Licensure Reference 175 NAC 12- 006.05(S) Based on observations, interviews, and record review; the facility failed to provide meal service that enhanced dignity by ensuring all residents were served at a table before serving the next table for 1 (Resident 5) of 1 sampled resident. The facility census was 26. Findings are: An observation on 7/22/2024 at 12:09 PM revealed Resident 5's four other table mates were served lunch meals. Resident 5 had been watching their other table mates eat. An observation on 7/22/2024 at 12:14 PM revealed a table of three seated behind Resident 5 were served lunch meals. Resident 5 had began to look around and continue to watch other residents eat. An observation on 7/22/2024 at 12:17 PM revealed Resident 5 was served their lunch meal. An interview on 7/22/2024 at 12:22 PM with Cook-B confirmed all residents should be served at one table at the same time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference 175 NAC 12-006.04(F)(i)(5) Based on interviews and record review; the facility failed to notify the physician of significant weight loss for 2 (Residents 8 and Resident 11) of 2 sampled residents. The facility census was 26. Findings are: A. A record review of a facility policy Notification of Change in Resident Condition with a last revised date of 1/2019 revealed all licensed personnel will notify the attending physician of any significant change in condition. A record review of Resident 8's Vitals record revealed Resident 8 weighed 120.8 pounds on 1/12/2024 and on 7/8/2024 Resident 8 weight was 104.5 pounds, a loss of 16.3 pounds or 13.5% since the weight on 1/12/2024. A record review of Resident 8's medical record did not reveal any evidence that Resident 8's physician was aware of the severe weight loss. An interview on 7/23/2024 at 10:25 AM with the Minimum Data Set (MDS, a federally mandated assessment tool used for care planning)) Coordinator confirmed there was no information Resident 8's physician had been notified of Resident 8's severe weight loss. The MDS Coordinator further confirmed the physician should have been notified of Resident 8's severe weight loss. B. A record review of Resident 11's MDS, dated [DATE] revealed Resident 11 had had a weight loss of 5% or more in the last month or of 10% or more in the last six months and was not on a prescribed weight loss plan. A record review of Resident 11's weights documented in their electronic health record revealed the resident weighed 120 pounds on 4/1/24 and 110 pounds on 5/7/24, which was an 8.3% weight loss in one month. The resident also had a weight of 101 pounds on 6/4/24, which indicated the resident had lost an additional 8.2% during the month of May 2024. A record review of Resident 11's Electronic Health Records and of their paper health records revealed no evidence of Resident 11's primary care provider (PCP) being notified of the resident's severe weight loss. An interview on 7/23/24 at 12:15 PM with the Director of Nursing (DON) confirmed Resident 11's weight loss and there was no evidence of their PCP being notified of the weight loss. A record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2023 revealed that weight changes of 5% in 1 month, 7.5% in 3 months, or 10% in 6 months should prompt a thorough assessment of the resident's nutritional status and that if significant weight loss is noted, the interdisciplinary team should review for possible causes of changed intake, changed caloric need, change in medication, or changed fluid volume status.

Licensure Reference Number 175 NAC 12-006.05(G) Based on observation, record review, and interviews; the facility failed to evaluate 1 (Resident 13) of 2 sampled residents of a potential use of a physical restraints. The facility census was 26. The Findings Are: A record review of facility policy Restraints with revised date of 9-99 revealed that restraints would only be used as a last resort to prevent a patient from injuring self or others and only when alternatives to restraints are not effective. The policy also stated that restraints were to have a physician's order except in the case of an emergency. A record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual revealed a physical restraint was defined as 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 restricts freedom of movement or normal access to one's body. A record review of Resident 13's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning), dated 5/7/24 revealed documentation that there were no restraints in use for Resident 13. A record review of Resident 13's Care Plan revealed an intervention dated 3/3/23 that stated: May use a gait belt (a safety device used by a caregiver to help transfer a person from one surface to another) on the legs for positioning. Resident 13 is able to remove. A record review of Resident 13's electronic health records and paper health records revealed no evidence of Resident 13 being assessed for their ability to remove the gait belt from [gender] legs on [gender] own. An observation on 7/17/24 at 9:24 AM revealed Resident 13 sitting upright in their wheelchair in [gender] room. There was a gait belt secured around Resident 13's thighs, holding the legs together. An observation on 7/17/24 at 12:30 PM revealed Resident 13 sitting in their wheelchair near the nurse's station. There continued to be a gait belt secured around Resident 13's thighs, holding the legs together. An interview on 7/22/24 at 1:42 PM with Medication Aide (MA)-D confirmed that the facility utilized a gait belt around Resident 13's legs for positioning. An interview on 7/23/24 at 9:20 AM with the Director of Nursing (DON) confirmed that Resident 13 was never assessed for their ability to remove the gait belt from their legs independently prior to or during the use of the gait belt around their legs as a positioning device. The DON revealed the DON had applied the gait belt to Resident 13's legs that morning and Resident 13 was not able to remove it from their own legs.

Licensure Reference 175 NAC 12-006.09(E) Based on record reviews and interview; the facility failed to develop a comprehensive care plan regarding Activities of Daily Living (ADL) for 2 (Resident 1 and Resident 8) of 13 sampled residents. The facility census was 26. Findings are: A record review of the facility's policy Activities of Daily Living Policy with a last review date of 12/2023 revealed an individual care plan is completed by the interdisciplinary team which specifies the direction and/or assistance needed for the activities of daily living for each resident. A. A record review of a Resident Face Sheet indicated the facility admitted Resident 1 on 1/04/2018 with diagnoses of: Multiple Sclerosis, Dementia, a contractures, and abnormal involuntary movements. A record review of Resident 1's quarterly Minimum Data Set (MDS, a comprehensive assessment that includes medical, psychosocial, cognitive, and functional status to assist with developing care plans for individual residents) with an Assessment Reference Date (ARD) of 4/16/2024 revealed Resident 1 had severe cognitive impairment. The MDS also revealed Resident 1 required total assistance for eating, oral hygiene, toileting, bathing, dressing, and personal hygiene. A record review of Resident 1's Care Plan under ADLs Functional, with a last edited date of 4/25/2024 revealed staff were to document assistance with bed mobility, dressing, eating, personal hygiene, and toileting. The care plan did not include specific information regarding the level of assistance needed for eating, dressing, bathing, or personal hygiene. B. A record review of a Resident Face Sheet indicated the facility admitted Resident 8 on 3/2/2020 with diagnoses of: Congestive Heart Failure, adjustment disorder with depressed mood, anxiety, and Celiac Disease. A record review of Resident 8's Significant Change MDS with an ARD of 5/14/2024 revealed Resident 8 had a Brief Interview for Mental Status score of 9/15, which indicated Resident 8 had moderate cognitive impairment. The MDS also revealed Resident 8 required substantial assistance with eating and oral hygiene and required total assistance for toileting, bathing, dressing, and personal hygiene. A record review of Resident 8's Care Plan under ADLs Functional, with a last edited date of 3/6/2024 revealed staff were to document assistance with bed mobility, dressing, eating, personal hygiene, and toileting. The care plan did not include specific information regarding the level of assistance needed for eating, dressing, bathing, or personal hygiene. An interview on 7/22/2024 at 3:33 PM with the MDS Coordinator confirmed the care plans were not comprehensive or person-centered for Resident 1 and 8.

Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on record reviews and interview; the facility failed to revise a care plan when the current interventions were ineffective for preventing significant weight loss for 1 (Resident 8) of 13 sampled residents. Findings are: A record review of a Resident Face Sheet indicated the facility admitted Resident 8 on 3/2/2020 with diagnoses of Congestive Heart Failure, adjustment disorder with depressed mood, anxiety, and Celiac Disease. A record review of Resident 8's Significant Change Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) with an Assessment Reference Date of 5/14/2024 revealed Resident 8 had a Brief Interview for Mental Status score of 9/15, which indicated Resident 8 had moderate cognitive impairment. A record review of Resident 8's Vitals revealed Resident 8 weighed 120.8 pounds on 1/12/2024. A record review of Resident 8's Vitals revealed Resident 8 weighed 103 pounds on 7/08/2024, which is a 13.5% significant weight loss in six months. A record review of a Care Conference Report with a date of 5/20/2024 revealed dietician's recommendation to start Ensure Clear supplements. A record review of Resident 8's Care Plan revealed no evidence of the intervention regarding starting a supplement drink. An interview on 7/23/2024 at 10:50 AM with the MDS Coordinator confirmed the care plan was not revised to reflect the dietician's recommendation of starting a supplement drink.

B. A record review of a Resident Face Sheet indicated the facility admitted Resident 6 on 4/9/2021 with diagnoses of stroke, Congestive Heart Failure, Dementia, and high blood pressure. A record review of Resident 6's Orders revealed an order for Coreg, a high blood pressure medication, to be given twice a day. The order included special Prescribers instruction to hold the medication if Resident 6's systolic (the first number in a blood pressure reading) blood pressure was under 110. A record review of Resident 6's Medication Administration Record with a date of 4/23/2024 to 5/23/2024 revealed Resident 6 had been administered Coreg at the following blood pressures: -4/24/2024 AM - 106/69 -5/6/2024 PM - 106/72 -5/14/2024 AM - 89/50 -5/14/2024 PM - 99/62 -5/17/2024 PM - 109/64 A record review of Resident 6's Medication Administration Record with a date of 5/24/2024 to 6/23/2024 revealed Resident 6 had been administered Coreg at the following blood pressures: -5/24/2024 PM - 101/60 -5/26/2024 AM - 103/74 -6/3/2024 PM - 109/61 -6/10/2024 PM - 109/62 -6/11/2024 PM - 108/72 -6/12/2024 AM - 95/55 -6/17/2024 PM - 106/63 -6/22/2024 AM - 109/76 -6/23/2024 PM - 106/70 A record review of Resident 6's Medication Administration Record with a date of 6/23/2024 to 7/23/2024 revealed Resident 6 had been administered Coreg at the following blood pressures: -6/23/2024 PM - 106/70 -6/30/2024 PM - 107/65 -7/1/2024 PM - 98/60 -7/2/2024 PM - 105/63 -7/20/2024 PM - 107/66 An interview on 7/23/2024 at 1:40 PM with the DON confirmed Resident 6's Coreg was administered in error and not according to the Prescribers' order on 4/24/2024, 5/6/2024, 5/14/2024, 5/17/2024, 5/24/2024, 5/26/2024, 6/3/2024, 6/10/2024, 6/11/2024, 6/12/2024, 6/17/2024, 6/22/2024, 6/23/2024, 6/30/2024, 7/1/2024, 7/2/2024, and 7/20/2024. Licensure Reference Number 175 NAC 12-006.09(H) Based on observations, record review, and interviews; the facility failed to implement a physician ordered treatment for 1 (Resident 25) of 1 sampled resident's edema and failed to ensure a hypertension medication was administered in accordance with the Prescribers' orders for 1 (Resident 6) of 5 sampled residents. The facility census was 26. The Findings Are: A. A record review of Resident 25's progress note dated 7/8/2024 revealed that Resident 25's left arm was swollen, and that the resident had been seen by a provider two days prior. A record review of Resident 25's progress note dated 7/16/24 revealed that Resident 25's provider had seen the resident that day for a follow up appointment related to their left arm swelling. The progress note stated there had been new order put into place for blood work, Tylenol, x-rays of the resident's left arm, and for an ACE wrap to the left arm. A record review of Resident 25's paper chart revealed an order from their provider dated 7/16/24 for OT (Occupational Therapy) evaluate and treat. Diagnosis (Dx): Left arm pain. Ace Wrap on during day and off at night & PRN (as needed). Dx: Left arm swelling. The paper chart also revealed orders dated 7/16/24 for an x-ray of the resident's left hand, wrist, and forearm, blood work, and routine Tylenol. An observation on 7/17/24 at 11:54 AM revealed Resident 25's left arm had swelling from the resident's shoulder to their hand. Resident 25's left arm was elevated on a pillow and there was no ACE wrap on their left arm. An observation on 7/18/24 at 8:57 AM revealed Resident 25 sitting in their recliner in their room. Resident 25's left arm continued to be swollen and was elevated on a pillow. There was no ACE wrap on Resident 25's left arm. An observation on 7/18/24 at 12:16 PM revealed Resident 25 sitting upright in their wheelchair in the dining room eating lunch. Resident 25's left arm continued to be swollen and was elevated on a pillow with no ACE wrap on the arm. An observation on 7/22/24 at 9:47 AM revealed Resident 25 sitting upright in their recliner with their left arm elevated slightly on a pillow. There was no ACE wrap on Resident 25's left arm. A record review conducted on 7/22/24 of Resident 25's current physician's orders in their electronic health record revealed no evidence of an order for Resident 25 to wear an ACE wrap around their left arm. An interview on 7/23/24 at 9:21 AM with the Director of Nursing (DON) confirmed the order for Resident 25's ACE wrap to their left arm was never implemented as the staff who entered the other orders written by the provider from that day did not enter this order in Resident 25's electronic health records.

Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, record review, and interview; the facility failed to ensure 1 (Resident 12) of 2 sampled residents' oxygen concentrator was not left on when unattended. The facility census was 26. The Findings Are: A record review of website www.inogen.com revealed that oxygen itself is not a flammable gas, but it does support combustion. This means that fires ignite and burn more easily, and hotter, in an oxygen-rich environment. In order to maintain a safe environment while using supplemental oxygen, it is important to adhere to safe practices. The website also listed a safe oxygen storage guideline of Turn off your oxygen when you're not using it. Don't set the cannula or mask on the bed or a chair if the oxygen is turned on. A record review of facility policy Oxygen Administration with review date of 11/23/13 revealed no guidance related to turning off the oxygen administration devices when not in use. A record review of Resident 12's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning), dated 4/16/24 revealed Resident 12 had a diagnosis of chronic respiratory failure with hypoxia, an absence of enough oxygen in the tissues to sustain bodily functions, and that the resident was receiving oxygen therapy. A record review of Resident 12's physician's orders revealed an order with a start date of 2/16/23 that stated oxygen 1-3 liters per minute (LPM) per nasal cannula to keep oxygen saturation at 88%-92%. Oxygen must be turned off when not in use and cannula and tubing stored in IP (infection prevention) bag. An observation on 7/17/24 at 10:23 AM revealed Resident 12 was not in their room. Resident 12's oxygen concentrator was turned on and running at 3 LPM. An interview on 7/17/24 at 10:26 AM with the MDS Coordinator confirmed that there was no one in Resident 12's room at that time and that Resident 12's oxygen concentrator had been left on.

Based on record review and interview, the facility failed to ensure an antibiotic had a stop date for 1 (Resident 13) of 1 sampled residents. The facility census was 26. The Findings Are: A record review of facility policy Antimicrobial Stewardship Program Committee with revised date of 7/24, revealed the goal of the Antimicrobial Stewardship Program was to ensure proper use and duration of antimicrobials within the entire facility. The policy stated that this would help reduce antimicrobial resistance and adverse reactions to antimicrobials. A record review of Center for Disease Control's (CDC) document The Core Elements of Antibiotic Stewardship for Nursing Homes APPENDIX A: Policy and Practice Actions to Improve Antibiotic Use revealed Surveys of antibiotic use have shown that (Urinary Tract Infection) UTI prophylaxis accounts for a significant proportion of antibiotic prescriptions. Very few studies support antibiotic use for UTI prophylaxis, especially in older adults, and many studies have shown this antibiotic exposure increases risk of side effects and resistant organisms. Therefore, efforts to educate providers on the potential harm of antibiotics for UTI prophylaxis could reduce unnecessary antibiotic exposure and improve resident outcomes.' A record review of Resident 13's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning), dated 5/7/24 revealed Resident 13 had a personal history of urinary tract infections (UTI), had an indwelling urinary catheter and was taking an antibiotic. A record review of Resident 13's care plan revealed an evaluation note dated 2/15/2024 revealing the resident was received an antibiotic(Cephalexin) prophylactically. A record review of Resident 13's physician's orders revealed the resident had been taking Cephalexin (an antibiotic medication used to treat infections) daily since 11/10/2021 for a diagnosis of personal history of urinary tract infections and that the order did not have a stop date. An interview on 7/23/24 at 1:05 PM with Registered Nurse (RN)-C confirmed that they were aware of Resident 13's long term use of Cephalexin and that the facility had not attempted to have Resident 13's medical provider discontinue the Cephalexin. RN-C stated that the pharmacist reviews each resident's medications monthly, and each resident's primary care provider (PCP) reviews the resident's medications every 60 days, so if either the pharmacist or the PCP felt the medication was unnecessary they would have taken action to discontinue it.

Licensure Reference 175 NAC 12-006.5(R) Based on observation, interview, and record review the facility failed to ensure private medical information was protected for 4 (Resident 2, 15, 22, and 23) of 4 sampled residents. The facility census was 26. Findings are: A record review of the facility policy Resident Rights Policy with a last reviewed date of 3/13, under section 3.25 revealed that privacy will be provided for residents' medical information to assure confidentially. An observation on 7/18/2024 at 2:30 PM of a medication room from a public hallway window revealed the ability to see Resident 2's name on a bottle of calmoseptine, Resident 15's name on an inhaler device, Resident 22's name on a bottle of glucose testing strips, and Resident 23's name on a bottle of MiraLAX. An interview on 7/18/2024 at 2:42 PM with Licensed Practical Nurse - H confirmed the medications were in public sight and was a violation of the resident's privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference 175 NAC 12- 006.11(E) Based on observations, interviews, and record reviews; the facility failed to a) ensure foods were disposed of prior to the expiration date and to label open food items, b) ensure beard restraints were in use, c) implement hand hygiene as required during meal preparation and meal service and d) ensure sanitation of the kitchen environment. This had the potential to affect all 26 residents who resided within the facility. A. A record review of a facility policy Food Handling - Storage with a last revised date of 10/17/2013 revealed foods which have been opened or prepared will be enclosed container, dated and labeled. Expiration dates will be checked on a regular basis and foods which have expired will be discarded. A record review of a facility policy Food - Handling - Leftovers with a last revised date of 10/16/2013 revealed refrigerated leftovers will be utilized within 72 hours. Items which do not have a planned use within 72 hours should be dated, labeled and placed within the freezer within 24 hours. A record review of 2017 Nebraska Food Code, under section 3-501.17 revealed food should be clearly marked to indicate the date or day by which food should be consumed or discarded. An observation during an initial kitchen tour on 7/17/2024 at 8:50 AM revealed the outside freezers contained cream cheese cookies with a use by date of 7/5, Traditional Cinnamon Roll dough with a use by date of 5/28/2024, a bag of meat that was ½ used without a date or being sealed, and beef pot roast in a plastic bag that was opened and not sealed off. In the reach-in refrigerator, a box of Danimals cups with a best by date of 7/10/2024. In another reach-in refrigerator, a container of beets with a preparation date of 7/9/2024, cream cheese with a best by date of 4/2/2024, and a container of baked beans with a use by date of 7/16/2024. In a reach-in freezer, a bag of butterscotch chips that were 7/8 used with a date of 5/8/2024. In the dry storage refrigerator, a bottle of Italian dressing with a use by date of 6/12/2024, bottles of barbecue sauce, [NAME] Lynch, and ranch without preparation dates or use by dates, and a container of pickle spears with a preparation date of 6/14/2024 and no use by date. In the dry storage freezer, 2 loaves of Soft Wheat Bread with best by 7/15/2024, and 2 loaves of [NAME] Texas Toast with best by dates of 7/12/2024. In the kitchen, under the food preparation table, flour and sugar were in bins without preparation or use by dates. An interview on 7/17/2024 at 9:19 AM with the Dietary Manager (DM) confirmed items should be disposed of after preparation or opening within 7 days, on expiration dates, and stored in an enclosed container once prepared or opened. B. A record review of a facility policy Dietary Dress Code / Hygiene with a last revised date of 9/25/2013 revealed hair and beard must be covered with a hair/beard restraint but did not provide information of when the hair and beard restraints are required to be worn. A record review of 2017 Nebraska Food Code, under section 2-402.11 revealed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-use articles. An observation on 7/17/2024 at 9:20 AM revealed the DM had a beard and had entered the kitchen without a beard restraint. An observation on 7/22/2024 at 10:50 AM revealed Dietary Aide (DA) - F was preparing fruit in a bowl for residents. DA-F had a goatee and was not wearing a beard restraint. An interview on 7/22/2024 at 11:03 AM with the DM revealed the DM believed beard covers were only required when serving or preparing foods. C. A record review of facility policy Hand Washing and the Use of Gloves with a last revised date of 12/2016 revealed hand hygiene should be completed before and after glove use and between contacts with different residents. It also revealed gloves should never be reused. An observation on 7/18/2024 at 12:14 PM revealed Medication Aide (MA) - D was wearing a glove on their right hand while assisting a resident with eating. MA-D then sanitized their glove and continued to wear it while assisting another resident. An observation on 7/18/2024 at 12:28 PM revealed MA-D was wearing a glove on their right hand while assisting a resident with eating. MA-D then sanitized their glove and continued to wear it. An observation on 7/18/2024 at 12:29 PM revealed MA-D was wearing a glove on their right hand while assisting a resident with eating. MA-D then sanitized their glove and continued to wear it. An observation on 7/18/2024 at 12:30 PM revealed MA-D was wearing a glove on their right hand while assisting a resident with eating. MA-D then sanitized their glove and continued to wear it. An observation on 7/18/2024 at 12:36 revealed MA-D was wearing a glove on their right hand while assisting a resident with eating. MA-D then sanitized their glove and continued to wear it. An interview on 7/18/2024 at 1:45 with MA-D revealed they had been wearing a glove on their right hand while assisting a resident with eating due to having a band aid on their thumb and was unaware of whether they should be sanitizing their gloves or changing the glove. An observation on 7/22/2024 at 9:53 AM revealed Cook-B removed a glove from their right hand, then opened a bag of raw Chicken Cordon Bleu, then applied a new glove to their right hand without the benefit of hand hygiene prior to application of the new glove. An interview of 7/22/2024 at 11:00 AM with Cook-B confirmed hand hygiene should be completed before and after changing their gloves. An observation on 7/22/2024 at 12:19 PM revealed DA-F delivered a plate of food to a resident, touched the resident's back, then delivered another plate of food to another resident without the benefit of hand hygiene in between residents. An interview on 7/22/2024 at 12:33 PM with DA-F revealed DA-F was only aware of the requirement to perform hand hygiene upon entering the kitchen. D. A record review of 2017 Nebraska Food Code, under section 6-501.111 revealed the premise shall be maintained free of insects. A record review of 2017 Nebraska Food Code, under section 2-401.11 revealed employees shall eat or drink only in designated areas where the contamination of exposed food, clean equipment, utensils, and linens cannot occur. An observation during an initial kitchen tour on 7/17/2024 at 8:50 AM revealed several flies around the kitchen, two dead flies on a window seal above where Styrofoam food containers were being stored, and a coffee cup with coffee on the shelf above a kitchen preparation table. An interview on 7/17/2024 at 9:19 AM with the Dietary Manager (DM) confirmed there were several flies, stating the feedlot nearby attracted the flies and it got worse in the summer. The interview also confirmed the need for sanitation of the window and that food/drinks were not allowed in the kitchen to be consumed by employees. A record review of the facility policy Sanitation -- General with a last revised date of 9/2013 revealed all food contact surfaces should be sanitized when beginning to work with another type of food and care shall be taken to minimize hand contact with food surfaces. A continuous observation on 7/22/2024 from 9:43 AM to 10:13 AM revealed Cook-B used scissors to cut open bags of uncooked pork, causing juices from the meat to contaminate the preparation table. Cook-B later prepared carrots and corn on the contaminated table. Cook-B had also set utensils down on the countertop, then stirred the vegetables with these utensils. An interview on 7/22/2024 at 11:00 AM with Cook-B confirmed the table should be sanitized any time a new task or food is began to be prepared.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference 175 NAC 12- 006.18(B) Based on observations, interviews, and record reviews; the facility failed to provide wound care for 1 (Resident 26) and failed to distribute laundry throughout the nursing unit in a manner that prevented the potential for cross contamination. The facility census was 26. Findings are: A. A record review of the Center for Disease Control's Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) with a date of 4/2/2024 indicated Enhanced Barrier Precautions, including donning a gown and gloves, should be implemented during all wound care or any skin opening that requires a dressing. A record review of the facility's policy Pressure Ulcers Treatment with a last reviewed date of 1/20/2023, under section Steps in the Procedure, indicated directions to maintain sterility. The policy did not include directions to implement Enhanced Barrier Precautions. A record review of Resident 26's admission Minimum Data Set (MDS), a standardized assessment tool that measures health status in nursing home residents, with an Assessment Reference Date of 5/21/2024 revealed Resident 26 had a Brief Interview for Mental Status score of 9/15, which indicated Resident 26 had moderate cognitive impairment. The MDS also indicated Resident 26 had a stage 2 pressure ulcer requiring pressure injury care. A record review of Resident 26's Orders revealed an order for a dressing change with instructions to apply Thera honey to wound bed, then cover with an Opti foam dressing. An observation on 7/18/2024 at 1:22 PM revealed Licensed Practical Nurse (LPN) - H performing wound care for Resident 26. During the wound care, LPN-H did not don a gown as required. LPN-H also opened the Thera honey cream and applied directly onto the Opti foam and had touched the tip of the tube on the Opti Foam. When completed, LPN-H put the unused remainder of Opti Foam back into the package with Resident 26's name on it and stored it on a counter with other residents' open treatment supplies. An interview on 7/18/2024 at 2:42 PM with LPN-H confirmed these practices were in violation of infection control practices. B. An observation on 7/23/24 beginning at 8:08 AM revealed Laundry Aide (LA)-G was distributing personal laundry to the residents. The laundry cart was parked on Lane 2 of the nursing unit outside resident room [ROOM NUMBER], the cart covering had been left open and no one was in the hallway at that time. At 8:09 AM, LA-G exited a resident room, performed hand hygiene (HH) via Alcohol Based Hand Rub (ABHR), obtained clothing from the laundry cart, and carried them into resident room [ROOM NUMBER], leaving the cover to the laundry cart open. LA-G then exited room [ROOM NUMBER], performed HH via ABHR, obtained hanging clothes and folded clothes from the laundry cart, and walked toward resident room [ROOM NUMBER]. LA-G stopped outside room [ROOM NUMBER], put the hanging clothes between their legs, and performed HH via ABHR, then grabbed the clothes from between their legs and carried them into resident room [ROOM NUMBER]. LA-G continued obtained laundry from the laundry cart, and carrying them into resident rooms [ROOM NUMBERS], performing HH via ABHR between rooms but leaving the cover open to the laundry cart throughout distribution of clothes to each room. LA-G then closed the cover to the laundry cart, pulled the cart to Lane 3 of the nursing unit, and parked it outside resident room [ROOM NUMBER]. LA-G proceeded to distribute resident clothing to rooms [ROOM NUMBER], performing HH via ABHR between each room but left the cover of the laundry cart open throughout the distribution of resident laundry to each room. After LA-G distributed clothing to the last room, LA-G performed HH via ABHR, closed the cover to the laundry cart, and returned the cart to the laundry area. An interview on 7/23/24 at 8:39 AM with Laundry Aide (LA)-G confirmed that LA-G had left the laundry cart cover open throughout their laundry distribution on Lanes 2 & 3, and that LA-G had placed the laundry for resident room [ROOM NUMBER] between their legs while they performed HH outside room [ROOM NUMBER].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Reference Number 175-NAC 12-006.09B Based on record review and interview; the facility failed to ensure the MDS (Minimum Data Set, a comprehensive assessment tool used to develop a resident's care plan) reflected the current status of 1 (Resident 12) of 1 sampled residents related to a Serious Mental Illness diagnosis. The facility identified a census of 29. Findings are: Record review of Resident 12's Face Sheet revealed the resident had been admitted to the facility on [DATE]. Record review of Resident 12's Level 1 PASSR dated 4/1/2022 revealed a PASRR (a federally mandated evaluation used to identify Mental Disorders (MD), Intellectual Disability (ID), or Related Disorders (RD) and to ensure appropriate facility placement with appropriate services) Level II Evaluation and Determination was not required at that time. Resident 12's PASRR did not identify any diagnoses or suspicion of serious mental illness (SMI), or intellectual disability or related condition. Record review of Resident 12's Banner Health History of Present Illness (H & P) dated 3/25/2022 revealed under Problems List, Resident 12 did not have a diagnosis of bipolar disorder. Record review of Resident 12 's diagnosis history revealed a diagnosis of bipolar disordered that was entered on 4/4/2022 and deleted on 6/6/2023. Record review of Resident 12's MDS dated [DATE] revealed Section I Active Diagnoses under the section Psychiatric/Mood Disorder, the resident had a diagnosis of bipolar disorder. Record review of Resident 12's Regional [NAME] Garden County Provider Order Sheet with a date of 4/4/2022 revealed a diagnosis of bipolar disorder that had a line through it without initials or a date of when it was crossed out. Interview on 6/27/2023 at 8:13 AM with the Assistant Director of Nursing (ADON) revealed Resident 12's MDS dated [DATE] identified resident had a diagnosis of bipolar. The ADON revealed Resident 12's admission diagnosis of bipolar had a line through it but it was added to Resident 12's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** License Reference Number NAC 175 12-006.11E Based on observations, record reviews, and interviews, the facility failed to 1) follow recipes during meal preparation, 2) failed to change gloves as required, and 3) failed to perform hand hygiene as required during meal preparation. This had the potential to affect all the residents who resided at the facility. The facility identified a census of 29 residents at the time of the survey. Findings are: Observation on 6/27/2023 of the facility's kitchen from 10:00 AM to 11:33 AM revealed the following; - The Food Service Coordinator (FSC) had donned gloves and on both hands and placed hamburger in a skillet on the stove. The FSC then doffed the gloves without performing hand hygiene and donned a new glove on their left hand. The FSC then opened the refrigerator with the left gloved hand and retrieved an onion and [NAME] Sauce. The FSC did not perform hand hygiene and immediately went and placed the onion on a cutting board, held the onion with the gloved hand, and diced it. The FSC then spread the diced donions over the hamburger and poured an unmeasured amount of [NAME] Sauce into the hamburger on the stove. -At 10:07 AM, the FSC doffed the left hand glove and did not perform hand hygiene. The FSC then moved dishes, a rag, and scooped out an unmeasured amount of dill relish from a plastic gallon container and placed it in a small bowl to make the sauce for sloppy joes. The FSC utilized their bare hand to reach into a brown sugar bag and scooped brown sugar with a portion cup. The FSC did not measure the amount of brown sugar placed into the sauce mixture. -At 10:12 AM, the FSC performed hand hygiene with soap and water for 12 seconds. The FSC then retrieved french fries from the freezer, touched their mouth, and went over to the stove to mix and chop the hamburger into smaller pieces. The FSC then went to the storage shed outside and retrieved chicken, peas, and french fries. The FSC did not perform hand hygiene. - At 10:27 AM, the FSC donned a pair of gloves, placed the chicken on a baking pan, poured the bag of peas into a pan, and placed them on the stovetop. - At 10:33 AM, the FSC had not performed hand hygiene or change gloves and placed additional french fries on a baking pan with the gloved hands. FSC then doffed their gloves but did not perform hand hygiene. - At 10:39 AM, the FSC mixed the cooking hamburger then grabbed two packages of buns, drained the hamburger, took the skillet to the dirty dish room, washed the skillet, put supplies away, wiped the food preparation counter,and placed an unmeasured amount of butter into the peas. The FSC then placed the hamburger into a pan, adjusted their glassess with their bare hands, and then poured the sloppy joe sauce over the hamburger. The FSC then wrote on a piece of paper, touched their right side of the neck, retrieved a package of gravy, filled a pot with water, and retreived a whisk and cutting board from a shelf. The FSC then performed hand hygiene with soap and water for 14 seconds. -At 10:56 AM, the FSC adjusted the left side of their glasses with their bare left hand. The FSC then removed a pan of chicken from the oven. The FSC then donned gloves, diced the chicken, removed their gloves, and placed the gloves on a cutting board. The FSC poured a powder gravy mix into the water and did not measure the gravy mix. The FSC had poured the chicken into the gravy and cleaned the preparation counter with a rag and took the dishes into the dish room and rinsed them. The FSC did not perform hand hygiene. - At 11:11 AM, the FSC had donned gloves and placed a piece of chicken on a cutting board where there was a pair of used gloves laying. The FSC grabbed the knife and diced the chicken on the cutting board next to the used gloves. The FSC then adjusted the left side of their glasses with their left hand and retrieved a thermometer from a drawer. The FSC did not perform hand hygiene. - At 11:19 AM, the FSC donned a pair of gloves, sprayed a blender and two plates with Vegalene food release oil spray. The FSC placed french fries, cream of celery soup, and butter into the blender and blended the food. The butter and cream of celery soup were not measured. The mixture was poured onto plates. -At 11:25 AM, the FSC doffed their gloves and performed hand hygiene with soap and water for 12 seconds. The FSC had put peas into the blender with the left-over potatoes and blended them. - At 11:29 AM, the FSC had rinsed the blender in the dish room and had not performed hand hygiene. The FSC then opened a package of bread and removed two slices with bare hands, and placed them into the blender with chicken gravy. The pureed food was placed onto the two pureed plates. Interview on 6/27/23 at 11:34 AM with the FSC revealed [gender] had not washed their hands with soap and water long enough, had not washed their hands after glove use, and did not change their gloves after touching items prior to handling food. The FSC further revealed they did not measure ingredients for the food they were preparing and did not follow recipes as [gender] had been cooking for a long time. The FSC revealed temperatures of the puree food were not taken prior to serving residents. Interview on 6/27/23 at 11:45 AM with the Food Service Manager (FSM) revealed hand hygeine is expected prior to starting meal preparation, anytime one touches their hair, clothing, or personal items, and after removing gloves. The FSM said facility staff are expected to wash their hands for 20-30 seconds with soap and water. The FSM revealed dietary staff are to follow recipes and ingredients should be measured. The FSM revealed FSC did not follow a recipie or measure ingreidents while preparing the sloppy joe meal. Record review of the undated Sloppy [NAME], Lutheran Ladies Bar B-Q recipe revealed it called for the following ingredients: 5 pounds of hamburger; 2 medium onions, chopped; 1 ¼ t garlic powder; 2 ½ t salt; ½ cup + 2T brown sugar; one 12 ounce tomato paste; 2 ½ T mustard; 1 quart of catsup; ½ cup + 2 T vinegar; and 3 C tomato soup. Bake 350 degrees for 3 hours. Record review of the undated Pureed Vegetables recipe revealed starchy (root-type) vegetable preparation (potatoes/yams/carrots/squash/beats/turnips/parsnips, 1) Use ½ c. portions per serving. 2) To each portion, add 1 tsp. margarine. 3) If the consistency is too stiff, add 1 T. broth, gravy, sauce, or hot milk. Watery (leaf, stem, flower-type) vegetable preparation- green beans/tomatoes/spinach/greens/cabbage/broccoli/peas, 1) Use 1/ c. portions per serving. 2) To each portion, add 1 tsp. margarine and 1 to 2 tsp. broth or hot water and puree. 3) Add 1 to 32 tsp. commercial thickener per portion if too thin. Record review of the Dietary Department's Food Handling-Temperatures policy with a last reviewed date of 11/2007, revealed food temperatures will be taken and recorded prior to each meal service. Record review of the facility's Hand Hygiene and Surgical Antisepsis policy with a revised date of 5/2022, revealed under the section, Procedural Notes Hand Hygiene-How to do it, handwashing (soap and water), wet hands and apply the product. Do not use hot water; repeated exposure to hot water may increase the risk of dermatitis. Rub hands vigorously for at least 15 seconds, covering all surfaces. Rinse hands with water and dry with a disposable towel. Use a towel to turn off the faucet to prevent re-contamination of hands. Hand hygiene- When to do it: Hand washing is to be done before eating and after using the restroom. After removing gloves. More About Gloves to Maintain Hand Hygiene: Gloves do not take the place of hand hygiene measures.

B) An observation on 03/07/2022 at 05:53 PM and 03/08/2022 at 12:05 PM revealed Resident 1 was sitting in the dining room in a wheelchair with the transfer sling draped over the back of the wheelchair in view of the public. Review of Resident 1's Care Plan revealed the following: goal date 06/08/2022 revealed full body mechanical lift and 2X assist for all transfers. Further review revealed instruction; may leave lift sling under Resident 1 in chair and wheelchair and make sure smooth and tucked away when in wheelchair and in dining room. An Interview with the Director of Nursing on 03/15/2022 at 09:54 AM confirmed that the sling for Resident 1 should be tucked away and not visible while the resident is in public areas and that the staff should follow the residents care plan instructions to promote dignity for Resident 1. Licensure Reference Number: 175 NAC 12-006.05 (21) Based on observations, record reviews and interviews; the facility failed to ensure that transfer slings were removed from the wheelchairs or tucked in while residents were in public areas to promote dignity for two current sampled residents (Residents 2 and 1). The facility census was 22 with 12 current sampled residents. Findings are: A. Observations on 3/7/22 at 5:45 PM and 3/9/22 at 12:00 PM revealed Resident 2 seated in a wheelchair in the dining room with the transfer sling draped over the back of the wheelchair. Review of the Care Plan, goal date 4/18/22, revealed that the resident required a full mechanical lift for transfers. Further review revealed instructions to leave the sling in place at the resident's request and tuck the sling legs and wings in the chair. Interview with the Director of Nursing on 3/15/22 at 9:00 AM confirmed that the staff were to follow the care plan instructions and tuck in the transfer sling while the resident was in public areas to promote dignity.

Licensure Reference Number: 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to ensure that APS (Adult Protective Services) was notified as required of a fall with injuries for one current sampled resident (Resident 9), The facility census was 22 with 12 current sampled residents. Findings are: Review of the facility Investigation Report, dated 5/24/21, revealed that Resident 9 fell and complained of right hip pain on 5/21/21. The resident was sent to the emergency room for evaluation and it was determined that the resident had a right hip fracture. Further review revealed that APS was notified of the incident on 5/24/21. Review of the facility Incident Checklist, not dated or signed, revealed that staff were to notify APS within 2 hours of an incident which required outside medical treatment. Interview with the Director of Nursing on 3/8/22 at 11:30 AM confirmed that staff were to notify APS within two hours of an incident with injuries which required medical assessment and care which was not done in this case.

Licensure Reference Number: 175 NAC 12-006.09D1c Based on observations, record review and interview; the facility failed to ensure that assistance was provided in the dining room for one current sampled resident (Resident 2) dependent on staff for assistance. The facility census was 22 with 12 current sampled residents. Findings are: Observation on 3/9/22 at 12:00 PM through 12:30 PM revealed Resident 2 seated in a wheelchair in the dining room. Further observations revealed the resident leaning heavily to the right side feeding self. The resident's clothing protector fell to the resident's lap and food and fluids falling from the resident's mouth onto clothing. Further observations revealed staff walking by the resident and no one stopped to assist the resident. Review of the Care Plan, goal date 4/18/22, revealed that the resident required some degree of assistance with all activities of daily living. Interview with the Director of Nursing on 3/15/22 at 9:00 AM confirmed that staff should have assisted the resident in the dining room.

Licensure Reference Number: 175 NAC 12-006.09D Based on observations, record review and interview; the facility failed to follow physical therapy recommendations for comfortable positioning in the wheelchair for one current sampled resident (Resident 2). The facility census was 22 with 12 current sampled residents. Findings are: Observations on 3/7/22 at 5:45 PM, 3/8/22 at 10:00 AM and 3/9/22 at 10:30 AM revealed Resident 2 seated in a wheelchair leaning to the right side at an approximate 45 degree angle. Further observations revealed that a chest strap was in place but no pillow or towel positioned at the right side for support. Review of the Care Plan, goal date 4/18/22, revealed that the resident had impaired mobility and function and was dependent on staff with all mobility, transfer and positioning needs. Review of the physical therapy evaluation, dated 11/22/21, revealed that the resident's positioning significantly improved when positioned appropriately in the wheelchair. Further review revealed that the resident would benefit from having a towel placed on the right lateral support to help decrease the right lateral trunk lean. Interview with the Director of Nursing on 3/15/22 at 9:00 AM confirmed that the staff were to utilize devices as directed to promote comfortable positioning and support for the resident in the wheelchair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, record review and interview; the facility kitchen staff failed to ensure that outdated foods were not available for use. This had the potential to affect all residents in the facility. The facility census was 22 residents. The sample size was12 residents. Findings are: An observation on 03/07/2022 at 02:21 PM during the initial tour of the kitchen revealed the following in one refrigerator: [NAME] Lynch, manufacturers date best if used by 11/24/21 and Thousand Island, manufacturers date best if used by 1/30/2022. On 03/07/2022 at 02:36 PM an interview with the Dietary Services Manager confirmed that there were 2 containers of salad dressing that were expired per manufacturer dates. Review of the 07/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for the food services sanitation practices, revealed the following: 3-201.11(C)Packaged food shall be labeled as specified by law, including 21 CFR 101 Food Labeling, 9 CFR 317 Labeling, Marking Devices, and containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under 3-202.17 and 3-202.18.