Every finding on record at Accura HealthCare of Tekamah

Based on record review and interview, the facility failed to ensure Registered Nurse [RN] coverage was provided at least 8 consecutive hours a day for 7 days a week. This had the potential to affect all residents. The facility census was 33. Findings are:Review of the Payroll-Based Journal [PBJ] (a mandatory reporting system requiring long term care facilities to electronically submit direct care staff data-including daily hours worked by employees and contract staff to the Centers for Medicare and Medicaid Services quarterly) Staffing Data Report dated 2/5/26 revealed the Metric 'No RN Hours' triggered for no RN hours on 7/6/25, 7/19/25, 8/2/25, & 8/16/25. In an interview with the Administrator on 2/11/26 at 10:35 AM confirmed there was no RN scheduled 7/6/25, 7/19/25 & 8/2/25.

Licensure Reference Number 175 NAC 12-006.04 Based on record review and interview, the facility failed to ensure 12 hours of yearly training was completed for 2 Nursing Assistant (NA) ( D and F) of 5 employees. The facility census was 33. Findings are: A. Record review of an undated list of employee with their date of hire revealed NA F was hired on 7-14-2020. Record review of a form titled Training Hours dated 2/11/26 revealed NA F had completed 6.1 hours annual training. Record review of an Inservice record dated 1/20/26 for Dementia and Behaviors revealed NA F had attended bringing her total yearly in-service hours to 7.1 hours to include 2.5 hours for dementia training and no Abuse training. B. Record review of an undated list of employee with their date of hire revealed NA D was hired on 8-14-2023. The facility was unable to provide information that NA D had completed any yearly training. In an interview with the Administrator on 2/11/26 at 10:35 AM the Administrator confirmed NA D and NA F did not complete the required yearly training and should have.

Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g) Based on observation, interview, and record review, the facility failed to obtain a valid order for Positive Airway Pressure (PAP)(a machine used to treat sleep apnea) device for 3 (Residents 11, 28, and 3) of 3 sampled residents. The facility census was 33. Findings are:A record review of the facility's Continuous Positive Airway (CPAP) and BiLevel Positive Airway Pressure (BiPAP) policy dated 11/18/2025 revealed the facility would obtain an order for the use of the device and settings from the practitioner. A. A record review of Resident 11's Care Plan with an admission date of 01/26/2026 revealed a focus area of CPAP/BiPAP therapy at night related to Obstructive Sleep Apnea (OSA) and oxygen (o2) continuous during waking hours via nasal cannula (a tubing the goes in the nose to deliver oxygen). It did not reveal PAP settings. A record review of Resident 11's Clinical Physician Orders dated 02/11/2026 revealed the resident had an order of: CPAP at current (with o2) connect o2 tubing to mask, apply at night and fill chamber with distilled water to fill line and o2 at 1-4 liters per minute (l/m) continuously, titrate to keep saturation at or above 90 percent (%). The Clinical Physician Orders did not reveal the mode or settings for the PAP device A record review of Resident 11's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated 02/01/2026 – 02/10/2026 revealed the resident wore the PAP and o2 every night. An observation on 02/09/2026 at 8:16 AM revealed Resident 11 was awake and sitting on the side of the bed. The oxygen concentrator (a machine used to purify oxygen) was running at 3 l/m and the nasal cannula was tucked into the top of the oxygen concentrator. The resident was not wearing the oxygen. The resident had a PAP device located on the bedside table to the right of the bed. An observation on 02/10/2026 at 6:45 AM revealed that Resident 11 was awake and in bed. The oxygen concentrator was running at 3 l/m and the nasal cannula was tucked in the handle on top of the oxygen concentrator. The resident did not have oxygen on. The resident had a PAP device located on the bedside table to the right of the bed. In an interview on 02/09/2026 at 8:16 AM, Resident 11 confirmed the staff told the resident that the resident's oxygen level was really good, and the resident did not need the oxygen. The resident confirmed that the resident wore the PAP every night and did not know what the settings were supposed to be. In an interview on 02/10/2026 at 1:43 PM, the Director of Nursing (DON) confirmed that the resident's PAP order did not include settings for the PAP device and the order for the oxygen during the day was for 1-4 l/m continuous oxygen and the resident was not wearing oxygen. B. A record review of Resident 28's Care Plan with an admission date of 07/17/2025 revealed a focus area of CPAP/BiPAP therapy for OSA but did not reveal the specific mode or settings for the PAP device. A record review of Resident 28's Clinical Physician Orders dated 02/11/2026 revealed the resident had an order of: Oxygen 2-3 l/m with BiPAP every night at bedtime but did not reveal PAP settings. A record review of Resident 28's MAR & TAR dated 02/01/2026 – 02/10/2026 revealed the resident wore the PAP and o2 every night. An observation on 02/09/2026 at 9:31 AM revealed that the resident had a ResMed Aircurve 10 VAuto on the bedside table to the right of the bed and an oxygen concentrator between the bed and the bedside table. An observation on 02/10/2026 at 6:51 AM revealed that the resident was already awake and sitting in the dining room. The resident had a ResMed Aircurve 10 VAuto on the bedside table to the right of the bed and an oxygen concentrator between the bed and the bedside table. In an interview on 02/10/2026 at 1:43 PM, the DON confirmed the facility did not have an order for the PAP mode or setting and should have had. C. Record review of an admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 1/26/26 for Resident 3 revealed and admission date of 1/6/26 with a Brief Interview of Mental Status (BIM's, a tool used to screen and identify the cognitive condition of the resident upon admission into a long-term care facility) score of 6/15 indicating severe problems with thinking or memory. Record review of admitting diagnosis included Acute and Chronic Respiratory Failure with hypoxia, Obstructive Sleep Apnea, Pulmonary Hypertension, Nondisplaced fracture of medal malleolus of left tibia. Record review of a physician order for Resident 3, dated 2/6/26 revealed BIPAP at preset settings (with 4L O2) Connect O2 tubing to mask, apply at night and fill chamber with distilled water to fill line at bedtime and every night shift. Observation of Resident 3 on 2/9/26 at 9:00 AM revealed Resident 3 had a PAP machine in his room. An interview with LPN A on 2//10/26 at 1:50 PM confirmed the orders for Resident 3 did not include the settings for the BiPAP and should have.

Licensure Reference Number 175 NAC 12.006.18(B)Licensure Reference Number 175 NAC 12.006.18(D)Licensure Reference Number 175 NAC 12.006.19(A)(i) Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene (cleaning) and glove changes during wound care on 1 (Resident 11) of 2 sampled residents and insulin administration on 1 (Resident 20) of 1 sampled resident, keep staff clothing off the floor in 1 (Resident 11) of 3 sampled resident's room that was in Enhanced Barrier Precautions (EBP), and clean Positive Airway Pressure (PAP)(a machine used to treat sleep apnea) masks daily for 2 (Residents 28 and 11) of 3 sampled residents to prevent potential cross contamination. The facility census was 33. Findings are: A. A record review of the facility's Hand Hygiene policy dated 11/13/2024 revealed hand washing with soap and water should be performed when going from a contaminated body site to clean body site on the same resident and between tasks and procedures. Hand sanitizer should be used before touching a resident, before putting gloves on and after glove removal. Hand washing with soap and water should have been completed for at least 20 seconds. A record review of the facility's Enhanced Barrier Precautions policy dated 11/13/2024 revealed that EBP was an infection control intervention designed to reduce disease transmission by using targeted gown and clove use during high contact resident care activities. A record review of Resident 11's Care Plan with an admission date of 01/26/2026 revealed a focus area of the resident was on EBP related to chronic non-healing wounds on the left lower extremity (LLE)(left lower leg or foot). Direct care staff would follow EBP. A record review of Resident 11's Clinical Physician Orders dated 02/11/2026 revealed the resident had an order of: Enhanced Barrier Precautions, provide EBP care with dressing, bathing, transferring, providing hygiene care, changing bed linens, toileting, device care and wound care. The resident had wound care orders with lymphedema wraps (low stretch compression bandages used to manage chronic swelling) to a wound on the LLE. An observation on 02/11/2026 at 6:45 AM revealed there was an EBP sign posted to the left as you enter the room. During the observation on 02/11/2026 at 6:45 AM Medication Aide (MA)-I assisted Resident 11 from the toilet to the wheelchair and was not wearing personal protective equipment. An observation on 02/12/2026 at 6:44 AM – 8:00 AM revealed the Occupational Therapist (OT)-J washed hands 3 times for less than 20 seconds before applying a gown and gloves during lymphedema wrap changes and the resident assessment. OT-J removed gloves and re-gloved 4 times without performing hand hygiene during lymphedema wrap changes and the resident assessment. OT-J placed OT-J's knees on the floor and sat on the floor in Resident 11's room without a barrier while completing lymphedema wrap changes and assessment. LPN-K allowed LPN-K knees to come in contact with the resident's floor without a barrier following the resident's uncovered LLE being on the floor after the resident's shower, and Licensed Practical Nurse (LPN)-K performed the entire wound care process on the LLE without changing gloves and doing hand hygiene when going from the dirty process of cleaning the wound to the clean process of applying the dressings. In an interview on 02/12/2026 at 8:41 AM, the Regional Clinical Consultant (RCC) confirmed staff should have washed hands greater than 20 seconds and between glove changes. OT-J and LPN-K should not have knelt or sat on floor without gown or barrier between clothing and floor. LPN-K should have performed hand hygiene when going from cleansing the wound and applying the clean dressings. B. A record review of the facility's Continuous Positive Airway (CPAP) and BiLevel Positive Airway Pressure (BiPAP) policy dated 11/18/2025 revealed the facility would obtain an order for the use of the device and settings from the practitioner and the facility would follow the manufacturer's recommendation for the use of the machine. A record review of the [NAME] Keeping it clean: CPAP hygiene guide dated 02/11/2026 revealed a PAP mask seal should be cleaned daily and the headgear should be cleaned weekly. https://www.[NAME].co.uk/c-e/hs/better-sleep-blog/better-sleep/keeping-it-clean-cpap.html A record review of Resident 11's Clinical Physician Orders dated 02/11/2026 revealed an order to wash CPAP or BIPAP mask with soap and water, rinse tubing and allow to air dry every AM every day shift. A record review of Resident 11's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated 02/01/2026 – 02/11/2026 revealed the resident wore the PAP and o2 every night and the mask had been cleaned. An observation on 02/09/2026 at 8:19 AM revealed Resident 11 was awake and sitting on the side of the bed. The resident's PAP mask was a [NAME] Respironics [NAME] View and was directly on the mattress on the left side of Resident 11's bed with facial oils on the seal, a brown crusty substance on the inside, and makeup on the headgear. An observation on 02/10/2026 at 6:45 AM revealed Resident 11 was awake and lying in bed. The resident's PAP mask was a [NAME] Respironics [NAME] View and was directly on the mattress on the left side of Resident 11's bed with facial oils on the seal, a brown crusty substance on the inside, and makeup on the headgear. An observation on 02/09/2026 at 1:28 AM revealed Resident 11 was awake and sitting on the side of the bed. The resident's PAP mask was a [NAME] Respironics [NAME] View and was directly on the mattress on the left side of Resident 11's bed with facial oils on the seal, a brown crusty substance on the inside, and makeup on the headgear. In an interview on 02/09/2026 at 8:16 AM, Resident 11 confirmed that the resident wore the PAP the night before. In an interview on 02/10/2026 at 1:34 PM, MA-I confirmed MA-I was the one that was supposed to clean the PAP masks and confirmed it had not been cleaned and should have. In an interview on 02/11/2026 at 7:05 AM, the Administrator confirmed the staff should have cleaned the PAP masks in the morning after the resident used it. C. A record review of the facility's Continuous Positive Airway (CPAP) and BiLevel Positive Airway Pressure (BiPAP) policy dated 11/18/2025 revealed the facility would obtain an order for the use of the device and settings from the practitioner and the facility would follow the manufacturer's recommendation for the use of the machine. A record review of the [NAME] Keeping it clean: CPAP hygiene guide dated 02/11/2026 revealed a PAP mask seal should be cleaned daily and the headgear should be cleaned weekly. https://www.[NAME].co.uk/c-e/hs/better-sleep-blog/better-sleep/keeping-it-clean-cpap.html A record review of Resident 28's Clinical Physician Orders dated 02/11/2026 revealed an order to wash CPAP or BIPAP mask with soap and water, rinse tubing and allow to air dry every AM every day shift. A record review of Resident 28's MAR & TAR dated 02/01/2026 – 02/10/2026 revealed the resident wore the PAP and o2 every night. An observation on 02/09/2026 at 9:31 AM revealed that Resident 28 had a [NAME] Respironics Wisp nasal mask on the bedside table to the right of the bed the mask contained facial oils on the seal and a white crusty substance. An observation on 02/10/2026 at 6:51 revealed that Resident 28 had a [NAME] Respironics Wisp nasal mask on the bedside table to the right of the bed the mask contained facial oils on the seal and a white crusty substance. In an interview on 02/10/2026 at 1:34 PM, MA-I confirmed MA-I was the one that was supposed to clean the PAP masks and confirmed it had not been cleaned and should have. In an interview on 02/11/2026 at 7:05 AM, the Administrator confirmed the staff should have cleaned the PAP masks in the morning after the resident used it. D. Record review of Resident 20's admission record revealed an admission date of 7/23/2019, with diagnosis of Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. Record review of Resident 20's Order Listing Report revealed an order dated 1/31/26 for Novolog PenFill Subcutaneous Solution Cartridge 100 unit/mL (Insulin Aspart) Inject as per sliding scale; 0-100=0; 101-200=5; 201-300=10; 301-400=15; 401-500=20, subcutaneously two times a day related to Type 2 diabetes mellitus with diabetic polyneuropathy Observation of a medication pass on 02/10/2026 at 12:00 PM revealed LPN A reported Resident 20's blood sugar was 373 which required Novolog sliding scale insulin 15 units to be given. The Insulin pen was removed from top drawer of the medication cart, cap was removed, the tip was cleaned with an alcohol wipe and the needle was applied, 2 units insulin were wasted, dial was turned to 15 Units. LPN A pulled gloves out of the left front pocket of the scrub pants and donned the gloves. LPN A entered Resident 20's room and administered the insulin. LPN A removed the gloves, walked to the medication cart and discarded the needle into the sharps container. Interview with LPN A on 2/10/26 at 12:05 PM confirmed the gloves were removed from the left front scrub pocket and were contaminated.

Licensure Reference Number 175 NAC 12-007.04D Based on observation and interview, the facility failed to ensure that ventilation systems were operational in resident bathrooms in 12 [Rooms 1E, 5E, 10E, 11E, 15E, 16E, 17E, 18E, 1S, 2S, 3S and 4S] of 27 occupied resident rooms in the facility. The facility census was 33. Findings are:Record review of the facility logbook documentation entitled Exhaust Fans dated completed on 1/28/26 revealed the following information:Check exhaust fans for proper operation1. Check all exhaust fans in bathrooms, shower room, soiled and clean utility rooms, janitor closets, kitchen, sink and laundry areas and oxygen room.2. Ensure the air flow is sufficient to hold a piece of paper to the vent when operating.Observation on 02/11/26 between 1:30 PM - 1:59 PM with the Maintenance Director [MD]and the facility Administrator revealed that the ventilation system did not draw a 1 ply square of toilet paper to the surface of the ventilation cover in resident bathrooms in resident rooms 1, 5, 10, 11, 15, 16, 17, 18 on the East hall and resident rooms 1, 2, 3 and 4 on the South hall of the facility. This indicated that the ventilation systems were not working properly at the time of the observation. Interview on 02/11/26 at 2:00 PM with the MD confirmed that the ventilation system did not draw a 1 ply square of toilet paper in resident bathrooms in rooms in resident rooms 1, 5, 10, 11, 15, 16, 17, 18 on the East hall and resident rooms 1, 2, 3 and 4 on the South hall of the facility. The MD confirmed that the ventilation systems were not working properly at the time of the observation. The MD confirmed that monthly checks of the ventilation system had been marked as completed in the electronic Exhaust Fan documentation on 1/28/26, but there was no record of which rooms had been tested or how many rooms had been completed. The MD confirmed that documentation revealed that the last time the ventilations system had been checked was on 1/28/26 and that specific rooms that had been tested had not been identified as completed.

Licensure Reference Number 175 NAC 12-006.05(G) Based on interview and record review, the facility failed to monitor for side effects related to psychotropic medication (medications that affect the mind, emotions, and behaviors) use for 3 (Residents 4, 6, and 33) of 5 sampled residents. The facility census was 33. Findings are:A record review of the facility's Use of Psychotropic Medications (s) dated 04/21/2025 revealed the resident's response to medications including the presence or absence of adverse consequences should have been documented in the resident's medical record. A. A record review of Resident 33's Clinical Census dated 02/10/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 33's Medical Diagnosis dated 02/12/2026 reveled the resident had diagnoses of Unspecified Dementia and Generalized Anxiety Disorder. A record review of Resident 33's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 01/22/2026 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 11 which indicated the resident was moderately cognitively impaired (confused). The resident required setup or clean-up assistance with eating, partial/moderate assistance with oral hygiene (cleaning), and was substantial/maximal assistance with toileting, footwear, dressing, and personal hygiene. The resident did not have mood or behaviors and was on antianxiety and antidepressant medications. A record review of Resident 33's Care Plan with an admission date of 11/19/2019 revealed the resident had focus areas of the resident used an antidepressant medication and an intervention to give antidepressant medications as ordered and monitor/document side effects and effectiveness. A record review of Resident 33's Clinical Physician Orders dated 02/10/2026 revealed the resident had orders for two times per day and as needed (PRN) Lorazepam (a psychotropic medication used to treat anxiety) and once a day at bedtime Mirtazapine (a psychotropic medication used to treat depression that can be used as an appetite stimulant). A record review of Resident 33's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated December 2025 - February 2026 revealed the resident's Lorazepam and Mirtazapine was administered but did not reveal side effect monitoring for the resident's psychotropic medications. A record review of Resident 33's Documentation Survey Report v2 dated December 2025 – February 2026 revealed the resident's behavior symptoms were being monitored but did not reveal side effects were being monitored for Resident 33's psychotropic medications. A record review of Resident 33's Electronic Medical Record and Paper Chart dated 12/01/2025 – 02/11/2026 did not reveal side effect monitoring for Resident 33's psychotropic medications had been completed. In an interview on 02/11/2026 at 11:25 AM, the facility's Administrator confirmed the facility staff should have been monitoring for side effects for Resident 33's psychotropic medications and documenting that on the residents MAR & TAR, and they were not. B. Record review of Resident 6's admission Face Sheet revealed that Resident 6 was admitted to the facility on [DATE] and included a diagnosis of anxiety disorder, panic disorder, obsessive compulsive disorder and Schizophrenia. Record review of Resident 6's quarterly MDS dated [DATE] revealed that Resident had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 15 which indicated that Resident 6 was cognitively intact (a score of 12-15 indicated intact cognition), exhibited physical and verbal behaviors directed toward others 1-3 days per week, exhibited other behaviors not directed toward others 1-3 days per week, rejected care 1-3 days per week, required substantial to maximum assistance with activities of daily living [dressing, bathing, grooming, transfers, toileting and Hygiene], and used antidepressant medications daily with indications for use present. Record review of Resident 6's Comprehensive Care plan dated identified that Resident 6 used antidepressant medications with the following interventions identified: [Resident 16 name] is on an antidepressant related to obsessive compulsive disorder. [Name] will remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. Date Initiated: 11/07/2019 Revision on: 04/22/2025, Revision on 02/27/2026 Administer medications as ordered. Observe for side effects and effectiveness. Initiated: 11/07/2019 revised on: 06/03/2025. Observe/record/report to MD [medical doctor] prn [as needed] side effects and adverse reactions of psychoactive medications. Date Initiated: 11/07/2019, Revision on: 06/03/2025 Record review of Resident 6's Physician Orders revealed that Resident 6 took the following antidepressant medication, of the selective serotonin reuptake inhibitor (SSRI) class [a class of medications used to treat obsessive compulsive disorder, panic disorder and several psychiatric disorders]: Fluvoxamine Maleate ER Oral Capsule Extended Release 24 Hour 150 MG (Fluvoxamine Maleate), Give 150 milligrams [mg] at bedtime related to Schizophrenia, started 08/01/2025. Record review of https://www.drugs.com 10/30/2025 revealed the following common side effects of Fluvoxamine: Drowsiness, dizziness, weakness Anxiety, depression, trouble sleeping. agitation Shaking, increased muscle movements Upset stomach, gas, loss of appetite Nausea, vomiting, diarrhea Dry mouth, yawning, sore throat Muscle pain Sweating, rash Sexual problems Record review of Resident 6's Medication Administration Record [MAR] for [DATE] and [DATE] revealed that Resident 6 received Fluvoxamine150 mg at bedtime daily and the medication was started on 8/1/25. Record review of Resident 6's Electronic Medical Record and paper chart revealed that no specific side effects had been identified related to the antidepressant medication use and no monitoring for side effects had been completed for Resident 6. Interview on 02/11/2026 at 12:58 PM with the facility Administrator confirmed there was no side effect monitoring for Resident 6's antidepressant medication use. The Administrator confirmed side effect monitoring should have been completed and documented on the MAR. The Administrator confirmed that some side effects had been identified in the care plan, but they did not make it on the MAR for documented monitoring. C. A record review of Resident 4's admission Face Sheet revealed an admission date of 9/28/2017, and diagnosis of delusional disorders, other specified persistent mood disorders, unspecified dementia, unspecified severity, with other behavioral disturbance, anxiety disorder, unspecified, other obsessive-compulsive disorder, A record review of Resident 4's Quarterly MDS, dated [DATE] revealed a BIM's score of 14/15. The resident required set up for eating, partial/moderate assistance for oral hygiene, substantial/max assistance with upper body dressing, and dependent with toilet hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear and personal hygiene. A record review of Physicians order dated 9/24/25 revealed an order for Quetiapine Fumarate Oral Tablet 25mg give 3 tablets by mouth four times a day related to Delusional Disorders, other obsessive-compulsive disorder, other specified persistent mood disorders. A record review of Resident 4's Care Plan with an admission date of 9/28/2017 revealed the resident had focus areas of the resident used a psychotropic medication and an intervention to administer psychotropic medications as ordered by physician and intervention to Monitor/document/report PRN any adverse reactions to psychotropic medications A record review of https://www.drugs.com last updated 3/20/25 revealed the following common side effects of quetiapine Chills Cold sweats Confusion Dizziness, faintness, or lightheadedness when getting up suddenly from lying or sitting position Sleepiness or unusual drowsiness A record review of Resident 4s Medication Administration Record and Treatment Administration Record (MAR & TAR) dated December 2025 - February 2026 revealed the resident's Quetiapine Fumarate was administered but did not reveal side effect monitoring for the resident's psychotropic medications. Record review of Resident 4's Electronic Medical Record and paper chart revealed that no specific side effects had been identified related to the antipsychotic medication use and no monitoring for side effects had been completed for Resident 4. In an interview with LPN A on 2/11/26 at 11:37 AM confirmed side effect monitoring was not being monitored and should have been.

Licensure Reference Number 175 NAC 12-006.09(E) Based on observation, record review and interview; the facility failed to develop the Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) to include activity of daily living needs for 3 (Resident's 21 and 28 and a Bilevel Positive Airway Pressure (BiPAP, a device that helps you breath by pushing pressurized air into your lungs) for Resident 3 of 26 sampled residents. The facility census was 33. Findings are:A. Record review of a facility Policy entitled Care Plan dated 12/3/25 revealed the comprehensive care plan will describe, at a minimum, the following:1) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated e) The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) assessment. The care plan will be updated in a timely manner to ensure that services to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. f) The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the residents' progress. Alternative interventions will be documented, as needed. B. Record review of Resident 21's MDS quarterly dated 1/22/26 revealed the following information: Resident 21 was admitted on and diagnoses included Alzheimer's Disease late onset, Non-Alzheimer's Dementia, anxiety, and depression. A Brief Mental Inventory [BIMS] score of 1 indicated severely impaired cognition, physical and other behavioral symptoms directed toward others, rejected care 1-3 days per week, and wandering 1-3 days per week. Resident 21 required substantial to maximum assistance to total dependance with Activities of Daily Living [ADL's] needs such as toileting hygiene, bathing, upper and lower body dressing, personal hygiene, putting on and taking off footwear, bed to chair and toilet transfers. The resident used a manual wheelchair, was frequently incontinence of bladder and occasional incontinence of bowels. Observation on 02/10/2026 at 8:05 AM revealed Resident 21 being assisted by Nursing Assistant [NA] G with eating. Observation on 02/10/2026 at 8:24 AM revealed NA H in the residents' room with Resident 21 and provided toileting assistance to the resident. Observation on 02/10/2026 1at 12:16 PM revealed Resident 21 being assisted with eating in the assisted dining room by NA H. Observation on 02/10/2026 1at 2:29 PM revealed NA H assisted Resident 21 with toileting and to lay down. Record review of Resident 21's CCP revealed no specific information related to the level of assistance needed with various activity of daily living needs for Resident 21. Interview on 02/11/2026 at 10:39 AM with the Administrator reviewed the CCP for Resident 21 and confirmed there was no ADL care plan developed and there should have been. The Administrator confirmed Resident 21 did require assistance with all ADL needs. C. A record review of Resident 28's Clinical Census dated 02/11/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 28's Medical Diagnosis dated 02/11/2026 reveled the resident had diagnoses of Unspecified Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure, Gout (a complex form of arthritis), Primary Generalized (Osteo) Arthritis, Muscle Weakness, Obesity (overweight), Unsteadiness On Feet, Down Syndrome (extra genetic material that alters development), and Need For Assistance With Personal Care. A record review of Resident 28's Minimum Data Set, dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 1 which indicated the resident was severely cognitively impaired (confused). The resident required setup or clean-up assistance with eating, needed partial/moderate assistance with oral hygiene (cleaning), was dependent on staff for toileting and bathing. The resident was partial/moderate assistance with sit to lying, lying to sitting on side of bed, sitting to stand positioning and chair to bed and bed to chair transfers, required substantial/maximal assistance with toileting, and dependent on staff for tub transfers. A record review of Resident 28's Rehabilitation (Rehab) Communication, Rehab Communication 2, and Daily Huddle sheets in a binder at the nurse's station dated 12/19/2025 – 12/10/2026 revealed the only entry for Resident 28 was on 12/19/2025 and that revealed the last recommendation for Resident 28 was on 12/19/2025 to only use the wheelchair for going to activities in south sunroom and on bath days going to spa. A record review of Resident 28's Care Plan with an admission date of 07/17/2025 did not reveal the resident had focus areas for transfers, positioning, or activities of daily living (ADLs). An observation on 02/09/2026 at 9:31 AM revealed Resident 28 transferred self to toilet. An observation on 02/10/2026 at 6:51 AM revealed that Resident 28 was eating breakfast in the dining room and the staff asked the resident to get up and go with them to the conference room to get weighed. The observation did not reveal staff assisted the resident to a standing position, on or off the scale, or sitting back in the chair in the dining room. In an interview on 02/10/2026 at 7:31 AM, Medication Aide (MA)-I confirmed the staff did not assist Resident 28 with transfers and the resident self-transfers with all transfers. In an interview on 02/10/2026 at 10:59 AM, Medication Aide (MA)-I confirmed the staff did not have a pocket care plan (summary of the resident's care needs) or anything in place that indicated Resident 28's needs. In an interview on 02/10/2026 at 11:08 AM, MA-L confirmed MA-L just knew Resident 28's care and transfer needs from working the floor. If MA-L had questions regarding a resident's needs MA-L would look at the book at the nurse's station that the staff puts the recommendations in. In an interview on 02/10/2026 at 1:07 PM, Licensed Practical Nurse (LPN)-A, that was the MDS Coordinator confirmed that Resident 28 required more assistance in the early mornings and evenings, and during the day the resident was independent. LPN-A confirmed the resident's ADL, transfer, and mobility needs should have been on the care plan but was not. LPN-A confirmed staff would not know the residents' current needs if not in the care plan or the huddle book. In an interview on 02/11/2026 at 10:20 AM, the Administrator confirmed Resident 28's ADL, transfers, and mobility needs were not on the resident's Care Plan and should have been. D. Record review of an admission MDS dated [DATE] for Resident 3 revealed an admission date of 1/6/26 with a BIM's score of 6/15 indicating severe problems with thinking or memory. Record review of admitting diagnosis included Acute and Chronic Respiratory Failure with Hypoxia, Obstructive Sleep Apnea, Pulmonary Hypertension, Nondisplaced fracture of medal malleolus of left tibia. Record review of MDS section O-Special Treatments, Procedures and Programs revealed Resident 3 had a Non-Invasive Mechanical Ventilator. Record review of a physician order dated 2/6/26 revealed BIPAP at preset settings (with 4L O2) Connect O2 tubing to mask, apply at night and fill chamber with distilled water to fill line at bedtime and every night shift. Record review of the Care Plan for Resident 3 initiated on 1/7/26 revealed a focus of Potential respiratory abnormalities related to chronic respiratory failure with hypoxia and a goal of Resident will remain free of respiratory infections over the next review period. The care plan did not mention the specifics of a PAP machine. Observation of Resident 3 on 2/9/26 at 9:00 AM revealed Resident 3 had a PAP machine in the room. Interview with LPN A on 2/10/26 at 1:50 PM confirmed the PAP machine had not been cared planned and should have been.

Licensure Reference Number 175 NAC 12.006.02(8) Based on observation, record review, and interview; the facility failed to thoroughly investigate and report an injury of unknown origin to Adult Protective Services [APS] and Department of Health and Human Services [DHHS] for 1 (Resident 16) of 1 resident identified with an injury of unknown origin. The facility census was 33. Findings are: A. Record review of a facility policy entitled Policy for Vulnerable Adult 10/19/22 Nebraska revealed the following information: Mandated reporters employed by [facility name] or providing services in our facility shall report abuse, neglect, mistreatment, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraints and injuries of unknown source sustained by a vulnerable adult that is not reasonably explained immediately (as soon as possible) after the discovery of the incident.Definitionsa) Vulnerable Adult1) Each adult resident of [facility name].2) Certain other adults that staff may come in contact with when administering their duties may also be vulnerable, regardless of where they live or what services they receive. Such people may include for example:i) Adult residents or residents of other nursing homes or non-residential facilities.ii) Other adults who possess a physical or mental infirmity or dysfunction such that they cannot protect themselves from maltreatment and are unable to provide for their own care.d) Mandated Reporter1) Each and every employee, volunteer or staff person providing services to residents at [facility name] or who provides services in the community such as home care, meals on wheels, or transportation for our facility. Persons performing services to ourfacility qualify as mandated reporters under the APS.j) Injuries of Unknown Source/ Unexplained Injuries1) An injury should be classified as an injury of unknown source when both of the following conditions are met:i) Federal:a) The source of the injury was not observed by any person or the source of theinjury could not be explained by the resident: andb) The injury is suspicious because of the extent of the injury or the location ofthe injury (e.g., the injury is located in an area not generally vulnerable totrauma) or the number of injuries observed at one particular point in time orthe incidence of injuries over time.ii) State:a) If a reporter has reason to believe that the vulnerable adult has sustained an injury which is not reasonably explained.Internal Reporting Procedurea) During the shift that the alleged abuse/neglect or unexplained injury is first observed, a mandated reporter will immediately make an initial report to their supervisor, after securing the residents safety. Following the review of the situation, the supervisor will immediately report to the Administrator and the Director of Nursing.b) Upon report to a Supervisor of the suspected abuse, the employee in question will be interviewed, re-assigned duties, placed under the direct supervision of a licensed nurse, assigned to non-resident related tasks or suspended pending investigation. This is for theprotection of the resident.c) The Administrator or Director of Nursing shall determine if the incident/allegation meets the criteria for a reportable incident. All incidents deemed reportable under Ne statute are submitted to APS or local law enforcement.d) The Supervisor, Director of Nursing or Administrator will immediately institute an internal investigation of the reported allegation or incident. The investigation may include:1) Interviews of staff2) Resident interviews3) Witness interviews4) Environmental review5) Resident health status6) Behavior review7) Medication reviewExternal Reporting Procedurea) The Administrator, Director of Nursing or their designee shall notify DHHS. b) The Administrator or Director of Nursing or their designee shall submit the report to DHHS/APS. Prior to notifying the DHHS/APS, the Administrator or Director of Nursing should be prepared to relay the following information, to the extent known at the time of the report.The facility shall ensure that alleged violations involving abuse, neglect, mistreatment, misappropriation of resident property including injuries of unknown source are reported immediately to the Administrator and to other agencies in accordance with state law through established procedures. [Facility name] shall have evidence that all alleged violations are thoroughly investigated and shall prevent further potential abuse while the investigation is in progress.Reporting Injuries of Unknown Sourcea) Who to Report to:1) Report immediately to Charge Nurse/Nurse Manager, DNS and Administratorb) What Injuries to Report:1) Injuries investigated and deemed suspicious. For example: bruises, abrasions, suspicious skin tears or lacerations. Other injuries for which there are no known causes and for which abuse is suspected.c) When to Report:1) Immediately upon discovering the injury and determining no known cause for injury.d) What to Report:1) Resident's name and date of birth 2) Diagnosis3) Resident Social Security Number4) Description of injury5) Previous injury or history of injuries6) What has been eliminated as source of injury and safeguards to prevent future injuries.[Facility name] shall have evidence that alleged violations are thoroughly investigated and shall prevent further potential abuse while the investigation is in progress.B. Record review of Resident 16's annual Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 11/20/25 revealed an admission date of 12/25/22 and diagnoses that included weakness, difficulty walking, cognitive communication deficit, dementia and mood disorder. The MDS showed a BIMS score of 3 which indicated severely impaired cognition [a score of 0-7 indicates severe cognitive impairment], physical behavioral symptoms directed toward others 1-3 days per week, substantial to maximum assist to total dependance on staff for activity of daily living cares such a bathing, toileting and transfers, no falls since prior assessment, no skin conditions, antianxiety medication use daily, hospice care while a resident and no restraints used. Interview on 2/9/26 at 11:15 AM with the family of Resident 16 revealed that Resident 16 had several abrasion injuries to both shins that extended from the knees to the ankles. The family member was unaware of how the injuries had occurred. Record review of a Progress Note dated 1/23/26 revealed wash BLE [bilateral lower extremities with soap and water and pat dry and apply Betadine BID [twice a day] and DC [discontinue] when healed to scabbed areas.Record review of Resident 16's January and February 2026 Treatment Administration Records [TAR] revealed treatments to the bilateral shin wounds began 1/23/26 and continued through 2/12/26.Observation on 2/10/26 between 10:10 AM and 10:25 AM with Licensed Practical Nurse [LPN] A revealed several scabbed and abraded areas up and down the length of each shin on both legs. LPN A proceeded to clean and administer a betadine [an antiseptic solution] treatment to the areas on both legs. Interview on 2/10/26 at 10:30 AM with LPN A revealed that it was unknown how Resident 16 obtained the abrasions to the legs. LPN A reported they had some ideas on how they had happened but did not know the cause of the abrasions. Interview on 2/11/26 at 7:00 AM with the facility Administrator confirmed there was no investigation completed to determine the cause of the injuries for Resident 16 and therefore no report had been made to APS and DHHS as required. The Administrator confirmed that Resident 16's injuries met the criteria for an injury of unknown origin and should have been investigated and reported to the required state agencies.Record review of a facility Performance Improvement Plan [PIP] for skin started on 11/12/25 revealed weekly meetings had been held with the last meeting being held on 2/4/26. The PIP did not identify Resident 16's wounds to the bilateral lower legs.

Licensure Reference Number 175 NAC 12-006.09(F)(iii)Based on observation, record review and interview; the facility failed to review and revise the Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) to include specific interventions related to skin breakdown for 1 (Resident 16) of 26 sampled residents. The facility census was 33. Findings are:A. Record review of a facility Policy entitled Care Plan dated 12/3/25 revealed the comprehensive care plan will describe, at a minimum, the following:1) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicatede) The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. The care plan will be updated in a timely manner to ensure that services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.f) The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the residents' progress. Alternative interventions will be documented, as needed. B. Record review of Resident 16's annual Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 11/20/25 revealed an admission date of 12/25/22 and diagnoses that included weakness, difficulty walking, cognitive communication deficit, Dementia and mood disorder. The MDS showed a BIMS score of 3 which indicated severely impaired cognition ( a score of 0-7 indicates severe cognitive impairment), physical behavioral symptoms directed toward others 1-3 days per week, substantial to maximum assist to total dependance on staff for activity of daily living cares such a bathing, toileting and transfers, no falls since prior assessment, no skin conditions, antianxiety medication use daily, hospice care while a resident and no restraints used.Record review of Resident 16's CCP dated 12/29/25 revealed Resident 16 was at risk for skin breakdown related to immobility. Interventions included:Consult Dietician as needed.Good peri care (cleaning of the genital area) after each incontinence and bowel movement [BM].Observe for red or open areas throughout each shift and during the bath and notify charge nurse right away.Observe for signs symptoms of urinary Tract infection and notify the charge nurse immediately. Charge nurse to notify the Medical Doctor [MD]. Provide pressure relieving mattress to bed and cushion for wheelchair.Provide well balanced diet.Weekly Skin Assessment by licensed nurse. Interview on 2/9/26 at 11:15 AM with the family of Resident 16 revealed Resident 16 had several abrasion injuries to both shins that extended from the knees to the ankles. The family member was unaware of how the injuries had occurred. Observation on 2/10/26 between 10:10 AM and 10:25 AM with Licensed Practical Nurse [LPN] A revealed several scabbed and abraded areas up and down the length of each shin on both legs of Resident 16. LPN A proceeded to clean and administer a Betadine [an antiseptic liquid] treatment to the areas on both legs. Interview on 2/10/26 at 10:30 AM with LPN A revealed that it was unknown how the resident obtained the abrasions to the legs. LPN A stated they had some ideas on how they had happened but did not know the cause of the abrasions. Record review of a Progress Note for Resident 16 dated 1/23/26 revealed wash BLE [bilateral lower extremities with soap and water and pat dry and apply Betadine BID [twice a day] and DC [discontinue] when healed to scabbed areas.Record review of Resident 16's January and February 2026 Treatment Administration Records [TAR] revealed treatments to the bilateral shin wounds began 1/23/26 and continued through 2/12/26. Interview on 02/11/2026 at 9:30 AM interview with the facility Regional Clinical Specialist [RCC] Registered Nurse [RN] revealed interventions that had been tried were sheepskin pads placed against the shins when the resident was transferred. The RCC reviewed Resident 16's Care Plan and confirmed that the interventions did not make it to the care plan and the treatment to the shins did not make it on to the care plan. The RCC confirmed that the Care Plan did not address specific interventions related to the areas on the shins. Observation on 02/11/2026 at 10:05 AM with Nursing Assistant [NA] E revealed sheepskin wraps were present on Resident 16's legs. Interview on 02/11/2026 at 10:53 AM with the facility Administrator, after review of Resident 16's CCP, confirmed there were no specific interventions identified on the CCP related to the shin wounds to prevent further breakdown and promote healing.

Licensure reference number 175 NAC 12-006.04B2a Based on interviews and record reviews, the facility failed to ensure a nursing assistant/medication aide had 12 hours of ongoing inservice training for this past year. This had the potential to affect all 28 residents who reside within the facility. The facility census was 28. Finding are: Record review of listing of facility staff names and hire dates revealed Medication Aide (MA) was hired on 8/16/21. Record review of MA's Relias (a company/program that provides education and training) transcript dated 10/31/24 revealed 0 hours of training for the last 12 months. Interview with Director of Nursing on 10/31/24 at 12:00 PM confirmed that MA had no ongoing inservice training since 7/9/23.

Licensure reference number 175 NAC 12-006.09E(iii) Based on observation, record reviews and interviews, the facility failed to develop and implement a Comprehensive Care Plan (CCP, a written interdisciplinary comprehensive plan which detailed how to provide quality care for a resident) catheter for 1 (Resident 5) of 1 sampled resident. The facility census was 28. Findings are: Record review of Resident 5's Admission record revealed admission was 8/27/24. Record review of Resident 5's diagnosis revealed Neuromuscular Dysfunction of Bladder, unspecified. Record review of Resident 5's Minimum Data Set (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) Section H, dated 9/3/24 revealed that Resident 5 did have a catheter. Record review of Physician's Orders for Resident 5 dated 08/27/2024 revealed: -Change dry dressing to Suprapubic Foley catheter insertion site daily and PRN. -Ensure catheter cares are completed during your shift. -Irrigate Suprapubic Catheter with 30ml of Normal Saline if clogged as needed. Record review of Physician's Orders for Resident 5 dated 09/01/2024 revealed: -Change Suprapubic Catheter - every month and PRN as needed based on clinical indications such as infection, obstruction, or when the closed system is compromised. Provide new drainage bag with new Foley catheter. Record review of Resident 5's Care Plan on 10/29/24 revealed that the Suprapubic catheter was not on the Care Plan. Interview with MDS coordinator on 10/30/24 at 9:28 AM revealed that the Resident 5's Suprapubic catheter should be on the care plan but wasn't. Record review of Care Plans Policy revised November 2023 revealed: Policy: It is the policy of this facility to develop a comprehensive, individualized plan of care for each resident. The care plan is developed by the interdisciplinary Care Plan Team and reviewed and revised as required. The Care Plan guides the care and treatment provided by all caregivers. 5. The care plan is individualized and addresses the resident's medical, nutritional, psychological, physical, functional, social, educational, and spiritual needs and the severity of the resident's condition, diagnosis, disease process, impairments, disability, medication, and treatments as indicated.

Licensure Reference Number 175 NAC 12-006.09(h) Based on observation, record review, and interview, the facility failed to monitor resident behavioral symptoms to ensure the effectiveness or continued need for an antipsychotic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medication for 1 resident (Resident 1) out of 15 sampled residents and the facility failed to have a stop date on a PRN (as needed) antianxiety medication for 1 resident (Resident 11) out of 15 sampled residents. The facility census was 28. Findings are: A. A record review of the facility Policy entitled: Use of Psychotropic Drugs reviewed 2/20 included the following information: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Policy Explanation and Compliance Guidelines -Residents who use psychotropic drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs. -Resident who use psychotropic drugs shall also receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs. A record review of Resident 1's Admission Record with the printed dated of 10/29/24 revealed that Resident 1 was admitted to the facility on [DATE] with the diagnosis of: - Paranoid Schizophrenia (characterized especially by delusions of persecution, grandiosity, or jealousy and by hallucinations (such as hearing voices) chiefly of an auditory nature), anxiety disorder (a feeling of fear, dread, or uneasiness). - Major depressive disorder (serious mood disorder that can affect how people feel, think, and behave). - Insomnia (unable to fall asleep, stay asleep or get quality sleep). - Unspecified dementia, unspecified severity with other behavioral disturbance (drastic changes in behavior which may seem to occur out of nowhere). - Cognitive communication deficit (a difficulty with communication caused by an impairment in cognitive processes). A record review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities) dated 8/26/24 revealed in section C-Cognitive Patterns a 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) score of 11 indicating Resident 1 has moderate cognitive impairment. A record review of Resident 1's Comprehensive Care Plan (CCP, a written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) dated 10/12/24 revealed target behaviors of paranoia, delusional thinking, hallucinations, verbal and physical aggression, insomnia, self- isolation, anxiety, and finger-painting feces. A record review of the Physicians orders dated 4/21/24 for Resident 1 revealed the following medication orders: -Trazodone 75 milligram(MG) for insomnia (A drug used to treat depression. It may also be used to help relieve anxiety and insomnia (trouble sleeping) and to treat certain other disorders. -Clonazepam 0.5 mg give one table twice a day and 1 mg in the morning (It can treat seizures, panic disorder, and anxiety). -Seroquel 50 mg give one daily in the morning (treats several kinds of mental health conditions including schizophrenia and bipolar disorder). -Sertraline HCL 150 mg give one tab daily (used to manage and treat the major depressive disorder, obsessive-compulsive disorder, panic disorder). -Seroquel 200 mg give one tab at bedtime ( treats several kinds of mental health conditions including schizophrenia and bipolar disorder). -Invega Trinza Intramuscular 819mg/2.63ml every 90 days (used to treat certain mental/mood disorders). A record review of Resident 1's Electronic Medical Record (EMR) revealed no specific target behaviors were documented for the months of October, November and December of 2023. A record review of Resident 1's Gradual Dose Reduction (GDR) dated 1/30/24 revealed physician documentation that GDR was contraindicated due to behaviors noted in the care plan and charting. An interview on 10/29/24 at 2:30 PM with the MDS Coordinator confirmed that there had been no behaviors charted in the last 3 months of Oct. 23 Nov. 23 Dec. 23 for Resident 1 with the last GDR being done on 1/30/24 for the doctor to sign rational not to attempt a drug reduction. An interview on 10/29/24 at 3:00 PM with the Director of Nursing (DON) confirmed that there had been no behavior charting for Resident 1 and the physician should of been made aware. B. A record review of the facility Policy entitled: Use of Psychotropic Drugs reviewed 2/20 included the following information: -If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. -PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. A record review of Resident 11 Admission Record with the printed date of 10/29/24 revealed that Resident 11 was admitted to the facility on [DATE] with the diagnoses of: -Unspecified dementia, unspecified severity, with other behavioral disturbance (drastic changes in behavior which may seem to occur out of nowhere). -Depressive disorder (a depressed mood or loss of pleasure or interest in activities). -Vascular dementia, unspecified severity with mood disturbance ( chronic condition that occurs when the brain's blood supply is interrupted, damaging brain tissue and causing a decline in thinking, memory, and behavior). -Anxiety disorder (a feeling of fear, dread, or uneasiness). A record review of Resident 11 Progress Notes dated 8/28/24 revealed a BIMS score of 12 indicating Resident 11 is moderate cognitive impairment. A record review of Resident 11 CCP dated 8/26/24 revealed focus, goals, and interventions for PRN depression medication. A record review of Resident 11 Physicians Orders revealed that Resident 11 had an order for Xanax Oral Tablet 0.5 MG (Alprazolam) Give 1 tablet by mouth every 24 hours as needed (PRN) for irritability with no stop date on 10/29/24 An interview on 10/29/24 12:17 PM with the DON confirmed that the PRN Xanax should have a stop date.

Licensure Reference Number 175 NAC 12-006.18(D) Based on observation, record review, and interviews, the facility staff failed to perform hand hygiene (hand washing using soap and water or an alcohol based hand rub) for 15 seconds or more during the provision of wound care to prevent potential cross contamination for 1 (Resident 8) of 1 sampled resident and failed to place Resident 5's catheter bag to prevent potential cross contamination for 1of 1 sampled residents. The facility census was 28. A. Record review of Resident 8's Admission record dated 10/29/24 revealed admission was 12/23/2018. Record review of Resident 8's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 8/15/24 revealed in Section C BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) was 15. Record review of Resident 8 diagnosis revealed: Chronic Venous Hypertension (idiopathic, describes a disease of unknown cause) with ulcer (a condition that occurs when blood pressure in the leg veins doesn't decrease while walking causing ulcers to form) of right lower extremity, Non-pressure chronic ulcer of other part of right foot with unspecified severity, non-pressure chronic ulcer of unspecified part of right lower leg with unspecified severity, and Type 2 Diabetes Mellitus (a chronic disease that occurs when the body is unable to control blood glucose levels) with diabetic chronic kidney disease (a long term condition that occurs when the kidneys are damaged and can't filter blood properly). Record review of Physicians Orders dated 09/10/24 for Resident 8 revealed: -Cleanse entire right leg with hibiclens in warm water and dry well. Soak wound bed of venous stasis ulcer to right anterior LE (lower extremity) with Vashe (a saline based wound cleanser) or 1/2 strength Dakin's (a bleach based wound cleanser) soaked gauze x 15 minutes prior to treatment application. Wipe wound bed well with moistened gauze to assist with removing biofilm (microorganisms) and debris (scattered pieces of waste or remains). Apply triad paste (a zinc-oxide based wound dressing paste) to peri-wound, Apply Hydrofera Blue dressing (an antibacterial foam dressing) to wound bed. Cover with an ABD (A highly absorbent pad used to treat wounds that drain heavily or are located in or on the abdomen) pad. Secure with gauze wrap and tape. Change 3 x weekly and PRN (as needed). Record review of Physician Orders dated 10/23/24 for Resident 8 revealed: -Cleanse right 2nd toe with hibiclense (an antiseptic skin cleanser that helps prevent skin infections) in warm water and dry well. Soak wound bed with Vashe or 1/2 Dakin's-soaked gauze x 15 minutes prior to treatment application. Wipe wound bed well with moistened gauze to assist with removing biofilm and debris, Apply triad paste to peri-wound, Apply Aquacel AG dressing to wound bed. Cover with gauze. Secure with gauze tape. Change 3x weekly and PRN (as needed) every day shift every Mon, Wed, Fri and as needed Interview with Registered Nurse (RN) on 10/30/24 at 9:57 AM revealed Resident 8 declines (refuses) some of the leg treatment frequently. RN said today resident is refusing to let the nurse do the soaking of the wound bed with Vashe for 15 minutes prior to treatment application or Triad paste to peri-wound of right 2nd toe and lower leg, and Resident 8's doctor is aware. Observation on 10/30/24 at 10:00 AM with RN for Resident 8 for wound care. RN donned (put on) gloves and cleansed the bedside table before placing supplies. RN doffed (removed) gloves and washed hands with soap and water for 12 seconds. RN donned (put on) a gown, mask, goggles and gloves. RN then removed the right 2nd toe dressing, doffed gloves, performed hand hygiene with hand sanitizer gel, then donned gloves. Resident refused to let the nurse do a Vashe or 1/2 Dakin's-soaked gauze x 15 minutes prior to treatment for leg or toe and refused triad paste. RN cleansed toe wound with hibiclens and normal saline to wound bed well to assist with removing biofilm and debris, rinsed with normal saline and dried. RN then cut a small piece of Aquacel AG dressing and applied to wound bed, covered with gauze, and secured with gauze tape. RN washed hands with soap and water for 9 seconds and donned gloves. RN removed the old dressing to right lower leg, doffed gloves, and performed hand hygiene with hand sanitizer gel, and donned gloves. RN cleansed the right leg wound and peri-wound with hibiclens in normal saline, wiped wound bed well with moistened gauze to assist with removing biofilm and debris, rinsed with normal saline and dried. RN performed hand hygiene, donned gloves, and applied Hydrofera Blue dressing to wound bed. RN covered with ABD pad and secured with gauze wrap and tape. RN dated the dressings. RN cleaned work area. RN removed gown, mask, goggles and gloves. RN then washed hands with soap and water for 9 seconds and took trash can liner out of room. Interview on 10/30/24 at 10:30 AM with RN confirmed that [gender] should have washed their hands at least 15-20 seconds. Interview on 10/30/24 at 11:20 AM with Director of Nursing (DON) confirmed that hand washing should be done for 20 seconds. Record review of Hand Hygiene Policy updated 2021 revealed: Policy: Hand hygiene - Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 5. Hand hygiene technique when using soap and water: a. Wet hands with water. Avoid using hot water because repeated exposure to hot water may increase the risk of dermatitis. b. Apply enough soap to cover all hand surfaces. c. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. d. Rinse hands with water. e. Dry thoroughly with a single-use towel. f. Use towel to turn off the faucet. B. Record review of Resident 5's Admission record revealed Resident 5 admitted to the facilty 8/27/24 with a Suprapubic foley catheter (a flexible tube that drains urine from the bladder through a small incision in the lower abdomen) because of a diagnosis of Neuromuscular Dysfunction of Bladder, unspecified (a condition that occurs when the nerves and muscles of the bladder don't communicate properly with the brain, resulting in bladder control issues). Observation on 10/28/24 at 10:50 AM revealed Resident 5's Suprapublic catheter bag was hooked onto the trash can by the bed and was resting on the floor without a protective bag covering it. Observation on 10/30/24 at 6:54 AM revealed Resident 5's Suprapubic catheter bag was hanging off the trash can with the catheter bag and was resting on the floor. Interview with DON on 10/30/24 at 6:58 AM confirmed the facility's expectation is not to have catheter bag on the floor.

Licensure reference number 175 NAC 12-007.04D Based on observation, interview, and record review the facility failed to ensure the ventilation system was in working order in 6 resident bathrooms (rooms 4E, 9S, 8S, 4S, 6S, and 15S) out of 13 sampled resident rooms. The facility census was 30. Findings are: Observation on 9/14/23 between 12:20 PM and 12:40 PM with the Administrator (ADM) and Corporate Maintenance Consultant (CMC), revealed the bathroom vents in rooms 4E, 9S, 8S, 4S, 6S and 15S were not working. During an interview on 9/14/23 at 12:40 PM, the CMC confirmed the bathroom vents in rooms 4E, 9S, 8S, 4S, 6S and 15S were not working. The CMC further confirmed that there was no need to test the other vents as they were on the same ventilation unit and would also not be working. The CMC revealed there were no work orders for the ventiliation system and the CMC was unaware the vents were not working. During an interview on 9/14/23 at 12:40 PM the ADM revealed the vents had not been tested for approximately 2 weeks. During an interview on 9/14/23 at 12:40 PM the ADM revealed [gender] was unaware the ventilation system was not working. During an interview on 9/14/23 at 12:40 PM the Director of Operations (DoO) revealed [gender] was unaware that ventilation system was not working. During an interview on 9/14/23 at 1:20 PM the ADM revealed the facility did not have a policy on ventilation monitoring. Record review of Exhaust Fan Monthly Inspection Log revealed the last check of ventilation system was on 7/23/23. Places the ventilation was checked were offices, resident room (no room listed) utility room, kitchen, dining, and restrooms documented as cleaned.

Licensure Reference 175 NAC 12-006.09B1(2) Based on record review and interviews, the facility failed to complete a Significant Change of Status Assessment (SCSA) Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities. The SCSA is required when there is a significant change in those capabilities) for Resident 25. This affected 1 of 13 residents reviewed for MDS completion. The facility census was 30. Findings are: A record review of Resident 25's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, diabetes, heart disease and repeated falls. A record review of the resident's Modification of Admission MDS dated [DATE] revealed the resident required supervision with bed mobility, transfers, and eating. A review of the resident's Quarterly MDS dated [DATE] revealed the resident required extensive assistance with bed mobility and transfers and set-up assistance with eating. An interview on 9-13-2023 at 8:58 AM with the MDS nurse confirmed that the resident should have had a SCSA MDS done.

LICENSURE REFERENCE NUMBER 175 NAC 12-0006.12E8 Based on record review, observation and interview; the facility failed to assure medications awaiting destruction were accounted for to prevent misappropriation of medications for residents. This affected 17 residents. The sample size was 30. The facility census was 30. Findings are: Observation on 7/21/22 at 9:55 AM revealed a cupboard in the medication room housed several cards of medications that were awaiting destruction. The medication room was locked and only accessible with a key. Record review on 7/21/22 at 9:55 AM revealed no evidence of a log to account for the medications that were stored in the medication room awaiting destruction. Interview on 7/27/22 at 9:55 AM with Licensed Practical Nurse (LPN-E) revealed that the medications were tracked after the medications were destroyed but the facility did not track the medications that were stored in the cupboard prior to destruction. Interview on 7/21/22 at 10:10AM with the Director of Nursing (DON) confirmed that the facility did not keep a log of the medications that were stored awaiting destruction. The facility only recorded the medications that had been destroyed and that there was not a process in place to account for the medications that were stored in the cupboard until destruction.

Licensure Reference Number 175 NAC 12-006.04B2 Based on interview and record review; the facility failed to ensure that abuse training was completed for 20 of 34 employees who were employed at the time of training. The facility had a census of 30. The findings are: Review of the facility policy Abuse, Neglect, Misappropriation and Exploitation with a reviewed date of 10/2019 revealed all new employees were to be educated during their initial orientation. Annual education and training were to be provided to all existing employees. Review of the facility report titled Module Completions revealed a module titled Dementia Care; Preventing and Responding to Abuse was to have been completed by all staff by 8/31/21. Further review revealed of the 34 current staff, 12 staff had not started and/or completed the required training. Review of a facility report titled Module Completions revealed a module titled Understanding Abuse and Neglect was to have been completed by all staff by 3/31/22. Further review revealed of the 34 current staff, 9 staff had not started and/or completed the required training. During an interview on 7/21/22 at 9:29 AM, Nursing Assistant (NA)-C confirmed failure to complete the required training related to Abuse, Neglect, Misappropriation and Exploitation the previous year. Furthermore, NA-C had still not finished the mandatory training. Interview with the Administrator on 7/22/22 at 10:33 AM confirmed 20 of 34 employees had not completed the required training.

Licensure Reference Number 175 NAC 12-006.18 Based on observation, record review and interview; the facility failed to ensure equipment was operational and floors, ceilings, walls, doors, and ventilation covers were clean and in good repair. The facility census was 30. Findings are: A. Review of the facility Environmental Policy with a reviewed date of 6/22 revealed a safe, functional, sanitary, and comfortable environment was to be maintained for residents, staff, and the public. The facility was to maintain all essential mechanical, electrical and patient care equipment in safe operating condition. All facility personnel were responsible for reporting broken, defective or malfunctioning equipment or furnishings. B. Observations on 7/18/22 from 9:48 AM to 1:00 PM and on 7/21/22 from 8:45 AM to 10:00 AM with the Maintenance Manager revealed the following environmental concerns: East Corridor -the plastic door guard/veneer to the bottom half of the entrance door of room 8 was detached to the inner corner and presented a sharpened edge; -the wall beneath the window and near the baseboard of room 9 had a hole in the dry wall approximately 6 centimeters (cm) by 3 cm with the wall gouged next to the hole and a 12 cm by 3 cm hole in the drywall with gouges behind the headboard of the bed; -exterior of a ventilation cover in the ceiling of the corridor with a coating of dust/debris; -5 ceiling tiles in the corridor with brown discoloration; and -exit door to an outside courtyard at the end of the corridor with a broken Mag lock (lock that uses an electric current to produce the magnetic force. Due to the increased strength because of the current, the doors can withstand pressure, so they can't be forced open without use of the confirmed access method). South Corridor -wall next to the bed in room 15 with a heavy layer of spackle/plaster which had not been sanded and/or painted; -exterior of a ventilation cover in the ceiling of the corridor with a coating of dust/debris; and -floor to room 18 with food crumbs and a bedside table and flooring underneath of the table stained with paint which was no longer cleanable and had not been replaced. C. Review of Daily Maintenance Checklist (form used to document water temperature checks in resident's rooms, daily alarm checks of exit doors, call light checks and room temperature checks) from 6/1/22 through 7/20/22 revealed the Mag lock to the East Courtyard was non-functional. D. Interview on 7/21/22 with the Maintenance Supervisor from 8:45 AM to 10:00 AM confirmed the following: -the plastic door guard/veneer on the entrance door of room 8 East, the wall in room East 9 and the wall in room South 15 required repaired; -the ceiling tiles in the East corridor and the floor and bedside table in room South 18 needed to be replaced; and -the Mag lock to the East courtyard exit had been broken for at least the last 2 months. The parts to replace the lock had arrived about a week ago but the Maintenance Manager had not had the time to address the broken lock. E. Interview on 7/21/22 at 10:30 AM with Housekeeper (HK)-M verified the ventilation covers in the South and East corridors were covered with a coating of dust and the ventilation covers were not on the current cleaning schedules. In addition, the floor in room South 18 frequently had food debris as the resident ate in the room for all meals.

Licensure Reference Number 175 NAC 12-006.11D Based on observation, interview and record review; facility staff failed to ensure meals were palatable and maintained at the food temperatures to prevent foodborne illness. This had the potential to affect all residents. The facility census was 30. Findings are: Review of the undated facility policy on food safety measures revealed dietary staff must obtain and document the temperatures of all menu items before and after the meal service. Additionally, temperatures should never fall within the danger zone of 41-135 degrees Fahrenheit. Review of the facility's Meal Temperature Log between 7/10/22 and 7/16/22 revealed the following: -on 7/10/22, the breakfast meal had no documented temperatures at the end of the meal service for the eggs and meat; and -on 7/16/22, there was no evidence temperatures were documented for all menu items served before and after both the breakfast and lunch meals. On 7/20/22 from 11:20 AM to 12:10 PM, observations of the noon meal service revealed the following: - At 11:25 AM, Dietary Cook (DC)-S, removed 3 chicken fried steaks from the baking pan, placed them in the blender and ground them. DC-S then mixed the ground meat with gravy and placed the meat mixture into the steam table pan, but did not check the temperature of the ground meat before serving it to residents. - At 12:10 PM, DC-S had served up the last meal to residents from the steam table. Upon request, the meal temperature was checked by DC-S and the chicken fried steak was 110 degrees Fahrenheit (F) and the breaded chicken patty was 80 degrees F. DC-S indicated these food items would normally be maintained and served at a minimum temperature of 140 degrees F. During an interview with the Dietary Manager (DM) on 7/20/22 at 12:15 PM, the DM confirmed the food items should have been maintained in the steam table at temperatures above 135 degrees F throughout the meal service. The DM also confirmed there were missing entries on the meal temperature log and staff should have obtained and documented temperatures of all menu items before and after each meal.

Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview; the facility failed to report allegations of potential abuse and/or neglect to the State Agency, to complete an investigation and then submit the results of the investigation for 1 (Resident 30) of 2 sampled residents within the required time frames. The facility census was 30. Findings are: A. Review of the facility Abuse, Neglect, Misappropriation and Exploitation Policy a reviewed date of 10/2019 indicated the facility would: -report any alleged abuse/neglect, injuries of unknown origin, or misappropriation of resident property in accordance with state regulations; -conduct an investigation of such allegations in accordance with state law; and -report all investigation findings to the State Agency in accordance with state regulations. B. Review of Resident 30's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/5/22 identified the resident was cognitively intact with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment further indicated the resident required total staff assistance with transfers and toileting and extensive staff assistance with bed mobility and dressing. Review of a Nursing Progress Note dated 5/1/22 at 1:05 AM revealed the resident had indicated Nurse Aide (NA)-B was no longer allowed to come into the resident's room. The note further revealed will address with day shift. Review of a Nursing Progress Note dated 5/2/22 at 2:09 AM revealed a police officer arrived at the facility at 1:15 AM regarding a phone call received by the resident. Review of an Adult Protective Services (APS) Intake Worksheet dated 5/2/22 at 2:42 AM revealed the resident had called the police as staff had removed the resident's water and the resident's blankets from the room. Review of facility investigations from 4/1/21 through 7/18/22 revealed no investigation had been completed and then sent to the State Agency regarding the resident's concern on 5/1/22 at 1:05 AM regarding NA-B and on 5/2/22 at 1:15 AM regarding staff removing the resident's water and blankets from the resident's room. During an interview on 7/20/22 at 10:47 AM, the Administrator confirmed no report had been made regarding the resident's concerns about NA-B on 5/1/22 or regarding the resident's call to APS and the police on 5/2/22. In addition, no investigation was completed regarding potential abuse and the results of the investigation sent to the State Agency in accordance with regulations.