Every finding on record at Adept Nursing & Rehab of Central City

Based on record reviews and interviews, the facility failed to provide notification to the physician for Resident #7 as required. The facility has a census of 58.Findings are: Record review of Resident 7's Medication Administration Record dated 12/3/25 revealed admission to the facility was on 4/8/25.Record review of Resident 7's progress notes dated 12/2/25 revealed several episodes on different days when this resident was screaming, flailing arms, hitting, thrashing about, kicking, and combative with cares.Record review of Resident 7's diagnoses dated 12/2/25 revealed bipolar disorder-current episode manic severe with psychotic features, anorexia nervosa, obsessive-compulsive disorder, mood disorder due to known physiological condition, body dysmorphic disorder, alcohol dependence-remission, major depressive disorder-recurrent and anxiety disorder.Interview with Director of Nursing on 12/2/25 at 3:00 PM revealed Resident 7 was transferred to [NAME] hospital on [DATE].An interview on 12/3/25 at 12:25 PM Licensed Practical Nurse (LPN-A) confirmed on 11/22/25 [gender] was notified by a nurses aide that Resident 7 was having an episode (screaming, kicking, and thrashing around). LPN-A went into the room to assess and then to medication cart to get Zyprexa IM for the resident. LPN-A said [gender] gave Zyprexa 2 times that shift due to the behavior. Interview with LPN-A on 12/3/25 at 12:28 PM confirmed that LPN-A did not notify the doctor, family or guardian on 11/22/25 regarding this episode.Interview via phone with the Guardian on 12/2/25 at 2:00 PM confirmed the last time [gender] was called from the facility was on 11/21/25 because of a fall where Resident 7 didn't hurt themselves and then again on 11/24/25 when they sent Resident 7 to [NAME] hospital.Interview On 12/3/25 at 2:30 pm with the 2nd emergency contact, stated that [gender] witnessed one of Resident 7 psychotic episodes there at the facility on 11/21/21. On 11/24/25 [gender] called the facility and found out that the resident was transferred to [NAME] earlier that day.An interview on 12/3/25 at 1:45 PM with the Assistant Director of Nursing confirmed the nurse should have called the physician, guardian and 2nd emergency contact of transfer to another facility and changes in behavior. Record review of The Oaks at Central City notification of changes policy dated 8/1/25 revealed: The purpose of this policy is to ensure the facility promptly informs the resident, consults the residents and physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. -Compliance Guidelines:1. Accidentsa. resulting in injuryb. Potential to require physician intervention2. Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental, or psychosocial status.a. Life-threatening conditions, orb. Clinical complications.3. Circumstances that require a need to alter treatment.This may include:a. New treatmentb. Discontinuation of current treatment due to:4. A transfer or discharge of the resident from the facility.5. A change of room or roommate assignment.2. Residents incapable of making decisions:a. The representative would make any decisions that have to be made.b. The resident should still be told what is happening to him or her.

Licensure Reference Number 175 NAC 12-006.11EBased on observations, interviews, and record reviews, the facility failed to store, prepare, and serve food in a manner to prevent potential for foodborne illness. Specifically failed were gloves while touching foods, failed to ensure food in storage were labeled, dated or sealed, failed to have thermometers in the milk refrigerator, failed to ensure foods and fluids were at the proper temperature and failed to ensure hand hygiene was completed. This had the potential to affect all 58 residents who ate food prepared in the kitchen.Findings are: Record review of the facility provided policy, titled “Personal Protective Equipment”, dated 4/1/24 revealed that staff should perform hand hygiene before donning gloves and after removal. Gloves are not a substitute for hand hygiene. Record review of the facility policy, titled “Hand Hygiene” dated 5/29/24 revealed a definition of hand hygiene as a general term for cleaning hands by hand washing with soap and water or the use of antiseptic hand rub, or alcohol-based hand rub (ABHR). Record review of facility Handwashing Inservice dated 6/3/25 revealed employees should wash hands for at least 20 seconds before and after handling food, after touching hair, face or body, and after touching a cell phone. Record review of the facility policy titled “Record of Food Temperatures”, dated 8/1/25 revealed it is the policy of the facility to record food temperatures daily to ensure food is at the proper serving temperature. Record review of facility policy, titled “Food Safety Requirements” dated 8/1/23 revealed: -food safety practices shall be followed throughout the facility’s entire food handling process. -food will be stored, prepared, distributed, and served in accordance with professional standards for food service safety -staff shall monitor food temperatures while delivering food to ensure proper hot and cold holding temperatures are maintained. Staff shall refer to the current FDA Food Code. -foods and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger Zone, according to the current Food Code. A. An observation on 7/29/2025 at 12:21 PM revealed [NAME] (C) – A reached into a bag of bread with an ungloved hand on the behavior unit. During an interview on 7/29/2025 at 12:23 PM C- A confirmed hand hygiene is only completed when entering the behavior unit and that (gender) hand handled food with bare hands. An observation on 7/29/2025 at 12:26 PM C – A grabbed a cold sandwich with ungloved hand and handed it to the Activity Aide (AA). An observation on 7/29/2025 at 12:27 PM AA - B grabbed a sandwich with an ungloved hand and gave it to a resident on the behavior unit. An observation on 7/29/2025 at 12:28 PM C – A grabbed a full bowl of salad from the top with an ungloved hand and touched lettuce, tomato, and cheese. An observation on 7/29/2025 at 2:09 PM C – A mixed coleslaw with gloved hands and then removed gloves and no hand hygiene performed. During an interview on 7/29/2025 at 2:10 PM C- A revealed (gender) usually does hand hygiene. An observation on 7/29/2025 at 2:13 PM C – C turned off music from a cell phone in the kitchen with bare hands and did not perform hand hygiene, then the cook dropped a closed container of vegetables on the floor of the kitchen and picked it up and put it in the refrigerator. During an observation on 7/29/2025 at 2:26 PM C – A washed hands for 15 seconds. During an observation on 7/29/2025 at 2:27 PM C – C washed hands for 10 second. During an observation on 7/29/2025 at 2:28 PM Dietary Aide (DA) – I washed hands for 15 seconds. During an interview on 7/29/2025 at 2:37 PM the Dietician (D) – D confirmed that all ready to eat foods should only be handled with a gloved hand. B. An observation on 7/28/2025 at 8:43 AM revealed milk refrigerator had no thermometer. During an interview on 7/28/2025 at 8:43 AM DA – F confirmed there should be a thermometer in every refrigerator. C. An observation on 7/28/2025 at 8:40 AM in the dry goods storage revealed 2 bags of opened macaroni noodles were not sealed or dated when opened. During an interview on 7/28/2025 at 8:41 AM Dietary Aide (DA) – F confirmed there shouldn’t be any open bags in storage. An observation on 7/28/2025 at 8:42 AM of Refrigerator 1 revealed an opened plastic container of raw hamburger that was not sealed, dated and was approximately 25% used. During an interview on 7/28/2025 at 8:42 AM DA – F confirmed there shouldn’t be any open hamburger meat packages in the refrigerator. An observation on 7/28/2025 at 8:44 AM of a bread bag on the counter in the kitchen was opened, not sealed and not dated. An observation on 7/28/2025 at 8:44 AM spices and a bottle of vanilla opened, used and not dated noted in the cupboard. During an interview on 7/28/2025 at 8:45 AM DA – F confirmed the bread bag should not be opened and all the spices should be dated when opened. During an interview on 07/31/2025 at 1:11 PM the Assistant Director of Nursing, who is also the Infection Preventionist, confirmed: - hand hygiene should be performed before gloving and after glove removal -performed for at least 20 seconds -no bare hand should touch food -upon hire in general orientation they do hand hygiene competencies -random audits in nursing are completed with return demonstration. D. Observation on 7/29/25 at 12:17 PM revealed the lunch meal trays were delivered to the memory care unit of the facility. Observation on 7/29/25 at 12:19 PM with NA-G using the facility thermometer obtaining the temperatures of the food as follows: -Cauliflower/broccoli 106.5 Fahrenheit. -Tuna melt sandwich 101.6 Fahrenheit. -Hamburger patty 120.9 Fahrenheit. Milk 48.9 Fahrenheit. An interview on 7/29/25 at 1:35 PM NA-G reported the hot food is supposed to be at least 120 F. An interview on 7/29/25 at 1:40 PM RN-H report hot food should be at least 140 F. An interview on 7/30/25 at 11:30 AM with the Dietary Manager (DM) revealed the holding hot foods should be 120 F. An interview on 7/30/25 at 11:33 AM with Regional Dietician (RD-E) reported the temperature for hot food should be maintained at 135 Fahrenheit (F) and the cold should be 41 F or lower. Record review of Food Temperatures Policy dated 3/26/25 revealed: -Hot foods will be held at 135 degrees Fahrenheit or greater. -Potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit. -No food will be served that does not meet the food code standard temperatures.

Licensure Reference Number 175 NAC 12-006.04(B)(ii)(2) Based on record reviews and interviews, the facility failed to ensure 4 Medication Assistants of 4 reviewed had competencies completed. The facility had census of 58. Findings are: Record review of 4 out of 4 sampled Medication Assistants (MA) employees' competencies for 2024 and 2025 revealed that the 4 MA's did not have competencies documented as completed. Record review of 4 employees that are MA's and their hire dates:-MA-M hire date was 1/29/2024-MA-J hire date was 8/23/2016-MA-N hire date was 5/20/2025-MA-O hire date was 6/11/2025 An interview on 7/30/25 at 1:10 PM with the Director of Nursing (DON) confirmed the facility did not have documentation of MA competencies. An interview on 7/30/25 at 2:40 PM with the Regional Director of Operations (RDO) revealed the facility was unable to find the MA's competencies. Record review of Training Requirements policy dated 7/1/25 revealed: It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual, and volunteers, consistent with their expected roles.-Competencies and skill sets for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers must be consistent with their expected roles.-All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program. Record review of the Medication Aide Procedure Checklist that is used when completing competencies with the Medication Aides revealed: The checklist consisted of PRN medications, oral medications, topical medications, Sublingual or Buccal medications, instillation medications, inhalers, nebulizers, oxygen, and ice bag.

Licensure Reference Number 175 NAC 12-006.09Based on observation, record reviews and interviews, the facility staff failed to complete an assessment and monitoring after receiving Dialysis services for 1 (Resident 10) of 1 residents. The facility has a census of 58.Findings are: Record review of Resident 10's admission record dated 7/29/25 revealed re-admission to the facility was on 3/11/2025. Record review of Resident 10's 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 6/2/25 revealed:-Section C: Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15 indicating cognitively intact.Section E: no rejection of care-Section GG: setup assist with eating, oral hygiene, personal hygiene, and upper body dressing. Moderate assist with bathing. Maximum assist with toileting hygiene, lower body dressing, and putting on/taking off footwear. Dependent assist with transfers.-Section O: Dialysis Record review of Resident 10's diagnoses dated 7/29/25 revealed: Chronic kidney disease stage 4. Record review of Resident 10's care plan dated 7/29/25 revealed: -Provide a sack lunch if resident receives dialysis during meal times. Date Initiated 4/09/2025.-Monitor dialysis dressing and change as ordered. Report abnormal bleeding to the physician. Date Initiated 4/09/2025.-Monitor/document/report to physician any signs or symptoms of infection at the access site such as redness, swelling, warmth, pain, or purulent drainage. Date Initiated 4/09/2025.-In case of dislodgment of dialysis access device, apply pressure to prevent bleeding, call emergency services, and notify physician. Date Initiated 4/09/2025.-Monitor for possible complications such as shortness of breath, peripheral edema, chest pain, elevated blood pressure, dry itchy skin, nausea & vomiting, or bleeding at access site. Date Initiated 4/09/2025.-Obtain lab work per physician orders and report results when available. Date Initiated 4/09/2025.- Resident has a Quinton Catheter to R chest wall. Date Initiated 4/09/2025. Record review of Resident 10's progress notes dated 7/29/25 revealed there was no documentation of monitoring and assessments upon return from the dialysis center for June 2025 except 6/28/25 and no documentation for July 2025 except 7/24/25. An interview on 7/29/25 at 7:30 AM with LPN-L. LPN-L stated, Resident 10 went to dialysis today, dialysis is through the catheter port in the right side of chest. The nurse does not need to do anything when [gender] returns from dialysis. We don't need to take the blood pressure or assess. Resident 10 goes to the Dialysis facility on Tuesday, Thursday and Saturday's. An interview on 7/29/25 at 1:20 PM with Resident 10 revealed [gender] returned from dialysis at 12:35 PM. Resident 10 said, sometimes the nurse here will check my blood pressure and fistula, but not all the time. I started dialysis in March of this year. An interview on 7/30/25 at 1:00 PM with the Director of Nursing (DON) confirmed that there was not any documentation from the nurses for an assessment or monitoring for Resident 10 after returning from dialysis. Record review of Hemodialysis Policy, copyright 2024 The Compliance Store, LLC revealed: This facility will provide the necessary care and treatment consistent with professional standards of practice. The physician orders the comprehensive person-centered care plan and the residence goals and preferences to meet the special medical, nursing, mental and psychosocial needs of residents receiving hemodialysis.-Purpose: The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: -The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility.-Ongoing assessment and oversight of the resident before, during and after dialysis treatment, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices; and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.-Documentation requirements are met to assure that treatments are provided as ordered by the nephrologist, attending practitioner and dialysis team; and there is ongoing communication and collaboration for the development and implementation of the dialysis care plan by the nursing home and dialysis staff.-The facility will monitor for and identify changes in the resident's behavior that may impact the safeadministration of dialysis before and after treatment and will inform the attending practitioner and dialysis facility of the changes.-The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis center to observe for bleeding or other complications.-The nurse will assure that the dialysis access site (e.g. AV shunt or graft) is checked before and after dialysis treatments and every shift for patency by auscultating for a bruit or palpating for a thrill. If absent, the nurse will immediately notify the attending physician, dialysis facility and or the nephrologist.-Residents with external dialysis catheters will be assessed every shift to ensure that the catheter dressing is intact and not soiled. Change dressing to site only per the dialysis facilities direction.-Provision of ongoing staff training, which is individualized to meet the needs of each peritoneal dialysis resident. Staff training must be provided by qualified dialysis facility instructors and include how to address emergencies.

Licensure Reference Number 175 NAC 12.006.05(E) Based on record review and interviews, the facility failed to have a signed advanced directive for one resident (resident 11) out of eight sampled residents. Facility census was 58. Findings are: A record review of resident 11's Minimum Data Set (MDS) (a comprehensive assessment used to develop a resident's care plan) dated 05/14/2025 revealed a brief interview of mental status (BIMS)(a score of a resident's cognitive ability) score of 11.This means the resident had moderate cognitive impairment. Based on the MDS, Preferences for Customary Routine Activities is somewhat to very important to Resident 11. A record review of Resident 11's Care Plan with an admission date of 05/08/2025 revealed resident was having adjustment issues with admission. Interventions listed include, identifying resident's activity preferences, learn to recognize/help the resident to identify stressors, and to provide the resident with as many situations as possible to allow control over the environment and care delivery. A record review of Resident 11's Clinical Census revealed an admission date of 05/08/2025. A record review of the facility's undated Resident Right's packet that is reviewed upon admission revealed: (12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advanced Directives). (i) The requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advanced directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable state law. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether to execute an advanced directive, the facility may give advance directive information to the individual's resident representative according to state law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. A record review of Resident 11's order's on 07/28/2025 at 2:21 PM revealed no order for an advanced directive or code status. A record review of Resident 11's electronic medical record (EMR) under the facility Misc. List on 7/28/2025 at 2:22 PM revealed no orders or copies of an advanced directive or code status. A record review of Resident 11's Advanced Directive Information dated 07/28/2025 with a fax time of 2:44 PM was located on 7/29/2025 in the social service office. A record review of the facility's policy Communication of Code Status dated 8/1/2023 and a revision date of 12/21/2024 revealed, It is the policy of the facility to adhere to residents' rights to formulate advanced directives. In accordance to these rights', this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information. In an interview on 07/29/2025 at 10:59 AM with the ADON confirmed they were looking for Resident 11's advanced directive and could not locate it. The ADON confirmed the Social Service Director (SSD) had an email stating the advanced directive was completed, and it was requested to be faxed. The ADON confirmed the advanced directive was dated 7/28/2025 and the received faxed time was 2:44 PM. In an interview on 07/30/2025 at 10:00 AM with the Regional Director of Operations (RDO) confirmed the advanced directive was received and dated 7/28/2025 at 2:44 PM. The RDO confirmed Resident 11 was admitted on [DATE].

Based on record reviews and interview, the facility failed to provide notice of end of Medicare coverage for 2 ( Resident 10 and 46) of 3 sampled residents. The facility has a census of 58. Findings are:A.Record review of Resident 46's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 6/23/25 revealed admission to the facility was on 4/18/23.Record review of Resident 46's Notice of Medicare Non-Coverage (NOMNC) and Advance Beneficiary Notice (ABN) was completed, although was signed on 7/25/25 with last covered date being 7/22/25.An interview on 7/30/25 at 8:00 AM with the Regional Business Office Manager confirmed that the facility did not have Resident 46 sign the NOMNC or ABN 2 days before the last day of Medicare-covered services.Record review of Advanced Beneficiary notices Policy dated 4/1/ 25 revealed: It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage.B.Record review of Resident 10's admission record dated 7/29/25 revealed re-admission to the facility was on 3/11/25.Record review of Resident 10's NOMNC and ABN with last covered day of Part A Service on 5/6/25 was not completed.An interview on 7/30/25 at 8:00 AM with the Regional Business Office Manager confirmed that the facility did not provide NOMNC and ABN to Resident 10.Record review of Advanced Beneficiary notices Policy dated 4/1/ 25 revealed: It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage.-To Ensure that the resident or representative, has enough time to make a decision whether or not to receive the services in question and assume financial responsibility. The notice shall be provided at least two days before the end of the Medicare covered Part A stay or when all of Part B therapies are ending. The notices must not be provided while the resident/ representative is under duress or in an emergency situation.

Based on interview and record review, the facility failed to notify the ombudsman (a state appointed advocate for residents of nursing homes) of resident discharge for 1 of 1 residents reviewed (Resident 66) as required. The facility census was 58 at the time of the survey. Findings are:Record review of the facility process titled Emergency Transfers from Facility revealed the emergency transfer document is to be sent each month to the ombudsman.Review of the discharge Minimum Data Set (MDS - a mandatory comprehensive assessment tool used for care planning) for Resident 66 dated revealed that Resident 66 admitted to the facility on [DATE]. The MDS revealed that Resident 66 had a discharge date of 5/2/2025.Record review of Resident 66's discharge summary revealed that the resident discharged from the facility on 5/2/2025.During an interview on 7/31/2025 at 11:06 AM the Regional Director of Operations (RDO) revealed that the facility staff gives notifications of emergency transfers and discharges to the ombudsman monthly.During an interview on 7/31/2025 at 1:01 PM the RDO confirmed documents of the Emergency Transfers from the facility to the ombudsman were dated November 2024 and February 2025 and were not completed monthly and should have been.Interview on 7/31/2025 at 1:03 PM the RDO further confirmed the facility staff did not notify the ombudsman of the discharge of Resident 66 as required.

Licensure reference number 175 NAC 12-006.09(H)(iv)(3)Based on observation, interviews and record reviews, the facility failed to maintain the catheter drainage bag below the bladder for 1 (Resident 39) of 1 sampled residents to prevent urinary tract infection. The facility has a census of 58.Findings are: Record review of Resident 39's admission record dated 7/29/25 revealed admission to the facility was on 4/18/23.Record review of Resident 39's 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 6/14/25 revealed:-Section C: short term and long term memory problems. Cognitive Skills for Daily Decision Making severely impaired-Section GG: Dependent assistance with eating, toileting hygiene, bathing, lower body dressing, putting shoes on and off, and transferring. Needs maximum assistance with oral hygiene, upper body dressing, personal hygiene, rolling left and right in bed. -Section H: Indwelling catheter Record review of Resident 39's Diagnoses revealed: neuromuscular dysfunction of bladder, unspecified. Record review of Resident 39's care plan dated 7/29/25 revealed:-Urinary Catheter: Resident has a urinary catheter and is at risk for urinary tract infections and injury.-Urinary catheter related to: neurogenic bladder with urine retention.-Position catheter bag and tubing below the level of the bladder. Date Initiated: 06/10/2025.-The resident has a Urinary Tract Infection, Date Initiated: 07/23/2025.-Give antibiotic therapy as ordered. Monitor/document for side effects andeffectiveness. Date Initiated: 07/23/2025. Record review of Resident 39's Physician Orders dated 7/29/25 revealed: -Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole- Trimethoprim) -Give 1 tablet by mouth two times a day for urinary tract infection (UTI) until 08/01/2025. Start Date- 07/23/2025.- Indwelling Catheter Type: foley, Catheter Size: 18Fr, 30cc balloon, Reason for use: neuromuscular dysfunction of bladder. Change day shift every 1 month(s) starting on the 19th for 1 day(s). Observation on 7/29/25 at 2:08 PM with Medication Assistant (MA(-J and Nursing Assistant (NA)-K of a Hoyer (machinal) lift transfer for Resident 39 revealed MA-J and NA-K placed the Hoyer sling handles into the Hoyer lift arm hooks. NA-K attached the urinary bag onto the lift arm hook that was at the resident's eye level. MA-J and NA-K then transferred resident 39 into bed and unhooked the sling from the lift. NA-K placed the urinary bag. An interview on 7/29/25 at 2:24 PM with MA-J revealed [gender] wasn't sure where to place the catheter bag when transferring resident. An interview on 7/29/25 at 2:25 PM with NA-K stated, maybe it would be better to place the catheter drainage bag on the lower area of the Hoyer lift when transferring resident. Interview with the Director of Nursing (DON) on 7/30/25 at 1:00 PM confirmed the catheter drainage bag should be below the level of the bladder. Record review of Catheter Care Policy dated 11/27/23 revealed:Policy: It is the policy of this facility to ensure that residents within dwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.-Ensure drainage bag is located below the level of. The bladder to discourage backflow of urine.

Licensure Reference Number 175 NAC 12-006.11(A)(iii) Based on record reviews, observations, and interviews the facility failed to ensure residents were offered alternate meal items when residents choose not to eat food that was initially served. This had the potential to affect all residents who received meals from the kitchen. The facility census was 56. Findings Are: Record review of the policy Food Preparation Guidelines dated 8/1/2023 revealed the policy intent is to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status. The policy explanation and compliance guidelines stated in section 4) Food shall be provided in a form that meets each resident's individual needs according to assessment and care plan; 5) Staff shall accommodate resident preferences providing appropriate alternatives; and 6) Staff shall offer residents appropriate alternatives when they choose not to consume food that is initially served or when a different food choice is requested. Observation on 2/26/2025 at 12:15 PM while residents were eating in the east formal dining room and the east assistive dining room revealed the residents were finishing their lunch meal and several of the residents had not eaten their broccoli and cheese dish. Observation of a sample meal tray provided by the facility on 2/26/2025 at 12:30 PM revealed a meal that consisted of a sloppy joe on a bun, broccoli with cheese and lime pears with a glass of milk or other beverage. The sloppy joe sandwich looked and smelled appealing. The broccoli and cheese looked pureed or ground and unappetizing; it was identifiable based on the color. At first glance, the pears looked like cubed melon due to the green color from lime gelatin which had been sprinkled on the pears. A. Record review of Resident 6's Care Plan conducted on 2/26/2025 revealed the resident was cognitively intact, had diagnoses of Diabetes Mellitus Type 2, vitamin deficiency; unspecified, and had orders for a concentrated carbohydrate diet with a regular texture. Interview on 2/26/2025 at 12:30 PM with Resident 6 who stated, I never eat pears because I don't like them. Resident 6 revealed the residents got a menu each day for the following day's meals and the residents were to mark what they wanted to eat. The resident stated that if they did not want something, they just didn't mark it so Resident 6 never marked the pears. When asked if there was a choice of something different to eat, Resident 6 revealed the residents didn't have any other choice on the menu, just what is supposed to be served. Resident 6 also stated that the kitchen did not send the residents a replacement for they food items they don't like. B. Record review of Resident 5's Care Plan conducted on 2/26/2025 revealed that Resident 5 was cognitively intact with some confusion in the evenings, had a diagnosis of a past stroke, some swallowing issues, and received a regular diet with ground meats and vegetables that were cut into small sized pieces. Interview on 2/26/2025 at 12:45 PM with Resident 5 who stated they did not eat the broccoli during the lunch meal that day. Resident 5 stated the facility always seemed to cook all the stems and it was hard to eat because the resident did not have any teeth. Resident 5 revealed the residents get a menu each day that they mark on for what they want to eat the following day. Resident 5 stated they did not mark the broccoli because the resident did not like to waste food. Resident 5 also stated the facility did not offer a second choice of food as an alternative to the broccoli and cheese. Interview on 2/26/2025 at 1:50 PM with the Food Service Manager (FSM) revealed all of the residents had a menu that they received the day before, so the staff would know how much of everything to cook the next day. FSM stated that the residents could choose other options for the main dish and that there were several things they could choose from. FSM stated that offering another vegetable, fruit or dessert had never come up and that if the residents did not mark the vegetable or fruit being offered, they just wouldn't get anything. FSM confirmed that residents who were not offered or provided an alternative vegetable or fruit would not recieve a well-balanced meal. Interview on 2/26/2025 at 4:00 PM with the Administrator (FA) who confirmed that the residents did have a choice of a different main course at each meal time, but that the facility did not usually offer a different vegetable or fruit. FA stated the facility had done this in the past but had gotten to where the staff were cooking two meals at each setting so they stopped offering an alternate for the vegetables and fruits.

Licensure Reference Number 175 NAC 12-006.11(D) Based on record reviews, observations, and interviews the facility failed to ensure residents were provided with nourishing and palatable meals. This had the potential to affect all residents who received meals from the kitchen. The facility census was 56. Findings Are: Record review of the policy Food Preparation Guidelines dated 8/1/2023 revealed the policy intent is to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status. The following three definitions were defined: -Food Attractiveness - the appearance of the food when served to residents, -Food palatability - the taste and flavor of the food, and -Proper (safe and appetizing) temperature meant appetizing food and minimizing the risk for scald and burns. The policy explanation and compliance guidelines stated 2) food shall be prepared by methods that conserve nutritive value, flavor, and appearance; 3) Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature; b) using spices or herbs to season food in accordance with recipes, c) serving hot foods hot and cold foods cold, e) honoring resident preferences regarding foods and drinks; 4) Food shall be provided in a form that meets each resident's individual needs according to assessment and care plan. Record review of the Nebraska Food Code of 2017 revealed that temperatures for hot meals must be served at 135 degrees Fahrenheit (F) or higher. Observation on 2/26/2025 at 12:15 PM while residents were eating in the east formal dining room and the east assistive dining room revealed the residents were finishing their lunch meal and several of the residents had not eaten their broccoli and cheese dish. Observation of a sample meal tray provided by the facility on 2/26/2025 at 12:30 PM revealed a meal that consisted of a sloppy joe on a bun, broccoli with cheese and lime pears with a glass of milk or other beverage. The sloppy joe sandwich looked and smelled appealing. The broccoli and cheese looked pureed or ground and unappetizing; it was identifiable based on the color. At first glance, the pears looked like cubed melon due to the green color from lime gelatin which had been sprinkled on the pears. The temperature of the sloppy joe was 124.3 degrees F. The temperature of the broccoli/cheese was 132.4 degrees F. The pears were cold. A. Record review of Resident 6's Care Plan conducted on 2/26/2025 revealed the resident was cognitively intact, had diagnoses of Diabetes Mellitus Type 2, vitamin deficieny; unspecified, and had orders for a concentrated carbohydrate diet with a regular texture. Interview on 2/26/2025 at 11:10 AM with Resident 6 revealed the resident typically ate their meals in their room and that the hot foods were not always served hot. B. Record review of Resident 5's Care Plan conducted on 2/26/2025 revealed that Resident 5 was cognitively intact with some confusion in the evenings, had a diagnosis of a past stroke, some swallowing issues, and received a regular diet with ground meats and vegetables that were cut into small sized pieces. Interview on 2/26/2025 at 11:20 AM with Resident 5 revealed that the hot meals were not consistent, sometimes the food was hot and sometimes it wasn't. Resident 5 also stated that they typically consumed their meals in their room. C. A review of Resident 4's Care Plan conducted on 2/26/2025 revealed this resident had a potential nutritional risk due to diagnoses of Diabetes Mellitus Type 2, morbid obesity, anemia, vitamin B12 deficiency, and diverticulosis. Resident 4 was on a concentrated carbohydrate diet. Observation on 2/26/2025 at 12:40 PM of Resident 4's lunch meal tray after the resident had finished eating revealed the tray still had the broccoli and cheese dish on it and this food appeared untouched. Interview on 2/26/2025 at 3:20 PM with Resident 4 revealed they did not eat the broccoli and cheese dish at the lunch meal that day because it looked like someone threw up on the plate. I didn't even want to taste it. Interview on 2/26/2025 at 1:50 PM with the Food Service Manager (FSM) confirmed that the broccoli and cheese dish that had been served to the residents as regular texture appeared to be a ground texture. Interview on 2/26/2025 at 4:00 PM with the Administrator (FA) confirmed the temperatures of the lunch meal foods were not served to the residents within the required temperature.

Licensure Reference Number 175 NAC 12-006.19 Based on record reviews, observations, and interviews the facility failed to ensure the facility was a clean and homelike environment, this affected two hallways of 4 sampled. The facility census was 56. Findings are: Record review of the policy Environmental Services Inspections dated 8/1/2023 revealed that it is the policy of the facility to regularly monitor environmental services to ensure the facility is maintained in a safe and sanitary manner on a regular basis. Record review of the policy Routine Cleaning and Disinfection dated 8/1/2023 revealed that it is the facility policy to ensure the provision of routine cleaning and disinfection in order to provide a sage, sanitary environment and to prevent the development and transmission of infections to the extent possible. The policy also revealed 1) Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms and at the time of discharge and 2) Cleaning will be completed before disinfecting. Observation of the facility when entered on 2/26/2025 at 8:40 AM revealed a faint odor of urine at the front door. As one walked further into the facility the smell of urine became much stronger. The smell of urine was evident in the hallway, which was carpeted and lead from the east entrance through to the main nurses' station. The smell of urine remained strong in the south hall and in some of the resident rooms. Observation on 2/26/2025 at 8:45 AM of the private room, room [ROOM NUMBER], on the east hallway revealed the room was unoccupied. The room smelled strongly of urine and the floor was sticky when walking on it. Observation on 2/26/2025 at 3:15 PM of the East Hall, room [ROOM NUMBER]. Housekeeping had come in to mop the floors and left the room. Prior to mopping the floor, the floors were sticky to walk on. After the housekeeper mopped and cleaned the floor, the floor was stickier while walking on it than it had been previously. The odor in the room became extremely strong and smelled of urine more so than prior to being mopped. Interview on 2/26/2025 at 2:40 PM with the Director of Nursing (DON) about the odors in the halls and the rooms revealed that the facility had issues with humidity, and this was the time of the year that the musty and urine odors really seemed to start getting more noticeable. Interview on 2/26/2025 at 4:00 PM with the Administrator (FA) confirmed the odor of urine was getting very strong in all of the hallways and in some of the rooms and this was due to the humidity in the facility. It seemed like when it started to warm up outside the smells start to permeate from every crack and crevice in the building. We don't really know what to do about the odors in the building. I think most of us are used to the smells and they don't bother us anymore.

Licensure Reference Number 175 NAC 12-006.05(F) Based on record reviews, observations, and interviews the facility failed to ensure call lights were answered promptly for 3 residents (Residents 5, 6, 4) of the 3 sampled residents. The facility census was 56. Findings are: A. Record review of the 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 2/15/2025 for Resident 5 revealed the resident had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15/15, which indicated the resident was cognitively intact. Resident 5 was able to walk 10 feet with moderate assistance due to a stroke 3 years prior. Record review of the September 2024 Grievance Summary Log revealed that Resident 5 had complained about call lights not being answered in a timely manner. Interview on 2/26/2025 at 11:20 AM with Resident 5 who stated it can take a long time for the staff to answer a call light, at times it had been approximately an hour. Resident 5 stated the call light response times had improved for a little while when Resident 5 put in their grievance, but that the facility had been having issues with the call lights being answered again. Record review of the call light log for Resident 5 revealed the following long call light times for the month of February 2025: -On 2/1/25 the call light was turned on at 2:39 PM and was not turned off for 35 minutes, -On 2/1/25 the call light was turned on at 7:00 PM and was not turned off for 31 minutes, -On 2/1/25 the call light was turned on at 7:43 PM and was not turned off for 27 minutes, -On 2/3/25 the call light was turned on at 6:59 AM and was not turned off for 27 minutes, -On 2/3/25 the call light was turned on at 9:13 AM and was not turned off for 28 minutes, -On 2/5/25 the call light was turned on at 7:26 AM and was not turned off for 35 minutes, -On 2/9/25 the call light was turned on at 12:42 PM and was not turned off for 48 minutes, -On 2/10/25 the call light was turned on at 7:17 AM and was not turned off for 1 hour and 32 minutes, -On 2/13/25 the call light was turned on at 2:38 PM and was not turned off for 34 minutes, -On 2/20/25 the call light was turned on at 1:01 PM and was not turned off for 36 minutes, -On 2/24/25 the call light was turned on at 7:02 AM and was not turned off for 40 minutes, -On 2/25/25 the call light was turned on at 1:03 PM and was not turned off for 45 minutes. B. Record review of the MDS dated [DATE] for Resident 6 revealed this resident had a BIMS score of 15/15, which indicated the resident was cognitively intact. Resident 6 needed assistance walking a maximum distance of 10 feet and was not able to walk alone using a walker. Resident 6 was to use a wheelchair due to falling precautions. Interview on 2/26/2025 at 11:30 AM with Resident 6 revealed the residents may have to wait an hour or more for someone to answer their call lights. Resident 6 stated they did not know why the staff did not answer the call lights quicker. Resident 6 also stated the need to use the restroom was often the reason Resident 6 activated their call light and that having to wait so long was very difficult. Record review of the call light log times revealed the following sampled times for the month of February 2025: -On 2/1/25 the call light was turned on at 8:04 AM and was not turned off for 24 minutes, -On 2/3/25 the call light was turned on at 7:46 PM and was not turned off for 28 minutes, -On 2/5/25 the call light was turned on at 5:18 PM and was not turned off for 27 minutes, -On 2/7/25 the call light was turned on at 7:38 PM and was not turned off for 61 minutes, -On 2/8/25 the call light was turned on at 9:58 AM and was not turned off for 46 minutes, -On 2/9/25 the call light was turned on at 7:23 PM and was not turned off for 37 minutes, -On 2/12/25 the call light was turned on at 12:50 PM and was not turned off for 47 minutes, -On 2/12/25 the call light was turned on at 5:46 PM and was not turned off for 45 minutes, -On 2/14/25 the call light was turned on at 8:18 AM and was not turned off for 33 minutes, -On 2/15/25 the call light was turned on at 5:01 PM and was not turned off for 62 minutes, -On 2/16/25 the call light was turned on at 5:33 PM and was not turned off for 1 hour and 4 minutes, -On 2/17/25 the call light was turned on at 7:46 PM and was not turned off for 32 minutes, -On 2/20/25 the call light was turned on at 6:08 PM and was not turned off for 36 minutes, -On 2/21/25 the call light was turned on at 5:11 PM and was not turned off for 42 minutes, -On 2/22/25 the call light was turned on at 7:31 AM and was not turned off for 39 minutes, -On 2/25/25 the call light was turned on at 7:29 PM and was not turned off for 46 minutes, -On 2/25/25 the call light was turned on at 8:16 PM and was not turned off for 59 minutes. C. Record review of the MDS dated [DATE] for Resident 4 revealed the resident had a BIMS score of 15/15, which indicated the resident was cognitively intact. Resident 4 was unable to walk and required the use of a mechanical lift by 2 staff members to get the resident from the wheel chair to the bed or bath. Interview on 2/26/2025 at 2:15 with Resident 4 revealed that when the resident was in their room, it took the staff a long time to answer Resident 4's call lights. Resident 4 stated that it can take an hour or more for them to come to my room to answer the light. Resident 4 also stated that some of the staff would go into the resident's room, turn off the call light, then say they were going to come right back, but then the resident would be waiting again for someone to answer their call light. Record review of the call light log for Resident 4 revealed the following long call light times for the month of February 2025: -On 2/1/25 the call light was turned on at 2:58 PM and was not turned off for 24 minutes, -On 2/1/25 the call light was turned on at 6:51 PM and was not turned off for 82 minutes, -On 2/2/25 the call light was turned on at 5:37 AM and was not turned off for 68 minutes, -On 2/2/25 the call light was turned on at 3:39 PM and was not turned off for 25 minutes, -On 2/2/25 the call light was turned on at 5:33 PM and was not turned off for 31 minutes, -On 2/3/25 the call light was turned on at 9:37 AM and was not turned off for 51 minutes, -On 2/3/25 the call light was turned on at 7:17 PM and was not turned off for 52 minutes, -On 2/4/25 the call light was turned on at 10:51 AM and was not turned off for 38 minutes, -On 2/4/25 the call light was turned on at 7:25 PM and was not turned off for 2 hours and 6 minutes, -On 2/5/25 the call light was turned on at 8:13 AM and was not turned off for 82 minutes, -On 2/5/25 the call light was turned on at 4:27 PM and was not turned off for 34 minutes, -On 2/12/25 the call light was turned on at 7:15 PM and was not turned off for 34 minutes, -On 2/13/25 the call light was turned on at 6:08 PM and was not turned off for 36 minutes, -On 2/16/25 the call light was turned on at 10:38 AM and was not turned off for 33 minutes, -On 2/16/25 the call light was turned on at 1:31 PM and was not turned off for 46 minutes, -On 2/16/25 the call light was turned on at 2:36 PM and was not turned off for 59 minutes, -On 2/18/25 the call light was turned on at 12:01 PM and was not turned off for 43 minutes, -On 2/21/25 the call light was turned on at 10:48 AM and was not turned off for 44 minutes, -On 2/21/25 the call light was turned on at 8:10 PM and was not turned off for 45 minutes, -On 2/22/25 the call light was turned on at 8:18 AM and was not turned off for 46 minutes, -On 2/25/25 the call light was turned on at 8:11 PM and was not turned off for 61 minutes. Interview on 2/26/2025 at 2:45 PM with the Director of Nursing (DON) who revealed that the call lights light up the messenger board at the main nurse's station and on Hall B (the north hallway). The staff also carried walkie's so that they were aware of the call lights that needed to be answered. The DON stated there were a couple of days when the call light for Resident 4 did not work as it was supposed to but that it had been fixed. Interview on 2/26/2025 at 3:05 PM with the Facility Administrator (FA) who confirmed that there were times that the call lights were longer than they should be when residents called for assistance, and that the FA was able to observe call light times from a monitoring screen in their office. FA stated that when the FA saw that a call light had been running for a long time, the FA would go out to the nurse's station to ask why the call hadn't been answered or would go directly to the resident who used the call light and see what that resident needed.

Licensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview the facility failed to communicate all health information to the receiving health care facility for 1 (Resident 1) of 3 sampled residents. This had the potential to cause resident health problems and safety concerns to not be identified by the receiving facility. The facility census was 56. Findings are: Record review of the facility policy titled Transfer and Discharge dated 2/5/25 revealed that the following information must be provided to the receiving provider for transfer to another provider: -Contact information of the practitioner responsible for the care of the resident. -Resident representative information. -All other information necessary to meet the resident's needs, which includes but may not be limited to resident status, diagnoses and allergies, medications, most recent relevant labs, all special instructions for ongoing care such as special risks for falls, the resident's comprehensive care plan goals, and all other information necessary to meet the resident's needs. Record review of the progress note dated 2/3/2025 at 12:00 PM for Resident 1 revealed that the unidentified nurse aide (NA) heard someone call Help. NA observed Resident 1 standing at the side of the bed with their walker upon entering the resident's room. The NA got the resident's wheelchair in position for the resident to sit. Resident 1 stated that their legs would not turn. Resident 1's legs gave out and the resident sat on the floor. Resident 1 was assessed and no injuries were noted. The mechanical total body lift (a mechanical assistive device used to transfer a resident unable to stand up on their own) was used to lift Resident 1 back into their bed. The physician, family member, Director of Nursing (DON) and Facility Administrator (FA) were notified. Record review of the 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) for Resident 1 dated 2/3/25 revealed that it was a resident discharge assessment. The MDS revealed that Resident 1 admitted into the facility on 1/13/25 and discharged from the facility on 2/3/25. The MDS revealed that this was a planned discharge. The MDS revealed that Resident 1 had a Brief Interview for Mental Status (BIMS, a brief screening tool that aids in detecting cognitive impairment) score of 15/15, which indicated the resident was cognitively intact. The MDS revealed that Resident 1 required moderate assistance of staff to stand from a sitting position. The MDS revealed that the resident's ability to walk 10 feet once standing was documented as not attempted due to medical condition or safety concerns. Section J0300 titled pain presence revealed that Resident 1 had no pain or hurting at any time in the past 5 days. Section J1800 revealed that the question Has the resident had any falls since admission/entry or reentry or the prior assessment? was marked No indicating that the resident had no falls. Record review of the progress note dated 2/3/2025 at 2:03 PM for Resident 1 revealed that Resident 1 discharged out of the facility to another long term care facility. All belongings and medications sent with the resident and transportation. Interview on 2/26/25 at 4:06 PM with the facility Assistant Director of Nursing (ADON) confirmed that the facility was to follow the facility policy for transfer and discharge. The ADON revealed that the facility was expected to complete a transfer assessment form that is sent with the resident to the receiving facility. The ADON confirmed that the transfer assessment form was to be completed in the resident's electronic health record. The ADON confirmed that the facility did not complete a transfer assessment form for Resident 1 when the resident discharged to another facility. Interview on 2/27/25 at 1:00 PM with Resident 1 by phone revealed that Resident 1 fell at around 12:00 PM on 2/3/25 in the facility prior to transfer to another facility. Resident 1 revealed that the wheelchair was out in the hall outside the resident's room at the time of the fall. Resident 1 revealed that the transportation driver from the facility the resident was being transferred to was at the facility to get the resident. Resident 1 revealed that a nurse was in the resident room. Resident 1 revealed that Resident 1 used the walker and tried to start walking to the wheelchair outside the room. Resident 1 revealed that the resident is unsure if the walker caught on something in the room that caused the resident to twist around and fall on their back. Resident 1 revealed that they landed flat on their back. Resident 1 revealed that their hip, left leg, and ankle was hurting after the fall. Resident 1 revealed that they told the nurse about their pain after the fall and that it felt like the left ankle was sprained. Resident 1 revealed that the nurse really didn't assess Resident 1. Resident 1 revealed that the staff sat the resident up on the floor and placed a lift sling in place. Resident 1 revealed that the staff used the total body lift and transferred Resident 1 off the floor and into the wheelchair. Resident 1 confirmed that the resident did not have any falls after leaving the facility. Resident 1 confirmed that the resident did not have any falls at the receiving facility. Resident 1 revealed that Resident 1 told the receiving facility about the ankle pain and the receiving facility assessed the injury to the left ankle on arrival. Resident 1 was seen by the medical provider. Resident 1 revealed that the resident had surgery to repair the left ankle. Record review of the medical record for Resident 1 revealed that it contained an incomplete Discharge Summary and Plan of Care assessment dated [DATE] at 2:03 PM. The progress note contained in the Discharge Summary and Plan of Care revealed that Resident 1 had a pain level of 4 upon discharge. The progress note revealed that upon discharge the resident was able to walk indoors with physical assistance. A current reconciled medication list was provided to the subsequent provider. The discharge plan had been discussed with the resident and/or the resident's representative and they had been offered a copy of the plan of care and discharge summary. The note contained no documentation of Resident 1's fall on 2/3/25. Record review of the medical record for Resident 1 revealed that it did not contain any documentation that the fall on 2/3/25 experienced by Resident 1 was communicated to the receiving facility. Interview on 2/26/25 at 3:36 PM with the Facility Administrator (FA) confirmed that the Discharge Summary and Plan of Care assessment for Resident 1 had not yet been locked (signed off) as a staff member was out of the facility and needed to complete their section of the assessment.

Based on record review and interviews; the facility failed to ensure a PASRR (Pre-admission Screening and Resident Review) for individuals with a mental disorder or intellectual disability were accurately completed to determine if a level II PASARR review was warranted for 1 (Resident 39) out of 20 sampled residents. The facility census was 60. Findings are: A record review of Admission Record with the printed date of 7/30/24 revealed Resident 39 was admitted on [DATE], and a re-admitted [DATE] with the diagnoses of Schizoaffective Disorder( a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions), Major depressive Disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life),post-traumatic stress Disorder,)a mental health condition that's triggered by a terrifying event-either experiencing it or witnessing it). A record review of the History and Physical from the Hospital dated 6/7/22 revealed a past medical history of schizoaffective disorder, PSTD, mood disorder, and depression. A record review of the MDS (Minimum Data Set, a comprehensive assessment of each residents' functional capabilities) dated 5/1/24 revealed in section I active diagnoses of depression, schizophrenia and Post-traumatic stress Disorder was marked with an X indicating yes. A record review of the PASRR dated 3/30/21 revealed in the section Behavioral Health Diagnosis: According to the PASRR 1 level screening this individual has a diagnosis of or a suspicious of Major Depressive Disorder and substance abuse. A record review of the PASRR dated 6/8/22 revealed that in the section Behavioral Health Diagnosis: According to the PASRR level 1 screening this individual has a diagnosis of or suspicious of the following. There is no diagnosis listed. An interview on 7/30/24 10:30 AM with DON (Director of nursing) confirmed that the diagnoses of schizoaffective disorder and post-traumatic stress disorder was not on the PASRR and schizoaffective disorder and post-traumatic stress disorder should have been on the PASRR An interview on 7/30/24 10:31 AM with Administrator confirmed that the diagnoses of PSTD and Schizoaffective disorder should have been on the PASRR and wasn't. The Administrator further revealed the PASRR was done at the hospital, and they did the PASRR incorrectly, but the Social Worker should have caught it. An interview on 7/31/24 9:14 AM with SSD (Social Service Director) confirmed that the diagnoses of schizoaffective disorder and Post Traumatic Stress Disorder was not on the PASRR and it should of been on the PASRR.

Licensure Reference Number 175 NAC 12-006.09 Based on record review, observations, and interviews; the facility failed to follow up and complete Physician's orders regarding Auto-PAP (Continuous positive airway pressure) for 1 (Resident 34) of 20 sampled residents. The facility census was 60. A record review of the Admission Record revealed that Resident 34 was admitted to the facility on [DATE] with diagnosis of: Obstructive Sleep Apnea(characterized by episodes of a complete airway collapse or a partial collapse with an associated decrease in oxygen saturation or arousal from sleep). An interview on 7/29/24 at 1:30 PM with Resident 34 confirmed that [gender] does not use the Auto-Pap machine because the mask is too tight on [gender] face. Resident 34 revealed that [gender] had informed the staff regarding the mask being too tight. An interview on 7/30/24 at 9:30 AM with Resident 34 revealed that [gender] did not wear the Auto-Pap last night. A record review of the hospital referral packet from Hospital dated 10/1/23 revealed patient active problem list state: Obstructive sleep Apnea on C-Pap since 11/20/18. A Record review of the Medical Clinic Nursing Home Visit form with a printed date of 10/18/23 revealed on the top of the form CC: how am I supposed to breath at night without my CPAP?, Resident 34 inquiring about a new CPAP. There are no orders addressing Resident 34 concerns regarding the CPAP. A record review of Physician orders dated 4/11/24 revealed an order for Auto-Pap. A record review of Medication Administration orders revealed an Auto-Pap with a start date of 5/3/24. A record review of Medication Administration orders revealed that starting on May 3 Resident 34 wore [gender] Auto-pap 17 times and refused to wear the Auto-pap 11 times. A Record review of Medication Administration orders revealed that in the month of June Resident 34 wore the Auto-Pap 9 days and refused to wear the Auto -Pap for 21 days. A Record review of Medication Administration orders revealed that in the month of July Resident 34 wore the Auto-Pap 4 times and refused to wear the Auto-Pap for 26 times. A Record review of the Progress Note dated 7/1/24 revealed that the facility placed a call to Midwest Respiratory to inquire about possible titration or other recommendations for Resident 34's Auto-Pap, the respiratory therapist will return call. There was no other follow up notes regarding Midwest. An interview on 7/30/24 at 11:30 AM with RN-A (Registered Nurse-A) revealed that [gender] was aware Resident 34 refuses the Auto-Pap, and was unaware if the Doctor had been notified. An interview on 7/30/24 at 2:00 PM with DON (Director of Nursing) and Administrator confirmed that they had contacted Midwest and their corporate nurse regarding Midwest stating they couldn't help. The administrator confirmed that the resident had a beard and thought that was making the mask feel tight. The DON confirmed that Resident 34's orders for the auto-pap should have been ordered on admission and follow up should have been done with the physician and respiratory therapist.

Licensure Reference Number 175 NAC 12-006.18 (B) & (D) Based observations, interviews, and record review; the facility failed to secure a catheter to prevent cross contamination during catheter cares for 1 (Residnet 53), and failed to change gloves and perform hand hygiene when performing peri care and wound care for 3 (Resident 53, 26, and 8) of 3 sampled residents. The facility census was 60. The Findings are: Record Review of Resident 53's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 4/28/24 revealed Resident 53 admitted to the facility on [DATE] with diagnoses of: Dementia ( Dementia is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life)with behavioral disturbance, neurogenic bladder (is a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition.), intellectual disabilities, and hypothyroidism (the thyroid gland doesn't make enough thyroid hormones to meet the body's needs). The MDS indicated Resident 53 had an indwelling catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid), and was dependent on staff assistance for eating, dressing, bed mobility, bathing, and personal hygiene. An observation on 7/30/24 at 7:57 AM revealed Registered Nurse (RN) D changing Resident 53's catheter bag. RN D entered the room with a new catheter drainage bag and several individually wrapped alcohol wipes. After performing hand hygiene and donning gloves, RN D located the connection between the urinary catheter and the drainage tubing, by rolling down Resident 53's pants. Then RN D opened the new catheter drainage bag and tubing, and the new bag and tubing fell to the floor. RN D picked up the catheter bag and proceeded to disconnect the old tubing from the catheter. While doing this the new catheter bag and tubing fell to the floor again and RN D holding the urinary catheter in the left hand used the right hand to pick up the catheter bag and tubing off the floor. Once RN D disconnected the old catheter tubing, [gender] used an alcohol wipe and scrubbed the end of the old catheter, and used another alcohol wipe to scrub the end of the new tubing and then connected the new tubing to the catheter. An interview was conducted with RN D on 7/30/24 at 9:34 AM confirmed that the catheter drainage bag and tubing fell to the floor while changing the catheter drainage bag. An interview with the Infection Control Preventionist (ICP) on 8/1/24 at 10:37 AM confirmed the catheter bag touching the floor had the potential to cause cross contamination. An observation on 7/31/24 at 7:00 AM revealed Medication Aide (MA) C performing urinary catheter care and pericare (the cleaning of the private areas of a patient) for Resident 53. Resident 53 was lying in bed, MA C performed hand hygiene and donned gloves then removed the covers from Resident 53. MA C using disposable wipes wiped Resident 53's right groin, then folded wipe and wiped the left groin and discarded the wipe in the trash. Then MA using a clean wipe wiped down the center of the peri area and discarded the wipe. Then MA C took a new wipe and wiped around the catheter insertion site and down the tubing away from the resident. Resident 53 was rolled to the left side and MA C using a new wipe, wiped the right buttock, folded and wiped the left buttock, folded and wiped the gluteal cleft. With the same soiled gloved hands applied a clean brief, support stockings, shirt and pants. An interview on 7/31/2024 at 7:22 AM with MA C confirmed [gender]did not change gloves and perform hand hygiene, after performing pericare for Resident 53. An interview with the ICP on 8/01/2024 at 10:40 AM confirmed that soiled gloves should be removed and hand hygiene performed after pericare and before applying clean clothes. Record Review of the facility Hand Hygiene policy dated 4/01/24 revealed all staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Included in the policy is a Hand Hygiene Table which indicated during resident care hand hygiene should be performed when moving from a contaminated body site to a clean body site. 47406 B. Record review of Resident 26's Admission Record revealed Resident 26 admitted to the facility on [DATE]. An observation on 7/30/24 at 10:44 AM with RN-A for Resident 26's wound care. RN-A performed hand hygiene with hand sanitizer and donned (put on) gloves and gown. The resident then stood up and turned around facing the recliner during wound care. RN-A pulled the slacks and pullup down. Without changeing gloves RN-A cleansed the wound with wound cleanser and gauze. RN-A then changed gloves without performing hand hygiene in between the glove change. RN-A then administered zinc paste to Resident 26's wound. Next RN-A pulled Resident 26's pullup and slacks up. RN-A doffed (took off) gloves, placed in the trash, then took trash to the shower room down the hallway where [gender] placed in the trash bin. RN-A then washed hands with soap and water for 20 seconds. An interview on 7/30/24 at 10:58 AM with RN-A revealed [gender] should have washed [gender] hands after removing dirty gloves, between glove changes, and before leaving residents' room. An interview on 7/31/24 at 1:06 PM with the DON revealed the expectation was for the nurse to do hand hygiene after removing dirty gloves and before donning gloves, and before leaving residents' room. C. Record review of Resident 8's Admission Record revealed Resident 8 admitted to the facility on [DATE]. An observation on 7/31/24 at 2:04 PM with Licensed Practical Nurse (LPN)-C performing wound cares on buttock and toe for Resident 8. LPN-C donned gloves and gown without performing hand hygiene prior. LPN-C pulled down the resident's pullups and slacks then cleansed the wound with gauze and wound cleanser. LPN-C then applied a new mepilex dressing using the same gloves. Next LPN-C pulled the pullups and slacks up for Resident 8. LPN-C doffed gloves and cleansed hands with hand sanitizer. LPN-C donned clean gloves and removed the sock from right foot. LPN-C using the same gloves cleansed the toe wound with gauze and wound cleanser and applied a new dressing. LPN-C then applied a clean sock. LPN-C removed the trash bag and took it to the shower/whirlpool room trash receptacle. LPN-C then washed [gender] hands with soap and water for 10 seconds. Interview with LPN-C on 7/31/24 at 2:22 PM revealed that [gender] should have performed hand hygiene before donning gloves when [gender] first entered the room, after removing the sock, after cleansing buttock and toe wound. LPN-C further confirmed [gender] should have washed hands with soap and water for 20 seconds. Interview on 7/31/24 at 2:24 PM with DON revealed that LPN-C should have done hand hygiene before donning gloves when [gender] first entered the room, after removing the sock, after cleansing toe wound. DON further revealed LPN-C should have washed [gender] hands with soap and water for 20 seconds. Record review of Hand Hygiene Policy dated 4/1/24 revealed: -All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. -Hand hygiene technique when using soap and water. Apply to hands the amount of soap recommended by the manufacturer. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. Rinse the hands with water. -Additional considerations: The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Licensure Reference Number 175 NAC 12.006.09D3 Based on interview and record review, the facility failed to ensure a full Urinalysis (UA)(a test that checks several components of a urine sample) was completed for 1 (Resident 49) of 2 sampled residents. The total facility census was 59. Findings are: A record review of the Laboratory Services and Reporting Policy dated 08/01/2023 revealed the facility must provide or obtain laboratory (lab) services to meet the needs of its residents, and the facility is responsible for timeliness of the services. A record review of Resident 49's Clinical Census dated 09/13/2023 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 49's Medical Diagnosis dated 09/13/2023 revealed the resident had a primary diagnosis of Type 2 Diabetes Mellites (DMII)(uncontrolled blood sugars). Other diagnoses include Chronic Candidiasis of Vulva and Vagina (persistent infection of the Vulva and Vagina), Acute Vaginitis (inflammation of the Vagina), Morbid Obesity (very overweight), and many others. A record review of Resident 49's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 08/22/2023 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 13 of 15 which indicates the resident was cognitive aware. The resident was a 2-person physical assist with dressing and personal hygiene (cleaning). The MDS revealed the resident was frequently incontinent (lack of control of the bladder). A record review of Resident 49's Care Plan with an admitted [DATE] revealed the resident had a Focus area of bladder incontinence related to a history of Urinary Tract Infection (UTI)(infection of the urinary tract) and had interventions to monitor for signs and symptoms of a UTI and clean the Perineurium area (peri)(area between the thighs). In an interview on 09/11/2023 at 1:37 PM, Resident 49 confirmed the resident had a burning sensation (feeling) when urinating and the facility recently took a urine. In an interview on 09/13/2023 at 10:26 AM, Resident 49 confirmed that it still burns when the resident urinates and had reported it to the staff. A record review of Resident 49's Progress Note dated 09/06/2023 a straight catheter (cath)(hollow tube inserted in the bladder) Urinalysis specimen was obtained as ordered by Resident 49's provider. A record review of Resident 49's Treatment Administration Record (TAR) dated September 2023 and the Clinical Physician Orders dated 09/13/2023 did not reveal an order for a UA. A record review of the Referral Form Office Visit dated 09/05/2023 revealed Resident 49's provider ordered a straight cath urine sample. A record review of Resident 49's Progress Notes dated 09/13/2023 did not reveal the UA results had been received or reported to the provider. In an interview on 09/13/2023 at 10:17 AM, Registered Nurse (RN)-C confirmed that the UA had been sent to the laboratory (lab) on 09/06/2023, but the lab had only completed the chemistry portion not a complete UA. RN-C confirmed the facility had not followed up with the lab on the missing portion of the UA. In an interview on 09/13/2023 at 10:21 AM, the Director of Nursing (DON) confirmed a UA was sent to the lab and only the chemistry portion had been completed, not the complete UA. The DON confirmed the complete UA had not been completed by the lab. In an interview on 09/13/2023 at 10:58 AM, the DON confirmed the facility staff should have contacted the lab the following day to get the complete results and send a new sample for a complete UA if the results were not back within 2 days. The DON confirmed that had not been completed and should have been. The DON confirmed the UA results had not been sent to the provider to treat the potential UTI.

Licensure Reference Number 175 NAC 12.006.09D6 (7) Based on observation, interview, and record review, the facility failed to ensure an oxygen concentrator (a machine that delivers purified oxygen to a resident) was set at the prescribed settin and that the humidifier remained full for 1 (Resident 32) of 2 sampled residents. The total facility census was 59. Findings are: A record review of the facility's Oxygen Administration Policy dated 08/01/2023 revealed oxygen is administered under the orders of a physician and the facility should have changed the humidifier bottle when it was empty. A record review of Resident 32's Clinical Census dated 09/13/2023 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 49's Medical Diagnosis dated 09/13/2023 revealed the resident had a primary diagnosis of Congestive heart Failure (CHF)(right sided heart failure) and a personal history of COVID-19. A record review of Resident 49's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 07/08/2023 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 15 of 15 which indicates the resident was cognitive aware. The resident was a 1-person physical assist with bed mobility and a 2-person physical assist with transfers. The MDS revealed the resident was on oxygen. A record review of Resident 49's Care Plan with an admitted [DATE] revealed the resident was a former smoker and had an intervention that the oxygen would be used as ordered. The Care Plan also revealed the oxygen setting was 2 liters per minute at hours of sleep (HS). An observation on 09/11/2023 at 9:23 AM revealed Resident 32 had oxygen on, and the oxygen concentrator was set to a flow of 5 liters per minute (l/m). The resident's humidifier bottle was empty and was hanging off the machine onto the flooor. An observation on 09/11/2023 at 2:43 PM revealed Resident 32 had oxygen on, and the oxygen concentrator was set to a flow of 5 l/m. The resident's humidifier bottle was empty and was hanging off the machine onto the floor. A record review of Resident 32's Clinical Physician Orders dated 09/11/2023 revealed the provider had ordered the resident to be on oxygen at 2 l/m at HS for decreased oxygen saturations at night. In an interview on 09/11/2023 at 2:54 PM, Registered Nurse (RN)-D confirmed RN-D seen the oxygen concentrator was set at 5 l/m and the humidifier was empty and hanging on the floor. RN-D confirmed RN-D reviewed Resident 32's Clinical Physician Orders and the oxygen concentrator should have been set at 2 l/m. RN-D confirmed the humidifier should have been changed and strapped on the machine. An observation 09/13/2023 at 9:45 AM revealed Resident 32 was on oxygen and his oxygen concentrator was set at 3 l/m. In an interview on 09/13/2023 at 9:45 AM, Resident 32 confirmed he was on oxygen, even though it was during the day, and that he had not adjusted his setting on the oxygen concentrator. An observation on 09/13/2023 at 10:12 AM with the Director of Nursing (DON) revealed Resident 32 was on oxygen and the oxygen concentrator was set at 3 l/m. In an interview on 09/13/2023 at 10:12 AM, the DON confirmed Resident 32's oxygen concentrator was set on 3 l/m and should have been set at 2 l/m.

Licensure Reference Number 175 NAC 12.006.16B2 Based on observation, interview, and record review, The facility failed to ensure weekly skin checks identified 1 (Resident 49) of 2 sampled resident's wounds and failed to document 1 (Resident 49) of 1 sampled resident's refusal of EdemaWare compression stocking. The total facility census was 59. Findings are: A record review of Resident 49's Clinical Census dated 09/13/2023 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 49's Medical Diagnosis dated 07/11/2023 revealed the resident had a primary diagnosis of Type 2 Diabetes Mellites (DMII)(uncontrolled blood sugars). Other diagnoses include Congestive Heart Failure (CHF)(right sided heart failure), Peripheral Vascular Disease (low blood flow in the arms and legs), Localized Edema, Anemia (low red blood cells), Hypertension (High blood pressure), Morbid Obesity (very overweight), and many others. A record review of Resident 49's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 08/22/2023 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 13 of 15 which indicates the resident was cognitive aware. The resident was a 2-person physical assist with dressing and personal hygiene (cleaning). The MDS did not reveal the resident had pressure wounds or skin problems. A record review of Resident 49's Care Plan with an admitted [DATE] revealed the resident had intervention for weekly skin inspections and observe for redness, open areas, scratches, cuts, and bruises, and report changes to the nurse. The resident had an intervention to keep feet separated in chair or bed to prevent pressure areas. The Care Plan did not reveal an intervention for edema wear. A. A record of the facility's Skin Assessment Policy dated 08/01/23 revealed the facility shall perform a full body skin assessment as part of their systematic approach to pressure injury prevention and management. It shall be conducted by a licensed or registered nurse weekly. The staff was to note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions. The staff was to document on the skin assessment observations, type of wound, and description of the wound. A record review of the facility's Documentation in Medical Record Policy dated 08/01/23 revealed the resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care. A record review of the New Skin risk management form dated 08/28/2023 revealed Resident 49 had a blister to the right ankle 2.0 centimeter (cm) by (x) 2.0 cm and a blister to the left first digit toe 0.5 cm x 0.5 cm. Immediate action was the staff applied Topical Antibiotic Ointment (TAO) to the right ankle, and an Optifoam dressing (a foam dressing) and applied TAO to the first digit toe and left open to air. A record review of Resident 49's Electronic Health Record (EHR) did not reveal other records related to the resident's right ankle or left first digit toe wounds. A record review of Resident 49's Clinical Physician Orders dated 09/13/2023 revealed the resident had an order for weekly skin assessment to be completed weekly and documented in the EHR. In an interview on 09/13/2023 at 9:34 AM Nursing Assistant (NA)-E confirmed Resident 49 did have sores on the feet that the staff applied ointment to. In an interview on 09/13/2023 at 1:19 PM, Resident 49 confirmed the staff put ointments and dressings on the feet when the staff thought about it, but not every day. An observation on 09/13/2023 at 1:06 PM with the Director of Nursing (DON) revealed the resident had a large reddened non-blanchable (red-blue-colored skin area with intact surface) area on the outside of the right ankle, a small brown crusted wound on the left great toe, and a brown flakey area on the top of the right foot. In an interview on 09/13/2023 at 1:06 PM, the DON confirmed Resident 49 did not have orders for wound treatments to the feet. The DON confirmed that the resident's provider had not responded to the communication that was faxed to the provider 08/28/2023, but that was not uncommon for that provider. The DON confirmed the facility had not followed up with the provider and should have. A record review of the Weekly Skin Checks dated 08/20/2023, 08/27/2023, 09/03/2023, 09/09/2023, and 09/10/2023 revealed the nurse that completed the weekly skin checks marked that the resident did not have current skin issues. In an interview on 09/13/2023 at 11:26 AM, the DON confirmed the Weekly Skin Checks were completed by a registered nurse (RN), and that RN should have documented the resident's skin issues every week but did not. B. An observation of Resident 49's legs on 09/12/2023 at 10:36 AM revealed the resident's legs were both swollen, and the resident was not wearing a compression stocking. An observation on 09/13/2023 at 9:27 AM revealed Resident 49's had edema (swelling from fluid) and did not reveal the resident had compression stocking on. A record review of the Clinical Physician Orders dated 09/13/2023 revealed Resident 49 had an order for compression stockings on in the morning and off in the afternoon for edema to the bilateral (left and right) lower extremities. A record review of the Treatment Administration Record (TAR) dated September 2023 revealed that the resident had compression stocking on every day. In an interview on 09/12/2023 at 10:36 AM, Resident 49 confirmed the resident did not wear compression stockings because they were too tight, and the staff had not suggested any other options. In an interview on 09/13/2023 at 9:29 AM, NA-F confirmed the facility had to order mesh stockings. NA-F confirmed NA-F had never seen stockings on Resident 49. In an interview on 09/13/2023 at 9:34 AM, NA-E confirmed Resident 49 had EdemaWear the resident wore, not compression stockings that the resident wore until about 1 week ago when the resident started to complain that they left marks on her legs. NA-E confirmed the resident had not worn EdemaWear for at least 7 to 10 days. An observation with the DON on 09/13/2023 at 10:04 AM revealed Resident 49 did not have compression stocking on BLE. A record review with the DON of the TAR dated September 2023 revealed that the resident had compression stockings on every day. In an interview on 09/13/2023 at 10:04 AM, the DON confirmed Resident 49 did not have compression stockings on and the resident had not worn them for over a week because the facility had to order the resident a new pair. The DON confirmed the TAR dated September 2023 was marked that the resident had compression stockings on daily, the resident did not, and the nurse should have documented not worn or refused and did not.

Licensure Reference Number 175NAC 12-006.09D2 Based on record review and interview, the facility failed to ensure that staff monitored non-pressure skin wounds to promote healing for 1 resident (Resident 1) of 4 residents reviewed. The facility census was 60. Findings are: Record review of the facility policy titled Care of Skin Tears-Abrasions and Minor Breaks dated September 2013 revealed the purpose of the procedure is to guide the prevention and treatment of abrasions (scrapes), skin tears, and minor breaks in the skin. The procedure directed staff to generate an Alteration in skin form and complete it. Assess the wound and surrounding skin for edema (swelling), redness, drainage, tissue healing progress and wound stage. Generate/update the alteration in skin evaluation (form) as needed. Record review of the Admission Record dated 1/4/23 for Resident 1 revealed that Resident 1 admitted into the facility on [DATE]. Diagnoses included peripheral vascular disease (fatty deposits in the blood vessels that reduce blood flow and can cause unhealing wounds), chronic embolism and thrombosis (a blood clot) of lower extremity, and candidiasis (a fungal infection) of the skin and nails. Record review of the current care plan dated 1/4/23 for Resident 1 revealed that Resident 1 has the potential for impairment (damage) to their skin integrity (skin health) due to falls, bumping into things, and incontinence (lack of voluntary control over urination or stool). Interventions included apply hydroguard to the back of the resident's thighs and buttocks twice daily for skin integrity. Follow facility protocols for treatment of injury. Record review of the progress note dated 10/22/22 for Resident 1 revealed that Resident 1 was noted to have an open area on the left gluteal fold (the crease in the skin between the bottom of the buttock and the upper thigh) that measured at 0.7 centimeters (cm) x 0.3 cm. Hydroguard (a silicone skin barrier to protect skin from moisture) was administered. A fax was sent to the resident's physician. Record review of the Physician Communication Form (fax) dated 10/21/22 revealed that Resident 1 was noted to have an open area on the left gluteal fold measured at 0.7 cm x 0.3 cm. Hydroguard applied. The section of the form titled Recommendation of the Physician/Nurse Practitioner (NP)/Physician Assistant (PA): (Orders) revealed that the medical provider ordered to continue to monitor treatment progress. Resident to have an Office Visit if the open area persists. The Recommendation of the Physician/NP/PA section of the form was signed by the medical provider and dated 10/22/22. Record review of the Skin Alteration Evaluation form (an electronic form to document abrasions (scrapes), skin tears, or other breaks in skin integrity) for Resident 1 dated 10/22/22 revealed that Resident 1 had an open area on the left gluteal fold that measured at 0.7 cm x 0.3 cm. The type of the open area was documented as a skin tear. The form revealed an onset date for the open area on the left gluteal fold as 10/21/22. Record review of the medical record for Resident 1 revealed that the next Skin Alteration Evaluation for Resident 1 was dated 11/13/22 (22 days after the previous evaluation/documentation of the open area on the left gluteal fold). Record review of the Skin Alteration Evaluation form for Resident 1 dated 11/13/22 revealed that the open area on the left gluteal fold was previously one area. The left gluteal fold now has 2 smaller areas with one open area measuring 0.4 cm x 0.4 cm (onset 10/21/22) and the other open area measuring 0.4 cm x 0.3 cm (onset date 10/21/22). Continue to apply hydroguard to the area. Record review of the medical record for Resident 1 revealed that no additional Skin Alteration Evaluation forms were completed for the open areas on Resident 1's left gluteal fold. Record review of the medical record for Resident 1 revealed no documentation of the monitoring of the size or condition of the open areas on the left gluteal fold after 11/13/22. Record review of the medical record for Resident 1 revealed that Weekly Skin Evaluation forms (documentation of the weekly assessment of the resident's skin for any alterations in skin integrity) were completed for Resident 1 on 10/24/22, 11/7/22, 11/14/22, 11/21/22, 11/28/22, 12/5/22, and 12/12/22. All of the completed Weekly Skin Evaluation forms documented a check in the box signifying No New skin alterations and contained no other documentation on the resident's skin. The weekly skin evaluation forms contained no assessment information on the open areas on Resident 1's left gluteal area. Interview on 1/4/23 at 2:16 PM with Resident 1 revealed that the resident has a reddish area on the back of the inner thighs that staff put a cream on. Resident 1 revealed that the area is painful at times. Interview on 1/4/23 at 3:53 PM with Registered Nurse-A (RN-A) revealed that the resident skin is monitored for changes through weekly skin checks with baths, cares, and documented on the weekly skin evaluation. RN-A revealed that the staff are to chart any skin issues in the nurse's notes. RN-A confirmed that Resident 1 had a skin alteration. RN-A confirmed that monitoring of the resident's skin is to be documented weekly and with any dressing changes. Interview on 1/4/23 at 4:54 PM with the Director of Nursing (DON) confirmed that Resident 1 currently has a skin issue that is to be monitored. Interview on 1/4/23 at 5:34 PM with the DON confirmed that the expectation is for staff to document the measurements and observations of resident skin issues (alterations) weekly. The DON confirmed that weekly documentation is required to determine if the skin issue is healing or not.

Licensure Reference Number 175 NAC 12-006.09D2a,b,c Based on observation, interview, and record review, the facility failed to ensure that pressure ulcer prevention measures were in place to prevent a pressure ulcer and failed to ensure that interventions were put in place to prevent further skin breakdown for Resident 39. This affected 1 of 2 sampled residents. Total census was 56. Findings are: A record review of Resident 39's Admission Minimum Data Set (MDS)(a comprehensive assessment of each resident's functional capabilities and health needs) dated 07/30/2021 revealed the resident was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 39 had a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. Continued record review of Resident 39's Admission MDS dated [DATE] did not reveal the resident had a pressure wound or other skin conditions. A record review of Resident 39's Weekly Skin Check sheet dated 07/20/2021 did not reveal a skin condition or area of concern. A record review of Resident 39's Progress Notes dated 07/26/2021 at 03:00 PM revealed no new skin issues noted. A record review of Resident 39's Progress Notes dated 07/28/2021 at 02:11 PM and 08/04/2021 at 02:11 PM revealed a Braden Scale for Predicting Pressure Ulcer (open sore on or in the body) Risk was completed and the resident was at low risk for developing a pressure ulcer. A record review of Resident 39's Skin Alteration (change) Evaluation dated 08/01/2022 did not reveal any skin issues on the resident's feet. A record review of Resident 39's Progress Notes dated 08/05/2021 at 07:25 PM revealed the Nursing Assistant (NA) notified the nurse of skin concerns when the NA removed the resident's socks for a bath. The nurse evaluated Resident 39 and resident had 2 wounds on the right great toe, and calloused (hardened skin) areas both heels and left great toe. The nurse notified the Director of Nursing (DON) and the resident's physician. A record review of Resident 39's Weekly Skin Check dated 08/05/2022 revealed calloused areas to the right and left heel and left great toe, and open area on right great toe. A record review of Resident 39's Care Plan revealed a focus area added 08/06/2021 that the resident has potential impairment to skin integretity with the following interventions: · Resident educated on not wearing gripper socks under Edemaware (a compression system used to reduce [CONDITION(S)]). · Pressure relieving bed mattress. · Avoid scratching and keep hands and body parts from excessive moisture. · Educate resident/family/caregivers of causative factors and measures to prevent skin injury. · Encourage good nutrition and hydration in order to promote healthier skin. A record review of Resident 39's Skin Alteration Evaluation dated 08/09/2022 did not reveal any skin alterations on the resident's feet. A record review of Resident 39's Progress Notes dated 08/10/2021 at 03:20 PM revealed the NA was changing the resident's socks and notified the Registered Nurse (RN) of the resident's skin condition. The RN noted a 3.5 by(x) 6.3 centimeter (metric unit of measure) open area where the calloused area previously was. The area was cleaned, and the physician was notified. A record review of Resident 39's Weekly Skin Check dated 08/15/2022 revealed there was a pressure injury concern and the right heel and toe both had large open areas. A record review of Resident 39's Clinical Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident 39's Progress Notes dated 08/15/2021 at 06:04 PM revealed Resident 39 was confused, had labored breathing with an oxygen saturation level (a measurement of how much oxygen is in the blood) of 78%, a temperature of 100.9, and flushed skin color. A record review of Resident 39's Progress Notes dated 08/16/2021 at 11:20 AM revealed Resident 39 was transferred to the hospital from the physician's office due to [CONDITION(S)] (a bacterial skin infection) and a Decubitus Ulcer (Pressure ulcer: damage to an area of the skin caused by constant pressure on the area for a long time. A record review of Resident 39's Physician History and Physical dated 08/16/2021 at 04:55 PM revealed that the resident was transferred to the hospital for [CONDITION(S)] and a Stage 4 (the most severe) pressure injury to the right heal. The resident needed bloodwork, intravenous (injected in the vein) antibiotics, and serial debridement's (when the dead skin is removed) of the right heel. A record review of the Hospitalist Progress Note with a Date of Service of 08/18/2022 revealed that Resident 39's blood pressure was stable, the resident was not running a temperature, the resident's white blood cells count (a value used to determine the level of infection) remained slightly elevated at 12,600. The Physician documented that Resident 39 had Severe [CONDITION(S)] (a life-threatening response the body has to an infection) due to a foot ulcer with Bacteremia (bacteria in the blood). A record review of Resident 39's Progress Notes dated 08/27/2021 at 07:05 PM revealed a Braden Scale for Predicting Pressure Ulcer Risk was completed and the resident was at risk for developing a pressure ulcer. A record review of Resident 39's Progress Notes dated 08/28/2021 at 05:36 AM revealed Resident 39 returned from the hospital at 07:10 PM with a wound vacuum in place to the right heel. A record review of the Central City Care Center Referral Form Office Visit dated 09/03/2021 revealed the Physician ordered: Please Care Plan preventative services that can be put into place to prevent further Decubitus. A record review of the Care Plan with an admitted [DATE] revealed Interventions were put in place 11/11/2021 for the right heel ulcer of: · Avoid exposure to temperature extremes · Carefully dry between toes but do not apply lotion between toes · Ensure appropriate protective devices are applied to affected areas · Monitor blood sugar levels · Monitor pressure areas for color, sensation (feeling), temperature · Monitor/document wound size · Document wound healing progress · Monitor/document/report any signs/symptoms of infection · Monitor/document/report any changes in wound A record review of the RX/OV (treatment order) Request form dated 04/21/2022 revealed RN-H requested the Physician change the orders to Thromboembolic Deterrent (TED) Hose (stockings designed to prevent blood clotting in the legs) to left foot, discontinue Edemawear, Prafo Boot to right heel on at all times 24 hours a day, offloading heel with lamb's wool. The Physician signed the form but did not complete the Orders section of the form. A record review of the Central City Care Center Referral Form Office Visit dated 06/10/2022 revealed the Physician ordered: · Return to office 2 weeks · Prafo boot to right foot at all times Never Off!!! to offload right heel. · Prevalon boot to left foot at all times · Wound is larger - need to offload with boot at all times right heel. · Edemaware toes to knee bilateral (both) legs. A record review of the Treatment Administration Record (TAR) dated August 2022 revealed the following orders in the Electronic Medical Record (EMR): · Prafo/Off loading [NAME] boot to right foot with padding to protect/cushion every shift on in the morning (AM), off at hours of sleep (HS) - document all refusals and removal by resident. Order date 04/22/2022 · Wash right heel daily with soap and water. Apply damp Therabond to wound daily. One time a day for right foot ulcer. Order Date 05/14/2022 · Apply TED hose daily and remove at night every shift. Order Date 08/06/2021 · TED hose to be applied to left lower leg every shift for [CONDITION(S)] maintenance on in AM, off at HS. Order Date 04/22/2022 Record review of the TAR dated August 2022 did not reveale evidence of the Prevalon boot being ordered as a current treatment, nor the Edemaware, and TED hose remained on the TAR and should have been discontinued on 06/10/2022 An observation on 08/10/2022 at 10:32 AM revealed Resident 39 was laying in bed, heels were not offloaded, and no boots on feet. Resident appeared confused. In an interview on 08/10/202 at 10:32 Am Resident 39 revealed that the resident's legs, feet, and heels were sore. The resident confirmed the resident's legs were swollen and just the resident felt horrible all over. An observation on 08/11/2022 at 07:53 AM revealed Resident 39 was out of the facility. The nurse reported the resident was at the hospital getting a chest x-ray and blood work. An observation on 08/11/2022 at 09:41 AM revealed the resident returned to the facility in a wheelchair with Resident 39's feet on the footrests. The resident wasn't wearing heel protectors or Edemaware. A record review of Resident 39's Progress Notes dated 08/11/2022 at 09:10 AM revealed COVID-19 test and chest x-ray results were negative for infection. A record review of Resident 39's Progress Notes dated 08/11/2022 at 16:11 PM revealed the resident was transferred to the hospital for the resident's kidney function and possible infection of the bone. A record review of Resident 39's Progress Notes dated 08/14/2022 at 11:24 AM revealed the resident returned to the facility from the hospital. A record review of Resident 39's After Visit Summary dated 08/14/2022 revealed the resident was admitted to the hospital for [CONDITION(S)] of the right heel ulcer and [CONDITION(S)] and acute kidney injury. The resident was discharged on [DATE] on an antibiotic. A record review of Resident 39's Progress Notes dated 08/15/2022 at 11:15 PM revealed the resident was on an antibiotic for right heel infection, heel boots applied. The Progress Note did not reveal the Edemaware was in place. An observation on 08/15/2022 at 11:25 AM revealed Resident 39 complained of left heel pain. The observation revealed the resident had the right heel offloaded on a stuffed animal. Left heel protector was on, right heel protector was on the floor. An observation on 08/15/2022 at 11:25 AM revealed Resident 39 had heel protectors in the room, but no Prafo boot or Edemaware was observed. An observation on 08/16/2022 at 07:48 AM revealed Resident 39 was in bed with the right heel offloaded on a stuffed animal, no heel protector on, and no [CONDITION(S)] ware was on. In an interview on 08/15/2022 at 02:57 PM, RN-H confirmed the heel protectors used on Resident 39 were the facility's substitution for Prafo and Prevalon boots. RN-H confirmed the resident was not wearing Edemaware, but the resident refused Edemaware most of the time because of pain, even though it is not documented as refused in the EMR. RN-H confirmed that the physician notification was not completed for the Prafo and Prevalon boots substitution or the Edemaware substitution. In an interview with the Director of Nursing (DON) on 08/16/2022 at 08:40 AM, the DON confirmed the heel protectors for Resident 39 are not the ordered heel protectors, and the Edemaware was not on per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Licensure Reference Number 175 NAC ,d+[DATE].009D7b Based on record review and interview the facility failed to provide Resident 1 with supervision to prevent falls and failed to document assments after a fall that resulted in Resident 1's death. The facility census was 59. Findings are: Record review of Resident 1's MDS (Minimum Data Set) is part of a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process entails a comprehensive, standardized assessment of each resident's functional capabilities and health needs) dated [DATE] revealed Resident 1 was admitted to the facility on [DATE]. Record review of Resident 1's Progress Notes dated [DATE] at revealed Resident 1 had a fall from the wheelchair at the nurse's station on [DATE] at 8:30AM. The resident was assisted to wheelchair and back to bed. Vital signs were obtained. No injuries were noted. Record review of Vital signs dated [DATE] at 12:16PM revealed temperature of 97.3, Pulse 73, Blood Pressure ,d+[DATE], respirations 16 and oxygen saturation 90%. Record review of vital signs logs dated [DATE] -[DATE] revealed that only one 1 set of vital signs was obtained on [DATE]. Record reviewe of Resident 1's neurological checks for [DATE] revealed no documentation was available. Record reivew of Resident 1's Progress Notes dated [DATE] at 12:20 at 9:43 AM revealed Resident 1 was taken to breakfast. Resident 1 Declines water, milk and orange juice. Resident 1 was offered apple juice which has worked in past, with no success. Resident 1 did take 5 bites of ice cream, but head is hanging down, and runs out of mouth. Resident to room and placed in bed as resident was sleeping in wheelchair. Resident 1 has remained in room in bed resting since 0845. Record review of Resident 1's Progress Note dated [DATE] at 12:20PM revealed Resident 1 has remained asleep since this AM. Attempt to wake for lunch without success. Respirations are even, Lungs CTA (clear to auscultation). BS (bowel sounds) present and Snoring lightly at this time. Record review of Resident 1's Progress Note dated [DATE] at 8:00AM revealed Resident 1 was resting in bed with eyes closed. Note respirations ( breaths in and out) are 40. Hospice nurse arrived and did her assessment. Vitals at time were 99.9, 66, ,d+[DATE]. Nurse was un able to get O2 Sat at time. Resident 1 was admitted to Hospice and orders requested for comfort. Reply received to discontinue all vitals and labs, comfort cares only. Resident not responding, cares done. Skin is warm pink and dry. Lung sounds are clear, bowel sounds hypo-active, no evidence of discomfort noted. Daughter here. at 1:00PM Resident 1 was repositioned and brief was changed. Resident 1 was more warm to touch, temp taken with result of 101.9. Tylenol suppository given. No BM present in rectal area. Resident did not respond to treatment and cares. [MEDICATION(S)] given for comfort. At 1:05PM This nurse summoned to room. Resident has change in color, no pulse or respirations upon examinaltion. Resident did void post mortem. Physician notified per fax, Hospice nurse also notified. An interview on [DATE] at 4:30 PM with DON confirmed no neurological checks were documented on [DATE] after Resident 1's Fall. Record review of Resident 1's Medication Administration Record revealed that Resident 1 received the following medication on [DATE] at 8:20AM [MEDICATION(S)] Sulfate solution 20MG/ML (dose give 5mg by mouth every 2 hours as needed for severe pain) and [MEDICATION(S)] concentrate 2MG/ML ((dose give 0.5Ml by mouth every 4 hours as needed for agitation/nonredirectable behaviors). Further record review of Resident 1's Progress Notes and Behavior charting revealed no documentation for Residents 1's pain or behavior requiring medications. An interview on [DATE] at 2: 00PM with CNA ( certified nursing assistant) D revealed that on [DATE] (gender) was working and was standing at the nurse's station with 2 other staff members ( CNA- E and Activity aide) and CNA- D back was turned away from Resident 1. CNA -D turned around when (gender) heard a thud sound and Resident 1 was lying on the floor on left side. CNA-E immediately went to floor to check on resident and called for help R.N (registered nurse) -A responded and preformed an assessment. An interview on [DATE] at 2:18PM with CNA -E reported (gender) was working on [DATE] day shift and was standing at the nurses station talking with 2 other staff members (CNA-D and Activity Aide) Resident 1 was not in CNA- E view due to being behind nurses station when (gender) heard Resident 1's tab alarm go off and walked around nurses station. Resident 1 was lying on the floor in a fetal position with head on her arm, also noted resident was sound asleep. CNA-E then called for help and RN-A responded and did an assessment and assisted resident into wheelchair and then to bed. An interview on [DATE] at 4:00PM with R.N (Registered Nurse) A revealed that on [DATE] (gender) was working in office near dining room and ( gender) heard someone call out that they could not leave dining room. Upon looking down hallway; Resident 1 was lying on the floor and 3 CNA's were talking with resident. RN-A went to Resident 1 completed an assessment, during assessment noted that resident was sound asleep on floor; assisted CNA's to lift resident back into wheelchair. Resident was then assisted into bed in room. RN-A did not document the assessment completed. An incident/ fall report was completed on [DATE] and a note was faxed to physician on [DATE]. RN-A stated that at the time of incident and responding to Resident-1 (gender) was not focused on the situation was still thinking about work on computer. RN -A told charge nurse that Resident 1 had fallen and that was the extent of report given. RN-A stated (gender) was not responsible for documenting Resident 1's fall as charge nurse was on the floor and R.N-A rarely works the floor. Record review of facility policy titled Accidents and Incidents- Investigating and Reporting dated ,d+[DATE] revealed the policy statement: All accidents or incidents involving residents, employees, visitors, and venders occurring on facility premises shall be investigated and reported to the administrator. Section 2 reveals the following shall be included on the Report of incident/ accident form date and time of accident, nature of injury/illness (bruise, fall etc ) the circumstances surrounding the accident, where the accident took place, names of witness and their accounts of the accident, the injured person's account of the accident, the time the injured persons attending physician was notified as well the time the physician responded and his or her instructions. The date and time the injured persons family was notified and by whom. The condition of the injured person, including his/her vital signs, any corrective action take, follow-up information, other pertinent data as necessary or required and the signature and title of the person completing the report. Record review of policy titled Neurological assessment dated [DATE] revealed a neurological assessment establishes a baseline, recognizes neurological trends and changes in the resident's condition and provides an evaluation tool for references when evaluating the resident's neurological status. Certain significant changes in the residents always require a more frequent neurological assessment: regression in the level if consciousness, any procedure that may alter neurological vital signs and any deterioration in condition. Vital signs- frequent monitoring of vital signs is important. Changes in pulse and blood pressure are late neurological signs of increase intracranial pressure. Changes in vital signs should be reported immediately. Record review of communication to Resident 1's Physician dated [DATE] at 7:39AM revealed that a fax had been sent to provider by R.N- 1. The document read that the situation was Resident 1 had a witnessed fall from wheelchair; no injuries noted at time. Background- Dementia. Follow - up communication from physician was not available. An interview on [DATE] at 4:30PM with Administrator revealed that (gender) was not in facility at the time of incident/ fall of Resident 1 that occurred around 8:30AM. Administrator arrived in facility around 9 - 9:30 AM. The Administrator was not notified of fall/incident until the following day [DATE]. An interview on [DATE] at 4:15PM with DON (Director of Nursing) confirmed her expectation of any nurse that responds to an incident should follow facility policy, complete and document assessments and tasks as needed. The DON stated that (gender) was off work the day of incident and was not made aware until the next day [DATE]. DON confirmed the facility had a fall assessment policy and neurological assessment policy that is available for all staff at the nurse's station. Record review of Progress Note dated [DATE] revealed Resident 1 had died on [DATE] at 1:05PM. The facility provided an abatement statement on [DATE] at 7:15PM, the statement was reviewed found to have substantial information to correct the (IJ) immediate jeopardy. The IJ was tagged at F689 and cited at G level for scope and severity.

Licensure Reference Number 175 NAC ,d+[DATE]. 05(8) Based on interviews and record reviews the facility failed to ensure Resident 1 was free of chemical restraints without documentation of behaviors or non pharmocological interverntions contributing to Resident 1's fall and death. The facility census was 59. Findings are: Record review of Resident 1's Electronic Health record revealed Resident 1 was admitted to facility on [DATE] and died in the facility on [DATE]. Record review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [DATE] at 12:14 AM [DATE] at 2:15 AM [DATE] at 4:30 AM [DATE] at 6:38PM [DATE] at 8:44PM 2//,d+[DATE] at 11:05 PM [DATE] at 1:15 AM [DATE] at 3:38AM [DATE] at 8:20 AM [DATE] at 11:00AM [DATE] at 1:00PM Record review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [DATE] at 8:00AM [DATE] at 9:45 PM [DATE] at 1:59AM [DATE] at 8:20 AM Record review of Resident 1's vital signs dated [DATE] revealed Resident 1's weight was 92.4 Pounds. Record review of Resident 1's behavior charting dated [DATE] - [DATE] revealed a blank document that the facility provided. Record review of Resident 1's Progress Note dated [DATE] at 1:05PM Resident 1 had no pulse or respirations. Resident 1's Physician was notified via fax of Resident 1's death. Record review of Resident 1's Care Plan (a written document describing the specific preferences and details of how care is to be provided for resident) dated [DATE] revealed Resident 1's focus problem Behavior - Resident 1 can be verbally and physically aggressive and was recently admitted to hospital for verbal and physical aggression. Goal: redirect without anger through next review. The nursing interventions include: try a different staff member, change environment, encourage activity, let resident be for a bit if resident is agitated and make sure she is safe, utilize PRN medications when other intervention are not working. An interview on [DATE] at 4:30 PM with DON confirmed no documentation for Resident 1's behaviors was available.

Based on record review and interview the facility failed to ensure a notice of Resident 1 fall on [DATE] was sent to Resident 1's physician. Resident 1 died in facility on [DATE]. The facility census was 59. Findings are: Record review of Resident 1's Progress Notes dated [DATE] at revealed Resident 1 had a fall from the wheelchair at the nurse's station on [DATE] at 8:30AM. The resident was assisted to wheelchair and back to bed. Vital signs were obtained. No injuries were noted. Record review of Vital signs dated [DATE] at 12:16PM revealed temperature of 97.3, Pulse 73, Blood Pressure ,d+[DATE], respirations 16 and oxygen saturation 90%. Record review of vital signs logs dated [DATE] -[DATE] revealed that only one 1 set of vital signs was obtained on [DATE]. An interview on [DATE] at 4:00PM with R.N (Registered Nurse) A revealed that on [DATE] (gender) was working in office near dining room and she heard someone call out that they could not leave dining room. Upon looking down hallway; Resident 1 was lying on the floor and 3 CNA's were talking with resident. RN-a went to Resident 1 completed an assessment, during assessment noted that resident was sound asleep on floor; assisted CNA's to lift resident back into wheelchair. Resident was then assisted into bed in room. RN-A did not document the assessment completed. An incident/ fall report was completed on [DATE] and a note was faxed to physician on [DATE] at 7:39AM. RN-A stated that at the time of incident and responding to Resident-1; RN-A was not focused on the situation (gender) was still thinking about other work on (gender) computer. RN -A told charge nurse that Resident 1 had fallen and that was the extent of report given. RN-A stated (gender) was not responsible for documenting Resident 1's fall as charge nurse was on the floor and R.N-A rarely works the floor. Record review of facility policy titled Accidents and Incidents- Investigating and Reporting dated ,d+[DATE] revealed the policy statement: All accidents or incidents involving residents, employees, visitors, and venders occurring on facility premises shall be investigated and reported to the administrator. Section 2 reveals the following shall be included on the Report of incident/ accident form date and time of accident, nature of injury/illness (bruise, fall etc ) the circumstances surrounding the accident, where the accident took place, names of witness and their accounts of the accident, the injured person's account of the accident, the time the injured persons attending physician was notified as well the time the physician responded and his or her instructions. The date and time the injured persons family was notified and by whom. The condition of the injured person, including his/her vital signs, any corrective action take, follow-up information, other pertinent data as necessary or required and the signature and title of the person completing the report. Record review of Progress Note dated [DATE] revealed Resident 1 had died on [DATE] at 1:05PM.

Licensure Reference Number 175 NAC 12-006.09D7 Based on observation, interview, and record review; the facility failed to ensure that interventions were in place to protect residents from injury while smoking. The facility census was 59 and this affected Resident 31 and 49. Findings are: [NAME] Review of the Minimum Data Set (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) for Resident 49 dated 6/26/19 revealed a [DIAGNOSES REDACTED]. Review of a History and Physical for Resident 49 dated 4/11/19 revealed the self injury behavior of hitting head against the wall. Review of facility Health Status Note 7/24/19 revealed Resident 49 was observed to have burn areas to bilateral wrists. Left wrist measuring at 1.2 cm x 0.8 cm and right wrist at 1 cm x 0.9 cm. Observation of Resident 49 on 07/24/19 3:06 PM revealed reddened burn areas to anterior area of bilateral wrists. Size and shape similar to the tip of a cigarette. Also observed numerous old scarred burn areas on bilateral upper arms of similar size and shape to the newly observed burns. Observation of Resident 49 smoking on 7/25/19 at 11:21 AM revealed the resident was not utilizing smoking gloves for either hand. The resident was utilizing both hands to smoke the cigarette. Observation of Resident 49 smoking on 7-29-2019 at 9:26 AM revealed no cigarette extender or smoking gloves were in use. Review of Resident 49's care plan revealed the intervention dated 7/24/19 of smoking gloves to be worn during smoke breaks. Review of Resident 49's care plan revealed the intervention dated 7/24/19 of smoking tip to be on during smoke breaks. Interview with the Director of Nursing (DON) on 7/25/19 12:37 PM revealed the intervention for glove use for smoking safety had not been utilized by staff as care planned for Resident 49 on 7/25/19 at 11:21 AM. Interview with activity assistant Z on 7/29/19 10:59 AM revealed Resident 49 had not been provided a smoking tip during smoking on 7-29-2019 at 9:26 AM. Resident 49 does not refuse smoking interventions. The updated protocol sheet for smoking was made available after smoke break on 7-29-2019 0915 to 0945. B. An observation on 07/29/19 at 09:26 AM of smoke break revealed 8 residents who were smoking and 1 staff member to monitor Resident 31 had no shoes on- apron placed on chair over the resident's lap and one on the upper body, smoking sleeves were in place for both arms. Staff lit the cigarette and took the cigarette and flicked the ashes. Record review of Investigation Report dated 6/7/18 revealed; Resident 31 had wounds noted to the Right forearm there were 2 circular areas measuring 0.8x0.8CM the areas were flush with skin and had red edges with a white center with dark brown coloring. Resident 31's [DIAGNOSES REDACTED]. The facility concluded that Resident 31 continued to smoke. Resident 31 needed to wear Geri- sleeves, long sleeve shirt or coat, during smoking time along with smoking apron and tip that was already in place for residents safety. Record review of Care Plan dated 6/6/18 revealed; that Resident 31 was noted to have 2 circular red areas to the right forearm. The intervention was to wear arm protectors while smoking. Record review of the investigation report dated 6/17/18 revealed; Resident 31 was smoking on the patio supervised by staff. Staff saw the resident drop it (the cigarette) on the smoking apron it rolled down landing on the foot before the staff get to it Injury to R) top of foot 0.8x 0.7 CM fluid filled area. The conclusion was staff will continue to observe Resident 31 for safety during smoking times with the newest intervention of assuring that Resident 31 had shoes on prior to smoking and or remind the resident of the safety risk if they did not wear shoes. Record review care plan dated 6/17/18 revealed: intervention Resident 31 would have feet covered with socks or shoes during smoke break or if they chooses not to wear shoes take them to the patio, hand them to the resident before the cigarette was lit and ask the resident to put shoes on. Intervention of the Guardian who requested that Resident 31 not be informed of the smoke break times due to safety risk [MEDICAL CONDITION] the resident requested a cigarette during smoke break allow them and follow all care plans for smoking. Annual Assessment MDS dated [DATE] revealed; that Resident 31 used tobacco Section J1300. An interview on 07/29/19 at 11:14 AM with AA (Activities Aide) Z confirmed; that the laminated interventions for smoking had been updated today and was given to the AA Z after the smoke break at 9:15AM. The Activity Aide confirmed; that the list is kept in the Caddy with all the cigarettes and lighter. Record review of Smoking Policy revealed; that the Resident's lighter and cig would be kept in the nurse's station in a locked area. Staff lighters and cig would be kept in a locker. Staff is allowed to smoke in the employee area located outside in the employee area by the garage. Residents were allowed to smoke on the North Patio area with staff supervision. All cigarette buds will be put on and in the dispenser by the staff supervising the event. Facility staff will evaluate safety of the resident upon admission and change of condition in the following was. [NAME] Resident cannot have any significant physical impairment or they will need supervision at all times. B. Staff will observe all new resident upon change of condition of a resident for 3 days to evaluate the safety of the resident on their smoking behavior. C. If resident is assess to be safe during smoking time they will be allowed to go to the smoking area unsupervised. An interview on 07/29/19 at 4:05 PM with the MDS (Minimum Data Set-a federally mandated comprehensive assessment that assist in developing the care planning process.) coordinator confirmed; that the intervention to have shoes on while smoking for Resident 31 was discontinued, and that the staff were to put the shoes on the resident prior to smoking. The MDS coordinator confirmed; that Resident 31 was at risk for burning feet without wearing shoes.

Licensure Reference Number 175 NAC ,[DATE].09 Based on observation, interview, and record review; the facility failed to monitor Resident 63 following a change in condition and failed to assess and identify Resident 49's potential for self-harm. The sample size was 2 and the facility census was 59. Findings are: [NAME] Review of the facility policy titled Resident Condition Changes that Require Physician Notification Guidelines with an effective date of [DATE] revealed an Emergent situation/condition warranted immediate physician notification and intervention. Emergent situations included an acute onset of chest pain or deviation of vital signs where interventions must be immediate. An urgent situation was identified as a situation/condition that required physician notification and physician response within ,[DATE] hours. Urgent situations included a fever greater than 101 degrees that responded to interventions or changes in vital signs or level of consciousness in a resident who had a do not resuscitate order. Further review revealed the licensed nurses were expected to recognize resident situation/conditions that required physician notification. The nurse should complete an assessment of the condition to determine the level of urgency. The resident's condition would be documented in the resident's chart with a notation made every shift for at least 72 hours. Review of Resident 63's undated Care Plan revealed the resident had hypertension (high blood pressure), [MEDICAL CONDITIONS] (build up in the arterial walls), [MEDICAL CONDITION] (a group of lung diseases that block airflow and make it difficult to breathe), [MEDICAL CONDITION] (a circulatory condition in which narrowed blood vessels reduce blood flow to the extremities), and type 2 diabetes mellitus. The resident was to report any chest pain and the facility was to alert the physician to any changes in status. Review of Resident 63's Progress Notes and Vitals Summary dated [DATE] through [DATE] revealed: - On [DATE] at 10:02 PM, the resident had a temperature of 100.2 degrees (with an average normal body temperature being 98.6 degrees). - On [DATE] at 10:04 PM, the resident complained of having chest pains off and on. - There was no evidence to indicate any further vital signs had been taken on [DATE], [DATE], or [DATE]. There was also no evidence to indicate the physician had been notified. - On [DATE] at 4:15 AM the resident complained of not feeling well. The resident had a temperature of 101.1 degrees with an oxygen saturation level of 76 percent (%) (with values under 90% being considered low). The resident refused oxygen but a breathing treatment was provided. The intervention decreased the resident's temperature to 98.7 degrees and improved the resident's oxygen saturation level to 82%. - On [DATE] at 5:54 PM, it was noted the resident had been seen by the Physician for coarse lung sounds and dyspnea (shortness of breath) with new orders for a cough syrup, an antibiotic, and a steroid medication. -There was no evidence to indicate the resident's vital signs had been taken after returning from the physician on [DATE]. No further vital signs were documented on [DATE] and [DATE]. - On [DATE] at approximately 7:00 AM, the resident was found to be deceased . During interviews with the Minimum Data Set (MDS) Coordinator on [DATE] at 2:40 PM and 3:06 PM the MDS Coordinator revealed Resident 63 had a significant heart history. Further interview confirmed the resident's status and vital signs should have been monitored more frequently. B. Review of facility Health Status Note [DATE] revealed Resident 49 was observed to have burn areas to bilateral wrists. Left wrist measuring at 1.2 cm x 0.8 cm and right wrist at 1 cm x 0.9 cm. Observation of Resident 49 on [DATE] 3:06 PM revealed reddened burn areas to anterior area of bilateral wrists. Size and shape [MEDICAL CONDITION] to the tip of a cigarette. Also observed numerous old scarred burn areas on bilateral upper arms of similar size and shape to the newly observed burns. Interview with the Director of Nursing (DON) with Registered Nurse (RN) B present on [DATE] 9:58 AM revealed the old burn wounds for Resident 49 should have been identified and communicated to the nursing staff after having been observed by staff during bathing and other cares. This behavior should have been identified and care planned to have a staff person watching the resident very closely and/or have additional safety interventions in place while smoking. Interview with RN B on [DATE] at 8:00 AM revealed that the nurse had seen the circular wounds on Resident 49 and the old scars were consistent with self injury behaviors. This should have been identified on the admission assessment. Interview with LPN D on [DATE] at 9:50 AM revealed there was no real tool for identifying or tracking these older injuries as behaviors. Interview with NA Y on [DATE] at 9:22 AM revealed bath aids are directed to report any skin issues identified during bathing. The NA had just bathed Resident 49 and had reported the healed burn areas on the resident's upper arms and also the new burn marks on bilateral wrists. Resident 49 had been bathed multiple times since admission. Review of the Minimum Data Set (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) for Resident 49 dated [DATE] revealed a [DIAGNOSES REDACTED]. Review of a History and Physical for Resident 49 dated [DATE] revealed the self injury behavior of hitting head against the wall. An assessment of Resident 49's old burn wounds was requested from the Administrator on [DATE] at 10:21 AM. An assessment identifying the numerous old scarred burn areas on bilateral upper arms was not provided during survey. Review of Resident 49's PCC Skin and Wound - Total Body Assessment, dated [DATE] did not identify the resident's numerous old scarred burn areas on bilateral upper arms.