manager (CDM) confirmed the thick-it, cornstarch, flour, and sugar observed during the initial kitchen tour should have been dated with an open and use by date. This interview also confirmed that the four plastic bags of red sauce only had a received by date written on them and lacked any additional identification. An observation on 8/12/24 at 9:05 AM of the walk-in freezer revealed four clear plastic bags of an unidentified meat product with an illegible handwritten date in black marker, with no other identifying information. There were 5 additional plastic bags with breaded food product on the same shelf labeled in the same fashion. An interview on 8/12/24 at 9:05 AM with Cook-B revealed that dietary staff takes the bags out of the boxes when they arrive from the vendor, write the received-by date on the bags, and put the bags on the shelves in the freezer. Cook-B stated that the four clear plastic bags contained cooked diced chicken and confirmed the bags were not labeled with that information. An interview on 8/12/24 at 12:45 PM with the CDM confirmed the bags of unidentified frozen meat products were labeled only with received by dates and lacked any additional identification. B. A record review of the 2017 Nebraska Food Code revealed in section 3-501.17 that ready-to-eat, time/temperature-controlled foods should be clearly marked to indicate the date or day by which the food should be consumed or discarded, which is a maximum of 7 days. The date of preparation should be counted as day 1. An observation on 8/12/24 at 10:17 AM revealed Cook-B was preparing a salad that included lettuce and shredded cheese from a mobile salad station for a staff member. The mobile salad station held containers of lettuce, onion, and shredded cheese that were each dated 8/5/24 as well as a container of pickles that was dated 7/27/24. An interview on 8/12/24 at 10:17 AM with Cook-B confirmed the four items (lettuce, onion, shredded cheese, and pickles) were more than seven days old. An interview on 8/12/24 at 11:38 AM with the CDM confirmed that the four items (lettuce, onion, shredded cheese, and pickles) were more than seven days old and needed to be removed from the mobile salad station.

Licensure Reference Number 175 NAC 12-007.04D Based on record review, observation, and interview; the facility failed to ensure that the ventilation system was operational in resident's bathrooms on 100, 200, and 300 wings. This had the potential to affect all 43 residents who resided within the facility. Findings are: A record review of a policy Maintenance Service with a last revised date of December 2009 revealed function of maintenance personnel include maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. An observation on 8/8/2024 at 9:29 AM revealed a strong odor of bowel movement in the 100 wing. An observation on 8/8/2024 at 9:45 AM with the Administration and Maintenance Personnel (MP) - E revealed rooms 101,104, 111, 200, 300, and 301 were not functional and would not draw a 1-ply square of toilet paper to the surface of the ventilation cover. An interview on 8/8/2024 at 10:00 AM with the Administrator and MP-E confirmed that the ventilation system for 100, 200, and 300 wing were not functional, confirming all residents would be affected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.06B Based on observations, interviews, and record review, the facility failed to follow up on a complaint regarding wheelchair equiptment for 1 (Resident 4) of 1 sampled residents. The facility identified a census of 48 residents at the time of the survey. Findings are: Record review of Resident 4's Face Sheet dated 5/11/2020 revealed the resident admitted on [DATE] with the diagnosis of Quadriplegia, C1- C4 Incomplete. Record review of Resident 4's Minimum Data Set (MDS) (an assessment completed to determine cares needed for the resident) dated 7/25/2023 revealed in Section C: the Brief Interview for Mental Status (BIMS) showed a score of 12 which indicates the resident was cognitively intact. In Section G: functional status showed Resident 4 needed extensive assistance and two-person physical assist in bed mobility, total dependence with a two-person physical assist for transfers and total dependence with a two-person assist for toileting. An interview on 09/20/2023 at 7:55 AM with Resident 4 revealed Resident 4's electric mobility wheelchair was broken and reported to Social Work (SS) with no resolution. Resident 4 revealed this was reported months ago. Resident 4 did not feel safe with the broken wheelchair. An observation on 9/20/2023 at 7:55 AM of Resident 4's electric mobility wheelchair revealed the right arm panel moved away from the wheelchair sideways about 4 inches, the left arm panel moved slightly sideways away from the wheelchair. The padding on Resident 4's foot pedals was secured with brown Coban that was unraveling and gray to black in color. An observation on 9/25/2023 at 1:30 PM of Resident 4's wheelchair revealed padding on foot pedals secured with brown Coban which was gray to black in color and unraveling. An observation on 9/25/2023 at 1:40 PM revealed Nurse Aid (NA-H) and Nurse Aide/Medication Aide (NA/MA-1) transferred Resident 4 from wheelchair to bed and the right arm on electric mobility wheelchair moved as Resident 4 was transferred out of the wheelchair. An interview on 9/25/2023 at 2:10 PM with the Administrator revealed Resident 4 was on a payer source that did not allow Resident 4 to get a new wheelchair at this time. The Administrator stated if the facility staff were unable to fix Resident 4's wheelchair, the storage would be checked. An interview on 9/25/2023 at 3:30 PM with Licensed Practical Nurse (LPN-A) confirmed that Coban should not be used on wheelchairs as the surface is uncleanable. LPN-A revealed that wheelchairs are fixed by maintenance in the facility if able. LPN-A further revealed that if Resident 4's chair was unable to be fixed therapy services would be involved to find a new wheelchair for the resident. An interview on 9/25/2023 at 4:00 PM with Social Serivces (SS) confirmed that Resident 4 had spoken with SS about the broken wheelchair. SS reported it to the Administrator but did not follow up with Resident 4. An interview on 9/25/2023 at 4:15 PM with DON confirmed Coban not a washable surface. Coban will unravel and should not be used to secure items on wheelchairs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05(8) Based on observations, record review, and interviews; the facility failed to identify a body pillow secured under a fitted sheet and placed along the edge of the bed as a potential restraint for 1 resident (Resident 12). The facility staff identified a census of 47 at the time of the survey. Findings are: An observation in Resident 12's room on 09/20/2023 at 9:29 AM revealed the resident lying in bed on their right side with their eyes closed and hollering lightly, Help, help, help. The lights were off in the room, the curtains were closed, a radio was playing, the bed was in a low position, a floor mat was on the floor next to the bed, and there was a camera sitting on the dresser facing the resident's bed. There was what appeared to be a body pillow tucked under a fitted sheet on the left side of the resident's bed and the right side of the bed was against the wall. An observation in Resident 12's room on 9/20/2023 at 3:03 PM revealed the resident was lying in bed on their right side with their eyes closed. A large mound was observed along the edge of their bed, on the left side. A grey body pillow was protruding from underneath the fitted sheet that was on Resident 12's bed. An observation in Resident 12's room on 09/21/2023 at 11:23 AM revealed Resident 12 lying in bed on their left side. A body pillow was observed tucked under the fitted sheet and along the mattress on the left side. A scoop mattress and an alarm pad were also visible underneath Resident 12. An observation in Resident 12's room on 9/21/2023 at 11:40 AM revealed Resident 12 lying in bed. RN-E and NA/MA-J were preparing to reposition and change the resident. NA/MA-J had removed a grey body pillow from underneath the fitted sheet that was lying along the left side and edge of the resident's bed and placed it on a chair in the room so they could turn and provide cares to Resident 12. A record review of Resident 12's admission Record revealed the resident admitted to the facility on [DATE]. The Adminission Record revealed Resident 12 had diagnoses of dementia in other diseases classified elsewhere, severe, with agitation, and Alzheimer's Disease with late-onset. A record review of Resident 12's Treatment Administration Record (TAR) with the dates of 9/1/2023-9/30/2023 revealed there was not a physician's order for a body pillow to be secured underneath the bed sheets to secure the resident in bed. A record review of Section P Restraints and Alarms of Resident 12's Minimum Data Set (MDS-a comprehensive assessment tool used to develop a resident's Care Plan) revealed Physical restraints were not being utilized. Letter C Limb restraint had a zero in the box with a code that they are not used. A record review of Resident 12's Care Plan (CP) revealed section A had a revision date of 9/12/2023 revealing the resident's cognition was severely impaired. Section D had a revision date of 12/20/2022 revealing Resident 12 was at risk for falls. There was an intervention for the use of body pillows but did not indicate the body pillow was to be tucked under the fitted sheet. An interview on 9/25/2023 at 5:25 PM with Medication Aide (MA)-K confirmed a grey body pillow was tucked under the sheet on the resident's bed and along the edge of the left side of the mattress. MA-K revealed [gender] was informed by a nurse that Resident 12 was a fall risk and to place a body pillow under the sheet to keep them from rolling out of the bed. MA-K revealed it was common practice at the facility and [gender] had seen a body pillow tucked under a fitted sheet being utilized for other residents who were at risk for falling. An Interview on 9/25/2023 at 5:36 PM with Nursing Assistant (NA)/MA-L revealed the Resident 12 had the following interventions in place to prevent them from falling: A scoop mattress; a body pillow that they tuck underneath their sheet on the bed so that the resident could not get over the bump when they roll; keep the resident's bed in low position; a lap buddy when in their wheelchair; an alarm in their bed and in their wheelchair; and a camera. An interview on 9/25/2023 at 6:05 PM with the Director of Nursing (DON) revealed they did not see a body pillow being secured under Resident 12's fitted sheet and along the edge of their bed as being considered a restraint. The DON had said Resident 12 had every intervention in place for the Resident to prevent them from falling (e.g., scoop mattress, fall matt, alarm pads, camera in the room, the use of body pillows, etc.). The DON confirmed Resident 12 was unable to move the secured body pillow if they wanted to. A record review of the facility's undated policy Mitchell Care Center Physical Restraints revealed the section titled Procedure, Number 1) Physical restraints are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restrict freedom of movement or normal access to one's body. Number 4) Physical restraints shall not be used to limit resident mobility for the convenience of staff. Number 5) Physician's orders must indicate the specific reason, type, and period of time for the use of restraints. Restraints must only be used as a last resort, and the medical record must indicate the events leading up to the necessity of the restraint. Number 11) The need for restraints will be re-evaluated at least quarterly to determine their continued need. Every effort will be made to eliminate their use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Referene Number: 175 NAC 12-006.05 (5) Based on record review and interview, the facility failed to notify the resident and/or the resident's representative in writing of a facility initiated transfer to the hospital for 1 (Resident 29) of 1 sampled residents. The facility identified a census of 47 residents at the time of the survey. Findings are: A record review of Resident 29's Face Sheet dated 9/25/2023 revealed Resident 29 was admitted to the facility on [DATE] with an admitting diagnosis of repeated falls. The Face Sheet also revealed Resident 29 had a Power of Attorney (POA)-Care. A record review of Resident 29's Progress Note dated 5/29/2023 at 7:13 AM revealed Resident 29 had been sent to the emergency room (ER) by the facility. A record review of Resident 29's Progress Notes did not reveal a written notifice of transfer was sent to Resident 29's representative. An interview on 9/25/2023 at 3:50 PM with SS revealed the facility does not notify the resident and/or their Representatives in writing of the reason for a facility-initiated transfers/discharges to the hospital.

Licensure Reference Number 175 NAC 12.006.17 Based on observations, interviews and record review, the facility failed to perform hand hygiene while providing direct resident care to 1(Resident 12) of 1 sampled residents. The facility census was 47. The Findings are: An observation in Resident 12's room on 9/21/2023 at 11:40 AM revealed Nursing Assistant/Medication Aide (NA/MA)-J and RN-E were preparing to reposition the resident and change their brief. Observation on 9/21/2023 at 11:40 AM revealed RN-E performed hand hygiene (HH) with soap and water for 8 seconds and had put gloves on. RN-E performed peri care (wiping the peri area with a moist disposable cloth) on Resident 12. RN-E did not change their gloves and had placed a clean brief on Resident 12. During the process of placing a clean brief on Resident 12, RN-E continued to wear soiled gloves and rolled Resident 12 from side-to-side, RN-E had touched the resident's bare legs, bare arms, bedding, and a draw sheet they were laying on as they placed the brief on them and repositioned the resident. RN-E then repositioned Resident 12's pillows. RN-E had the same soiled gloves throughout the duration of care. Observation on 9/21/2023 at 11:50 AM revealed RN-E had taken off the soiled gloves and washed their hands with soap and water for 9 seconds. An interview with RN-E on 9/21/2023 at 3:07 PM revealed hand hygiene should occur prior to donning gloves and after doffing gloves. RN-E further revealed they should wash their hands for a minimum of 20 seconds. RN-E confirmed they had not performed hand hygiene as required during care to Resident 12 on 9/21/2023 at 11:40 AM. A record review of the facility's policy, Handwashing/Hand Hygiene with a revised date of August 2015, revealed Number 7) Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and waster for the following situations: Number 7) b. Before and after direct contact with residents; g. Before handling soiled dressings, gauze pads, etc.; k. After handling used dressings; and m. After removing gloves. Number 9) The use of gloves does not replace handwashing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. The section, Washing Hands, Number 1) Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) under a moderate stream of water.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** D. A record review of Resident 51's Facesheet dated 9/26/23 revealed Resident 51 was admitted to the facility on [DATE] with a principal diagnosis of Myxedema Coma. Resident 51's Facesheet also revealed the resident had a Power of Attorney (POA)-Care. A record review of Resident 51's Progress Note dated 7/22/23 at 3:30 AM revealed Resident 51's POA was contacted via telephone and notified of Resident 51's current medical condition. The POA consented to the resident being sent to the Emergency Room. The Progress Note did not mention Resident 51 or their POA being notified of the facility bed holding policy. A record review of a Bed Holding Policy document dated 7/22/23 revealed a signature line with Unable to sign handwritten on it. There was no evidence on the document of Resident 51 or their POA being notified of the facility Bed Holding Policy at time of the resident's hospitalization. An interview on 9/25/2023 at 3:50 PM with SS revealed the facility does not notify the resident and/or their Representatives in writing of the reason for facility-initiated transfers/discharges to the hospital. The SS also confirmed that the facility staff writes unable to sign on the signature line of the Bed Holding Policy if the resident cannot sign the form independently. C. A record review of Resident 40's Facesheet dated 9/26/23 revealed Resident 40 was admitted to the facility on [DATE] and had a principal diagnosis of Urinary Tract Infection, Unspecified. Resident 40's Facesheet also revealed the resident had a Power of Attorney-Care. An interview on 9/20/23 at 3:48 PM with Resident 40 confirmed Resident 40 was hospitalized approximately two weeks ago. A record review of Resident 40's Progress Note dated 8/30/2023 at 12:22 PM revealed Resident 40 was sent to the emergency room (ER) per family request due to severe right leg pain and neck pain. The Progress Note also revealed the POA was aware of the transfer to the ER. The Progress Note did not mention Resident 40 or their POA being notified of the facility bed holding policy. A record review of Resident 40's Progress Note dated 8/30/2023 at 4:18 PM revealed Resident 40 was admitted to the hospital with a tibia/fibula (two bones in the lower leg) fracture. A record review of Bed Holding Policy dated 8/30/23 revealed the facility did not obtain a signature from Resident 40 or their POA. There was no evidence on the document of Resident 40 or their POA being notified of the facility Bed Holding Policy at time of the resident's hospitalization.Licensure Reference Number 175 NAC 12-006.05(5) Based on interviews and record reviews, the facility failed to provide notice to the residents and/or their Representatives of the Facility's Bed Holding Policy before facility-initiated transfers to the hospital. This failure affected 4 of 4 sampled residents (Resident 29, Resident 36, Resident 40, and Resident 51). The facility census was 47 at the time of the survey. The Findings are: A. A record review of Resident 29's Facesheet dated 9/25/2023 revealed they were admitted to the facility on [DATE] with an admitting diagnosis of repeated falls. The Facesheet also revealed Resident 29 had a Power of Attorney (POA)-Care. A record review of Resident 29's Progress Note dated 5/29/2023 at 7:13 AM revealed that Resident 29 had been sent to the emergency room (ER) by the facility. The facility did call Resident 29's Power of Attorney (POA) and informed them of the resident's health status and transfer to the ER. There was no documentation in the progress note of the POA being made aware of the facility's Bed Holding Policy. An interview on 9/25/2023 at 3:11 PM with Social Services (SS) revealed the facility did not have a Bed Holding Policy document for Resident 29's transfer to the ER and hospitalization on 5/29/2023. SS revealed that if the residents are unable to sign the bed-holding policy forms, the facility staff writes a note on the form that the POA was notified of the bed-holding policy. B. A record review of Resident 36's Facesheet dated 9/25/2023 revealed Resident 36 was admitted to the facility on [DATE] with a principal diagnosis of unspecified fall, initial encounter. Resident 36's Facesheet also revealed they had a Power of Attorney-Care. A record review of Resident 36's Progress Note dated 8/4/2023 at 7:51 AM revealed Resident 36 had an episode of shaking and then fell back in bed. Upon assessment, the resident was clammy and was not responding when the nurse called the resident's name. Resident 36's blood pressure and pulse were elevated. The nurse called their POA who stated they would like the resident to be seen. The nurse called the resident's physician and was instructed to send the resident to the Emergency Room. A record review of Resident 36's Progress Note dated 8/4/2023 at 12:35 PM revealed the resident was going to be admitted to Regional [NAME] Medical Center. A record review of the facility's Bed Holding Policy document for Resident 36's hospitalization on 8/4/2023 revealed x unable to sign was handwritten on the signature line of the document.

Licensure Reference Number 175 NAC 12-006.11E Based on observations, interview and record reviews, the facility failed to utilize proper hand hygiene practices during the preparation and serving of food to prevent the potential for foodborne illness. This had the potential to affect 46 of 47 residents who ate from the kitchen. Findings are: A. An observation on 9/21/2023 at 7:30 AM at the start of the breakfast meal service revealed Dietary Aide (DA-G) performed no hand hygiene prior to meal service. DA-G was observed grabbing plates and bowls with bare hands, placing fingers inside of the bowls and on top of the plates, sitting them down to fill with food and sending them out to the residents. DA-G then grabbed the menus and repeated the same process throughout breakfast food service. On one plate, eggs fell off onto the serving table, DA-G picked up the plate, placed thumb on the plate touching the eggs wtih bare hands and sent the plate out to a resident. When cleaning the egg off the serving table, a washcloth from the bucket containing the sanitizer was used then DA-G used a bare hand to wipe off the rest of the egg. No hand hygiene was performed throughout the breakfast meal service by DA-G. An observation on 9/21/2023 at 7:45 AM of Dietary Manager (DM) carrying a plate, that was picked up from the pass, with thumb on top of the plate and served it to the resident. B. An observation on 9/21/23 from 7:31 AM until 7:36 AM in the dining room during breakfast revealed the following concerns: The DM placed their bare thumbs on the top edge of Resident 43's and Resident 18's bowls that were filled with hot cereal and then went back to the serving window without having performed hand hygiene (HH) prior to getting another resident's plate. The DM then picked up another resident's plate and had their bare thumbs on the top edge/rim of the plate while delivering it to the resident's table, the DM then returned to the serving window and picked up a 4th resident's plate and had their bare thumbs on the top edge/rim of the plate and delivered it to the resident's table and then again returned to the serving window without the benefit of HH. Next, the DM retrieved a 5th resident's plate, placed it on the resident's table, placed their left fist on the table, touched the resident's left shoulder and then did not perform HH prior to going back to the serving window and getting a 6th resident's plate of food and placing their bare right thumb on the top rim of the resident's plate while delivering it to the resident. An observation on 9/21/23 at 8:01 AM in the dining room revealed Resident 10's plate was placed in front of them and the staff sitting beside the resident seasoned the resident's eggs per their request. The staff placed an egg on Resident 10's bread using a fork. The staff then picked up Resident 10's bread using their bare hand, folded the bread in half and handed it to the resident. Resident 10 took a bite and then handed the bread back to the staff. The staff took the bread with their bare hand, added more seasoning and then handed it back to the resident. An observation on 9/21/23 from 11:46 AM until 12:13 PM in the dining room during lunch revealed the following concerns: Residents 10 and 35 were assisted with eating by the same staff person. The staff used same the hand to feed both residents and did not perform HH between giving bites to each resident, MA-D wiped a resident's mouth with a napkin using their bare hand while the resident was coughing at the table, MA-D did not perform HH afterwards. Restorative/LPN was observed assisting two female residents with eating, used the same hand for both residents, and did not perform HH between giving bites to each resident. An observation on 9/21/23 from 12:05 PM until 12:17 PM in the dining room during lunch revealed the following concerns: The DM had placed their bare thumbs on Resident 17's bowl of dessert and another resident's plate and had not performed HH. The DM then returned to the serving window without first performing HH, retrieved a 3rd resident's plate and their bare thumb was on the top rim/edge of the plate next to the salad that was served to the resident. An interview on 9/25/2023 at 2:45 PM with Dietary Manager (DM) confirmed that staff received on the job training on how to carry plates and bowls. DM stated staff was trained to carry bowls and plates by the lip. Record review of the Nebraska Food Code taken from the 2017 recommendations of the United States Public Health Service, Food and Drug Administration with sections taken from the Pure Food Act and used as an authoritative reference for food service sanitation practices revealed the following: 1) 3-301.11 Preventing Contamination from hands. A)Food Employees shall wash their hands as specified under 2-301.12 2) 81-2,272.10 (Replaces 2017 Food Code 3-301.11 (B), (C), (D) and (E) Preventing Contamination from Hands revealed on (1) Food employees shall wash their hands as specified in the Nebraska Pure Food Act. Record review of the Assistance with Meals Policy dated 2001 and revised 10/19/2023 on Policy Interpretation and Implementation number 7) All employees who provide resident assistance with meals will be trained and shall demonstrated competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. Record review of the Food Preparation and Service Policy dated 2001 and revised on 10/2018 revealed under Policy Interpretation and Implementation section Food Preparation Area number 5) food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Record review of the Handwashing/Hand Hygiene Policy dated 2001 with a revision date of 8/2015 in the section Policy Interpretation and Implementation number 2) all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** License Reference Numbers 175 NAC 12-006.17B and 175 NAC 12-006.17D Based on observations, record review, and interviews; the facility failed to ensure 1) staff followed the facility policy for performing hand sanitization as required and 2) failed to ensure equipment was disinfected after residents' use. This had the potential to affect 18 of 46 residents. The facility identified a census of 46 residents at the time of the survey. Findings are: 175 NAC 12-006.17B Observation on 3/1/2023 of Certified Nursing Assistant (NA)-1 on the 100 Hallway at 3:30 PM revealed NA-1 had carried a bag of soiled linen to the laundry room, removed gloves, entered room [ROOM NUMBER], removed a Full lift, and a bag of trash. NA-1 had parked the lift in the 100 hallway. NA-1 discarded a bag of trash in the 100 Hall soiled utility room. NA-1 did not sanitize the full lift after a resident's use and had not performed hand sanitization before entering room [ROOM NUMBER] A to answer the resident's call light. An interview with NA-1 on 3/1/2023 at 3:53 PM confirmed the Aide had not completed hand sanitization as required before and after resident cares and in-between resident cares. NA-1 further confirmed they had not sanitized the Full lift after a resident's use. An interview with the Infection Control Nurse on 3/1/2023 at 4:12 PM revealed lifts and sit-to-stands were to be cleaned with sanitizing wipes in-between residents' use. Night shift facility staff were to be Deep cleaning the lifts weekly. The sanitizing wipes are in the Hopper rooms. Continued interviews with the Infection Control Nurse revealed they had started completing one on one audits with agency staff when they first start working in the facility but could not provide evidence that an audit had been completed with NA-1. A review of the facility policy, Cleaning and Disinfection of Resident-Care Items and Equipment with a revised date of July 2014, revealed number 1) d. Reusable items are cleaned/disinfected or sterilized between residents (e.g., durable medical equipment). Number 3) Durable medical equipment (DME) must be cleaned and disinfected before being reused by another resident. 175 NAC 12-006.17D Observation on 3/1/2023 of Certified Nursing Assistant (NA)-1 on the 100 Hallway at 3:30 PM revealed the following: -NA-1 had not performed hand hygiene upon entering room [ROOM NUMBER]. NA-1 had turned the call light off. The resident had requested to be changed as the resident was saturated with urine. -NA-1 had removed the resident's blanket, removed a pair of pants and a shirt from the resident's closet, and placed them in the bathroom. -NA-1 had washed their hands in the resident's bathroom sink with soap and water for four seconds. NA-1 assisted the resident to the bathroom. NA-1 applied gloves, assisted the resident with removing clothes, and cleaned the resident's skin. NA-1 removed the gloves, assisted the resident with changing their clothes, placed soiled linens in a bag, and placed the trash in another bag. NA-1 had exited room [ROOM NUMBER] without performing hand hygiene and walked to the supply closet that was located next to the nurse's station. -NA-1 had keyed in the door code, entered the storage room, retrieved a package of briefs, and returned to the bathroom in room [ROOM NUMBER]. The resident had requested a new, Soaker pad for their recliner as the other one was wet. NA-1 removed the soiled pad from the recliner with bare hands and placed it in the bag with soiled linens. NA-1 had not performed hand hygiene before exiting room [ROOM NUMBER]. NA-1 had entered the 100 Hallway clean linen closet without performing hand sanitization and retrieved a clean soaker pad. NA-1 had re-entered room [ROOM NUMBER] and hand sanitization had not been performed. The resident had been assisted back to their recliner and NA-1 had readjusted the resident's blanket and placed it on them. NA-1 did not perform hand hygiene but applied gloves before placing loose linens and trash in plastic bags. NA-1 had removed their gloves, grabbed the top edge of a soiled brief, and placed it into a trash bag. NA-1 did not perform hand hygiene before or after exiting room [ROOM NUMBER]. NA-1 discarded the trash bag in the soiled utility room in the 100 hallway and walked up the hallway to the laundry room and placed the bag of soiled linens in a cart. NA-1 did not perform hand hygiene. -NA-1 had walked through the dining room doorway where there was a kitchenette and was going to get a cup of milk for the resident in room [ROOM NUMBER] A. Hand hygiene had not been performed up to that point, so the task was not completed at that time. An interview with NA-1 on 3/1/2023 at 3:53 PM confirmed the Aide had not completed hand sanitization as required before and after resident cares and in-between resident cares. NA-1 further confirmed they had not sanitized the Full lift after a resident's use. NA-1 revealed they had been working at the facility for almost eight weeks and was a traveling NA. NA-1 explained they had been a NA for twelve years. An Interview with NA-1 on 3/1/2023 at 5:26 PM revealed they had not been audited or trained in handwashing or any other care areas. An Interview with the Administrator on 3/1/2023 at 5:33 PM revealed the facility goes by the training the agency had provided the contracted staff for orientation and competency for NAs. The facility only provides bathtub training to agency staff. A review of the facility policy, Handwashing/Hand Hygiene with a revised date of August 2015, revealed number 2) All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; 7) Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following: b. Before and after direct contact with residents and m. after removing gloves. Number 9) The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Under the section, Washing Hands number 1) Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds or longer. Under the section, Applying and Removing Gloves number 1) Perform hand hygiene before applying non-sterile gloves. A review of the facility policy, Personal Protective Equipment-Gloves with a revised date of July 2009, revealed number 3) The use of disposable gloves is indicated: d. When handling soiled linen or items that may be contaminated and number 8) Wash your hands after removing gloves. A review of the facility policy, Personal Protective Equipment-Gloves with a revised date of July 2009, revealed number 3) The use of disposable gloves is indicated: d. When handling soiled linen or items that may be contaminated and number 8) Wash your hands after removing gloves.

Licensure Reference Number: 175 NAC 12-006.05 (4) Based on record reviews and interviews, the facility failed to ensure that bathing was provided as scheduled or requested for two current sampled residents (Residents 30 and 29). The facility census was 47 with 15 current sampled residents. Findings are: A. Review of the weekly bathing schedule, dated 7/14/22 - 7/24/22, revealed that Resident 30 was scheduled for routine bathing on Tuesdays and Saturdays. Review of the Documentation report, dated July 2022, revealed that the resident received a bath on 7/12/22, 7/16/22 and 7/23/22. B. Interview with Resident 29 on 7/21/22 at 11:15 AM revealed was not getting a bath routinely or at least every week. Further interview revealed that the resident preferred to have a bath at least three times a week. Review of the weekly bathing schedule, dated 7/14/22 - 7/24/22 revealed that the resident was scheduled to receive a bath on Mondays, Wednesdays and Fridays. Review of the Documentation, report revealed that the resident received a bath on 7/4/22, 7/6/22, 7/21/22 and 7/25/22. Interview with RN (Registered Nurse) - B, Charge Nurse, on 7/25/22 at 1:40 PM revealed that the residents were to receive a bath at least weekly. Interview with the Administrator on 7/25/22 at 2:45 PM confirmed that the residents did not receive their baths as requested or scheduled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.17B Based on observations and interview, the facility failed to ensure that 1) towel bars were labeled in a shared bathroom (room [ROOM NUMBER] for Residents 34 and 30) and 2) oxygen equipment was covered to reduce the risk of cross contamination. The facility census was 47 with 15 current sampled residents. Findings are: A. Observations of room [ROOM NUMBER]'s bathroom (shared by Residents 34 and 30) on 7/20/22 at 11:50 AM, on 7/25/22 at 11:50 AM and on 7/26/22 at 8:45 AM revealed the towel bars were not labeled. B. Observations of Resident 18's dresser on 7/20/22 at 12:00 PM, on 7/25/22 at 12:00 PM and on 7/26/22 at 8:45 AM revealed an uncovered oxygen mask and tubing. Interview with RN (Registered Nurse) - A, Infection Preventionist, on 7/26/22 at 8:45 AM confirmed that the bathroom towel bars should be labeled and the oxygen equipment covered or bagged to reduce the risk of cross contamination.