**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.02(H) Based on record review and interview the facility failed to submit a written investigation for alleged abuse to the state agency within 5 working days as required for 2 of 3 residents (Residents 12 and 19). The facility census was 38. Findings are: A. Record review of the undated facility policy titled Abuse Neglect and Misappropriation of Property Policy revealed that the facility supports a zero tolerance for resident abuse, neglect, and/or misappropriation of property. The definition of physical abuse includes hitting, slapping, pinching, and kicking. The section titled Resident to Resident Abuse revealed that staff must intervene to protect the residents and separate the individuals immediately. In all cases of alleged abuse, neglect, or misappropriation/exploitation of resident property the role of the facility is to intervene in the situation; report the situation to the proper authorities; investigate the allegation; prevent abuse while the investigation is in process; and have documented evidence that the facility intervened, reported, prevented, and investigated. The facility must ensure that all alleged violations are reported immediately to the administrator of the facility and to other officials in accordance with State Law. A facility investigation report form will be filled out and sent/faxed within 5 working days to: Health Facility Investigations (the State Agency). Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 12 dated 1/29/25 revealed that Resident 12 admitted into the facility on [DATE]. Resident 12 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 3 indicating severely impaired cognition. Resident 12 requires maximal assistance (the staff does more than half the effort) for personal hygiene, toileting and transferring. Resident 12 is frequently incontinent of bladder (urine) and occasionally incontinent of bowel (stool). Record review of the progress note dated 9/4/24 at 8:31 AM for Resident 12 revealed that Resident 12 was in the dining room. The tablemate of Resident 12 spilled their eggs and Resident 12 attempted to assist the tablemate with cleaning up the eggs. The tablemate balled their fist and hit Resident 12 on the forearm. The Director of Nursing, Facility Administrator, and Social Services Director were informed of the resident to resident incident. Record review of the progress note dated 9/4/24 at 12:41 PM for Resident 12 revealed that the facility contacted Adult Protective Services (APS) (the State of Nebraska agency designated for receiving reports of abuse, neglect, or exploitation) to file the report of the resident to resident incident. Record review of the medical record of Resident 12 revealed no documentation that a written investigation of the 9/4/24 resident to resident incident was completed and submitted to the state agency. Interview on 3/26/25 at 2:27 PM with the Facility Administrator (FA) confirmed that the 9/4/24 resident to resident incident had been reported to APS as alleged resident to resident abuse. Interview on 3/26/25 at 2:39 PM with the facility Director of Nursing (DON) confirmed that the resident to resident incident directed towards Resident 12 occurred on 9/4/24 and was reported to APS. The DON revealed that the resident that hit Resident 12 was moved to a different table. The DON confirmed that the facility did not submit the written investigation to the state agency as required. B. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 19 dated 2/12/25 revealed that Resident 19 admitted into the facility on 2/15/21. Resident 19 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 3 indicating severely impaired cognition. Resident 19 is dependent on staff for personal hygiene and bathing. Resident 19 requires maximal assistance (the staff does more than half the effort) for toileting and transferring. Resident 19 is frequently incontinent of bowel (stool) and bladder (urine). Record review of the progress note dated 12/18/24 at 3:26 PM revealed that a nurse aide went to help Resident 19 with cares last evening (12/17/24). Resident 19 became agitated and combative. The nurse aide grabbed the arms of Resident 19 and held them near the resident's chest. The licensed nurse intervened and the Director of Nursing (DON) was called. Record review of the Adult Protective Services Intake Worksheet dated 12/19/24 revealed that APS was notified of the physical abuse on 12/18/24 at 5:14 PM. The worksheet revealed that on 12/17/24 the nurse aide went to provide care for Resident 19. Resident 19 declined and requested to continue watching television in the gathering area. The nurse aide tried to forcibly move Resident 19 from the gathering area by grasping the resident's arms and putting them across the resident's chest while Resident 19 was in the wheelchair. Another staff saw this and immediately intervened. Record review of the medical record of Resident 19 revealed no documentation that a written investigation of the 12/17/24 staff to resident incident was completed and submitted to the state agency. Interview on 3/26/25 at 2:27 PM with the Facility Administrator (FA) confirmed that the 12/17/24 staff to resident incident had been reported to APS. Interview on 3/26/25 at 2:39 PM with the facility Director of Nursing (DON) confirmed that the DON was notified of the staff to resident incident on 12/17/24 and came to the facility. The DON revealed that the staff member involved was agency staff and the DON escorted the staff member out of the building. The DON revealed that that staff member was not allowed to return to work in the facility. Interview on 3/26/25 at 4:22 PM with the DON confirmed that the facility completed an Incident Investigation Report (a written investigation) dated 12/18/24. The DON confirmed that the investigation report was not submitted to the state agency as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 1/31/25 for Resident 38 revealed that Resident 38 admitted into the facility on 1/27/25. Diagnoses included Diabetes. Medications included insulin injections (a medication that regulates the amount of glucose (sugar) in the blood). Record review of the Order Summary dated 3/25/25 for Resident 38 revealed a physician's order for Insulin injection per sliding scale (An insulin order that varies the dose of insulin based on the blood sugar level. The higher your blood sugar the more insulin you take) dated 1/27/25. The order directed that staff are to call the physician for blood sugar results over 450. Record review of the Care Plan (an individualized written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) dated 3/24/25 for Resident 38 revealed the potential for adverse drug reactions related to low blood sugar. Interventions included blood glucose monitoring and medications as ordered by the physician and report as warranted. Record review of the Blood Sugar Summary dated 3/26/25 for Resident 38 revealed the blood sugar results for Resident 38 from 1/27/25 through 3/26/25. Blood sugar results over 450 were obtained on 2/21/25 (461); 2/24/25 (461); and 3/2/25 (460). Record review of the progress note dated 2/24/25 at 2:10 PM revealed that Resident 38's blood sugar at 11 AM was 461. The nurse gave the sliding scale insulin and called Resident 38's physician and informed the physician of the blood sugar. Record review of the resident record revealed no documentation that the physician was notified of the blood sugar results over 450 as required for the blood sugar result of 461 on 2/21/25 or the blood sugar result of 460 on 3/2/25. Interview on 3/26/25 at 12:57 PM with the facility Director of Nursing (DON) confirmed that staff are expected to follow physician orders including notification of blood sugars as ordered by the physician. Licensure Reference Number 175 NAC 12-006.09 Based on record reviews and interviews the facility failed to follow orders to notify the physician when blood glucose levels were outside of set parameters. This affected two residents, Resident 24, and Resident 38. The facility census was 38. Findings are: A. A review of an admission Record dated 03/24/2025 showed Resident 24 admitted on [DATE] with primary and admitting diagnoses of: -Parkinson's Disease (a brain disorder causing uncontrollable movements) -Calculus of Kidney (formed stones in the kidneys caused by preexisting conditions) -Type 2 Diabetes Mellitus with Diabetic Polyneuropathy (a condition is which the body does not use insulin properly and nerve damage caused by high blood sugars) A review of Resident 24's Care Plan Report dated 03/18/2025 revealed: -Focus: Patient Medical History of Diabetes Mellitus with insulin -Intervention: Diabetic medications as ordered; blood sugars as ordered A review of Resident 24's Medication Review Report for the month of 03/2025 signed and dated by the physician on 03/12/2025 revealed orders: -Notify MD (medical doctor) when blood sugar is < (less than) 60 or >(greater than) 400, order dated 08/28/2024 -Insulin Lispro Injection Solution 100 Unit/ML(milliliter) (Insulin Lispro) Inject as per sliding scale: if 0-70 = 0 CALL PCP(Primary Care Provider); 71-149= 0; 150-199= 1; 200-249= 2; 250-299= 3; 300-349= 4; 350-399=5; 400-999= 5 CALL PCP, subcutaneously four times a day related to Type 2 Diabetes Mellitus with Diabetic Polyneuropathy A review of Resident 24's blood sugars (BS) from 01/01/2025 through 03/21/2025 revealed BS's outside of parameters: -03/21/2025 12:02 534.0 mg (milligram)/dL(deciliter) -02/16/2025 16:38 425.0 mg/dL -01/17/2025 21:18 425.0 mg/dL A review of Resident 24's Progress Notes dated 12/23/2024 through 01/22/2025 revealed that on 01/17/2025, notification to the physician on the BS reading had not occurred. A review of Resident 24's Progress Notes dated 01/23/2025 through 02/22/2025 revealed that on 02/16/2025, notification to the physician on the BS reading had not occurred. A review of Resident 24's Progress Notes dated 02/23/2024 through 03/25/2025 revealed that on 03/21/2025, notification to the physician on the BS reading had not been documented as occurred. A review of policy titled Midwest Covenant Home Clinical Policy-Routine Medication Monitoring System dated 07/2023 revealed: -Medication-Diabetic Medication oral or insulin-BG checked per accu-check (a blood glucose monitoring device)-scheduled ordered by doctor-Call PCP if BG (blood glucose/blood sugar) is greater than 450 or lower than 50, unless otherwise directed. An interview with the Director of Nursing (DON) on 03/26/2025 at 12:57 PM revealed that the nurse was confused on when to notify the physician on parameters, therefore did not notify when Resident 24's BS reading was between 400 and 450. A review of facility policy/procedure titled Standards of Care with a revision date of 01/01/2024 revealed Professional Nursing Standards: -Staff will notify each resident's physician when needed. -Medications will be administered as ordered by the physician or designee. -Staff will follow all orders given by the physician or designee.

Based on record review, observation, and interviews, the facility failed to discard outdated foods. This had the potential to affect all residents who consumed food from the kitchen. The census was 38. Findings are: Record review of the facility policy and procedure Food Storage dated the year 2021 stated that policy will be that sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Record review of the BakerSource company's product data sheet dated 09/26/2024 revealed that the shelf life of Cinnamon Streusel Coffee Cake Mix is 546 days from the date of manufacturer in ambient conditions as was the shelf life of the Carrot Cake Mix. Observation on 03/24/2025 at 9:35 AM in the facility kitchen; One (1) box of Cinnamon Streusel with a manufactured date of 09.28.2023. Three (3) boxes of Cinnamon Streusel with a manufactured date of 11.28.2023. Five (5) boxes of Carrot Cake mix with a manufactured date of 07.08.2023. Four (4) Angel Food Cake mixes from the grocery store had best if used by dates of 4.28.2024. Two (2) Frozen packages of bologna in upright freezer had a use by date of 03.04.2024. One (1) Frozen packages of bologna in upright freezer had a use by date of 01.06.2024. Interview on 03/24/2025 at 9:30 AM with the Food Service Manager (FSM) confirmed to not knowing how long the cake mixes and bologna were good for after the manufacturing date. The angel food cake mixes had best if used by dates on them. The frozen lunch meat (bologna) had a date but was unsure how long it could be in the freezer without need of being discarded or used. Interview on 03/24/2025 at 2:50 PM with the FSM conducted. FSM reported that once manufactured, the cinnamon streusel and carrot cake mixes had a shelf life of 546 days at room temperatures. FSM confirmed that the 5 boxes of the Carrot Cake mixes were outdated (expired) and that the FSM destroyed them. Interview on 03/25/2025 at 1:45 PM with the FSM conducted. FSM stated that the local grocery store was unable to state how long the angel food cake mixes could be used past the used by date, so these were destroyed (thrown away) by the food service manager. Interview on 03/26/2025 at 9:20 AM with the FSM revealed that the manufacturer would not stand by any foods that had gone past the outdate even if the bologna had been kept in the freezer, so these were destroyed (thrown away). Interview on 3/26/2025 at 11:40 AM with the FSM confirmed that all outdated food identified on 03/24/2025(listed above) were destroyed (thrown away).

Licensure Reference Number 175NAC 12-006.02(8) Based on interview and record review the facility failed to submit an investigation for alleged abuse to the state agency within 5 days as required for 1 (Resident 10) of 3 sampled residents. The facility census was 43. Findings are: Record review of the undated facility policy titled Abuse, Neglect and Misappropriation of Property revealed that the facility supports a zero tolerance for resident abuse, neglect, and/or misappropriation of property. In all cases of alleged abuse, neglect, or misappropriation/exploitation of resident property the facility is to intervene in the situation, report the situation to the proper authorities, investigate the allegation, prevent abuse and neglect while the investigation is in process. The facility is to have documented evidence that the facility intervened, reported, prevented abuse/neglect/misappropriation, and investigated. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse are reported immediately to the administrator of the facility and to other officials in accordance with state law. The aggressor will be removed from the situation. If the aggressor is an employee, they will be suspended without pay until the investigation is completed. The section titled Reporting revealed that all alleged cases of resident abuse, neglect, and misappropriation will be reported to the administrator or his/her designee. The Administrator or his/her designee will immediately contact the proper authorities. Local law enforcement will be contacted as determined necessary. The Administrator or his/her designee should report the following to Adult Protective Services (APS): Any allegation of abuse/neglect/misappropriation that results in a resident being physically injured; unreasonably confined. A Facility Investigation Report Form will be filled out and sent/faxed within 5 working days to: Health Facility Investigations (the state agency). Record review of the admission Record dated 4/1/24 for Resident 10 revealed that Resident 10 admitted into the facility on 4/12/23. Diagnoses included dementia, anxiety, and major depressive disorder. Record review of the letter dated 8/10/23 addressed to the facility Director of Nursing (DON) revealed that Licensed Practical Nurse-A (LPN-A) strapped the right foot of Resident 10 to the wheelchair foot pedal with a gait belt. The letter reported that this was a restraint affecting Resident 10. Record review of the Investigation Form dated 8/10/23 provided by the DON revealed that the DON completed the form. The form documented that the DON was notified of LPN-A using a gait belt improperly. The other Licensed Practical Nurse (unidentified) on duty was told to check it out. The unidentified LPN in charge on duty removed the gait belt from Resident 10's wheelchair and no injury was noted to Resident 10. Verbal education was done with LPN-A on proper use of gait belts. The form revealed in the section titled Next Investigative Steps - Visit with staff, LPN-A, and take further steps if required. Interview on 4/01/24 at 2:52 PM with Nurse Aide-C (NA-C) revealed that the facility provided NA-C with abuse and neglect training. NA-C revealed that a resident tied to their wheelchair would be considered abuse and NA-C would report that to the charge nurse. Interview on 4/02/24 at 8:17 AM with the facility Director of Nursing (DON) confirmed that the letter dated 8/10/23 for the 8/10/23 incident involving Resident 10 was received from an agency staff and would be considered potential abuse. The DON confirmed that the facility should follow the facility Abuse, Neglect, and Misappropriation of Property policy for alleged abuse. The DON revealed that the DON was out of state at the time of the incident involving Resident 10. The DON revealed that the previous facility Administrator determined the occurrence did not need to be reported. The DON confirmed that the facility had no documentation of the investigation by the previous facility Administrator. The DON confirmed that a facility investigation report had not been submitted to the state agency.

Licensure Reference Number 175NAC 12-006.09 Based on record review, observation, and interviews, the facility failed to implement resident care consistent with the resident's physician orders for 1, (Resident 4) of 5 sampled residents. Facility stated census of 43. Findings are: A. Review of an admission Record dated 03/28/2024 indicated that the facility admitted Resident 4 on 04/04/2023 with diagnoses of: Type 2 Diabetes (which is a condition in which the body has trouble controlling blood sugar and using it for energy), Neuromuscular dysfunction of the bladder, (which is a condition where there is a lack of bladder control due to a brain, spinal cord, or nerve problem), and Pressure ulcer of the right heel (which is a area of skin damage due to prolonged pressure on the skin and or lack of blood flow to the area). The Quarterly Minimum Data Set (MDS which is a mandatory comprehensive assessment tool that measures the health status of nursing home residents and is used for care planning), with and Assessment Reference Date (ARD) of 01/02/2024, revealed Resident 4 had a Brief Interview for Mental Status (BIMS is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 10, indicating the resident was moderately cognitively impaired. The resident required supervision and touching assistance with eating, partial to moderate assistance with bed mobility and was totally dependent on staff assistance with transfers and toilet use. The resident had an indwelling catheter, which is a tube placed in the bladder, and had a stage 2 pressure ulcer. Review of Resident 4's Care Plan dated 03/28/2024, revealed the resident had a pressure ulcer to the right heel that was present on admission with interventions that included to elevate heels off of the bed with a pillow under the legs, heel protector to the left heel and prafo (Multi-Podus boots are often prescribed for patients who must spend extended periods of time in bed. These devices are worn on the calf and foot. They suspend or float the heel and hold the ankle in a neutral (90 degree) position.) boot to the right heel at all times, Nurses to perform wound care as recommended by the medical provider, and to see the medication and treatment record for current intervention for pressure relief, protections, and treatment. All interventions date of initiation was 10/04/2023. The resident had a supra-pubic catheter (which is a tube that goes through the abdomen and into the bladder to drain the bladder), with an intervention of supra pubic catheter cares with morning and bedtime care with and initiation date of 01/06/2023. Review of Resident 4's electronic physician orders revealed the following orders: -An order start date of 08/24/2023, to clean the supra pubic catheter and site with warm water and change the gauze sponge every shift. -An order start date of 03/23/2024Wash Resident 4's wound daily with Hibiclens, (which is an antimicrobial cleanser), and water or soap and water. Wash in an outward circular fashion. Apply Thera Bond dressing, (which is a thin cloth like material infused with silver used in wound care), to wound bed only and secure. On 04/01/2024 at 2:51 PM the following was observed in the room of Resident 4: Resident 4 was lying in bed flat on the [gender] back. Medication Aide (MA)-L obtained 2 disposable wipes from a package located on the bedside table located near the head of the resident's bed. MA-L then dispensed 4 pumps of a thick white solution from a container labeled Tena Cleansing Cream onto the center of the disposable wipes. MA-L then rubbed the wipes together dispensing the thick white solution over a larger area of the wipes. MA-L then placed their left hand to Resident 4's abdomen just below the resident's belly button and used the hand to hold on to the resident's supra catheter that was located there. MA-L used the disposable wipes with the cream on them to wipe the resident's supra catheter from where MA-L's left hand was at the resident's abdomen to approximately 3 inches down the supra catheter tubing. MA-L then threw the wipes away in a trash can. MA-L then obtained 2 additional wipes from the package on the overbed table and repeated the supra catheter cleansing actions as listed above. In an interview conducted on 04/01/2024 at 3:15 PM with MA-L, revealed that the Medication Aides or the Nurse Aides (NA) complete supra catheter cares twice a day in the morning and evening. MA-L further revealed that they use the disposable washcloths and the Tena Cream or soap and water for supra catheter cares. MA-L denied knowing if the resident had orders for an alternate form of supra catheter cares to be provided. In an interview conducted on 04/02/2024 at 10:45 AM with Licensed Practical Nurse (LPN)-D, confirmed that Medication Aides or Nurse Aides complete supra catheter cares on residents twice a day following facility policy for supra catheters. LPN-D further confirmed that Resident 4's physician ordered supra supra catheter cares dated 08/24/2023, which gave directions to clean supra pubic catheter and site with warm water and change the sponge every shift, day, evening, and night. Record review of facility supplied Policy labeled Perineal Care Using Tena Wipes dated 01/2024 revealed under procedure #9 if a resident has a supra catheter wipe around catheter insertion site with the wipe and down 3 to 5 inches of the catheter tubing. In an interview on 04/02/2024 at 8:19 AM with the Director of Nursing (DON), revealed the facility was in the process of re-writing the facilities policy for care of supra catheters. DON further revealed MA-L performed the care using the new process and not the physicians' ordered directions or the facilities current policy. B. Review of Resident 4's electronic physician orders revealed, an order start date of 08/24/2023, to clean supra pubic catheter and site with warm water and change the gauze sponge every shift and to wash Resident 4 wound daily with Hibiclens, (which is an antimicrobial cleanser), and water or soap and water. Wash in an outward circular fashion. Apply Thera Bond dressing, (which is a thin cloth like material infused with silver used in wound care), to wound bed only and secure with and order start date of 03/23/2024. Review of Resident 4's medical chart revealed a document labeled Physician Orders dated 03/23/2024 with documentation stating to start Thera Bond, daily, wash wound with soap and water, signed by the provider, and noted by a nurse. Observation on 04/01/2024 at 10:17 AM LPN-D in the room of Resident 4 completed wound care for Resident 4's pressure ulcer in the following manner: LPN-D used a light teal bottle with a white cap labeled Hibiclens. LPN-D then took a crumpled piece of white gauze and depressed it into the bed of the wound. LPN-D moved the gauze in the wound bed in multiple half circular motions. LPN-D disposed of the used piece of gauze and obtained a clean piece of gauze. LPN-D placed the gauze to the wound bed and rotated it in half circular motions. LPN-D took a thin silver-gray colored piece of mater out of a package labeled TherBond. LPN-D cut the material in a circle shape and placed the material in a cup of tap water located on the resident's bedside table. With a gloved hand LPN-D removed the material from the cup and then using their gloved finger pressed the material into the wound bed. The material was observed to be overlapping the wound edges and setting on the skin surrounding the wound. LPN-D continued to press the silver-gray material into the wound bed until the material only was located over the wound bed. In an interview conducted on 04/01/2024 at 11:15 with LPN-D, [gender] confirmed that the physicians ordered wound care for Resident 4's wound care stated to wash the resident's heel with Hibiclense and water or soap and water, wash outward in circular fashion, apply Thera Bond dressing to wound bed only and secure. LPN-D confirmed [gender] should not have put the Hibiclense directly on the wound bed and not rinsed it off. LPN-D also confirmed the Thera Bond dressing should have been cut smaller size and there was not direction from the physician to soak the material in the tap water. LPN-D further confirmed that the wound should have been cleansed using a circular motion starting in the center and working outward to the skin surrounding the wound. Record review of a document labeled Hibiclense dated 2024 revealed under how to use Hibiclense to rinse the skin before applying. Apply only enough to cover the area you are treating. Do not apply this medicine to deep cuts, scrapes, or open skin wounds. Record review of a facility supplied document labeled Wound Cleaning undated revealed for an open wound to gently clean the wound in a full or half circle beginning in the center and working toward the outside clean at least 1 inch beyond the end of the new dressing or 2 inches beyond the wound margins. Record review of a document labeled Open Wound Cleansing dated June 30, 2017 by The Wound Care Education Institute revealed for cleansing of open wounds, gently clean the wound in a full or half circle beginning in the center and working toward the outside and to clean at least one inch beyond the end of the new dressing or two inches beyond the wound margins. In an interview on 04/02/2024 at 8:19 AM the DON confirmed that LPN-D did not follow the physician prescribed directions for wound care for Resident 4 and did not use the proper technique when cleansing the residents wound. DON further confirmed the providers directions for wound care were not transcribed into the electronic medical health record correctly.

Licensure Reference Number 175NAC 12-006.09D7b Based on record review and interviews, the facility failed to identify causal factors and implement interventions to prevent incidents and accidents. This affected 1 (Resident 7) of 5 sampled residents. Facility stated census of 43. Findings are: Review of an admission Record dated 03/28/2024 indicated that the facility admitted Resident 7 on 04/05/2021 with diagnoses of: Cerebral Infarction (which is a stroke where blood supply to part of the brain is deprived and brain cells die), Hypertension (which is high blood pressure), Osteoarthritis (which is a degenerative disease of the joints often resulting in pain and stiffness in the joint), and Muscle Weakness. The Comprehensive Minimum Data Set (MDS which is a mandatory comprehensive assessment tool that measures the health status of nursing home residents and is used for care planning), with and Assessment Reference Date (ARD) of 02/27/2024, revealed Resident 7 had a Brief Interview for Mental Status (BIMS is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) Score of 15 indicating the resident was cognitively intact. The resident required set up or clean up assistance with eating and supervision or touching assistance with bed mobility, transfers, and toilet use. The resident was indicated as taking an antiplatelet medication which is a medication that prevents blood clots from forming. Review of Resident 7's Care Plan dated 03/28/2024, revealed a focus of the resident had a potential for adverse drug reactions related to taking aspirin, which is a blood thinning medication, dated 03/03/2024 with an intervention of staff to monitor the resident for signs and symptoms of excessive bruising and bleeding and to report this dated 03/03/2024. A focus of standard basic care plan information dated 02/29/2024 with an intervention of staff to monitor skin for bruising and report to the nurse. The nurse is to notify the provider as needed and to refer to the medication and treatment record and skin condition report for current interventions, monitors and protections dated 03/03/2024. A focus stating the resident is alert and oriented and able to tell staff what they want or need dated 02/28/2024. With a intervention of the resident being able to tell the staff what they want or need if staff have trouble hearing the resident to eliminate background noise or come closer dated 02/28/2024. A focus of the resident needing assistance with bed mobility dated 02/29/2024 with a focus of the resident needing more assistance with activities of daily living and staff to aid of one with transfers and bed mobility dated 03/05/2024 and for staff to provide skin care and reposition assistance as needed. Staff to apply lotion to the residents' extremities dated 03/03/2024. Review of the resident's care plan revealed no focus, goal, or intervention for prevention of bruising to skin during transfers or guidance to staff on how to assist resident with transfers to prevent injury or bruising. In an interview on 03/27/2027 at 3:39 PM with Resident 7, revealed that when staff assist the resident with getting out of bed the staff pull on the residents left arm and hand, and this causes bruising to the residents' hand. Resident further revealed that now [gender] tells staff not to pull on [gender] arm or left hand when they assist the resident out of bed or with transfers. A record review of Resident 7's Progress Notes revealed on 06/13/2023 a bruise was noted to the residents left hand measuring 4 centimeters by 4 centimeters and the resident stated it was from staff grasping the residents' hands when assisting up. On 01/12/2024 a Progress Note was entered that the resident reported to staff of having a quarter sized bruise to the residents left hand and the resident stated the bruise came from staff while being assisted with the morning cares. A record review of facility supplied Incident and Accident Report dated 06/13/2024 revealed documentation of a bruise to Resident 7's left hand due to staff grasping the residents' hands when assisting the resident. There were no interventions for prevention or investigation of causative factor listed on the report. In an interview on 04/01/2024 at 9:01 AM with Nurse Aide (NA)-C, revealed staff aide Resident 7 with transfers and bed mobility. NA-C stated the resident tells the staff how to provide the assistance to the resident and is specific for staff not to pull on the resident's arms or hands, so the staff just help as the resident directs. NA-C denies being educated or directed to aide Resident 7 with any special equipment or in a specific special manner. Stated if found a bruise on a resident would report it to the nurse. In an interview on 04/01/2024 at 4:03 PM with Licensed Practical Nurse (LPN)-D, revealed staff are to report skin issues including bruises to the nurses. The Nurse it was reported to would then investigate to see if the area was new or old if new would ask the resident how it happened if the resident does not know or could not answer then the nurse would ask the staff. LPN-D further revealed the nurse would assess the area including measurements, notify the provider and the family, and complete and incident accident report and document everything in a progress note. In an interview on 04/01/2024 at 4:30 PM with the Director of Nursing (DON), confirmed that resident had received bruises to the resident's hand while being assisted by staff. DON confirmed no incident report was completed for the bruise occurring on 01/12/2024. DON confirmed no interventions were placed to prevent this from continuing to occur. DON stated the facility did not have a policy directly to address incidents or accidents occurring to the skin. Stated staff would follow the New Skin Issue Checklist form and follow those instructions. A record review of facility supplied document labeled New Skin Issue Checklist not dated revealed directions for staff to fill out an incident report making sure to fill out the form completely with an explanation of what happened and what the staff did as a treatment or intervention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** License reference number 175 NAC 12-006.10D Based on observation, record review, and interview the facility failed to ensure facility staff primed insulin pen needles as required to ensure the correct dosage administration for 2 residents of 2 residents observed (Residents 10, and 32). The facility census was 43. Findings are: A. Record review of the [NAME] Lilly manufacturer's directions on both the drug insert and information located on [NAME] Lilly company website, the Insulin injection pen for Lispro Injection Solution, specifies Insulin needles must be primed prior to use. To prime the Insulin pen needle (priming means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly and assures that the needle is filled) one must first observe for any discoloration and/or air bubbles that may in the medication chamber, then dial the device to 2 units, and finally remove the top of the needle and click the pen to push out the two units while holding the pen vertically to observe a small amount of insulin at the top of the needle prior to use. It is at this point that one will then dial the pen to the prescribed insulin dose. The pen is now ready for giving the medication. Inform the patient there will be a small stick and insert the needle, click the pen to administer, then count to 5 slowly prior to removing the insulin needle to allow for complete injection of the insulin from the pen. LISKP-0006-IFU-20230721 https://uspl.lilly.com/lispro/lispro.html#ug1 Revised date 9/2023 Record review of the annual nursing competencies for insulin which had the revision date of 6/6/2011 revealed that the Insulin Competencies did not include information or checkoffs related to Insulin injection pens including the requirement to prime the needle. Record Review on 4/1/24 of the Electronic medical record revealed Resident 10 had a physician order for Insulin Lispro Injection Solution (Insulin Lispro) Inject 5 unit subcutaneously two times a day with breakfast and noon meal. There was a second physician order for Resident 10 for sliding scale insulin. This order stated Insulin Lispro Injection Solution (Insulin Lispro) Inject as per sliding scale: if blood sugar level 151 - 200 = 1 unit; 201 - 250 = 2 units; 251 - 300 = 3 units; 301 - 350 = 4 units; 351 - 400 = 5 units; 401 - 450 = 6 units; 451 - 500 = 6 units and recheck blood sugar in 15 minutes. subcutaneously three times a day for diabetes. An observation on 3/27/24 at 12:00 PM Licensed Practical Nurse (LPN)-E checked blood sugar of Resident 10 which was 182. This indicated the need for one additional unit of insulin per the sliding scale insulin order. Licensed Practical Nurse-E (LPN-E) attached the needle, dialed the pen to 6 units and administered the insulin. The needle was not primed. The needle was not held in place for a total of 5 seconds or a slow count to 5. Interview on 4/2/24 at 11:05 AM with LPN-E revealed how insulin pens are used and the procedure steps to follow in giving insulin with an insulin pen. LPN-E followed all the correct steps however the step of priming the needle was not included. LPN-E did state that the needle needs to be left in the skin for a few seconds before removing the needle. LPN-E revealed employment at the facility for the past ten years and that the insulin pens have been used in the facility for a few years. Interview on 4/2/24 at 10:35 AM with LPN-D revealed how Insulin pens are used and the procedure steps to follow in giving an insulin that had both a regular order as the need for Sliding scale insulin based upon an elevated blood sugar. LPN-D followed through with all the correct steps including priming the needle with 2 Units prior to dialing the correct dose of the insulin on the insulin pen to be given. LPN-D reveal that they had worked in other facilities in which insulin pens were used. They always had to prime the insulin pen needles by dialing in 2 units. LPN-D also revealed that the Insulin pens are more accurate than using a multi-dose vial as the insulin pen eliminates the possible error in drawing up insulin into a syringe. When questioned about the annual competencies, LPN-D stated the staff either demonstrate how to do procedures or use table discussion procedure discuss the correct steps to follow. LPN-D did not know that the annual training competencies do not include training for the insulin pens or the need to prime the insulin pen needles. LPN-D has been employed at this facility for 2 years. Interview on 4/2/24 at 1:30 PM with the facility Director of Nursing (DON) confirmed the facility did not have a policy and procedure for the use of the insulin pens. At that point, the DON did present a copy of a Policy and Procedure that they were thinking of implementing in the facility. After review, the DON revealed that there was a step missing in that policy that did not include the need to prime the needle of the insulin pen. B. Record Review on 4/1/24 of the Electronic medical record revealed Resident 32 had a physician order for Insulin Lispro Solution 100 UNIT/ML (milliliter) Inject 6 units subcutaneously three times a day. There was a second physician order for Resident 32 to receive sliding scale insulin if needed based on blood sugar parameters. This order stated Insulin Lispro Solution 100 UNIT/ML Inject as per sliding scale: if blood sugar 0 - 149 = 0 If less than 70, call PCP: 150 - 199 = 1 units; 200 - 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units; 350 - 399 = 5 units; 400 -450 = 6 units If greater than 400, give 6 units and call PCP., subcutaneously before meals and at bedtime. Observation on 4/1/24 at 4:24 PM. Medication Aide (MA)-F checked blood sugar of Resident 32 (the blood sugar was 177) then waited to do the prescribed Insulin injection until just prior to going to meal. MA-F voiced awareness that Resident 32 must have something to eat within 15 minutes of the insulin injection. Just prior to sending Resident 32 to the dining room for the noon meal, the insulin was given. The resident required the regular dose as well as one additional unit of insulin per the dosing instructions for the sliding scale insulin based on blood sugar parameters. MA-F attached the needle, dialed the pen to 7 units and administered the insulin. MA-F did not prime the needle. The injection needle was not left in place for a slow count to five or for 5 seconds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175NAC 12-006.10D Based on observation, record review, and interview the facility failed to ensure the medication error rate was under 5% with an observed medication error rate of 21.21%. This affected 7 of 15 residents observed (Residents 10, 32, 13, 9, 8, 22, and 21). The facility census was 43. Findings are: A. Record review of the [NAME] Lilly manufacturer's directions on both the drug insert and information located on [NAME] Lilly company website, the Insulin injection pen for Lispro Injection Solution, specifies Insulin needles must be primed prior to use. To prime the Insulin pen needle (priming means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly and assures that the needle is filled) one must first observe for any discoloration and/or air bubbles that may in the medication chamber, then dial the device to 2 units, and finally remove the top of the needle and click the pen to push out the two units while holding the pen vertically to observe a small amount of insulin at the top of the needle prior to use. It is at this point that one will then dial the pen to the prescribed insulin dose. The pen is now ready for giving the medication. Inform the patient there will be a small stick and insert the needle, click the pen to administer, then count to 5 slowly prior to removing the insulin needle to allow for complete injection of the insulin from the pen. LISKP-0006-IFU-20230721 https://uspl.lilly.com/lispro/lispro.html#ug1 Revised date 9/2023 Record review of the annual nursing competencies for insulin which had the revision date of 6/6/2011 revealed that the Insulin Competencies did not include information or checkoffs related to Insulin injection pens including the requirement to prime the needle. Record Review on 4/1/24 of the Electronic Medical Record revealed Resident 10 had a physician order for Insulin Lispro Injection Solution (Insulin Lispro) Inject 5 unit subcutaneously two times a day with breakfast and noon meal. There was a second physician order for Resident 10 for sliding scale insulin. This order stated Insulin Lispro Injection Solution (Insulin Lispro) Inject as per sliding scale: if blood sugar level 151 - 200 = 1 unit; 201 - 250 = 2 units; 251 - 300 = 3 units; 301 - 350 = 4 units; 351 - 400 = 5 units; 401 - 450 = 6 units; 451 - 500 = 6 units and recheck blood sugar in 15 minutes. subcutaneously three times a day for diabetes. An observation on 3/27/24 at 12:00 PM Licensed Practical Nurse (LPN)-E checked blood sugar of Resident 10 which was 182. This indicated a need for one additional unit of insulin per the sliding scale insulin order. LPN-E attached the needle, dialed the pen to 6 units and administered the insulin. The needle was not primed prior to the administration. The observation further revealed that the needle was not held in place for a total of 5 seconds or a slow count to 5 during the administration of insulin to the resident. Interview on 4/2/24 at 10:35 AM with Licensed Practical Nurse (LPN)-D revealed how Insulin pens are used and the procedural steps to follow when administering an insulin injection that needed both a regular order and sliding scale insulin based upon an elevated blood sugar. LPN-D followed through with all the correct steps of priming the needle with 2 Units prior to dialing the correct dose of the insulin on the insulin pen to be given to the resident. LPN-D reveal that they had worked in other facilities in which insulin pens were used and was taught to prime the insulin pen needles by dialing in 2 units. When questioned about the annual competencies, LPN-D revealed the staff either demonstrate how to do procedures or use table discussion procedure discuss the correct steps to follow. LPN-D did not know that the annual training competencies do not include training for the insulin pens or the need to prime the insulin pen needles. LPN-D has been employed at this facility for 2 years. Interview on 4/2/24 at 11:05 AM with LPN-E. Discussed how insulin pens are used and the procedure that must be followed when giving insulin with an insulin pen. LPN-E followed nearly all the correct steps but missed the step of priming the needle, which was not included. LPN-E did state that the needle needs to be left in the skin for a few seconds before removing the needle. LPN-E revealed employment at the facility for the past ten years and that the insulin pens have been used in the facility for a few years. B. Record Review on 4/1/24 of the Electronic medical record revealed Resident 32 had a physician order for Insulin Lispro Solution 100 UNIT/ML (milliliter) Inject 6 units subcutaneously three times a day There was a second physician order for Resident 32 for sliding scale insulin. This order stated Insulin Lispro Solution 100 UNIT/ML Inject as per sliding scale: if blood sugar 0 - 149 = 0 If less than 70, call PCP: 150 - 199 = 1 units; 200 - 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units; 350 - 399 = 5 units; 400 -450 = 6 units If greater than 400, give 6 units and call PCP., subcutaneously before meals and at bedtime. Observation on 4/1/24 at 4:24 PM. Medication Aide (MA)-F checked the blood sugar of Resident 32 (the blood sugar was 177) then waited to do the prescribed Insulin injection until just prior to going to meal. MA-F revealed that Resident 32 must have something to eat within 15 minutes of the insulin injection. Just prior to sending Resident 32 to the dining room for the noon meal, the insulin was given. The resident required the regular dose as well as one additional unit of insulin per the dosing instructions for the sliding scale insulin based on blood sugar parameters. MA-F attached the needle, dialed the pen to 7 units and administered the insulin. MA-F did not prime the needle. The injection needle was not left in place for a slow count to five or for 5 seconds. Interview on 4/2/24 at 1:30 PM with the facility Director of Nursing (DON), confirmed the facility did not have a policy and procedure for the use of the insulin pens. At that point, the DON did present a copy of a Policy and Procedure that they were thinking of implementing in the facility. After review, the DON revealed that there was a step missing in that the policy did not include the need to prime the needle of the insulin pen. C. Record review of the Voltaren instructions for use dated 2024 revealed the need to use the dosing card to measure the correct dose each time the medication is administered. Gently rub Voltaren Arthritis Pain Gel into the skin using your hand. One should apply it 4 times a day for best results. Only apply to clean, dry skin that doesn't have any cuts, open wounds, infections, or rashes. Do not apply in the same area as any other medicine or products applied to the skin. The dosing card should always be used to measure a dose. For each upper body area (hand, wrist, or elbow) squeeze out 2.25 inches (2 grams). For each lower body area (foot, ankle, or knee) squeeze out 4.5 inches (4 grams). https://www.voltarengel.com/arthritis-pain-gel Updated 2024 Record Review on 4/1/24 of the Electronic Medical Record revealed that Resident 13 had a physician's order for Voltaren External Gel 1 % (Diclofenac Sodium (Topical)) (A topical medication for pain) Apply to knees topically four times a day; apply 4 grams to knees. Observed on 4/1/24 at 4:00 PM Voltaren cream was administered to Resident 13 by Licensed Practical Nurse-G (LPN-G). The measuring tool was not used to measure the correct dosage of Voltaren gel for each knee. LPN-G simply placed the Voltaren gel to the resident's knee and squeezed the tube until she had enough. This was approximately 1 to 1 ½ of medication on each knee of Resident 13. (A 4-gram dose of Voltaren is 4.5 inches of gel.) In an interview on 4/1/24 at 4:00 PM while LPN-G was squeezing the Voltaren cream, LPN-G revealed [gender] would squeeze the tube until [gender] had enough. D. Record review of the online article entitled How to Put In Eye Drops updated on July 23, 2021 from the National Eye Institute and the National Institute of Health revealed if your doctor prescribes eye drops to treat glaucoma or another eye condition, it's important to use eye drops correctly so that all the medicine gets into your eye. If you don't use them correctly, you could lose your vision. Follow these steps to put in your eye drops: Tilt your head back and look up. With 1 hand, pull your lower eyelid down and away from your eyeball - this makes a pocket for the drops. With the other hand, hold the eye drop bottle upside down with the tip just above the pocket. Squeeze the prescribed number of eye drops into the pocket created when pulling the eye lid down and away from eyeball. For at least 1 minute, ask the patient or resident to their close eye and press a finger lightly on the tear duct (small hole in the inner corner of your eye next to the nose) - this keeps the eye drop from draining into your nose. If you need to use more than 1 type of eye drop, like different drops for different eye conditions, wait at least 5 minutes between each type. To prevent infections when you use eye drops, follow these tips to protect your eyes: Wash your hands with soap and water (or apply gloves) before you use eye drops. Don't touch the tip of the eye drop bottle with your hands. Don't let the tip of the eye drop bottle touch your eye or eyelid https://www.[NAME].nih.gov/Glaucoma/glaucoma-medicines/how-put-eye-drops Last updated: July 23, 2021 Record review on 4/1/24 of the Electronic Medical Record for Resident 9 revealed orders for Artificial Tears Ophthalmic Solution 1.4 % (Polyvinyl Alcohol) Instill 1 drop in both eyes every 2 hours for eye comfort until 04/02/2024. Observed on 4/1/24 at 4:10 PM MA-F entered the room of Resident 9 to give an eye drop in the right eye. Resident 9 informed MA-F that the medication order had been changed as Resident 9 had just returned from the eye doctor and the new orders were hanging on the closet door. MA-F told the resident MA-F had to return to the medication cart to review the new orders. This was a potential for error had Resident 9 not intervened to tell MA-F of the new orders. Both eyes of Resident 9 needed one eye drop every two hours. The eye drops were given in the middle of the lower lid instead in the outer area. E. Record review on 4/1/24 revealed a physician order for Resident 8 for Artificial Tears Solution 0.4 % (Hypromellose) (an eye drop solution); Instill 1 drop in both eyes four times a day related to macular degeneration (a degenerative disease-causing loss of vision). Observation on 4/1/24 at 4:30 MA-F instilled eye drops in the eyes of Resident 8. Both of Resident 8's eyes remained closed when giving the eye drops. MA-F (Medication Aid) did give one drop in each eye, did not open the eye or attempt to create a pocket in which to instill the drops. F. Record review on 4/1/24 of the Electronic Medical Record for Resident 22 revealed an order for Systane Complete Ophthalmic Solution 0.6 % (Propylene Glycol (Ophth) eye drop solution). Instill 1 drop in both eyes four times a day for dry eyes and history of cataracts. Observed on 4/1/24 at 4:37 LPN-G performed Hand Hygiene (cleansed hands) with alcohol-based hand sanitizer then donned clean gloves while standing at the medication cart. LPN-G removed the cap of the eye drops to show this surveyor that the drops had a different type of top and the drops were more difficult to administer. Upon entering the room, LPN-G explained that it was time for Resident 22's eye drop administration then gave the resident the eye drops. LPN-G contaminated the bottle of eye drops as the bottle of eye drops were rubbed in a back-and-forth motion on the eye lashes of both closed eyes when giving the drops. At no point did LPN-G try to open either eye or try to create a pocket for the administration of the eye drops. Resident 22 did not open either eye for the procedure. Unknown how much and if the drops were put into the eyes as LPN-G simply squeezed the bottle while rubbing both eyes and no drop was actually observed coming from the bottle. G. Record Review of the Electronic Medical Record on 4/1/24 for Resident 21 revealed a physician order for Dry Eye Relief Drops Solution 0.2-0.2-1 % (Glycerin-Hypromellose-PEG 400) eye drop solution. Instill 1 drop in both eyes three times a day for dry eyes. Observed on 4/1/24 at 4:42 LPN-G touched the bottom of the right eye lid of Resident 21 with the tip of the bottle of solution when instilling the eye drops thus contaminating the bottle. LPN-G did not create a pocket in which to instill the eye drops.

Licensure Reference Number 175NAC 12-006.11E Based on observations, record reviews and interviews, the facility failed to monitor the required temperature for sanitization of facility dishware that had the potential to affect all facility residents; failed to ensure sanitary procedures between raw and cooked foods to prevent the potential for foodborne illness that had the potential to affect all facility residents; and the facility failed to monitor food temperatures for the prevention of foodborne illnesses for 12 of the 43 residents that ate from the kitchen. The facility census was 43. Findings are: A. On 04/01/2024 at 1:14 PM Dietary Aide (DA)-J was observed processing dishware in the soiled dish area. Dietary Aide (DA)-K was observed assisting in the soiled dish area assisting DA-J with dishwashing. The temperature gauge markings for the dish machine were not readable due to either internal steam or scaling of the glass covering the temperature markings. DA-J was interviewed on the dishware process and stated that the dishes get rinsed off, placed on the rack, sometimes covered when needed. DA-J included that the lever is pulled to open the machine, the rack enters the machine, the lever is switched to be closed and the button is pushed. DA-K was interviewed on the sanitization process and stated that the water is checked with a small strip and checked for amount of proper sanitization parts per million (ppm). The ppm is then annotated on a form that is hanging behind a cabinet door a few steps away from the dish machine. When inquired about the gauge on the dish machine, DA-K revealed that the temperatures were not observed or recorded as part of their process. The facility Dietary Manager (DM) was interviewed on 04/01/2024 at 1:45 PM about the dishwashing process. The facility DM revealed that the dish machine is a low temperature machine and uses chemical sanitization as part of their dish sanitization process. The facility DM stated that temperatures for the low temperature machine have not been monitored as part of their process. A review of the dish machine Manufacturers Specification information dated 5/9/2005 revealed that the wash minimum Fahrenheit (F) for the machine they are using is for 120 degrees F. During an interview on 04/02/2024 at 2:55 PM the facility DM confirmed that all facility residents eat out of the kitchen. B. On 04/01/2024 at 10:19 AM Dietary Aide (DA)-M was observed washing raw chicken in the prep sink, a tray with parchment paper was in place over the sink overlapping the sink compartment as DA-M washed the raw chicken in the prep sink, during the process, splashing was occurring on the top and bottom of the tray that held the chicken being prepped. DA-M placed the washed raw chicken on the parchment paper on the tray. The tray of chicken was then placed on the prep table across from the prep sink and Dietary [NAME] (DC)-B began to put marinade on the chicken. This chicken was then placed in oven #2 for cooking at 425 degrees F. The prep table was observed to not be sanitized after preparation of the chicken. DC-B then brought out a pan of chicken from oven #2, placed the tray on the same prep table, checked the chicken temperature which revealed to be at 170 degrees F. The chicken was placed back into oven #2. On 04/01/2024 at 10:24 AM DC-B was observed grabbing a large stock pot from the stove, placing it on the prep table. The prep table had not been sanitized. The rice was temped and found to be at 199.9 degrees F. DC-B began scooping out rice from the stock pot into a larger pan covered in a food grade liner. DC-B was then observed lifting the large stock pot and dropping the bottom of the pot into the rice, then placing the pot back down on the prep counter, scooping the rice out until almost completed, once again lifting the stock pot, scraping the rice out. DC-B then placed the pan of rice on a small cart and placed into the steam table and covered with a lid. C. On 04/01/2024 at 10:33 AM DC-B was observed pulling a tray of chicken from oven #2 and placed on the prep counter. This chicken was temped and found to be at 165.5 degrees F. The large pan was pulled from oven #1 that contained more chicken. This chicken was placed on the counter and the tray of chicken was added to the larger pan, one piece of chicken remained on the tray. The large pan of chicken was placed on a wheeled cart and added to the steam table. The one piece of chicken was not temped and was placed into a blender for later use. On 04/01/2024 at 11:15 AM this surveyor observed the one piece of chicken to still be in the blender. The chicken had not been temped. On 04/01/2024 at 11:40AM DC-B is observed to be adding tap water and pureeing the chicken that has been sitting in the blender since 10:33 AM. Thickener is added to the puree and a powder of gravy mix is added then blended. This was poured and scraped into a small pan with a liner covering. The pan was taken to the steam tray then covered. DC-B did not obtain a temp of the gravy. DC-B was then interviewed about the reason for the blended chicken. DC-B stated that the gravy is used for ground, chopped and preferred use. Meal service was observed on 04/01/2024 starting at 12:04 PM, no temperatures were recorded at the start of service or during service. The third plate observed to be dished was a chopped/ground meat, gravy was added to this meat. Meal was delivered to the resident. An interview on 04/02/2024 at 2:55 PM with the facility DM revealed that 12 residents; 23, 21, 42, 35, 14, 17, 6, 7, 32, 3, 18, 10 eat chopped and or ground meats out of the kitchen. Interview with the facility DM also revealed that DC-B was personally trained and will be undergoing ServSafe training (a program that provides food safety training) in the future. The DM further confirmed that tempertures should be checked prior to service. A review of the facility policy and procedure manual on food temperatures indicated that: The temperatures of all food items will be taken and properly recorded prior to service of each meal. Procedure: 1. All hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees. a. cooking temperatures must be reached and maintained according to regulations, laws, and standardized recipes while cooking. b. Hot food items may not fall below 135 degrees after cooking, unless it is an item which is to be rapidly cooled to below 41 degrees and reheated to at least 165 degrees prior to serving. Caution should be taken to avoid serving food and liquids at temperatures that are too hot to avoid the risk of burns. 3. Temperatures should be taken periodically to assure hot foods stay above 135 degrees F and cold foods stay below 41 degrees F during the holding and plating process and until food leaves the service area.

Based on record review and interview, the facility failed to provide Resident 43 with Written Notice of Transfer on transfer to the hospital. This affected 1 of 1 resident sampled for Hospitalization. The facility's census was 39. Findings are: A review of Resident 43's Progress Notes revealed that on 1/19/23 the resident fell at the facility and was sent to the hospital. The facility was unable to provide a copy of the Written Notice of Transfer upon request. In an interview conducted on 3/8/23 at 11:53 AM, the Administrator confirmed that the facility had not been providing residents or their representatives with Written Notices of Transfer upon discharge or transfer to the hospital.

Licensure Reference Number 175 NAC 12-006.09D1c Based on observation, record review and interview; the facility failed to provide assistance with oral care for 1 (Resident 17) of 3 sampled residents. The facility census was 39. Findings are: An observation on 3/6/23 at 10:30AM revealed Resident 17 with white debris build up on the base of Resident 17's lower teeth. The observation further revealed Resident 17 missing multiple upper teeth. In an interview on 3/6/23 at 10:30AM Resident 17's responsible party and Resident 17 confirmed that Resident 17's teeth had not been brushed and do not get brushed. An observation on 3/7/23 at 10:49AM revealed Resident 17 with white debris build up on the base of Resident 17's lower teeth. In an interview on 3/7/23 at 10:49AM Resident 17's responsible party and Resident 17 confirmed that Resident 17's teeth had not been brushed. A record review of Resident 17's Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care), dated 12/6/22, revealed: -Brief Interview for Mental Status (BIMS- a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) Summary Score of 5, which indicated severe impairment. -Had no rejection of care -Required extensive assistance for personal hygiene A record review of Resident 17's comprehensive care plan (written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care), dated 12/7/22, revealed that Resident 17 needed extensive assist with all of Resident 17's cares. In an interview on 3/7/23 at 1:00PM, NA-B (Nurse Aide) confirmed that Resident 17 had white debris build up on the base of Resident 17's lower teeth and that Resident 17's teeth had not been brushed. A record review of the facilities: Midwest Covenant Home Standards of Care, revised 4/4/19, revealed: -Caregiving Standards: teeth/dentures are cleaned at least daily as resident will allow

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. A review of Resident 2's admission record revealed that Resident 2 admitted to the facility on [DATE] with the diagnoses of: Influenza, Pneumonia, Respiratory failure, and Chronic Obstructive Pulmonary Disease. An observation on 3/6/23 at 10:22AM revealed Resident 2's Positive Airway Pressure (PAP-a machine used to deliver pressure to the airway to keep it open during sleep) mask on a bedside table with a residual amount of water in the chamber and dust particles on the machine. An observation on 3/7/23 at 10:47AM revealed Resident 2's PAP mask on a bedside table with a residual amount of water in the chamber and dust particles on the machine. A review of Resident 2's Treatment Administration Record (TAR), dated 3/7/23, revealed the following: -Continuous PAP (CPAP) orders: on at bedtime (HS) and off in AM. Wipe down daily -Wipe CPAP mask or pillow, tubing and humidity basin if used with warm soapy water daily and dry In an observation and interview on 3/7/23 at 12:32PM, the Director of Nursing (DON) confirmed the presence of residual water in the chamber and dust particles on the machine. The DON further confirmed that the PAP mask and machine had not been wiped down. A record review of Northwest Respiratory Services CPAP/BiPAP Safety Precautions, undated, revealed: -Clean and disinfect mask, tubing, and humidifier regularly -Wipe off machine with a clean damp cloth as needed 175 NAC 12-006. 17D and 175 NAC 12-006.18B Based on observations, record reviews and interviews, the facility failed to ensure Hand Hygiene (cleaning the hands with soap and water or the use of an alcohol based hand rub (ABHR) to help prevent the spread of infection) was completed during wound care for 1 Resident (40) out of 2 sampled for Pressure Injury, and the facility failed to maintain clean Respiratory equipment for 1 Resident 2 sampled for Respiratory Care. The facility census was 39. A. On 3/8/23 at 10:24 AM an observation was made of a dressing change for Resident 40's right heel wound completed by Licensed Practical Nurse (LPN) A. -LPN A washed their hands with soap and water and put on clean gloves. -LPN A then removed the resident's shoe, sock, and old dressing, then cleaned the open area with gauze and wound cleanser. -LPN A then discarded the old dressing and the gauze used for cleaning, removed the soiled gloves, and without performing Hand Hygiene put on new gloves and put on a clean dressing. A review of the undated facility policy for Wound Care revealed that after removing the old dressing, it should be discarded, and the nurse should remove their gloves and wash their hands again. In an interview on 03/08/23 at 10:39 AM, LPN A confirmed that they should have performed Hand Hygiene between removing soiled gloves and putting on clean gloves.