Every finding on record at Adept Nursing & Rehab of North Platte

Based on record review and interview, the facility failed to ensure the medical provider followed up on monthly medication reviews for 5 (Resident 3, 5, 6, 8, 34 and 61) of 5 sampled residents. The facility identified a census of 67. Findings are:Review of facility policy Medication Regimen Review (MRR) dated 08/01/2023 and revised date 05/06/2026 revealed the pharmacist shall document, either manually or electronically, that each medication regimen review has been completed. Further review of the MRR policy revealed the pharmacist does not need to document a continuing irregularity in the report each month of the attending physician has documented a valid clinical rationale for rejecting the pharmacist's recommendation. A. Record review of Resident 5's admission Record dated 07/21/2026 revealed the resident was admitted to the facility 05/03/2022. Record review of Resident 5's medical record revealed MRRs with the following dates: 07/14/2025 – recommendation for follow up labs for medication monitoring and gradual dose reduction (GDR, Stepwise tapering of a dose to determine whether or not symptoms, conditions, or risks can be managed by a lower dose or whether or not the dose or medication can be discontinued) for clonazepam (anti-anxiety medication) 0.5mg twice a day (GDR to 0.25mg by mouth and 0.5mg at bedtime) was unanswered by the provider. 08/30/2025 – recommendation for follow up labs and gradual dose reduction (GDR) for: fluoxetine (antidepressant medication) 60mg per day, trazodone (antidepressant medication) 75mg at bedtime, aripiprazole (antipsychotic medication) 15mg per day, clonazepam 0.5mg at bedtime, and prazosin (medication for high blood pressure) 2mg at bedtime was unanswered by the provider. 08/30/2025 – recommendation for discontinuation of PRN (as needed) clonazepam and application of clobetasol cream (a topical steroid) went unanswered by the provider. 09/26/2025 – recommendation for discontinuation of PRN clonazepam and GDR for fluoxetine 60mg per day, trazodone 75mg at bedtime, aripiprazole 15mg per day, clonazepam 0.5mg at bedtime, and prazosin 2mg at bedtime went unanswered by provider. 09/26/2025 - recommendation for discontinuation of PRN (as needed) clonazepam and application of clobetasol cream went unanswered by provider. 02/28/2026 – recommendation for discontinuation of duplicate therapy with either triamcinolone cream (a topical steroid) or clobetasol cream as well as evaluation of potential drug to drug interaction went unanswered by the provider. 04/19/2026 – recommendation for evaluation of inappropriate polypharmacy went unanswered by the provider. 06/05/2026 – recommendation for discontinuation of PRN medications that had not been utilized in the last 30 days and reassessment of the need for PRN clonazepam went unanswered by provider. An interview on 07/22/2026 at 2:30 PM with the ADON confirmed the facility had not received a response from the medical practitioner regarding Resident 5's medication regimen reviews. B. Record review of Resident 6's admission Record dated 07/27/2026 revealed the resident was admitted to the facility 02/03/2026. Record review of Resident 6's medical record revealed MRRs with the following dates: 02/28/2026 – request for appropriate diagnosis to support use of aripiprazole went unanswered by the provider. 03/18/2026 – request for current order for Fosamax (medication used to prevent osteoporosis) to include specific administration instructions went unanswered by the provider. 04/20/2026 – request for clarification on an incomplete order for diclofenac gel (gel that is applied to the affected area to relieve pain and inflammation) went unanswered by provider. 05/12/2026 – recommendation to discontinue either diclofenac gel or lidocaine patch (patch applied to area to relieve pain by numbing the affected area) as well as pantoprazole (medication to decrease the amount of acid produced in the stomach) and famotidine (medication to reduce stomach acid and treat ulcers) went unanswered by the provider. An interview on 07/22/2026 at 2:30 PM with the ADON confirmed the facility had not received a response from the medical practitioner regarding Resident 6's medication regimen reviews. C. Record review of Resident 34's admission record dated 07/22/2026 revealed the resident was admitted to the facility 01/20/2026. Record review of Resident 34's medical record revealed MRRs with the following dates: 05/14/2026 – request for evaluation of continued need for PRN (as needed) lorazepam (medication to treat anxiety) and evaluation of ferrous sulfate (supplement to treat iron deficiency anemia) ordered four times a day due to high daily dosage went unanswered by the provider. 06/05/2026 – request for gradual dose reduction of aripiprazole 10mg at bedtime and buspirone (medication used to treat mental health disorders) 10mg twice a day went unanswered by the provider. An interview on 07/22/2026 at 2:30 PM with the ADON confirmed the facility had not received a response from the medical practitioner regarding Resident 34's medication regimen reviews. D. Record review of Resident 61's admission record dated 07/21/2026 indicates the resident was admitted to the facility 05/26/2026. Record review of Resident 61's medical record revealed an MRR with the following dates: 05/28/2026 – lorazepam (medication used to treat anxiety) pharmacy review with the requirement to re-evaluate the need for continued use after 14 days went unanswered by the provider. An interview on 07/22/2026 at 2:30 PM with the ADON confirmed the facility had not received a response from the medical practitioner regarding Resident 61's medication regimen reviews. E. Record review of Resident 8's admission Record, dated 07/21/2026, revealed the resident was originally admitted to the facility on [DATE]. Record review of a paper copy of Consultant Pharmacist MRR Recommendation to Prescriber, undated, for Resident 8 revealed 5 recommendations without a provider response. They read on the paper as: Recommendation #1: possible duplication therapy with Zolpidem and Alprazolam; MRR Date: 2/28/2026 Recommendation #2: change medication route to via G-tube for MiraLAX; MRR Date: 3/30/2026 Recommendation #3: add administration instructions for MiraLAX; MRR Date: 5/23/2026 Recommendation #4: ordered dose for Amiodarone was 200mg, but hospital discharge record revealed to take 400 mg bid for 5 days then 200mg bid; add administration instructions for MiraLAX; MRR Date: 6/11/2026 Recommendation #5: GDR recommendation for Zolpidem MRR Date 7/8/2026 Record review of a paper copy of Consultant Pharmacist MRR Recommendation to Prescriber, dated 7/15/2026, for Resident 8 revealed 1 of 1 recommendation was acknowledged and signed by the provider. The MRR Date for this 1 recommendation was 7/8/2026. The paper revealed the provider disagreed with doing a GRD on Zolpidem and signed electronically on 7/15/26. Record review of paper copies of Medical Director and DON Copy of Consultant Recommendations, undated, for Resident 8 revealed the following recommendations created between 2/28/2026 and 7/8/2026: MRR Date: 2/28/2026; Category: Duplicate Therapy; Follow-Through: Note written to physician MRR Date: 3/30/2026; Category: admission Review; Follow-Through: Note written to physician MRR Date: 5/23/2026; Category: admission Review; Follow-Through: Note written to physician MRR Date: 6/11/2026; Category: admission Review; Follow-Through: Note written to physician MRR Date: 7/8/2026; Category: psych – GDR; Follow-Through: Note written to physician These are the same recommendations from the Consultant Pharmacist MRR Recommendation to Prescriber from above. There were no signatures or evidence of acknowledgement from the provider on these forms. An interview with DON on 07/27/2026 at 2:43 PM confirmed there was no evidence of the provider acknowledging the recommendations between 2/28/26 and 6/11/2026. F. Record review of Resident 3's admission Record, dated 07/21/2026, revealed the resident was originally admitted to the facility on [DATE]. Record review of a paper copy of Pharmacist's Recommendation to Prescriber, dated 9/30/2025, and a copy of Pharmacist's Report to Nursing, dated 9/30/2025, for Resident 3 revealed the pharmacist had 2 recommendations from the MRR on 9/29/2025. These recommendations included: Clarifying whether ear drops continued to be clinically necessary Draw A1c because of Type 2 Diabetes and Resident 3 being on insulin There was no acknowledgement from the provider whether the provider agreed or disagreed with the recommendations. There was no provider signature on the above forms. Record review of paper copies of Consultant Pharmacist MRR Recommendation to Prescriber, undated, for Resident 3 revealed a recommendation for the MRR date of 2/28/2026 about possible duplication therapy. There were 2 recommendations for the MRR date of 3/18/2026. These included concerns about polypharmacy and discontinuing medications and checking an A1C because of Resident 3's diagnosis of Diabetes. The provider acknowledged these recommendations on 4/20/2026. Record review of a paper copy of Medical Director and DON Copy of Consultant Recommendations, undated, for Resident 3 revealed the following recommendation was created between 7/7/2026 and 7/8/2026: MRR Date: 7/8/2026; Category: General; recommendation to taper off prednisone pe hospital discharge orders; Follow-Through: Note written to physician There was no signature or evidence of acknowledgement from the provider on this form. There is no evidence of the provider's acknowledgement of this recommendation on any other forms received from facility. Record review of Resident 3's Electronic Medical Record and the paper copies received from the facility revealed no evidence of Resident 3 having an MRR in the month of October 2025. An interview with DON on 07/23/026 at 12:50 PM confirmed that if the provider does not acknowledge the recommendations made by the pharmacy within 2-3 days of sending the recommendations to the provider, then the facility should have reached out to the provider, so the recommendations are acknowledged.

Licensure Reference Number 175 NAC 12-006.05(D) Based on record review and interview, the facility failed to procure psychotropic medication consents prior to medications being administered for 6 (Residents 3, 5, 6, 8, 34 and 61) of 6 sampled residents. The facility identified a census of 67. Findings are: A record review of facility policy titled Use of Psychotropic Medication(s) dated 08/01/2023 with a revision date at 05/06/2026 revealed prior to initiating or increasing a psychotropic medication, the resident, family, and /or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. A. Record review of Resident 5's admission record dated 07/21/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 5's order summary revealed the resident had the following psychotropic medication (medication used to treat mental health disorders) orders: aripiprazole (an antipsychotic medication used to treat mental health disorders) was started 02/05/2025. fluoxetine (a medication used to treat depression) was started 01/01/2025. lamotrigine (a medication used to treat mood disorders) was started 01/01/2025. trazodone (a medication used to treat depression) was started 01/01/2025. clonazepam (a medication used to treat anxiety) was started on 01/01/2025. A record review of Resident 5's medical record revealed an informed consent for use of psychotropic medication for fluoxetine was signed and dated 06/11/2026. Further review of Resident 5's medical record revealed absence of informed consent for the use of aripiprazole, lamotrigine, trazodone, or clonazepam. An interview with the Director of Nursing (DON) on 07/23/2026 at 12:57 PM confirmed there were no psychotropic medication consents on file for Resident 5 for the use of aripiprazole, lamotrigine, trazodone, or clonazepam. B. Record review of Resident 6's admission record dated 07/27/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 6's order summary revealed the resident had the following psychotropic medication orders: aripiprazole was started 02/04/2026. memantine (a medication used to slow the progression of Alzheimer's disease) was started 02/04/2026. sertraline (a medication used to treat depression) was started 02/03/2026. A record review of Resident 6's medical record revealed an informed consent for use of psychotropic medication for aripiprazole, memantine and sertraline were all signed and dated 07/07/2026. An interview with DON on 07/23/2026 at 12:57 PM confirmed there were no psychotropic medication consents on file prior to 07/23/2026 for Resident 6's psychotropic medications. C. Record review of Resident 34's admission record dated 07/22/2026 revealed the resident was admitted to the facility 01/20/2026. A record review of Resident 34's order summary revealed the resident had the following psychotropic medication orders: aripiprazole was started 01/26/2026. donepezil (medication used to treat dementia) was started 01/20/2026. Nuplazid (medication used to help reduce hallucinations and delusions in Parkinson's disease psychosis) was started 01/21/2026. buspirone (medication used for anxiety) was started 01/20/2026. fluoxetine was started 01/20/2026. A record review of Resident 34's medical record revealed an informed consent for use of psychotropic medication for aripiprazole, donepezil, Nuplazid, buspirone and fluoxetine were all signed and dated 07/23/2026. An interview with the DON on 07/23/2026 at 12:57 PM confirmed there were no psychotropic medication consents on file prior to 07/23/2026 for these medications. D. Record review of Resident 61's admission record dated 07/21/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 61's order summary revealed the resident had the following psychotropic medication order: lorazepam (medication used to treat anxiety) was started 05/26/2026. A record review of Resident 61's medical record revealed an informed consent for use of psychotropic medication for lorazepam was signed and dated 07/23/2026. An interview with the DON on 07/23/2026 at 12:57 PM confirmed there were no psychotropic medication consents on file prior to 07/23/2026 for these medications. E. Record review of Resident 8's admission Record dated 07/21/2026 revealed the resident was originally admitted to the facility on [DATE]. A record review of Resident 8's Order Recap Report, dated 07/27/2026, revealed the resident had the following psychotropic medication orders: alprazolam for anxiety, started 01/05/2026 sertraline hydrochloride for depression and anxiety, started 06/06/2026. zolpidem tartrate for insomnia, started 01/05/2026. Record review of Resident 8's Informed Consent for Use of Psychotropic Medication received from the facility on 7/23/2026, revealed telephone consents for alprazolam, sertraline, and zolpidem all were signed and dated 07/23/2026. An interview with the DON on 07/23/2026 at 12:57 PM confirmed there were no psychotropic medication consents for these medications on file prior to 07/23/2026. F. Record review of Resident 3's admission Record dated 07/21/2026 revealed the resident was originally admitted to the facility on [DATE]. A record review of Resident 3's Order Recap Report, dated 07/27/2026, revealed the resident had the following psychotropic medication order: quetiapine for schizophrenia, started 1/27/2026. Record review of Resident 3's Informed Consent for Use of Psychotropic Medication received from the facility on 7/23/2026, revealed in-person consent for quetiapine; this was signed and dated 07/23/2026. An interview with the DON on 07/23/2026 at 12:57 PM confirmed there was no psychotropic medication consent for this medication on file prior to 07/23/2026.

Licensure Reference Number 175 NAC 12-006.09(H)(iv)(2) Based on record review and interviews, the facility failed to ensure orders were in place to care for an indwelling catheter for 1 (Resident 2) of 1 sampled resident. The facility identified a census of 67. Findings are: Record review of a facility policy entitled Catheter Care dated 08/01/2023 with a revision date of 07/21/2026 revealed the facility was to ensure residents with indwelling catheters received appropriate catheter care. The policy further revealed catheter care would be performed every shift and as needed by nursing personnel.Record review of Resident 2's admission record dated 07/21/2026 revealed Resident 2 was admitted to the facility 06/15/2026.Record review of Resident 2's Minimum Data Set (MDS, a federally mandated standardized assessment used in long-term care to evaluate residents' health, functional abilities and care needs) dated 06/19/2026 revealed the resident had an indwelling (inside the body) catheter (a thin, flexible, rubber or plastic tube that healthcare providers use to drain urine from the bladder).Further record review of Resident 2's care plan initiated 06/17/2026 reveal interventions related to the care of urinary catheter in place, however additional review of Resident 2's orders dated 07/21/2026 reveal no orders for nursing to provide any type of cares related to the resident's catheter.Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 07/23/2026 at 11:41 AM confirmed they would both expect catheter cares to be completed and documented every shift.Interview with Resident 2 on 07/23/2026 at 12:14 PM confirmed the resident emptied their own catheter bag and has not had any staff care for the catheter site since Resident 2's arrival to the facility.Interview with ADON 07/23/2026 at 12:22 PM confirmed there were no orders in Resident 2's chart for catheter care and further confirmed staff have been charting resident is continent (able to control passage of urine) in daily charting.

Licensure Reference Number 175 NAC 12-006.09(I)Based on record review and interviews, the facility failed to safely store smoking materials for 1 (Resident 78) of 2 sampled residents.Findings are: Review of undated facility policy Resident Rights - Smoking revealed smokers are not permitted to retain cigarettes, pipes, tobacco, e-cigarettes, vape pens and other smoking articles or lighters within their possession.Record review of Resident 78's admission record dated 07/21/2026 revealed resident was admitted to the facility 07/15/2026.Record review of Resident 78's Admission/readmission assessment dated [DATE] revealed Resident 78 understood that smoking accessories (cigarettes, lighters, matches, etc.) must be returned to and kept under the control of the center staff when not in use.Observation 07/21/2026 at 1:31 PM while in Resident 78's room with RN-A revealed Resident 78 had cigarettes and lighter in a locked box in their room. RN-A witnessed Resident 78 removing items from lock box and acknowledged they were going outside to smoke.Interview 07/22/2026 at 3:55 PM with the Director of Nursing confirmed residents are not to have any smoking products in their rooms.

Licensure Reference Number 175 NAC 12-006.09(E)(iii)Based on observations, record review, and interviews, the facility failed to develop and implement a comprehensive care plan for 1 (Resident 12) of 2 sampled residents. The facility identified a census of 67. Findings are:A.A record review of Resident 12's admission Record revealed they were admitted on [DATE] with diagnoses of osteoporosis with current pathological fracture in the spine (a condition where the bones become weak and can break under usual stress), diabetes type 2 (a condition where the body cannot regulate blood sugar effectively), heart failure (inability of the heart to pump blood effectively), urinary retention (inability to completely empty the bladder), chronic pain, and dementia (a degenerative condition that affects memory, language, and behavior).A record review of Resident 12's undated care plan revealed the following:Resident is incontinent of bowel and bladder related to activity intolerance, date initiated was 06/26/2026, last revised 06/26/2026.Check frequently for wetness and soiling and change as needed, date initiated was 06/26/2026.Use briefs or incontinence products as needed for protection. Apply barrier cream to skin after incontinent episodes, date initiated 06/26/2026.Monitor for and report signs and symptoms to the medical doctor of urinary tract infection, including pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns, date initiated 06/26/2026.A record review of Resident 12's physician orders revealed an order for Foley catheter care every shift for urinary retention with an order date of 06/27/2026. An observation on 07/21/2026 at 2:36 PM of Resident 12 revealed the resident was lying in bed in their room with catheter tubing and a urine collection bag visible. An interview on 07/23/2026 at 1:07 PM with the Director of Nursing (DON) confirmed that Resident 12's comprehensive care plan did not accurately reflect the method of toileting or the utilization of enhanced barrier precautions.

Licensure Reference Number 175 NAC 12-006.09(F)(i) Based on record review and interview, the facility failed to ensure a baseline care plan was completed within the required time frame for 2 (Residents 34 and 73) of 2 sampled residents. The facility identified a census of 67. Findings are: Record Review of the facility's Baseline Care Plan (BCP, a plan of care for the resident that includes the minimum information needed to provide effective, person-centered care immediately upon admission) policy, revised 9/29/2025, revealed the baseline care plan should be developed within 48 hours of a resident's admission. Further review of the BCP policy revealed a supervising nurse should verify within 48 hours that a baseline care plan had been developed. A.Record review of Resident 73's admission Record, dated 7/22/2026, revealed the resident was admitted to the facility on [DATE] for orthopedic aftercare related to a fall resulting in a displaced fracture (broken bone) of the right femur (thigh bone), a fracture of the left humerus (upper arm bone between shoulder and elbow), contusion (bruise) on part of the head, and acute pain.Record review of a requested printed copy of Resident 73's ARCC-AS- Baseline Careplan - V 2, received on 7/22/2026 at 2:55 PM, revealed Section 2: Nursing and Section 5: RN Attestation were not completed or signed.Interview with Director of Nursing (DON) on 7/23/2026 at 1:00 PM confirmed that sections 2 and 5 were not completed on Resident 73's baseline care plan as of 7/22/2026. DON confirmed that the baseline care plan was supposed to be completed within 48 hours of Resident 73's admission, but was not. DON confirmed the floor nurses start the baseline care plan, and it should be signed within 48 hours of resident admission. B.Record review of Resident 34's admission Record, dated 7/27/2026, revealed the resident was admitted to the facility on [DATE] with diagnoses of dementia (a usually progressive condition marked by the development of multiple cognitive deficits [such as memory impairment, aphasia, and the inability to plan and initiate complex behavior]), type 2 diabetes (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production), and Parkinson's disease (a slow brain disorder causing tremors, muscle stiffness, and slowed movement). Record review of Resident 34's ARCC-AS-Baseline Careplan - V 2 revealed Section 2: Nursing and Section 5: RN Attestation of Resident 34's baseline care plan was signed on 1/26/2026, six days after admission. Interview with DON on 7/23/2026 at 1:00 PM confirmed that sections 2 and 5 of Resident 34's baseline care plan were completed and signed on 1/26/2026 and further confirmed the BCP was not completed within 48 hours of admission and should have been.

Licensure Reference Number 175 NAC 12-006.09(D)Based on record review and interview, the facility failed to submit accurate 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) data for 3 (Residents 1, 8, and 34) of 22 sampled residents. The facility identified a census of 67. Findings are:Record review of a Minimum Data Set 3.0 Completion policy revised 9/29/2025 revealed the facility utilizes the Resident Assessment Instrument (RAI, a standardized evaluation system used in nursing homes to assess resident needs, consisting of the MDS) specified by the state to conduct a comprehensive, accurate, and standardized assessment of each resident's functional capacity.Record Review of the MDS 3.0 RAI User's Manual dated 10/2025 revealed under 3.3: Coding Conventions that the standard look-back period for the MDS 3.0 is 7 days. A.Record review of Resident 1's admission Record dated 7/21/2026 revealed the resident was originally admitted to the facility on [DATE] for orthopedic aftercare due to a fracture of the right femur and an open wound on the lower right leg. The resident had a diagnosis of a local infection of the skin and subcutaneous (fatty) tissue with an onset date of 4/14/2026.Record review of Resident 1's MDS with an Assessment Reference Date (ARD, the specific endpoint for the observation [or look-back] periods in the MDS assessment process) of 4/17/2026, revealed in Section H - Bladder and Bowel, H0100 Appliances was marked as indwelling catheter (a flexible tube inserted into the bladder to drain urine), indicating Resident 1 had a catheter within the look-back period. Section H0300 Urinary Continence was marked as the resident was occasionally incontinent.Record review of Resident 1's Order Recap Report, dated 7/27/2026, for the period of 4/1/2026-7/31/2026 revealed no orders for an indwelling catheter.Record review of Resident 1's Care Plan Report, undated, revealed no focuses, goals, or interventions related to an indwelling catheter.Interview with the MDS Coordinator (MDS-C) on 7/27/2026 at 3:38 PM revealed Resident 1 was readmitted to the facility on [DATE]. MDS-C confirmed that the resident did not have a catheter when Resident 1 was readmitted . MDS-C confirmed there was no evidence of Resident 1 having an indwelling catheter during the look-back period. MDS-C further confirmed the MDS needed to be modified to correct Section H0100. B.Record review of Resident 8's admission Record dated 7/21/2026 revealed the resident was originally admitted to the facility on [DATE]. Resident 8 had a diagnosis of a fistula (an abnormal tunnel or connection between two body parts) of the stomach and duodenum (first part of the small intestine) with an onset date of 12/25/2020, and a diagnosis of vesicointestinal fistula (an abnormal opening between the intestine and the bladder) with an onset date of 1/5/2026.Record review of Resident 8's MDS with an ARD of 6/13/2026, revealed in Section K - Swallowing/Nutritional Status that K0520: Nutritional Approaches, B. Feeding tube was marked as While Not a Resident, and Z. None of the above was marked as While a Resident indicating that Resident 8 did not have a feeding tube while a resident at the facility.Record review of Resident 8's Order Recap Report dated 7/27/2026, for the period of 1/1/26-7/31/26 revealed enteral feed orders started on 1/7/2026. The report revealed a feeding tube site order that started on 1/5/2026, with no end date.Record review of Resident 8's Progress Notes dated 7/21/2026 revealed a Daily Skilled Note dated 6/10/2026 that Resident 8 had a feeding tube.Record review of Resident 8's Care Plan Report, undated, revealed a focus for Feeding Tube initiated on 1/8/2026.Interview with MDS-C on 7/27/2026 at 3:45 PM confirmed that Resident 8 had a feeding tube since admission to the facility, and that the MDS should have been marked that the resident had a feeding tube while a resident.C.Record review of Resident 34's admission Record dated 7/27/2026 revealed the resident was admitted to the facility on [DATE] with diagnoses of dementia (a usually progressive condition marked by the development of multiple cognitive deficits [such as memory impairment, aphasia, and the inability to plan and initiate complex behavior]), type 2 diabetes (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production), Parkinson's disease (a slow brain disorder causing tremors, muscle stiffness, and slowed movement), depression, and anxiety. Record review of Resident 34's MDS with an ARD of 5/17/2026 revealed in Section N - Medications, in N0415: High-Risk Drug Classes: Use and Indication, A. Antipsychotics was marked as is taking and indication noted. N0450: Antipsychotic Medication Review was marked as 0 indicating antipsychotics were not received since admission/entry or reentry or the prior assessment. Record review of Resident 34's Order Recap Report dated 7/27/2026 for the period of 4/1/2026-7/31/2026 revealed an order for Nuplazid (an atypical antipsychotic medication approved to treat hallucinations and delusions associated with Parkinson's disease psychosis) started on 1/21/2026. Record review of Resident 34's Medication Administration Record, dated 7/27/2026, revealed Resident 34 was administered Nuplazid the entire month of May, besides 5/10/2026-5/13/2026 when the resident was in the hospital. Resident 34 did receive Nuplazid 5/14/26-5/17/26, which was in the MDS' look-back period. Interview with MDS-C, on 7/27/2026 at 3:48 PM confirmed that Resident 34 had been on antipsychotics and received Nuplazid during the look-back period. MDS-C confirmed the MDS should have been coded that the resident did receive antipsychotics.

Licensure Reference Number 175 NAC 12-006.05(C)Based on record review and interview, the facility failed to provide the Medicare/Medicaid Coverage/Liability ABN (Advance Beneficiary Notice) to 2 (Residents 13 and 48) of 2 sampled residents. The facility identified a census of 67. A. A record review of Resident 13's admission Record revealed they were originally admitted to the facility on [DATE]. A record review of a facility-provided document titled, SNF (Skilled Nursing Facility) Beneficiary Notification Review for Residents who Received Medicare Part A Services, revealed the following:Resident 13's Medicare Part A skilled services episode start date was 2/19/26. Resident 13's last covered day of Part A service was 4/9/26. The facility initiated the discharge when benefit days were not exhausted.The NOMNC (Notice of Medicare Non-Coverage) Form CMS-10123 was given to Resident 13.A record review of an undated facility document titled, Notice of Medicare Non-Coverage, dated 4/9/26 was signed by Resident 13 on 4/11/26.A record review of Resident 13's medical record revealed there was no B.A record review of Resident 48's admission Record revealed they were originally admitted to the facility on [DATE]. A record review of a facility-provided document titled, SNF Beneficiary Notification Review for Residents who Received Medicare Part A Services, revealed the following:Resident 48's Medicare Part A skilled services episode start date was 3/26/26. Resident 48's last covered day of Part A service was 6/8/26. The facility initiated the discharge when benefit days were not exhausted.The NOMNC Form CMS-10123 was given to Resident 48.A record review of an undated facility document titled, Notice of Medicare Non-Coverage, dated 6/9/26 was signed by Resident 48 on 4/11/26.An interview on 7/22/2026 at 1:30 PM with the Regional Director of Operations (RDO) confirmed the facility had given Resident 13 and 48 the NOMNC forms, but had not given the SNF Advanced Beneficiary Notice (ABN) Form CMS-10055 to either resident as required. The RDO further confirmed both Resident 13 and 48 should have received the SNF ABN form.

Licensure Reference Number 175 NAC 12-006.10(D)Based on record review, observation, and interview, the facility failed to ensure a medication error rate below 5%. There were 28 medication administration opportunities which resulted in 5 errors for an error rate of 17.86%. This affected 2 (Resident 24 and 39) of 3 sampled residents and the facility identified a census of 67.Findings are: Record review of Medication Administration policy, revised 05/28/2026, revealed the facility would ensure the six rights of medication administration are followed including the right dosage. Further review of the policy directed staff to compare medication source (bubble pack) with the medication administration record (MAR) to verify dose. The policy further directed staff to crush medications as ordered. Do not crush medications with do not crush instructions. The policy listed examples of Do Not Crush Medications as medications that are slow release (extended/delayed release) and enteric coated medications. A. Record review of Resident 24's admission Record, dated 07/22/2026, revealed the resident was admitted to the facility on [DATE]. Record review of Resident 24's Order Summary Report, dated 07/22/2026, revealed the resident had the following medication orders:Okay to have crushed meds in chocolate pudding per resident's preference dated 07/14/2026.aspirin Low Tablet 81mg Enteric Coated (EC). Give one tablet orally one time a day for treatment to prevent heart attack related to atherosclerotic heart disease of native coronary artery without angina pectoris dated 03/05/2025.desvenlafax tablet 100mg extended release (ER). Give one tablet orally one time a day related to major depressive disorder, single episode, without psychotic features dated 03/07/2025.metformin tablet 500mg ER. Give 2 tablets orally one time a day related to type 2 diabetes mellitus without complications dated 03/05/2025.pantoprazole tablet 40mg. Give 1 tablet orally two times a day related to Barrett's esophagus without dysplasia dated 03/04/20205. Observation on 07/22/2026 at 8:18 AM revealed Medication Aide(MA)-D crush the following medications:24 Hour desvenlafax 100 mg ER oral tablet - 1 tab.pantoprazole 40 mg tablet delayed release - 1 tab.metformin hydrochloride 500 mg ER Tablet - 2 tabs.aspirin 81 mg oral tablet EC - 1 tab.MA-D observed to administer the above medications, after being crushed, to Resident 24. Interview with Assistant Director of Nursing (ADON) on 07/22/2026 at 4:10 PM reviewed the order about crushing medications with surveyor. ADON confirmed that Resident 24 can received medications that are able to be crushed in that form, but the medications that are not able to be crushed should not have been crushed and should have been given whole. B. Record review of Resident 39's admission Record, dated 02/23/2026, revealed the resident was admitted to the facility on [DATE]. Record review of Resident 39's Order Summary Report, dated 07/23/2026, revealed an order for topiramate tablet 25mg, give 3 tablets orally two times a day for seizures. Observation on 07/22/2026 at 9:25 AM revealed MA-E administered 1 tablet of topiramate 25mg. Interview with MA-E on 07/22/2026 at 9:30 AM confirmed that MA-E only gave 1 tablet for each medication administered on 07/22/2026 at 9:25 AM. MA-E reported that none of the medications required multiple tablets. MA-E confirmed only 1 tablet of the topiramate was administered. When the surveyor told MA-E the MAR said to give 3 tablets, MA-E gave Resident 39 two more tablets of topiramate. Interview with ADON on 07/22/2026 at 4:10 PM confirmed MA-E should have double checked the order to ensure the right dose of topiramate was administered initially.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5)Based on record reviews and interviews, the facility failed to provide routine medications to meet the needs of the residents for 4 (Resident 1, 3, 4, 5) of 5 sampled residents. The facility census was 66. Findings are:A record review of a facility policy titled, Medication Reordering dated 1/8/26 revealed:It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident.1. The facility will utilize a systemic approach to provide or obtain routine and emergency medications and biologicals in order to meet the needs of each resident.2. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner.5. In the event of new orders, the facility is allowed (24) hours to begin a medication unless otherwise specified by the physician.6. For stat (immediately or without delay) medications, a supply of medications typically used in emergency situations will be maintained in limited supply by the pharmacy in a portable, but sealed emergency box or container. An interview with the Licensed Practical Nurse (LPN)-D on 4/22/26 at 11:20AM revealed the pharmacy is an issue. When asked about when delivery times are, LPN-D revealed they deliver in the evening and supposed to do every day, but the medications ordered do not come right away.An interview with the Director of Nursing (DON) and the Administrator (Admin) on 4/22/26 at 4:15PM revealed knowing that medications were not being delivered to the facility consistently and timely for newly admitted residents. The Admin and the DON also revealed that they had not notified the physician at the time that medications were not being dispensed per facility policy and procedure. During the interview with the Admin and DON, they further revealed that there is no process in place to follow up if medications needed are not available. There is no local pharmacy to obtain medications if they are not delivered the same day or next day.

Licensure Reference Number 175 NAC 12-006.09(H)Based on record reviews and interviews, the facility failed to follow physician orders for 4 (Resident 1, 3, 4, 5) of 5 sampled residents. The facility census was 66. Findings are:A.A record review of a facility policy titled, Pain Management dated 1/8/26 revealed:The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.The facility will utilize a systemic approach for recognition, assessment, treatment and monitoring of pain.2. Facility staff will observe for nonverbal indicators which may indicate the presence of pain.Pain Assessment:1. The facility will use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain.Pain Management and Treatment:1. Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission.7. Pharmacological interventions will follow a systemic approach for selecting medications and doses to treat pain. The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain. A record review of a facility policy titled, Medication Reordering dated 1/8/26 revealed:It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident.1. The facility will utilize a systemic approach to provide or obtain routine and emergency medications and biologicals in order to meet the needs of each resident.2. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner.5. In the event of new orders, the facility is allowed (24) hours to begin a medication unless otherwise specified by the physician.6. For stat (immediately or without delay) medications, a supply of medications typically used in emergency situations will be maintained in limited supply by the pharmacy in a portable, but sealed emergency box or container. A record review of Resident 1's admission Record dated 4/22/26 revealed an admission date of 6/23/25. A record review of Resident 1's Progress Notes dated 4/22/26 revealed on 4/14/26 Resident 1 sent to emergency room and return from hospital on 4/17/26. A record review of Resident 1's Discharge Summary dated 4/17/26 revealed a physician review of Resident 's condition stating, the resident is approved for comfort measures, vitals are highly unstable and would expect gender to pass soon.A record review of Resident 1's Order Summary dates 4/22/26 revealed the most recent orders from the latest admission from a hospital stay on 4/17/26:- Atropine Sulfate Ophthalmic Solution 1 %, give 1 drop sublingually every 1 hour as needed (for reducing secretions) start date 4/17/26- Lorazepam Oral Concentrate 2 milligram (MG)/milliliter (ML) give 0.25 ml sublingually every 1 hour as needed for anxiety (mental health condition characterized by excessive, persistent worry and fear that interferes with daily life) start date 4/17/26- Morphine Sulfate (Concentrate) Solution 20 MG/ML give 0.5 ml sublingually every 1 hour as needed for pain or air hunger (symptom of anxiety and panic where the brain mistakenly signals a need for more oxygen, resulting in rapid, shallow breaths) start date 4/17/26 A record review of Resident 1's Progress Notes dated 4/22/26 revealed on 4/17/26 the frequency of comfort kit medication were noted to be missing from transition orders and a call was placed to the physician's office revealing no available nurse or clinician manager is currently available and clarification is needed asap to relay to the pharmacy. Progress notes further relayed pharmacy will not process orders without the information, and no new orders were obtained at that time. A record review of Resident 1's Medication Administration Record (MAR; a legal document used by healthcare professionals to document the administration of medicines) dated 4/22/26 for April 2026 revealed: Morphine Sulfate (Concentrate) Solution 20 MG/ML was not provided until 4/18/26. An interview on 4/22/26 at 3:45PM with Medication Aide (MA)-A revealed they were the medication aide responsible for administering medications to Resident 1 on 4/17/2026. When MA-A was interviewed about medications available for Resident 1, MA-A revealed that Resident 1 did not appear to be in any pain upon return from the hospital, because Resident 1 was sleeping the entire time MA-A was on the medication cart until 4:00PM. MA-A further revealed that Resident 1 stated that family requested MA-A to provide Resident 1 with round the clock Morphine, however did not have the comfort kit medications available and explained to the family to contact the Assistant Director of Nursing (ADON) for further information. An interview on 4/22/26 at 4:00PM with Licensed Practical Nurse (LPN)-B revealed they were the nurse on the floor for specified halls and are responsible for completing daily assessments and completed pain assessments for Resident 1. When LPN-B was interviewed about pain assessments for Resident 1, LPN-B reviewed prior documentation and revealed that Resident 1 was not in any pain and was resting a lot. An interview on 4/22/26 at 4:10PM with MA-C revealed comfort kit medications were available on 4/18/26 for Resident 1, however were not aware of when they became available. An interview with the Director of Nursing (DON) and the Administrator (Admin) on 4/22/26 at 4:15PM revealed knowing that medications were not being delivered to the facility consistently and timely for newly admitted residents and residents returning from the hospital with new orders. The Admin and the DON also revealed that they had not notified the physician at the time that medications were not available or being dispensed per physician orders and per facility policy and procedure. B.A record review of Resident 3's admission Record dated 4/22/26 revealed an admission date of 3/12/26. A record review of Resident 3's Order Summary dated 4/22/26 revealed orders from admission date 3/12/26:- Apixaban Oral Tablet 5 milligrams (MG) give 1 tablet by mouth two times a day for paroxysmal atrial fibrillation (an irregular, rapid heart rhythm) - order date 3/12/26- Acetaminophen Tablet 325 MG give 2 tablet by mouth every 6 hours as needed for mild or moderate pain- order date 3/12/26- Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) 2 puffs inhale orally every 6 hours as needed for wheezing (a high-pitched, whistling sound produced by narrowed or inflamed airways) - order date 3/12/26- Amlodipine Besylate Oral Tablet 10 MG give 10 mg by mouth in the morning for hypertension (a chronic condition where blood force against artery walls and is consistently too high) - order date 3/12/26- Atorvastatin Calcium Oral Tablet 80 MG give 80 mg by mouth at bedtime for hyperlipidemia (condition characterized by excessively high levels of lipids in the blood) - order date 3/12/26-Carvedilol Oral Tablet 25 MG give 25 mg by mouth two times a day for hypertension- order date 3/12/26- Ferrous Sulfate Oral Tablet 325 (65 Fe (Iron)) MG give 1 tablet by mouth in the afternoon for supplement related to acute posthemorrhagic anemia- order date 3/12/26- Furosemide Oral Tablet 20 MG give 1 tablet by mouth in the morning related to chronic pulmonary edema- order date 3/12/26- Hydralazine HCl Oral Tablet 100 MG give 1 tablet by mouth three times a day related to hypertension - order date 3/12/26- Jardiance Oral Tablet 10 MG give 1 tablet by mouth in the morning related to Diabetes (condition causing high blood sugar because the body cannot make or properly use insulin) - order date 3/12/26- Levothyroxine Sodium Oral Tablet 50 microgram (MCG) give 1 tablet by mouth in the morning related to hypothyroidism (underactive thyroid condition where the gland fails to produce enough hormones) - order date 3/12/26- Magnesium Oxide Oral Tablet 400 MG Give 1.5 tablet by mouth in the morning for low amount of magnesium in the blood related to Hypomagnesemia (an electrolyte disorder defined by low blood magnesium) - order date 3/12/26- Metformin HCl Oral Tablet 500 MG give 1 tablet by mouth two times a day related to diabetes - order date 3/12/26-Oxycodone HCl Oral Tablet 5 MG Give 1 tablet by mouth every 8 hours as needed for moderate or severe pain- order date 3/12/26-Pantoprazole Sodium Oral Tablet Delayed Release 40 MG give 1 tablet by mouth two times a day related to gastro-esophageal reflux disease (a chronic digestive disorder occurring when stomach acid frequently flows back into the esophagus, irritating its lining) - order date 3/12/26-Potassium Tablet Give 20 milliequivalent (mEq) by mouth two times a day for Potassium Replacement related to Hypokalemia (a condition defined by low blood potassium levels (typically <3.5 mEq/L), often causing muscle weakness, fatigue, constipation, and in severe cases, dangerous heart arrhythmias) - order date 3/12/26-Umeclidinium-Vilanterol Inhalation Aerosol Powder Breath Activated 62.5-25 Microgram/Actuation (MCG/ACT) 1 puff inhale orally in the morning related to chronic pulmonary edema - order date 3/12/26-Valsartan Oral Tablet 80 MG give 1 tablet by mouth two times a day for hypertension - order date 3/12/26 A record review of Resident 3's MAR dated 4/22/26 for March 2026 revealed:-Amlodipine was not provided until 3/14/26-Apixaban was not consistently provided until 3/19/26-Atorvastatin was not provided until 3/14/26-Carvedilol was not provided until late on 3/13/26-Furosemide was not provided until 3/14/26-Hydralazine was not consistently provided until 3/16/26-Jardiance was not provided until 3/14/26-Levothyroxine was not provided until 3/14/26-Magnesium was not provided until 3/14/26-Metformin was not consistently provided until 3/16/26-Pantoprazole was not provided until 3/14/26-Potassium was not consistently provided until 3/17/26 and then again on 3/25/26-3/31/26-Valsartan was not consistently provided until 3/18/26-Umeclidinium-Vilanterol Inhalation Aerosol was not provided until 3/14/26 A record review of Resident 3's Progress Notes dates 4/22/26 revealed medications were either not available or the facility was still waiting on medication for the previously listed medications. An interview with Resident 3 on 4/22/26 at 4:05PM revealed no negative impact related to medications being missed. An interview with the Director of Nursing (DON) and the Administrator (Admin) on 4/22/26 at 4:15PM revealed knowing that medications were not being delivered to the facility consistently and timely for newly admitted residents and residents returning from the hospital with new orders. The Admin and the DON also revealed that they had not notified the physician at the time that medications were not available or being dispensed per physician orders and per facility policy and procedure. C.A record review of Resident 4's admission Record dated 4/22/26 revealed an admission date of 4/8/26. A record review of Resident 4's Order Summary dated 4/22/26 revealed orders from admission date 4/8/26:-Acetaminophen Oral Tablet 500 MG give 1 tablet by mouth every 6 hours as needed for moderate pain - order date 4/8/26-Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083%1 vial inhale orally every 6 hours as needed for wheezing - order date 4/8/26-Apixaban Oral Tablet 5 MG Give 1 tablet by mouth two times a day for history of treatment for Venous Thromboembolism (VTE; a serious medical condition encompassing two related blood clot conditions) - order date 4/8/26-Benzonatate Oral Capsule 100 MG give 1 capsule by mouth every 6 hours as needed for cough related to chronic obstructive pulmonary disease (COPD; a progressive, incurable lung disease) - order date 4/8/26-Celecoxib Oral Capsule 200 MG Give 2 capsule by mouth in the morning for chronic pain related to chronic pain - order date 4/8/26-Empagliflozin Oral Tablet 10 MG Give 1 tablet by mouth in the morning for diabetes-Lamotrigine Oral Tablet 200 MG Give 1 tablet by mouth at bedtime for bipolar disorder (a chronic mental health condition causing extreme,, debilitating shifts in mood, energy, and activity levels, ranging from manic highs to depressive lows) - order date 4/8/26-Midodrine HCl Oral Tablet 10 MG Give 1 tablet by mouth three times a day for hypotension - order date 4/8/26-Montelukast Sodium Oral Tablet 10 MG Give 1 tablet by mouth in the morning for allergies related to COPD - order date 4/8/26-Potassium Chloride ER Oral Capsule Extended Release 10 MEQ Give 1 capsule by mouth in the morning for hypokalemia - order date 4/8/26-Pramipexole Dihydrochloride Oral Tablet 0.25 MG Give 1 tablet by mouth at bedtime for restless legs syndrome (a common neurological sleep-movement disorder causing an irresistible urge to move legs) - order date 4/8/26-Prazosin HCl Oral Capsule 1 MG Give 3 capsule by mouth at bedtime for induced nightmares related to Post traumatic stress disorder (PTSD; a mental health condition triggered by experiencing or witnessing terrifying events, such as war, abuse, or disasters) - order date 4/8/26-Primidone Oral Tablet 50 MG Give 0.5 tablet by mouth four times a day for essential tremor (a common, often inherited, neurological disorder causing involuntary, rhythmic shaking usually in the hands during movement) - order date 4/8/26-Torsemide Oral Tablet 20 MG Give 1 tablet by mouth in the morning for visible water retention related to heart failure - order date 4/8/26-Ziprasidone HCl Oral Capsule 20 MG Give 1 capsule by mouth two times a day for manic-depression related to major depressive disorder - order date 4/8/26-Bevespi Aerosphere Inhalation Aerosol 9- 4.8 MCG/ACT 2 puff inhale orally two times a day for bronchospasm prevention with COPD - order date 4/8/26 A record review of Resident 4's MAR dated 4/22/26 for April 2026 revealed:-Apixaban - was not provided until 4/10/26-Empagliflozin - was not provided until 4/10/26-Lamotrigine - was not provided until 4/10/26-Midodrine - was not provided until 4/10/26-Montelukast - was not provided until 4/10/26-Potassium - was not provided until 4/10/26-Pramipexole - was not provided until 4/9/26-Prazosin - was not provided until 4/10/26-Primidone - was not consistently provided until 4/10/26-Ziprasidone - was not consistently provided until 4/10/26 An interview with Resident 4 on 4/22/26 at 3:52PM revealed no negative impact related to medications being missed. An interview with the Director of Nursing (DON) and the Administrator (Admin) on 4/22/26 at 4:15PM revealed knowing that medications were not being delivered to the facility consistently and timely for newly admitted residents and residents returning from the hospital with new orders. The Admin and the DON also revealed that they had not notified the physician at the time that medications were not available or being dispensed per physician orders and per facility policy and procedure. D.A record review of Resident 5's admission Record dated 4/22/26 revealed an admission date of 4/10/26. A record review of Resident 5's Order Summary dated 4/22/26 revealed orders from admission date 4/10/26:- Levothyroxine Sodium Oral Tablet 125 MCG Give 1 tablet by mouth one time a day for low amount of thyroid hormone related to hypothyroidism - order date 4/10/26- Memantine HCl Oral Tablet 5 MG Give 1 tablet by mouth in the morning for dementia - order date 4/10/26- Ropinirole Hydrochloride Oral Tablet 0.25 MG Give 1 tablet by mouth at bedtime for restless legs syndrome - order date 4/10/26- Rivaroxaban Oral Tablet 15 MG Give 1 tablet by mouth in the morning for atrial fibrillation - order date 4/10/26 A record review of Resident 5's MAR dated 4/22/26 for April 2026 revealed:- Levothyroxine - was not provided until 4/12/26- Memantine - was not provided until 4/12/26- Ropinirole - was not provided consistently since admission.- Rivaroxaban - was not provided consistently since admission. An interview with the Director of Nursing (DON) and the Administrator (Admin) on 4/22/26 at 4:15PM revealed knowing that medications were not being delivered to the facility consistently and timely for newly admitted residents and residents returning from the hospital with new orders. The Admin and the DON also revealed that they had not notified the physician at the time that medications were not available or being dispensed per physician orders and per facility policy and procedure.

LICENSURE REFERENCE NUMBER 12-006.09 (H)(vi)(3)Based on observations, record review, and interview, the facility failed to administer oxygen to 3 of 4 sampled residents (Resident 1, 2, and 3). The faciity identified a census of 70. A record review of a facility policy titled, Oxygen administration, last revised 3/19/25, revealed that the residents' care plans identify interventions for oxygen therapy, based on their assessments and provider orders. A. Record review of Resident 1's face-sheet revealed they were admitted on [DATE] with diagnoses of chronic respiratory failure, chronic obstructive pulmonary disease, type 2 diabetes mellitus, and obesity. Record review of Resident 1's practitioners orders dated 4/23/25 revealed orders for oxygen to be administered by nasal cannula at the rate of 3 liters per minute at rest and with activity, and for staff to adjust the resident's oxygen flow rate to keep the residents blood oxygen saturation above 90 %. A record review of Resident 1's provider orders dated 4/23/2025 revealed nursing staff should monitor the resident's oxygen saturations every shift, and ensure oxygen supply is in place at all times. A record review of a facility of a practitioner note dated 12/24/25 revealed Resident 1's primary care provider's stated Resident 1 needs to wear oxygen at all times, and that they were taken to that appointment without their supplemental oxygen. Record review of Resident 1 electronic medical record under the section identified as vital signs revealed staff charted Resident 1 as being on room air (no supplemental oxygen administered) on the following dates: 2/17, 2/18, 1/28, 1/22, 1/21, 1/19, 1/16, 1/7, 1/1, 12/30. A record review of Resident 1's medical record revealed they were discharged from an inpatient stay at the hospital for a stroke on 3/20/25 with an order to continue to take portable oxygen at the rate of 3 liters per minute continuously, with the indication of emphysema. A continuous observation on 3/25/26 from 12:05 PM to 12:10 PM revealed Resident 1 was in their wheelchair near the nurses station. There was not an oxygen tank connected to their wheelchair or oxygen tubing on their face. Further observation on 3/25/26 at 12:10 PM revealed staff members took Resident 1 in their wheelchair back to their room and then shut the door and at 12:13 PM brought out wearing oxygen tubing. An interview on 3/25/26 at 11:58 AM with Licensed Practical Nurse-C revealed that only medication aides and nurses are allowed to change an oxygen tank (from an empty one to a full one). An interview on 3/25/26 at 12:17 PM with Resident 1 revealed that staff brought them out of her room to the area close to the oxygen storage room, then returned them to their room, and brought them out after changing their oxygen tank. B. A record review of Resident 3's face sheet revealed Resident 3 was admitted on [DATE] with diagnoses of chronic respiratory failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease, obesity, congestive heart failure, and atrial fibrillation. A record review of Resident 3's provider orders dated 1/27/26 revealed Resident 3 was to use oxygen via nasal cannula 3-4 LPM at rest and with activity. A record review of Resident 3's provider orders dated 1/28/26 revealed the nurse was to ensure the resident's oxygen tank be full for meals and activities. An observation on 3/25/26 at 8:10 AM revealed Resident 3 was sitting in a wheelchair in the dining room waiting for their breakfast to be delivered. The needle in their oxygen tank regulator was in the red area of the gauge, indicating the tank was near empty or was empty, and the flow rate was set to 3 liters per minute. An observation on 3/25/26 at 8:23 AM revealed Resident 3 was sitting in the same location in the dining room and the oxygen tank gauge needle was still in the red area. An observation on 3/25/26 at 9:23 AM revealed Resident 3 was sitting in the same location in the dining room and the oxygen tank gauge needle was still in the red area. Resident 3 was unable to say whether any oxygen was coming out of the oxygen tubing. An observation on 3/25/26 at 9:47 AM revealed Resident 3 was in their room sitting in a recliner, with their oxygen tubing connected to a running oxygen concentrator. Their wheelchair was present in their room, with the same unchanged tank on the back of the wheelchair. An observation on 3/25/26 at 11:45 AM revealed Resident 3 was in their wheelchair in the dining room, and their family member exited the dining room and asked multiple people where a nurse was. The oxygen tank on the back of Resident 3's wheelchair was set to 3 liters per minute flow and the needle in the gauge was in the red area. An interview with Resident 3's family member on 3/25/26 at 12:50 PM revealed they were trying to find a nurse earlier because the oxygen tank on the back of Resident 3's wheelchair was empty and needed to be changed. C. Record review of Resident 2's undated care plan revealed an admission date of 2/20/2026 with the following diagnoses: -Fracture of lower end of right femur -Chronic Obstructive Pulmonary Disease (COPD) -Chronic Diastolic Heart Failure -Idiopathic sleep related nonobstructive alveolar hypoventilation (a rare condition characterized by shallow breathing and low oxygen levels during sleep, without airway obstruction or an identifiable underlying medical condition, causing elevated carbon dioxide levels leading to fragmented sleep, morning headaches, and severe daytime fatigue) Record review of Resident 2's undated Care Plan revealed a focus of: Oxygen: Resident uses oxygen therapy routinely or as needed and is at risk for ineffective gas exchange. This is related to COPD, Asthma, Recurrent Pneumonia. Interventions are listed as follows with an initiation date of 1/30/2026 -Administer oxygen therapy per physician's orders. -Monitor for signs and symptoms of respiratory distress and report to the physician as needed. Respiratory distress could include an increased respiratory rate, tachycardia, diaphoresis, lethargy, confusion, persistent cough, pleuritic pain, accessory muscle use, decreased oxygen saturation, or changes in skin color such as a bluish or grey tint. A focus of Respiratory Status: Impaired: Resident has impaired respiratory status and is at risk for shortness of breath, respiratory distress, increased anxiety, and hypoxia. Interventions are listed as follows with an initiation date of 1/30/2026 -Monitor for shortness of breath, respiratory distress, wheezing, fatigue, increased anxiety and implement appropriate ordered interventions. Notify physician if interventions are not effective. -Monitor pulse oximetry as ordered and report abnormals to the physician -Assess lung sounds and monitor vital signs per physician orders. Assess respiratory status to include rate, depth, pattern, peripheral skin color, and pulse oximetry. Record review of Resident 2's practitioners order dated 1/28/2026 revealed oxygen (O2) at 1 liter per minute (LPM) via nasal cannula (NC) at hour of sleep (HS) Further record review of O2 saturation summary document revealed Resident 2 was not receiving oxygen,when Resident 2 should have, on the following days and times: 3/24/2026 at 12:36 AM 3/21/2026 at 1:33 AM 3/12/2026 at 12:25 AM 2/27/2026 at 10:55 PM 2/22/2026 at 11:08 PM 2/11/2026 at 1:31 AM 2/9/20206 at 11:51 PM 2/9/2026 at 2:39 AM 2/6/2026 at 12:07 AM 2/3/2026 at 3:50 AM A record review of Resident 2's Minimum Data Set (MDS, a federally mandated assessment tool use for care planning) dated 2-26-2026 revealed Resident 2 dependent on staff for chair/bed to chair transfers, toilet transfers, sit to lying, lying to sitting at edge of bed, and they require substantial/maximal assistance to roll left and right. In addition the facility assessed Resident Brief Interview of Mental status (BIMS as a 15. According to the MDS [NAME] a score of 13 to 15 indicates a person is cognitively intact. An interview on 3/25/2026 at 12:55 PM was conducted with Resident 2. During the interview Resident 2 confirmed staff did not give Resident 2 oxygen at bed time on 3/24/2026 and in the morning of 3/25/2026 for the 20 minutes. A record review of a facility policy dates 8/1/2023 revealed Personnel authorized to initiate oxygen therapy include physicians, Registered Nurses, Licensed Practical Nurses, and Respiratory Therapists.

Licensure Reference Number 175 NAC 12-006.10(D) Based on observation, interview, and record review; the facility failed to ensure 2 (Residents 3 & 2) of 8 sampled residents were free of significant medication errors. The facility census was 74.Findings Are: A record review of facility policy Medication Reordering dated 2025 revealed a policy statement of It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of the resident. The policy guidelines states acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. Each time a nurse is administering medications and observes 6 or less doses left of one kind, that nurse will reorder the medication, time permitting. In the event of new orders, the facility is allowed 24 hours to begin a medication unless otherwise specified by the physician. A.A record review of Resident 3's admission Record dated 1/21/2026 revealed the resident was admitted to the facility on [DATE]. An observation on 1/21/26 at 7:34 AM revealed Licensed Practical Nurse (LPN)-A preparing medications for Resident 3. Upon entering Resident 3's room, the resident stated to LPN-A that their jaw was hurting really bad. LPN-A replied that it can take some time for antibiotics to begin working and the resident replied that no one had given them their antibiotic yet. The LPN stated that they would look into this as the antibiotic had been ordered the day prior. After completion of Resident 3's medication and cares, LPN-A returned to the medication cart and confirmed that there was no antibiotic listed in Resident 3's orders. An interview on 1/21/2026 at 7:38 AM with LPN-A revealed that when new orders are received the orders are sent to the pharmacy, the pharmacy staff enters the order into the resident's medical records and then brings the medication to the facility. LPN-A confirmed that Resident 3 had been seen by the dentist on 1/20/2026 and that LPN-A had personally faxed the new antibiotic order to the pharmacy during their 6 AM to 6 PM shift, so LPN-A was unsure why the order was not in the resident's order list to administer. An observation on 1/21/2026 at 7:43 AM revealed LPN-A had logged onto the computer at the nurse's station and then called the pharmacy. LPN-A explained to the pharmacy that Resident 3 had an antibiotic order that had been faxed to the pharmacy the day prior but there was no order in their medical records. The pharmacist told LPN-A that the medication was at the facility and LPN-A reminded the pharmacy that they could not administer the medication until the pharmacy entered the order into the medical record. The pharmacy told LPN-A that they would get the order entered. A record review of Resident 3's Progress Note dated 1/20/2026 revealed the resident had returned to the facility from a dental appointment with a new order for Augmentin (an antibiotic medication) twice a day (BID) for 10 days and that the medication was to be delivered by the pharmacy. A record review of a dental provider note for Resident 3 dated 1/20/2026 revealed the resident had been evaluated for pain/infection of lower teeth. The provider prescribed an antibiotic and was going to schedule the resident for teeth extraction. A record review of a fax dated 1/20/26 revealed the fax had been sent to the pharmacy and stated Resident 3 had a dental order for Augmentin 875/160 BID for 10 days and was to be delivered by the pharmacy. The document was noted by LPN-A. An interview on 1/21/26 at 12:17 PM with Resident 3 revealed the resident was wanting to know if they had any medications due at that time because they were needing something for their pain. An interview on 1/21/26 at 2:05 PM with the Director of Nursing (DON) confirmed that the pharmacy did enter the facility's medication orders and that there had been some breakdowns in this process. The DON stated that the day nurse on 1/20/2026 should have reported off to the night nurse about Resident 3's antibiotic order to ensure it was entered into the medical record by the pharmacy that day. The DON confirmed Resident 3 should have received their first dose of the antibiotic the same day it was ordered. B.A record review of Resident 2's admission Record dated 1/21/2026 revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of Type 2 Diabetes Mellitus (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production). A record review of Resident 2's January 2026 Medication Administration Record revealed the resident had an order for Ozempic (a non-insulin diabetic medication) 8 milligrams/ 3 milliliters. The order stated to inject 2 milligrams every 7 days for Type 2 Diabetes Mellitus. The order had a start date of 9/3/2025 and an administration time of 7:00 AM. An observation on 1/21/26 at 7:22 AM revealed LPN-A preparing to administer medications to Resident 2. LPN-A was unable to locate the resident's Ozempic injection on the medication cart or in the medication storage room. An interview on 1/21/2026 at 7:22 AM with LPN-A confirmed they had not been able to locate Resident 2's Ozempic injection that was due to be administered that morning. LPN-A stated that normally this medication would be reordered when the last dose was administered since it was a once weekly injection, but it appeared this had not been done. An interview on 1/21/26 at 12:02 PM with LPN-A revealed the LPN had confirmed Resident 2's Ozempic had not been reordered when the last dose was administered the week prior, that the LPN had contacted the pharmacy and that the pharmacy would be delivering the medication later that day. A record review of Resident 2's Progress Note dated 1/21/2026 at 12:35 PM revealed LPN-A had been unable to give the resident their Ozempic injection and that it was reordered from the pharmacy. The note also revealed the pharmacy had confirmed the reorder and that it would be delivered that evening with drop off meds. An interview on 1/21/26 at 2:05 PM with the DON confirmed that last person to administer Resident 2's Ozempic would have been responsible for reordering the medication, and that this had not occurred.

Licensure Reference Number NAC 175 12-006.11(E) Based on observations, interviews, and record review, the facility failed to store, prepare, and serve food in a manner to prevent potential for foodborne illness. This included not wearing gloves while touching food, not wearing beard covers in the food preparation area, not using water from a clean source for food preparation or steam table. This had the potential to affect all 59 residents who resided within the facility. Findings are: A. An observation on 6/23/25 at 10:58 AM in the walk-in cooler of the kitchen revealed: - 1 Sunkist orange juice concentrate 3-liter container, more than 75% used, no open date. - 1 Sunkist apple juice concentrate 3-liter container labeled 5/17, approximately 25% used. An observation on 6/23/25 at 11:18 AM in the dry goods storage area revealed: - 1-gallon jugs (128 fluid ounces) of Pearl [NAME] Company Original syrup, including 1 unopened jug with a best by date of 12/29/24 and 1 opened partial jug with an opened date of 3/20/24 and best by date of 12/29/24, and three unopened jugs with a best by date of 11/9/24. - Seven unopened 46-oz boxes of Grove brand pineapple juice, all labeled with an expiration date of 5/30/25. A record review of a facility policy titled, Food Safety Requirements, last revised 3/26/25, revealed that food should be labeled, dated, and monitored so it is used by its use-by date. An interview with the Dietary Manager (DM) on 6/23/25 at 11:36 AM revealed the following: - The 5/17 written on the apple juice concentrate referred to the date the item was received in the kitchen, and that there was no open date written on either container of concentrated juice. - The DM had consulted the juice manufacturer's website and found that the shelf life for the concentrated juice if opened was 10 days. The DM stated that the accepted practice is for kitchen staff to label the containers with an open date and follow the manufacturer's recommendations, and that the juice should have been discarded. An interview with DM on 6/23/25 at 11:36 AM confirmed the food items listed above were not safe or suitable for resident use and should have been used or discarded prior to the best by dates, and that opened items should have been labeled with an open date. B. Observations on 6/23/25 at 10:53 AM in the kitchen food preparation area revealed the DM and Cook-B were not wearing any covering over their lip and chin facial hair. An observation on 6/23/25 at 10:57 AM revealed that Dietary Aide-D (DA-D) had facial hair on their upper lip and chin but was not wearing a beard cover. An observation on 6/23/25 at 11:15 AM revealed that Dietary Aide-C (DA-C) walked through dry storage area to dining room. DA-C had facial hair on their upper lip and chin but was not wearing a beard cover. Record review of a facility policy titled, Food Safety Requirements, last revised 3/26/25 revealed that dietary staff must wear hair restraints, including beard covers, to prevent hair from contacting food. A record review of a facility policy titled, Maintaining a sanitary tray line, last revised 3/26/25 revealed staff shall wear hair restraints when preparing or handling food. An interview with DM on 6/23/25 at 11:36 AM revealed that beard covers were worn by kitchen staff for hair longer than ¼ in length, and that the staff members with hair or beards longer than that should have been wearing beard covers. DM confirmed that staff members Cook-B, DA-C, DA-D, and themselves (DM) should have worn beard covers while in the kitchen. C. An observation on 6/23/25 at 11:36 AM in the kitchen revealed Cook-B putting a clean grill scraper (a stainless-steel blade with plastic handle) into an uncovered stainless-steel pan with a charcoal block, next to several cleaning chemicals under a sink where dirty dishes were washed. A record review of a facility policy titled Food Safety Requirements, last revised 3/26/25, revealed, clean dishes shall be kept separate from dirty dishes. A record review of the 2017 Nebraska Food Code Section 7-201.11 revealed that toxic materials should be stored so they cannot contaminate food, equipment, and utensils. An interview with Cook-B at that time revealed the location observed under the sink was where the grill cleaning tools were always kept. An interview with DM on 6/23/25 at 11:40 AM confirmed that the grill cleaning tools were kept in that location. DM stated they were unaware the grill tools should not be kept in that location but agreed that accidental contamination could occur. D. An observation on 6/23/25 at 11:34 AM revealed Cook-B making a half sandwich of pulled pork on a hamburger bun. Cook-B touched the bun with an ungloved left hand and cut in half from top to bottom, scooped meat onto the opened bun, and then placed the top of the bun onto the meat without wearing gloves. Cook-B used a metal scoop to put macaroni and cheese in a small bowl, put the bowl on the plate with the half sandwich, then put into the serving window. Cook-B continued with the lunch service for additional residents. A record review of a facility policy titled Food Safety Requirements, last revised 3/26/25 revealed that staff shall not touch food with bare hands. The policy also revealed that gloves would be worn when directly touching ready-to-eat foods. A record review of a facility policy titled, Maintaining a sanitary tray line, last revised 3/26/25 revealed staff shall wear gloves when handling food items, especially when handling ready-to-eat foods. An interview with Cook-B on 6/23/25 at 11:38 AM revealed that Cook-B performed frequent handwashing instead of wearing gloves because they had been instructed in the past by another staff member that it was acceptable to do so. An interview with the DM at this time revealed that they had questioned the practice of not wearing gloves while touching ready-to-eat food in the past, but they were told by a superior the practice was allowed. E. An observation of food preparation on 6/25/25 at 9:53 AM revealed Cook-E dispensing water from the faucet in the handwashing sink into pitchers. The water from the handwashing sink was transferred into two separate pans for making boiled carrots and 2 more containers for instant mashed potatoes. At 10:35 AM water from the handwashing sink was added to the steam table. A record review of the 2017 Nebraska Food Code Section 5-205.11 revealed that a handwashing sink may not be used for another purpose besides handwashing. An interview with Cook-E on 6/25/25 at revealed they were not aware that the Nebraska Food Code stated the handwashing sink may only be used for handwashing. Cook-E stated the sink that was supposed to be used for clean water was on the opposite side of the kitchen. An interview with DM revealed the handwashing sink was being used for water because the hot water routinely took too long to reach the other faucets in the kitchen. Following education regarding the Food Code, they confirmed the practice could result in cross contamination.

Licensure Reference Number NAC 175-12 006.09(F) Based on record review and interviews, the facility failed to implement a Comprehensive Care Plan (a detailed, individualized guide that outlines a residents medical, functional, and psychosocial needs) addressing the need for repositioning bars based on assessed physical needs. A review of 1 (Resident 23) out of 3 sampled residents. The facility identified a census of 59. Findings are: A record review of the facilities Positioning Rails and Monitoring Policy dated 10/08/2024 revealed positioning rails are to only be implemented when clinically indicated. A record review of a Minimum Data Set (MDS, a federally mandated assessment tool for nursing homes reveals) a Brief Interview for Mental Status (BIMS) score of 11 idicating the resident is moderately cognitive impairment. An observation on of Resident 23's bed 6/23/2025 at 10:00 AM revealed 2 bed canes (a type of bed rail), 1 on each side of the bed. An interview with Resident 23 on 6/23/2025 10:00 AM revealed the (gender) did not know why bed canes were on (gender) bed. Resident revealed the repositioning bars were on the bed when (gender) was admitted . A record review of a Resident 23's Care Plan revealed no documentation for the use of the repositioning bars. An interview with the Assistant Director of Nursing (ADON) at 9:15 AM confirmed that resident 23s Care Plan did not include the use of bed canes and that it should have.

Based on interviews and record review, the facility failed to assess a wound and obtain wound care orders for Resident 67. The sample size was 6 with the facility identifying a census of 59. Findings are: A record review of Resident 67's admission Summary revealed Resident 67 was admitted to the facility on [DATE] after a surgery to the right ankle for intravenous (IV) antibiotics, wound care, and physical therapy services. Resident 67 had an admission diagnosis of Osteomyelitis (a bone infection, most often caused by bacteria) and Cellulitis (a bacterial infection of the skin and underlying tissues) to the right ankle. A record review of Resident 67's Physician Orders revealed no documented evidence of wound care orders to the right lower leg or Resident 67's weight-bearing status (the amount of weight that can safely be placed on a body part during healing after an injury or surgery). A record review of a progress note on 6/21/25 revealed that Resident 67 is alert and oriented to person, place, time, and situation. The note revealed that Resident 67 is able to make their needs known. An interview with Resident 67 on 6/23/25 at 9:30 AM revealed that their dressing had not been changed since they arrived because the facility stated they had no wound care orders. Resident 67 stated that no one has taken off their dressing to look at their wound. Resident 67 stated that they also thought they were supposed to be non-weight bearing but that the facility has been doing toe touch transfers. An interview with RN-A on 6/24/25 at 12:25 PM confirmed that there had been no dressing change or visualization of the wound since Resident 67 has been admitted on [DATE]. RN-A confirmed that the facility had no wound care orders at that time. RN-A further revealed that they thought Resident 67 was to be non-weight bearing but would need to clarify. RN-A confirmed that there is no weight bearing status order in Resident 67's order set. An interview with NA-F on 6/23/25 at 11:35 AM revealed they were not totally sure how Resident 67 transferred but thought they were non-weight bearing. An interview with the Rehab Services Director (RSD) on 06/25/25 at 9:26 AM revealed that Resident 67 is on their caseload and that they had orders that Resident 67 was to be non-weight bearing. The RSD revealed that they receive their orders from the Physical Therapist. The RSD later produced a document from Resident 67's discharge paperwork that revealed Resident 67 was to be non-weight bearing upon discharge from the hospital.

Licensure Reference Number NAC 175-12 006.09(G)(i)7 Based on record review and interviews, the facility failed to document a recapitulation (a complete summary of resident stay in nursing facility from admittance to discharge) for a resident-initiated discharge for 1 (Resident 50) of 6 sample resident. The facility identified a census of 59. Findings are: A record review of a Discharge summary and Plan of Care dated 06/08/2025 of Resident 50 revealed no documentation of a recapitulation summary of residents stay at facility. An Interview with the Social Service Director (SSD) on 06/24/2025 02:30 PM revealed that the recapitulation has not been part of the facilities discharge process, and that the facility utilized a Discharge Summary and Plan of Care. The SSD confirmed they were unaware of the regulatory requirement for the Recapitulation Summary and stated they would work to incorporate it in the discharge process in the future.

Licensure Reference Number 175 NAC 12-006.09(H)(i)(3) Licensure Reference Number 175 NAC 12-006.09(J)(i)(1) Based on observations, record reviews, and interviews; the facility failed to implement interventions to prevent weight loss for 2 (Residents 6 & 7) of 4 sampled residents. The facility census was 68. Findings Are: A record review of the facility policy Nutritional Management with review/revise date of 4/9/24 revealed the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of (gender) overall condition. In the Care plan implementation section, the policy stated an example of an intervention was to provide physical assist or provision of assistive devices and stated that real food would be offered first before adding supplements. A record review of a facility provided document Staff Education dated 2/11/2025 revealed that a nurse must be present in the dining room during every meal. A. A record review of Resident 6's Admission Record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of dementia. A record review of Resident 6's most recent 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 12/26/24 revealed the resident had not had any weight changes, was on a therapeutic diet, and required supervision or touch assistance with eating. A record review of Resident 6's undated Care Plan revealed a Focus area stating the resident was at nutritional risk, which had a goal dated 12/16/24 of I will maintain a stable weight with no significant changes. The care plan also revealed in the Activities of Daily Living section that for eating/dining the resident required prompting, cueing, and set up. A record review of Resident 6's weights documented in their electronic health records revealed the following: -On 2/7/25 the resident weighed 82.5 pounds (lbs) and on 3/14/25 the resident weighed 76 lbs. This was a 7.8% weight loss in one month. -On 12/13/24 the resident weighed 86.5 lbs and on 3/14/25 the resident weighed 76 lbs. This was a 12.1% weight loss in 3 months. -On 9/13/24 the resident weighed 84.5 lbs and on 3/14/25 the resident weighed 76 lbs. This was a 10% weight loss in 6 months. A record review of Resident 6's Medication Administration Record (MAR) for February and March of 2025 revealed the resident had an order for Ensure or Glucerna three times a day, with a start date of 8/15/2024. Further review revealed the resident drank 100% of most doses. A record review of Resident 6's Task Monitor Amount Eaten documentation from 2/16/25 through 3/17/25 revealed Resident 6 consumed less than 50% of 40 out of the 90 meals, and there were 16 out of the 90 meals that had no documentation. A record review conducted on 3/18/25 of Resident 6's Progress Notes revealed a progress note dated 2/2/25 which stated the resident had been seen by their provider with no changes to medications and a statement to encourage protein drink/supplement daily. There were no additional progress notes after that date. A record review conducted on 3/18/25 of Resident 6's electronic medical records revealed no evidence that the facility had reached out to a provider or the dietitian in the prior 30 days related to the resident's weight loss. An observation on 3/17/25 beginning at 11:57 AM in the dining room revealed staff were bringing residents into the room at that time. At 12:10 PM the dietary aides began passing meal trays out to the residents who were in the room. At 12:16 PM nurse aides began entering the room and assisting residents with eating at two of the tables. Resident 6 was sitting in a chair approximately 1.5 feet away from the table where their food and drinks were. At 12:29 PM Resident 6 dropped their fork on the floor and a nurse took a new one to the resident. At 12:41 PM, Resident 6 left the dining room after consuming less than 25% of their food, 50% of their water, and 25% of their tea. No staff approached the resident during the meal to assist them to scoot their chair closer to the table, ask if they needed any assistance, or ask if they would like something different to eat. An observation on 3/18/25 from 7:37 AM through 8:23 AM of breakfast meal service in the dining room revealed Resident 6 was not in the dining room. An observation on 3/18/25 at 8:25 AM revealed the door to Resident 6's room was closed. In the dining room, Resident 6's meal ticket was sitting on the table next to the serving window, which is where the facility kept them until the resident was served their meal. A continuous observation on 3/18/25 beginning at 8:44 AM revealed Resident 6's call light was turned on and their room door was closed. At 8:57 AM, staff entered Resident 6's room, turned off the call light, and left the room. At 9:00 AM, the bath aide entered Resident 6's room and 3 minutes later both the bath aide and Resident 6 exited the room and walked down the hallway. Resident 6 attempted to walk into the dining room and the bath aide redirected the resident into the bathing room, stating lets go take a bath first. At 9:24 AM, Resident 6 exited the bathing room, and the bath aide guided the resident to a table in the dining room where the resident sat down. At 9:27 AM, the bath aide returned to the dining room and placed a plate of food, cup of orange juice, and cup of hot tea in front of Resident 6. The aide then left the dining room, the resident and a dietary aide remained in the dining room. Resident 6 spent from 9:27 AM until 9:34 AM opening their sugar packets and pouring them into the hot tea cup. Resident 6 began eating their breakfast at 9:36 AM. An interview on 3/18/25 at 9:36 AM with Dietary Aide (DA)- E revealed that there were typically 3-4 days per week at breakfast time where 2-3 residents were not taken to the dining room for their meal until after most of the other residents were done eating. An interview on 3/18/25 at 10:10 AM with NA-C revealed the staff did not provide assistance to Resident 6 during meals because this resident did not need assistance. When asked what staff were to do if a resident did not eat very well during a meal, NA-C stated the facility did not have any set guidelines, but that NA-C would offer the resident something different if the resident did not want to eat what had been served. An interview on 3/18/25 at 10:20 AM with Licensed Practical Nurse (LPN)-B revealed the nurse's responsibility when a resident had weight loss identified was to ask staff to re-weigh the resident to verify the weight, and to fax the resident's doctor and ask for Ensure. LPN-B stated that the nurse working the medication cart was responsible for administering any Ensure that was ordered for residents. LPN-B stated Resident 6's morning dose of Ensure was usually given around 8:00 AM with their breakfast and medications, and that Resident 6 usually drank all of their Ensure. An interview on 3/18/25 at 10:25 AM with the Director of Nursing (DON) revealed that the facility addresses resident's not eating well on a case-by-case basis. DON stated the facility discusses residents with weight loss during their daily stand up meetings, during weekly risk meetings, and during monthly Quality Assurance (QAPI) meetings. DON stated Resident 6 has had weight loss and receives a supplement three times a day, which the resident did drink routinely. DON stated that Resident 6 was an independent person and did not often want assistance from staff, but that the DON would still expect staff to offer to assist the resident if they were not eating during meals. B. A record review of Resident 7's Admission Record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of an unspecified fracture of shaft of left femur (the bone in the upper portion of the leg). A record review of Resident 7's Admission MDS dated [DATE] revealed the resident required set up or clean up assist with eating. A record review of Resident 7's undated Care Plan revealed a nutritional status goal of Resident will maintain adequate nutritional and hydration status as evidenced by weight being stable with no signs or symptoms of malnutrition or dehydration being present. An intervention in this section stated, Registered dietitian to evaluate and make diet/supplement change recommendations as needed. In the Activities of Daily Living section, it revealed the resident was independent with eating. A record review of Resident 7's weights documented in their electronic health record revealed the following: -The resident was admitted to the facility on [DATE] with a weight of 117.5 and on 3/1/25 their weight was 110.5. This was a 5.9% weight loss in one month. A record review of Resident 7's MAR for February and March 2025 revealed an order with a start date of 2/2/25 for Ensure or house supplement twice a day; to be administered between 7 AM-11 AM and between 4 PM-7 PM. The order did not allow for documentation of how much the resident consumed. A record review of Resident 7's Task Monitor Amount Eaten documentation from 2/16/25 through 3/17/25 revealed the resident refused their meal for 11 out of the 90 meals and consumed 0-25% of 47 out of the 90 meals. There was also no documentation present for 16 out of the 90 meals. A record review of a scanned document Appointment Order Form dated 3/7/25 for Resident 7 revealed the resident was seen by their provider that day and had an order to start taking a multivitamin. There was no evidence that the provider had been made aware of Resident 7's weight loss. An observation on 3/17/25 from 11:57 AM through 12:39 PM in the dining room revealed residents entering the dining room in preparation for the lunch meal. At 12:10 PM, staff began distributing meal trays to the residents that were present in the room, at this time Resident 7 was sitting in their wheelchair at a table. At 12:19 PM an aide sat down between Resident 7 and another resident but neither resident had their meals yet. Resident 7 received their meal shortly after this. At 12:31 PM, Resident 7 had taken a couple of bites of food and a drink of their tea. The aide sitting next to Resident 7 had been assisting another resident at the table. At 12:39 PM, Resident 7 independently exited the dining room after consuming less than 25% of their meal. Staff had not provided any assistance to the resident during the meal. An observation on 3/18/25 from 7:37 AM through 10:17 AM revealed staff began taking residents into the dining room at 7:37 AM, Resident 7 was sitting in a recliner outside the dining room at that time. The first meal trays began to be delivered at 8:02 AM in the dining room. At 9:00 AM, an aide set up a meal tray on an overbed table in front of Resident 7, who remained sitting in the recliner outside the dining room with their feet elevated, in a slouched position and leaning to the left. Resident 7 could be heard stating to their spouse that they could not get their feet down. The overbed tray was level with Resident 7's chin, and their silverware was sitting on the tray on the far side of their juice cup. The plate contained scrambled eggs, sausage links, and a slice of raisin toast. At 9:02 AM, Resident 7 picked up their juice cup and took a drink. Resident 7 did not take any further drinks from their cup or attempt to eat any of the food on their plate from 9:02 AM through 10:17 AM, and no staff approached the resident. At 10:18 AM, an aide approached Resident 7, cut a piece of egg, held the egg up to the resident and asked if the resident wanted a bite. Resident 7 said no, and then the aide took the plate and silverware into the dining room without any further conversation with the resident. An interview on 3/18/25 at 10:17 AM with Registered Nurse (RN)-A revealed the facility staff removed food trays from residents once they had been sitting out for 2 hours. RN-A then instructed a nearby aide to go see if they could assist Resident 7 after the surveyor pointed out that resident had had their meal tray for over an hour with no food consumption. An interview on 3/18/25 at 10:10 AM with NA-C revealed the staff knows which residents need assistance with meals by looking at the resident care plans which are in a book at the nurse's station. NA-C stated each resident's meal slip, which is placed on their tables with their meals, also states what type of assistance the residents need. When asked what staff were to do if a resident did not eat very well during a meal, NA-C stated the facility did not have any set guidelines, but that NA-C would offer the resident something different if the resident did not want to eat what had been served. NA-C stated that Resident 7 did need assistance with meals but that the resident would not eat. NA-C stated staff sit Resident 7 with their spouse for meals and offers the resident something different that they might enjoy more. NA-C also stated that sometimes Resident 7 ate in the dining room and sometimes in a recliner outside the dining room depending on the day and how the resident was feeling. An interview on 3/18/25 at 10:25 AM with the Director of Nursing (DON) revealed that the facility addresses resident's not eating well on a case-by-case basis. DON stated the facility discusses residents with weight loss during their daily stand up meetings, during weekly risk meetings, and during monthly Quality Assurance (QAPI) meetings. When asked about Resident 7, the DON stated that this resident doesn't ever want to eat. Facility recently changed resident's primary provider at the request of the resident's family due to the previous provider not meeting the resident's needs. DON stated the facility has tried supplements and milkshakes for this resident. DON also stated they would expect staff to cue Resident 7 at mealtimes and as needed. DON stated the facility's Dietitian works remotely and did provide consulting for some residents on 3/14/25, but not for Resident 7. The DON was unsure why Resident 7 was not reviewed/consulted on that date.

Licensure Reference Number 175 NAC 1-005.06(D) Based on observation, interview, and record review, the facility failed to don (put on) Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP- infection control measures that involve targeted use of gowns, gloves, and mask during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms) for one (Resident 5) of three sampled residents. The facility identified a census of 67. Findings are: A record review of an Enhanced Barrier Precautions Policy dated 4/1/24 revealed that EBP was required while performing high-contact care including: dressing, bathing, transferring, hygiene, changing linens, changing briefs or assisting with toileting, device care (central lines, urinary catheters, feeding tubes) and wound care. An observation on 3/17/24 at 1:00 PM revealed Nurse Aid (NA)-C and NA-F use a hoyer lift (a mechanical device designed to assist caregivers in safely transferring individuals with limited mobility from one place to another) to transfer Resident 5 from their wheelchair to their bed for the purpose of perineal (the area of skin and underlying tissues located between the anus and the genitals) care and catheter care. Resident 5 was noted to have an EBP sign on the outside of door related to their urinary catheter. NA-C and NA-F were observed entering Resident 5's room without donning PPE, with the exception of gloves, which were applied while performing perineal care and catheter care. An interview with NA-F on 3/17/25 at 1:50 PM revealed that NA-F was knowledgeable of the EBP policy and situations in which that policy was enacted. NA-F confirmed that Resident 5 was on EBP due to their urinary catheter. NA-F confirmed that perineal care and catheter care are considered high-contact care and confirmed that they were not wearing the PPE that was required per facility policy. An interview with NA-C on 3/17/25 at 1:45 PM revealed that NA-C was knowledgeable of the EBP policy and the situations that required EBP to be implemented. NA-C confirmed that Resident 5 had an EBP sign on their door which indicated the use of PPE for high-contact care. NA-C confirmed that they should have applied the required PPE prior to perineal care and catheter care. An interview with the Director of Nursing (DON) on 3/17/25 at 3:00 PM revealed staff are expected to apply PPE when performing any high-contact cares. The DON confirmed that both nurse aides should have applied PPE prior to providing care for Resident 5.

Licensure Reference Number 175 NAC 12.006.09(H)(i)(3) Based on observation, interview, and record review, the facility failed to provide assistance with activities of daily living for one (Resident 4) of five sampled residents. The facility identified a census of 67. Findings are: A record review of a Day Shift Routine/Checklist revealed at 6:15 AM Nurse Aides (NA) were to begin AM cares, including brushing teeth, and getting residents up and ready for breakfast. They were to obtain daily weight and vital signs as ordered. All residents should get dressed. If they refuse to get up or dressed, inform the Charge Nurse. A record review of an admission face sheet revealed Resident 4 was admitted to facility 11/26/24. Resident 4's pertinent diagnoses are as follows: Acute Kidney Failure (a significant decline in kidney function that leads to an accumulation of waste products in the blood), Chronic Obstructive Pulmonary Disease (a disease that causes inflammation and damage to the airways and air sacs in the lungs, leading to breathing difficulties), Muscle Weakness, Repeated Falls, and Anxiety. A record review of a quarterly Minimum Data Set (MDS- a federally mandated assessment tool used in nursing homes to evaluate level of function) revealed in Section C that Resident 4 has a Brief Interview for Mental Status (BIMS- a standardized assessment tool used to screen for cognitive impairment and track cognitive function in long-term care facilities) score of 9/15 indicating mild cognitive impairment. A record review of an Interdisciplinary Team Meeting Note dated 2/24/25 revealed Resident 4 required set up assistance with eating. Resident 4 was noted to dependent with all other cares including dressing/undressing, bathing, toileting, and transferring. An observation on 3/17/24 at 11:00 AM revealed Resident 4 in their room, laying on their back in bed. Resident 4 had on a yellow hospital gown with small green dots and a small pink food/liquid stain on the upper left collar. Resident 4's hair had a disheveled and uncombed appearance. An oxygen concentrator was turned on with the tubing draped over Resident 4's stomach and was not attached to their nose. Resident 4 did not show any signs of shortness of breath at that time. The bedside table was noted to be over the bed and had a clear, dried sticky substance on the surface. A nutritional supplement was observed on the bedside table with a straw inserted. When asked if Resident 4 had gotten up for breakfast or planned on getting up for lunch, [gender] responded they don't get me up, there's no need to. An observation on 3/17/25 at 12:30 PM of Resident 4 in their room revealed Resident 4 laying in bed, on their back, with oxygen tubing draped over abdomen and not placed in nose in the same fashion as previous observation. Resident 4 was noted to be awake and alert. No changes were noted from the previous observation. An observation on 3/17/25 at 3:00 PM of Resident 4 in bed, laying on their back with oxygen tubing draped over abdomen and not placed in nose. The bedside table was free from debris and trash. An observation on 3/18/25 at 7:50 AM revealed Resident 4 in bed, laying on their back. The oxygen tubing was noted to be placed in the nose and the concentrator was turned on. Resident 4 discussed their family photos at that time. An observation on 3/17/25 at 11:00 AM of Resident 4 in their room revealed Resident 4 laying in bed, on their back. Resident 4 was awake and talking with this surveyor. Resident 4's oxygen concentrator was turned on and the tubing was placed in their nose. Resident 4 had on a yellow hospital gown with green dots with a small pink food/fluid stain on the upper left collar. It appeared to be gown observed on 3/17/25. Resident 4 was observed to have their eyes closed and had a neck pillow placed behind her head. An interview on 3-17-25 at 3:15 PM with Nurse Aid (NA) G revealed Resident 4 is totally dependent on staff for cares. NA-G revealed that they, personally, have never assisted Resident 4 out of bed, but states they have asked Resident 4 if they'd like to and that [gender] has refused. NA-G stated that Resident 4 is supposed to be repositioned every few hours and have their brief changed. An interview on 3/17/25 at 3:30PM with Registered Nurse (RN) A revealed that Resident 4 is on comfort cares and is bed bound and stated that they were using the lift on [gender] but not anymore. RN-A revealed that Resident 4 wore a gown to make it easier to change [gender] brief. RN-A stated I told the same thing to the family when [gender] asked me about why Resident 4 had to wear the gown all the time. RN-A confirms it is the shift expectation for all residents to be assisted with cares including: washing face, brushing teeth, combing hair, and getting dressed for the day. RN-A confirmed that Resident 4 is not actively dying and was often awake and alert enough to get out of bed. 3-18-25 at 9:15 AM Interview with the Director of Nursing (DON) revealed staff are educated regarding the implementation and expectation of assistance with cares including dressing for the day, combing hair, and getting out of bed. The DON confirmed that Resident 4 should not be left in a gown for staff convenience and if Resident 4 chooses to wear a gown that it should be changed daily. The DON confirms that Resident 4 should be assisted with AM cares every morning and PM cares every evening. The DON confirms that if Resident 4 wants to stay in bed then it should be documented and that a more rigorous repositioning schedule should be implemented.

Licensure Reference 175 NAC 12-006.09(I) Based on interviews and record reviews, the facility failed to identify causative factors, and develop and implement new interventions for falls for 3 (Resident 1, 3, 4) of 4 sampled residents. The facility also failed to develop and implement interventions for 1 (Resident 5) of 4 sampled resident at-risk for elopement. The facility identified a census of 54. The facility was notified on 10/16/2024 at 8:40 PM of an Immediate Jeopardy (IJ) which began on 7/4/2024. The IJ was removed on 10/17/2024, as confirmed by the surveyor onsite verification. Findings are: A record review of facility policy Fall Prevention Program with a last revised date of 10/16/23 revealed when a resident experiences a fall, the facility will review and update the resident's care plan. The policy did not include identifying causative factors of falls. A. A record review of an Admission Record indicated the facility admitted Resident 1 on 7/4/2024 with diagnoses of vascular dementia, disorientation, muscle weakness, and repeated falls. A record review of Resident 1's discharge Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning), with a date of 9/30/2024, indicated Resident 1 had moderate cognitive impairment. A record review of Resident 1's Progress Notes with a date of 7/4/2024 revealed Resident 1 was found on the room of their floor. Resident 1 had a skin tear to their right elbow. A record review of a Post Fall Assessment with a date of 7/4/2024 revealed the causative factor of Resident 1's fall as unknown. A record review of Resident 1's Progress Notes with a date of 8/7/2024 at 7:20 AM revealed Resident 1 was found sitting on the floor in front of their closet. Resident 1 had complained of excruciating lower back pain and had two skin tears to their right elbow. Resident 1 was sent to the Emergency Department for evaluation. A record review of an Unwitnessed Fall without Injury report with a date of 8/7/24 revealed Resident 1 was observed sitting on the floor in front of their closet and stated he was trying to get pants. Confusion, noncompliance, and impaired memory were identified as causative factors of the fall. A record review of Resident 1's Progress Notes with a date of 8/7/2024 at 11:00 AM revealed Resident 1 was being admitted to the hospital with lumbar compression fracture and pneumonia. A record review of Resident 1's Progress Notes with a date of 8/12/2024 revealed Resident 1 was observed laying on the floor. Resident 1 had been complaining of chest pain. Resident 1 also suffered a skin tear to their right elbow. A record review of an Unwitnessed Fall without Injury report with a date of 8/12/24 revealed Resident 1 was laying found on the floor. Identified causative factor was poor lighting. A record review of an Unwitnessed Fall without Injury report with a date of 8/13/24 revealed resident was found on the bathroom on their knees. Resident 1 had stated they were trying to get back in their wheelchair when they lost their strength when trying to stand. Confusion and gait imbalance were identified as causative factors and ambulating without assistance. A record review of Resident 1's Progress Notes with a date of 9/28/2024 revealed Resident 1 had arrived from the Emergency Department. Resident 1 was found 20 minutes later on the floor and had been laying in a puddle of blood. Resident 1 was transported by the ambulance back to the hospital. Resident 1 later returned to the facility with a glued facial wound. Resident 1 was placed on 1 on 1 cares. A record review of a Post Fall Assessment with a date of 9/28/2024 revealed the causative factor of Resident 1's fall as noncompliance. A record review of Resident 1's Progress Notes with a date of 9/29/2024 revealed Resident 1 was being non-compliant with staying in the bed. A record review of Resident 1's Progress Notes with a date of 9/30/2024 revealed Resident 1 was found on the ground noted to be bleeding from a previous laceration to his face. Resident was transferred to the Emergency Department by the ambulance. A record review of Resident 1's Progress Notes with a date of 9/30/2024 revealed Resident 1 had been admitted to the hospital following the CT results of having a brain bleed and was also noted to have a cut to their left ear, four stitches to their left eyebrow, a skin tear to their left elbow, and an abrasion to their left shoulder. A record review of an Unwitnessed Fall with Injury report with a date of 9/30/2024 indicated Resident 1's post fall Emergency Department notes indicated Resident 1 was hospitalized with a brain bleed after fall. It also revealed non-compliance, gait imbalance, and ambulating without assistance as causative factors for the fall. A record review of Resident 1's fall care plan revealed Resident 1 was at risk for falls due to cognitive impairment, confusion, unaware of safety needs, and wandering. It also revealed no interventions were placed after Resident 1's fall on 7/4/2024 and the intervention for Resident 1 was 1 to 1with the resident by a staff member from 9/28/2024 was not resolved until 10/4/2024. It also revealed the intervention for Resident 1's fall identified as due to poor lighting was to schedule a doctor's appointment. An interview on 10/16/24 at 5:10 PM with Nurse Aide (NA) - C revealed that fall mats, side rails, and cameras were the only fall interventions NA-C was aware of. Regarding Resident 1, NA-C stated Resident 1 did not like female staff assisting them and would get upset when female staff tried to redirect [gender] or assist [gender]. An interview on 10/16/24 at 5:15 PM with LPN-B revealed that when a resident has a fall, LPN-B does not put new interventions into place for the residents. LPN-B stated they would, however, make sure the resident's bed was in low position and their call light was within reach. When asked about fall interventions, LPN-B stated the only fall interventions they were aware of for the residents were to make sure the residents' beds were in low position and that their call lights were within reach. An interview on 10/16/2024 at 8:12 PM with the Administrator confirmed mental status and noncompliance were not causative factors of falls as the residents are vulnerable adults and lack the safety awareness to protect themselves from falls. The interview also confirmed no causative factor was identified or follow up intervention placed after Resident 1's fall on 7/4/2024. Interview also revealed an intervention of 1 to 1 with staff until settled was placed for Resident 1's fall on 9/28/2024, but no causative factor was identified. The Administrator stated 1 to 1 with staff was discontinued, but was unsure of when, but believed it was on 9/29/2024. The Administrator did confirm the intervention was not resolved off the care plan until 10/4/2024 and confirmed no documentation 1 to 1 with staff was removed or Resident 1 had settled, the Administrator also acknowledge the Progress Note written on 9/29/2024 stated that Resident 1 had been non-compliant with staying in bed. The Administrator also confirmed intervention for Resident 1's fall on 8/12/24 was not appropriate. B. A record review of an Admission Record indicated the facility admitted Resident 4 on 2/16/2024 with diagnoses of chronic pain and repeated falls. A record review of Resident 4's quarterly MDS with a date of 8/15/2024 indicated Resident 4 had severe cognitive impairment. It also indicated Resident 4 had two or more falls since their last assessment. A record review of Resident 4's Progress Notes with a date of 7/1/2024 revealed Resident 4 was in the restroom and had fallen. The progress note did not identify a causative factor of the fall. A record review of Resident 4's Fall report with a date of 7/1/2024 revealed no causative factors of Resident 4's fall had been identified. A record review of Resident 4's Progress Notes with a date of 8/6/2024 revealed Resident 4 was found sitting on the floor by the end of their roommate's bed. The progress note did not identify a causative factor of the fall. A record review of Resident 4's Unwitnessed Fall without Injury with a date of 8/6/2024 revealed no causative factors of Resident 4's had been identified. A record review of Resident 4's Progress Notes with a date of 8/27/2024 revealed Resident 4 had a witnessed fall while sliding off their bed. A record review of an Unwitnessed Fall without Injury report with a date of 8/27/2024 revealed Resident 4 had slid off their bed and fell . A causative factor had been identified as wet floor. A record review of Resident 4's Progress Notes with a date of 8/29/2024 revealed Resident 4 had an unwitnessed fall. Resident 4 had tried to slide from the bed to the trashcan to have a bowel movement and fell . Resident 4 had no injuries. A record review of an Unwitnessed Fall without Injury report with a date of 8/29/2024 revealed resident was attempting to transfer from bed to the trashcan due to needing to have an urgent bowel movement. Causative factors were identified as incontinence and ambulating without assist. A record review of Resident 4's Progress Notes with a date of 9/11/2024 revealed Resident 4 was found laying in the lobby between a chair and their wheelchair. Resident 4 reported [gender] had hit [gender] head. The on-call physician had recommended Resident 4 be sent to the emergency room for evaluation due to being on a blood thinner. The family declined. A record review of an Unwitnessed Fall without Injury report with a date of 9/11/2024 revealed Resident 4 had fallen in the lobby. Causative factors of confusion and noncompliance had been identified for Resident 4's fall. A record review of Resident 4's Progress Notes with a date of 9/29/2024 revealed Resident 4 was found sitting on their bottom with their legs under the bed. Resident was unable to explain what they were doing at the time of fall. Resident 4 had no injuries. A record review of an Unwitnessed Fall without Injury report with a date of 9/29/2024 revealed Resident 4 was observed sitting on their bottom with legs under the bed. Resident 4 was unable to explain what they had been doing doing. Identified causes of Resident 4's fall were determined as poor lighting and improper footwear. A record review of Resident 4's Progress Notes with a date of 10/1/2024 revealed Resident 4 was found sitting on the floor next to their bed and had stated they were trying to get ready for bed. Resident 4 had no injuries. A record review of an Unwitnessed Fall without Injury report with a date of 10/1/2024 revealed Resident 4 was observed sitting on the floor next to their bed, and had stated I was going to bed. It also revealed causative factor identified as impaired memory, confusion, and ambulating without assist. A record review of Resident 4's fall care plan with a date initiated of 3/7/2024 revealed Resident 4 was at risk for falls due to dementia/confusion, gait imbalance, incontinence, and unaware of safety needs. It also revealed the following: - Intervention from fall on 10/1/2024 was a duplicate of 9/27/2024 to educate staff. - An intervention for Resident 4's fall on 9/11/2024 had not been developed and implemented on the care plan. - The intervention for Resident 4's fall on 8/27/2024 was to ensure appropriate footwear, when Resident 4 rolled out of bed. An interview on 10/16/2024 with the Director of Nursing (DON) confirmed no causative factors were identified for Resident 4's falls on 8/6/2024, 7/1/2024. The DON also confirmed Resident 4's intervention for 8/29/2024 and 9/29/2024 were not appropriate. The DON also confirmed Resident 4's fall on 8/27/2024 causative factor and interventions were not appropriate. An interview on 10/16/2024 at 6:17 PM with the Administrator confirmed Resident 4's fall intervention for 10/1/2024 was already used on 9/27/2024. An interview on 10/16/2024 at 6:45 PM with the Administrator confirmed mental status and noncompliance were not causative factors of falls as the residents are vulnerable adults and lack the safety awareness to protect themselves from falls. The Administrator also confirmed the intervention for Resident 4's fall on 8/27/2024 was not appropriate. C. A record review of an Admission Record indicated the facility admitted Resident 3 on 3/8/2022 and had diagnoses of cognitive communication deficit, muscle weakness, repeated falls, difficulty in walking, and osteoporosis. A record review of Resident 3's annual MDS with a date of 8/7/2024 revealed Resident 3 had moderate cognitive impairment. It also revealed Resident 3 had fallen two or more times since the last assessment. A record review of Resident 3's fall care plan with an initiated date of 11/22/2021 revealed Resident 3 was at risk for falls and had recent falls. A record review of Resident 3's Progress Notes with a date of 9/7/2024 revealed Resident 3 had been heard yelling for help. Resident 3 was found sitting on the floor next to their bedroom door. Resident 3 had no injuries. A record review of Resident 3's AS- Post Fall Assessment with a date of 9/7/2024 revealed root cause analysis and interventions boxes were left uncompleted. An interview on 10/16/2024 at 5:48 PM with the Director of Nursing (DON) confirmed a causative factor of Resident 3's fall on 9/7/2024 had not been identified at the time of Resident 3's fall. An interview on 10/16/2024 at 8:06 PM with the Administrator confirmed a causative factor of Resident 3's fall on 9/7/2024 had not been identified at the time of Resident 3's fall. D. A record review of an undated facility policy titled Elopements and Wandering Residents revealed the facility will identify and assess risk and implement interventions when a resident is at risk for elopement. The policy also revealed the team will evaluate unique factors contributing to the resident's risk in order to develop a person-centered care plan. A record review of an Admission Record indicated the facility admitted Resident 5 on 10/2/2024 with diagnoses of heart failure, Chronic Kidney Disease, and Type II Diabetes Mellitus. A record review of the facility's Elopement Log, the facility's list of residents who have been identified to be at-risk for elopement, revealed that Resident 5 was added to the Elopement Log, on 9/4/2024. A record review of Resident 5's undated Care Plan revealed Resident 5 had no care plan focus, goals, or interventions related to elopement, exit seeking, or wandering. A record review of Resident 5's physician's orders revealed Resident 5 had no orders related to their Wanderguard or other orders of interventions for exit seeking. An interview on 10/16/24 at 7:50 PM with Licensed Practical Nurse (LPN) - A revealed they were unaware Resident 5 was at risk for elopement and were unaware Resident 5 had a Wanderguard. LPN-A also confirmed they check the functionality of Wanderguards on nightshift, but had not been checking Resident 5's Wanderguard. An interview on 10/16/2024 at 7:00 PM with the DON confirmed Resident 5 had no focus area regarding elopement or wandering on their care plan. The DON also confirmed Resident 5 had no orders for the Wanderguard or to check the functionality placed in their orders. The facility took the following immediate actions to remove the immediacy of the situation: Facility Abatement Statement: How are we going to identify residents at risk for fall and Elopement: -Fall assessment upon admission -Elopement assessment upon admission How will you remove the deficient practice and when? -Resident 1 (as of 10-16-2024) resident is no longer residing in the facility -Residents 3 and 4 (environmental check will be completed to ensure room is free of clutter, fall hazards and new interventions will be implemented as indicated after check is completed by end of day 10-16-2024) -Resident 5 Wander guarded location and functionality order to monitor was placed on the TAR and Care Plan updated to reflect elopement risk. 10-16-2024 -All staff present now will be educated regarding fall prevention, root cause analysis and elopement, and all other staff will be educated prior to working their next shift. -A Fall Risk assessment will be completed on all HC residents by end of day 10-17-2024 any resident identified as at risk for falls will have appropriate interventions implemented and an care plan updated. -An Elopement assessment will be completed on all HC residents by end of day 10-16-2024 any resident identified as at risk for elopement will have appropriate interventions implemented and care plan updated. -Fall Care Plan created upon admission and reviewed quarterly and as indicated by Fall assessment score. -Residents at risk for falls will have fall care plans (baseline initially) and comprehensive care plan with interventions in place. -With each fall a post fall assessment will be completed, and a root cause analysis will be completed to determine the cause of the fall, and appropriate interventions will be added to prevent a recurrence. -Residents at high risk for elopement as identified by the Elopement assessment score will be provided a wander guard, they will be added to the elopement binder, and an order for monitoring the device will be placed in the orders (location and functionality) every day and night shift. -Risk for elopement will be placed on the care plan with interventions. -Staff will be educated on the location of the Elopement book at the nurse's station, a reminder sign will be added to the staff bulletin board, and a list posted on the facility bulletin board in PCC. -All staff present now will be educated regarding falls and elopement, and all other staff will be educated prior to working their next shift. -A Fall Risk assessment will be completed on all HC residents by end of day 10-17-2024 any resident identified as at risk for falls will have appropriate interventions implemented and an care plan updated. -An Elopement assessment will be completed on all HC residents by end of day 10-16-2024 any resident identified as at risk for elopement will have appropriate interventions implemented and care plan updated. How will we ensure this will not reoccur: -Falls will be reviewed daily in Daily Clinical -Administrator or Designee will utilize the fall review checklist to audit fall review, Root Cause analysis, and intervention implementation weekly x 12 weeks. -Falls will be reviewed weekly in Risk meeting to ensure interventions are effective and if not, new interventions will be implemented. -Administrator or Designee will audit fall review in risk weekly x 12 weeks. -Elopement assessment scores will be reviewed upon admission in Daily Clinical. -Administrator or Designee will audit Elopement assessment scores to ensure appropriate interventions are in place weekly x 12 weeks. At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level.

Licensure Reference Number 175 NAC 12-006.09D2a Licensure Reference Number 175 NAC 12-006.09D2b Based on record review and interview the facility failed to ensure that it developed and implemented interventions to prevent pressure ulcers (a Pressure injury-a localized wound of the skin and/or underlying tissue, usually over a bony area. A bedsore.) for 1 resident (Resident 103). The facility census was 47. Findings are: Record review of the facility policy titled Pressure Ulcers/Skin Breakdown dated April 2018 revealed that the nursing staff will assess and document an individual's significant risk factors for developing pressure ulcers; for example immobility, recent weight loss, and a history of pressure ulcer. The staff will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. Record review of the Admission Record for Resident 103 dated 6/6/23 revealed that Resident 103 admitted into the facility on [DATE] for orthopedic aftercare (care provided after a surgical procedure). The Admission Record revealed that Resident 103 discharged from the facility on 6/20/22. Record review of the progress note for Resident 103 dated 5/20/22 at 12:24 PM revealed that Resident 103 was non-weight bearing on their ankle for 6 to 8 weeks. Record review of the Braden Scale for Predicting Pressure Ulcer Risk (a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure injuries) dated 5/19/22 for Resident 103 revealed that Resident 103 had a score of 18. A score of 18 indicates the resident is at mild risk for pressure ulcer development. The assessment listed clinical suggestions for interventions to put into place to prevent pressure ulcers. No interventions were selected. Interview on 6/8/23 at 2:53 PM with the Facility Administrator (FA) revealed that staff are expected to conduct a Braden Scale assessment on admission and then weekly for 3 weeks for all admissions to the facility. Record review of the medical record for Resident 103 revealed no additional Braden Scale assessments documented for Resident 103 to assess the resident's risk for developing pressure ulcers. Record review of the undated care plan for Resident 103 revealed that it contained no focus area for Resident 103's risk of pressure ulcer development and no interventions for staff to provide care to prevent the development of pressure ulcers for Resident 103 until after Resident 103 developed a pressure ulcer. The focus area titled I have a potential for pressure ulcer development related to immobility was initiated (added to the care plan) on 6/24/22 (this was 4 days after Resident 103 discharged from the facility). Record review of the facility Weekly Skin Check (a form used to document an assessment of the resident's skin) dated 5/19/22 for Resident 103 documented that Resident 103 had skin that was intact (no breaks, scrapes, cuts, or other openings in the skin). (Resident 103 had no pressure ulcers). Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 5/25/22 for Resident 103 revealed that it was the admission assessment for Resident 103. The MDS revealed that Resident 103 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 8 (a score of 8 indicates that the resident has moderately impaired cognitive abilities). The MDS revealed that Resident 103 required the extensive assistance of 2 or more staff providing physical assistance for bed mobility (turning side to side and repositioning) and toilet use. The MDS revealed that Resident 103 was at risk of developing pressure ulcers. The MDS revealed that Resident 103 did not have any unhealed pressure ulcers. The MDS revealed that the only skin and ulcer/injury treatments in place for Resident 103 were surgical wound care, applications of ointments/medications, and application of dressings to the feet. Pressure ulcer prevention interventions of pressure reducing device for chair, pressure reducing device for bed, and turning/repositioning program were not documented as applicable for Resident 103 and were not in place. Record review of the progress note for Resident 103 dated 5/28/22 at 8:54 AM revealed that a pressure area to the sacrum (a triangular bone in the lower back just above the tailbone) was cleansed and the dressing changed. Record review of the facility skin Alteration Evaluation (a facility form used to document breaks in a resident's skin) for Resident 103 dated 5/29/23 documented that Resident 103 now had a pressure ulcer on the left buttock measuring 4.5 centimeters (cm) long, 0.6 cm wide, with no depth. The stage of the pressure ulcer (a classification assigned to a pressure ulcer based on the depth, severity, types of tissues affected, and other characteristics) was marked NA non applicable. The evaluation documented that Resident 103 now had a pressure ulcer on the sacrum (a triangular bone in the lower back just above the tailbone) that measured 3 cm long, 1.5 cm wide, and was 0.8 cm deep. The pressure ulcer was classified as unstageable (full thickness loss of tissue). Record review of the progress note dated 5/29/22 at 3:05 PM for Resident 103 revealed that the facility notified the physician and requested a wound care appointment for Resident 103's open areas to their buttocks. Record review of the progress note for Resident 103 dated 5/30/22 at 9:35 PM revealed that Resident 103 is now on a turn schedule (a schedule for repositioning a resident to reduce pressure on one part of the body for an extended period of time). The note revealed that Resident 103 now had a pressure reducing device to their chair and their bed. (This was 2 days after Resident 103 was identified as having a pressure ulcer on the sacrum.) Record review of the medical record for Resident 103 revealed no documentation of any pressure ulcer prevention interventions prior to the progress note dated 5/30/22. Record review of the facility policy titled Pressure Ulcers/Skin Breakdown dated April 2018 revealed that the nurse shall describe and document the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates (drainage) or necrotic tissue (dead body tissue). b. pain assessment as needed. c. Resident's mobility status. d. Current treatments, including support surfaces. e. All active diagnoses. Interview on 6/8/23 at 2:53 PM with the FA confirmed that Resident 103 developed pressure ulcers while in the facility. The FA confirmed that the facility only had 1 Braden Scale assessment documented for Resident 103. The FA confirmed that the 3 weekly Braden Scale assessments expected after admission were not completed. The FA confirmed that the expectation is for staff to assess and document pressure ulcer measurements and the description of pressure ulcers weekly and as needed until healed. The FA revealed that the staff should complete the Skin Alteration Evaluation weekly until the pressure ulcer is healed. The FA confirmed that weekly monitoring of pressure ulcers including their measurements and description is required to identify if the pressure ulcer is healing or if a new treatment should be considered. Record review of the Weekly Skin Check for Resident 103 dated 6/2/22 revealed that Resident 103 had no new skin alterations. The skin check documented that Resident 103 had pressure injury of the left buttock and sacrum. The documentation did not contain any measurements or description of the pressure injuries for Resident 103. Record review of the Weekly Skin Check for Resident 103 dated 6/9/22 revealed that Resident 103 had no new skin alterations. The skin check documented that Resident 103 had pressure injury of the left buttock and sacrum. The documentation did not contain any measurements or description of the pressure injuries for Resident 103. Record review of the Weekly Skin Check for Resident 103 dated 6/16/22 revealed that Resident 103 had no new skin alterations. The skin check documented that Resident 103 had specific skin concerns of the left buttock and sacrum. The type of skin concern (pressure injury) was not documented. The documentation did not contain any measurements or description of the pressure injuries for Resident 103. Record review of the facility skin Alteration Evaluation for Resident 103 dated 6/16/22 documented that Resident 103 had an open area on the left buttock that measured 0.5 cm long by 1 cm wide, with no depth. The stage of the pressure injury was not documented. The evaluation documented that the area on the sacrum was an unstageable pressure ulcer that measured 4.5 cm long, 2.5 cm wide, and had a depth of 4 cm. The section titled other relevant information documented that the resident was seeing wound care for treatment of the left buttock and sacrum. Record review of the MDS Discharge Assessment for Resident 103 dated 6/20/22 revealed that Resident 103 had two stage 2 pressure ulcers. Interview on 6/8/23 at 3:50 PM with the FA revealed that Resident 103 went out of the facility for wound care treatment with the contracted wound care clinic once the resident developed pressure ulcers in the facility. The FA revealed that the facility had difficulty getting any documentation from the wound clinic. Interview on 6/8/23 at 3:50 PM with the FA confirmed that the care plan for Resident 103 was updated to include the potential for pressure ulcer development on 6/24/22. The FA confirmed that the update to the care plan was completed to document the interventions that were put into place on 5/29/22 for Resident 103 after Resident 103 developed a pressure ulcer. The FA confirmed that the care plan for Resident 103 did not contain interventions to prevent a pressure ulcer prior to the development of pressure ulcers.

Licensure Reference Number 175 NAC 12-006.09D6 Based on observations, record reviews and interviews; the facility failed to ensure that oxygen was in place and administered as ordered and that respiratory status was monitored for one sampled resident (Resident 39) who frequently removed oxygen resulting in low oxygen blood levels. The facility census was 50 with 17 current sampled residents and 2 closed records. Findings are: Review of the Resident Face Sheet revealed that Resident 39 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, edited 1/20/17, revealed that the resident was at risk for impaired gas exchange related to chronic [MEDICAL CONDITION]. Approaches included administer oxygen per nasal cannula, assess and record signs of impaired gas exchange (confusion, restlessness, irritability), resident refuses to wear oxygen frequently, monitor oxygen saturation as ordered and monitor and document respiratory status as needed with changes in respiratory status. Interview with a family representative on 1/24/17 at 12:30 PM revealed they often found the resident without oxygen. Further interview revealed that the resident was more confused, restless and agitated when the oxygen wasn't kept on which made it even more difficult to get the resident to keep the oxygen in place. Observations on 1/24/17 at 8:45 PM revealed the resident seated in the wheelchair in room with oxygen cannula (tubing placed in the nose to administer supplemental oxygen) on the floor. Further observations revealed NA (Nursing Assistant) - M attempted to place the oxygen on the resident and the resident refused. NA - M reported to LPN (Licensed Practical Nurse)- H, Charge Nurse, that the resident refused the oxygen and was agitated. LPN - H entered the room and encouraged the resident to use the oxygen and the resident complied. LPN - H checked the resident's oxygen saturation which was 79% (normal oxygen saturation is greater than 90%). LPN - H encouraged the resident to take deep breaths and after several minutes the oxygen saturation was 80%. At 9:15 PM, LPN - H reported that a respiratory treatment was administered and then the resident's oxygen saturation rate was 90%. Observations of the resident on 1/24/17 at 9:45 PM revealed that the resident's oxygen was off and the cannula was draped over the arm of the wheelchair. Interview on 1/24/17 at 10:00 PM with NA - M revealed that the resident continued to refuse to get ready for bed. Observations on 1/25/17 at 4:30 AM, 5:30 AM and 6:00 AM revealed the resident sleeping in bed with the oxygen cannula off. Interview with RN (Registered Nurse) - L on 1/25/17 at 6:05 AM revealed that RN-L was not aware that the resident's oxygen had been off this morning. RN - L checked the oxygen saturation which was reported to be 86%. Observations on 1/25/17 at 7:00 AM revealed the resident sleeping in bed with the oxygen cannula off. Observations on 1/25/17 at 8:20 AM revealed MA (Medication Aide) - E awakened the resident for morning cares. MA - E shut the oxygen concentrator off. Further observations revealed that the resident did not have oxygen on during the morning cares. MA - E applied the oxygen for the resident at 8:50 AM. Review of the Nurses Notes revealed no notes after 1/11/17 which stated that the resident was off Medicare A skilled nursing services. There was no documentation of the resident's refusal to use oxygen as ordered, restlessness and agitation or low oxygen saturation levels. Review of the Treatments, dated January 2017, revealed an order, dated 12/12/16, for oxygen at 2 liters per minute per nasal cannula continuously. Review of the Routine Medications, dated January 2017, revealed an order, dated 12/12/16 for respiratory treatments four times a day. Review of the Respiratory Assessment Flow Sheet, dated January 2016, revealed an assessment completed daily after a respiratory treatment which showed oxygen saturation levels of 94% - 98%, and lungs clear. Interview with the DON (Director of Nursing) on 1/26/17 at 8:30 AM confirmed that the nurses should monitor and document the resident's respiratory status, in addition to the daily assessment, as the resident was at risk for low oxygen saturation levels, increased restlessness, agitation and discomfort when the oxygen was removed.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.07 Based on observations, record reviews, and interviews conducted during the annual standard survey; the facility's Quality Assurance Committee (QA) failed to: 1) meet at least quarterly, 2) ensure the physician attended the QA meetings at least quarterly, and 3) develop and implement plans of actions to correct multiple issues of deficient practice relevant to resident care and services. The facility failed to implement effective plans of action to maintain correction for 6 previously cited areas of deficient practice identified (F253, F272, F309, F323, F325, and F363) during surveys completed on 5/7/12 and 2/9/11. The facility census was 50. Findings are: A. During an interview on 7/31/13 at 3:00 PM, the Administrator revealed the QA committee met quarterly. The Administrator revealed the Registered Pharmacist observed medication administration, but did not attend the QA Committee meetings. The Administrator revealed the assessment and monitoring of interventions for weight loss was discussed every quarter, but the committee hadn't looked at whether or not the interventions were resident specific. The Administrator revealed the QA Committee had not addressed the monitoring and implementation of behavioral interventions because there was not a lot to address because "we don't have a strong behavioral management committee." The Administrator revealed dietary following the preplanned menu when serving meals hadn't been a problem before, so hadn't been addressed. The Administrator revealed resident's end of life issues probably had not been discussed unless it was brought up with a nutrition or skin issue. The Administrator revealed the accounting for resident property and personal inventories had not been addressed at the QA Committee meetings. B. Review of the facility's QUALITY ASSURANCE ATTENDANCE SIGN IN sheets revealed the QA Committee had met on 5/31/12, 8/28/12, 11/28/12, and 3/7/13. An interview on 7/31/13 at 3:00 PM, the Administrator revealed the QA Committee hadn't met in June 2013, but did on 7/11/13. The Administrator stated that was probably out of compliance, but the committee went ahead and reviewed issues. C. Review of the facility's QUALITY ASSURANCE ATTENDANCE SIGN IN sheets revealed the physician had not attended the 3/7/13 meeting. D. The facility was found to be deficient in multiple areas of regulatory compliance after the tasks of the annual standard survey were completed. The facility failed to maintain corrections for the regulations identified as repeat deficiencies and failed to identify and develop plans of action to prevent deficient practice in the areas identified below. Please refer to the Tag citations for specific detailed findings: - F157 Failed to notify residents' physicians of a change in condition; - 7166 Failed to address and resolve residents' grievance; - F253 Failed to provide a clean and well-maintained environment. Previously cited on 5/7/12; - F272 Failed to completed comprehensive assessments of residents' needs. Previously cited on 5/7/12; - F279 Failed to develop comprehensive care plans that addressed residents' needs; - F309 Failed to assess fluid restriction and failed to assess and monitor residents' impaired skin conditions. Previously cited at F327 on 2/9/11; - F323 Failed secure chemicals to prevent accidents, previously cited at F252 on 2/9/11 and failed to implement interventions to prevent resident falls. Previously cited on 5/7/12; - F325 Failed to implement interventions to prevent significant weight loss. Previously cited on 5/7/12 and on 2/9/11; - F332 Failed to ensure the medication administration error rate was 5% or less; - F363 Failed to follow the preplanned menu during meal service. Previously cited on 2/9/11; - F520 Failed to maintain an effective Quality Assurance Program. E. Review of the procedures for the QA Committee, that had been submitted by the Administrator revealed the committee meetings were "held quarterly" and listed the committee members. There were 8 committee member which included the Director of Nursing, a physician, and 6 members from various departments. The process for how the committee functioned was not described.

LICENSURE REFERENCE 175 NAC 12-006.09D8b Based on record review, observation and staff interview, the facility failed to evaluate and implement interventions to prevent significant weight loss from occurring for 1 (Resident 37) resident reviewed. The facility census was 50 at the time of the survey and the survey sample size was 46. Findings are: Resident 37 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] according to the RESIDENT ADMISSION RECORD on the medical record. The following [DIAGNOSES REDACTED]. Review of Resident 37's WEIGHTS record from January 2013 to July 2013 revealed the following weights: January 24, 2013 -185 lbs (pounds) nude April 23, 2013 -164.5 lbs nude June 21, 2013 -154 lbs dressed July 23, 2013 -150 lbs nude From January 24, 2013 to July 23, 2013, Resident 37 lost 35 lbs, going from 185 lbs to 150 lbs, representing an 18.9% significant weight loss in 6 months. From April 23, 2013 to July 23, 2013, Resident 37 lost 14.5 lbs, going from 164.5 lbs to 150 lbs, representing an 8.8% significant weight loss in 3 months. From June 21, 2013 to July 23, 2013, Resident lost 4 lbs, going from 154 lbs to 150 lbs, representing a 2.6% weight loss in a month. Review of the 1/9/2013 NUTRITIONAL ASSESSMENT performed on Resident 37 revealed a weight of 195 lbs on admission to the facility. A weight dated 1/8/2013 of 197.5 lbs was also documented on this same NUTRITIONAL ASSESSMENT. With that admission weight, Resident 37 experienced a 24% significant weight loss from 1/8/2013 to 7/23/2013. That weight also showed a 6% weight loss in 16 days from date of admission on 1/8/2013 to 1/24/2013. Documentation dated 1/10/2013 on Resident 37's NUTRITIONAL ASSESSMENT revealed that meal intakes were > (greater than) 50%. Documentation dated 1/19/2013 on Resident 37's NUTRITIONAL ASSESSMENT revealed a weight of 189.5 lbs, showing a weight loss of 8 lbs in 10 days from 1/8/2013 to 1/19/2013, representing a 4% weight loss. On 1/22/2013, documentation on the NUTRITIONAL ASSESSMENT revealed that Resident 37 had been started on super cereal "about week ago". The Consulting Dietitian also documented that if oral "intakes do not improve, will consider a supplement in order to improve oral intakes". There were no other documented nutritional interventions implemented at that time. Review of the January 2013 DIET INTAKE records for Resident 37 did not reveal any documentation to indicate that super cereal was being offered, served or consumed. Review of Resident 37's NUTRITIONAL ASSESSMENT PLAN dated 3/8/2013 showed a weight of 185.5 lbs, indicating that the resident continued to lose weight. The plan showed that a general mechanical soft diet with small portions was to be served to Resident 37 and to continue to serve super cereal, hydration plan and supplement. Review of Resident 37's DIET INTAKE record for March 2013 still did not indicate that the resident was being offered, served or consuming any super cereal. 11 of 31 days, there was a line through or no documentation for cereal at breakfast to indicate that the super cereal was even offered or served. Interview on 7/29/2013 at 2:59 PM with the DM (Dietary Manager) revealed that a line through food items on the DIET INTAKE sheets for any month did not give any information as to whether the food item had been served for Resident 37. Review of Resident 37's NUTRITIONAL PROGRESS NOTES dated 3/19/2013 revealed that the family requested to offer pudding with each meal as the resident enjoyed pudding. Review of Resident 37's DIET INTAKE records for March 2013 revealed that only one time was pudding offered and consumed at 100% on 3/30/2013 at the lunch meal. Further review of Resident 37's DIET INTAKE records for April, May, and July 2013 did not reveal any documentation that the pudding was offered or consumed at any meal. The June 2013 DIET INTAKE record for Resident 37 was not located. Review of Resident 37's NUTRITIONAL PROGRESS NOTES dated 3/25/2013 revealed a recommendation to offer double portions of fortified cereal at breakfast, offer 3 PM ice cream snack and to increase Med Pass 2.0 to 180 cc (cubic centimeters) TID (three times a day). Further review of Resident 37's DIET INTAKE records did not reveal any evidence that the double portions of fortified cereal were offered or consumed. In addition, there was no documentation that a 3 PM ice cream snack was offered or consumed to try to prevent further weight loss from occurring. Further review of Resident 37's NUTRITIONAL PROGRESS NOTES dated 3/25/2013 revealed that the resident experienced skin breakdown with a Stage II pressure ulcer to the coccyx. On 4/1/2013, the Consulting Dietitian documented in Resident 37's NUTRITIONAL PROGRESS NOTES that there were no additional nutritional recommendations at that time, even though Resident 37 continued to experience weight loss and had skin breakdown. The skin breakdown was healed as of 4/24/2013. On 6/21/2013, the Dietary Tech documented notification of another Stage II pressure sore to the gluteal crease as of 6/17/2013 for Resident 37. There were no new nutritional interventions implemented at that time for the continued weight loss and skin breakdown. Interview on 7/29/2013 at 2:39 PM with the Consultant Dietitian confirmed that Resident 37 was to be served a 3 PM snack of ice cream, double portion of fortified cereal at breakfast and pudding with meals. In addition, the Consulting Dietitian and the Dietary Manager stated that everyone was offered a HS (bedtime) snack; however, there was no documentation to ensure that a HS snack was offered or consumed by Resident 37. Review of the facility planned menus for all days of the survey revealed that residents on a mechanical soft diet were to be served a cup of whole milk with all meals. Observation of the noon meal on 7/29/2013 at 12:10 PM revealed that Resident 37 was not served any milk or offered a milk substitute. The resident did receive and consumed 100% of the Med Pass supplement which was documented on the MAR (Medication Administration Record) by nursing. Interview on 7/29/2013 at 2:15 PM with the DM and Consultant Dietitian revealed that they both agreed that milk was on the noon menu and Resident 37 did not get served any milk. In addition, there was no milk substitute offered. Review of the Dietary serving card for the noon meal on 7/29/2013 revealed that milk was on list of fluids that Resident 37 would consume. Interview on 7/30/2013 at 1:50 PM with the DM and the Dietary Tech confirmed that pudding had only been documented one time in May 2013 at breakfast; however, it had not been documented as offered or consumed since implemented by the Consulting Dietitian on 3/19/2013. The DM and the Dietary Tech also confirmed there was no documentation that the double portion of fortified cereal at breakfast was being offered or consumed. Review of Resident 37's comprehensive care plan dated 4/18/2013 did not identify that the resident had experienced a significant weight loss over the past 6 months. In addition, the interventions implemented by the consulting Dietitian over the past months were not reflected on the care plan for further assessment or evaluation to ensure that interventions were implemented to prevent further weight loss from occurring.

LICENSURE REFERENCE 175 NAC 12-006.09D8b Based on record review and staff interview, the facility failed to evaluate residents and implement nutritional interventions to prevent significant weight loss from occurring for 1 (Resident 61) of 9 sampled residents. The facility census was 64 at the time of the revisit and the sample size was 9. Findings are: Resident 61 was admitted to the facility on [DATE] according to the ADMISSION RECORD on the medical record. The following [DIAGNOSES REDACTED]. Review of Resident 61's VITAL SIGNS AND WEIGHT FLOW RECORD sheet from 3/8/2011 to present date of 4/3/2011 revealed the following weights: March 8, 2011--114 lbs (pounds) March 16, 2011--122 lbs March 23, 2011--114 lbs March 30, 2011--107.5 lbs April 3, 2011--107 lbs From March 8, 2011 to April 3, 2011, Resident 61 lost 7 lbs, going from 114 lbs to 107 lbs, representing a 6% significant weight loss in 4 weeks time. From March 16, 2011 to April 3, 2011, Resident 61 lost 15 lbs, representing a 12% significant weight loss in 3 weeks time. Interview on 4/6/2011 at 11:20 AM with the Consulting RN (Registered Nurse) confirmed that the correct weights for Resident 61 had been documented on the resident's VITAL SIGNS AND WEIGHT FLOW RECORD sheet. Review of Resident 61's physician's orders [REDACTED]. Review of Resident 61's INDIVIDUAL MEAL INTAKE RECORD for March 2011 revealed that there was no documentation that the Power Packed cereal had been served as per the physician's orders [REDACTED]. Interview on 4/6/2011 at 11:20 AM with the Consulting RN (Registered Nurse) confirmed that the Power Pack cereal for Resident 61 was not initiated until 3/23/2011, 2 weeks after the physician had signed the physician's orders [REDACTED]. In addition, the physician had been notified of Resident 61's weight loss on 3/15/2011 with recommendations to start Med Pass 2.0 90 cc (cubic centimeters) TID (three times a day) with the goal to halt further weight loss and stabilize weight. Review of Resident 61's MAR (Medication Administration Record) for March 2011 revealed that the Med Pass 2.0 90 cc TID had been implemented on 3/16/2011; however, there was no documentation from 3/16/2011 to 3/28/2011 to indicate how much of the intervention was consumed by Resident 61 to evaluate the effectiveness of the intervention. On 3/23/2011, a fax message had been sent to Resident 61's physician requesting an order for [REDACTED]. In addition, review of the April 2011 MAR indicated [REDACTED]. Interview on 4/6/2011 at 9:52 AM with the Consulting RN revealed that the Mighty Shake 4 oz did not get transferred from the March 2011 MAR indicated [REDACTED]. The Consulting RN confirmed there was no evidence that the Mighty Shake had been administered to Resident 61 from 4/1/2011 to 4/5/2011. The Consulting RN also confirmed that Nursing staff were responsible to administer this intervention to Resident 61.

LICENSURE REFERENCE 175 NAC 12-006.09D8b Based on observation, record review, resident interview and staff interview, the facility failed to evaluate residents and implement nutritional interventions to prevent significant weight loss from occurring for 3 (Resident 12, 06 and 15) of 15 residents reviewed. The facility census was 62 at the time of the survey and the survey sample was 15. Findings are: A. Review of the Roster/Sample Matrix completed by the facility on 2/3/2011, the first day of the survey, did not identify Resident 12, 06 and 15 as having significant weight loss in the past 6 months. B. Resident 12 was admitted to the facility on [DATE] according to the ADMISSION RECORD on the medical record. The following [DIAGNOSES REDACTED]. Review of Resident 12's VITAL SIGNS AND WEIGHT FLOW RECORD from July 2010 to January 2011 revealed the following weights: July 27, 2010 - 135.5 lbs (pounds) August 31, 2010 - 132 lbs September 27, 2010 - 129.5 lbs October 25, 2010 - 131.5 lbs November 22 - 125.5 lbs December 27, 2010 - 113 lbs January 24, 2011 - 105 lbs From July 27, 2010 to January 24, 2011, Resident 12 lost 30.5 lbs, going from 135.5 lbs to 105 lbs, representing a 22% significant weight loss in 6 months. From October 25, 2010 to January 24, 2011, Resident 12 lost 26.5 lbs, going from 131.5 lbs to 105 lbs, representing a 20% significant weight loss in 3 months. From December 27, 2010 to January 24, 2011, Resident 12 lost 8 lbs, going from 113 lbs to 105 lbs, representing a 7% significant weight loss in a month. Review of Resident 12's physician's orders [REDACTED]. This had originally been ordered on [DATE]. The order had never been clarified as to the amount to be administered. Review of Resident 12's physician's orders [REDACTED]. Review of the January and February 2011 MAR/TAR (Medication Administration Record/Treatment Administration Record) revealed that Resident 12 had been administered Ensure supplement BID, taking 25% to 100%; however, there was no amount specified to evaluate if the supplement needed to be increased or for the effectiveness of the intervention. Review of the MEDICAL NUTRITION THERAPY RECOMMENDATIONS for Resident 12, documented by the Consulting Dietitian revealed the following on visits dated: "8-4-10 wt (weight) loss. Presently 129, down 5.5 pounds this week. Resident has been started on dietary supplement between meals per M.D. (Physician). Intake remains fair. Resident is recovering from shingles. Will continue with meals, supplements and encouragement". "8-17-10 wt - Follow-up on weight loss. Weight this week 131, up from 129. Speech therapy is also on board due to coughing at times when (gender) swallows. Will continue with interventions". According to the MEDICAL NUTRITION THERAPY RECOMMENDATION notes, Resident 12 was not reviewed again for weight loss until 1-5-11 when the Consulting Dietitian wrote that the resident was continuing to experience weight loss with a weight of 110.5 lbs. The Consulting Dietitian wrote that some of the laboratory values were indicative of very poor renal function and that in December 2010, Resident 12 had been started on an appetite stimulant and to continue with the regular diet and supplements with encouragement to consume. The Consulting Dietitian also wrote that "Continued weight loss will probably continue due to physical condition". The Consulting Dietitian did not recommend any new interventions on 1/5/2011 to prevent further weight loss from occurring. Review on Resident 12's NUTRITIONAL PROGRESS NOTES revealed that the DM (Dietary Manager) documented on 9/7/2010 that the resident was seated at an assisted table but there were no further dietary interventions implemented at that time. On 11/26/2010, the DM documented to continue power packing foods and all other interventions but did not indicate what foods were power packed. On 12/8/2010, the DM documented that Resident 12 had more weight loss and occasionally took 25% of the supplement and/or Ensure pudding. The DM documented that the facility had tried to power pack hot cereal and other food but Resident 12 was just not eating. There were no other interventions documented as being implemented; even though, Resident 12 had lost 16% significant weight loss by December 2010. On 1/17/2011, the DM documented again that Resident 12's weight was down and the charge nurse was notified; however, again there were no dietary interventions initiated or implemented to prevent further weight loss from occurring. Interview on 2/3/2011 at 2:05 PM with the DON (Director of Nursing) and the DM revealed that power packed foods and 4 oz of House Supplement with each meal were implemented on 10/10/2010 for Resident 12; however, there was no documentation of the consumption of the supplement to evaluate the effectiveness of the intervention. The DON and DM confirmed that the facility failed to document the consumption of these interventions to evaluate and intervene if the interventions were not being effective for weight loss for Resident 12. The DM confirmed that no new interventions had been implemented since 10/10/2010 for Resident 12 to try to prevent further weight loss from occurring. Review on 2/9/2011 of Resident 12's dietary meal cards used for service of meals revealed that a regular diet was to be served. There was no documentation on the dietary meal card that Resident 12 was to receive power packed foods or other dietary interventions to promote weight gain and prevent further weight loss from occurring. Observation on 2/3/2011 at 12:07 PM revealed that Resident 12 received pureed fruit eating 100%, 6 oz (ounces) juice, consuming 50%, 4 oz milk taking sips, green beans consuming none, mashed potatoes and gravy consuming 10%, bread stix taking a bite, and chicken leg consuming 25%. NA (Nursing Assistant) S assisting Resident 12 with eating made no attempt to obtain more pureed fruit or to offer other foods for the resident to consume. There was no supplement offered with the noon meal. Resident 12's eating was interrupted numerous times by NA S assisting other residents at the table with consuming their meals. NA S gave Resident 12 the last assistance with eating at 12:43 PM and left the dining room to assist other residents with returning to their rooms. At 1:31 PM, NA J approached Resident 12, asked the resident if (gender) was done eating or if (gender) wanted any more of the lunch meal. Resident 12 said no and was removed from the dining room at that time. Observation on 2/9/2011 at 8:42 AM revealed that Resident 12 was being assisted by NA T with eating while lying in bed. NA T attempted to give Resident 12 bites of hot cereal; however, Resident 12 moaned, did not open eyes or eat anything. NA T then removed the tray from the room without attempting to offer Resident 12 any other food. Resident 12 consumed none of the breakfast meal. There was no supplement offered on the breakfast tray. Review of Resident 12's INDIVIDUAL MEAL INTAKE RECORD for January and February 2011 revealed no record of the amount of consumption of power packed foods or any supplements offered with meals to evaluate the effectiveness of the intervention to prevent further weight loss from occurring. Review of Resident 12's comprehensive care plan dated 11/24/2010 and updated on 1/8/2011 did not reflect that Resident 12 had experienced significant weight loss over the past 6 months and to ensure that facility staff were consistently providing dietary interventions to prevent further weight loss from occurring. C. Resident 06 was admitted to the facility on [DATE] according to the ADMISSION RECORD on the medical record. Resident 06 sustained a fractured right hip after a fall on 12/19/2010 and was admitted to the hospital for repair of the hip. According to a HISTORY AND PHYSICAL dated 12/19/2010, Resident 06 had the following [DIAGNOSES REDACTED]. Resident 06 was also readmitted to the hospital on [DATE] from the hospital with a pressure sore. Review of Resident 06's VITAL SIGNS AND WEIGHT FLOW RECORD revealed the following weights: 11/10/2010 - 100 lbs 11/23/2010 - 102.5 lbs 12/1/2010 - 102 lbs 12/8/2010 - 98.5 12/23/2010 - 94 lbs 12/29/2010 - 94.5 lbs 1/5/2011 - 100 lbs 1/11/2011 - 99.5 lbs 1/19/2011 - 94.5 lbs 1/26/2011 - 94 lbs 2/2/2011 - 91 lbs From 1/5/2011 to 2/2/2011, Resident 06 lost 9 lbs, going from 100 lbs to 91 lbs, representing a 9% significant weight loss in a month. Review of Resident 06's current physician's orders [REDACTED]. Review of the MEDICAL NUTRITION THERAPY RECOMMENDATIONS documented by the Consulting Dietitian revealed that Resident 06 had only been reviewed one time on 10/26/2010, 3 weeks after admission to the facility. At that time, the Consulting Dietitian documented that Resident 06 received Ensure one time a day and was nutritionally stable. The Consulting Dietitian had not reviewed Resident 06 since 10/26/2010, even though Resident 06 had had skin breakdown and experienced significant weight loss. There had been no further dietary interventions implemented. Interview on 2/9/2011 at 10:30 AM with the Consulting Dietitian confirmed that there had been no further review of Resident 06 since 10/26/2010. The Consulting Dietitian stated that Resident 06 was "missed" . Review of Resident 06's MAR/TAR and INDIVIDUAL MEAL INTAKE RECORD for January and February 2011 did not reveal any documentation of intake of the Ensure. The Consulting Dietitian had documented that Resident 06 was receiving the Ensure on a daily basis on 10/26/2010. Interview on 2/9/2011 at 10:30 AM with the Consulting Dietitian, DM and DON revealed documentation on Resident 06's December 2010 MAR/TAR that the resident had received the Ensure daily until admitted to the hospital for the [MEDICAL CONDITION]. After return from the hospital, the intervention had not been continued for Resident 06 to assist with healing of the fracture, surgical incision and to prevent further weight loss from occurring. In addition, the Consulting Dietitian stated that Resident 06 received power packed hot cereal; however, there was no documentation on the INDIVIDUAL MEAL INTAKE RECORD to indicate that the resident was receiving it, how much was consumed to evaluate the effectiveness of the intervention and to ensure that further weight loss did not occur. Interview on 2/9/2011 at 10:30 AM with the DM confirmed that Resident 06 was not receiving any specialized snacks between meals and was not receiving the Ensure one time a day. Review on 2/9/2011 of Resident 06's dietary meal card used for service of meals did not indicate that the resident was to receive any type of power packed foods or supplements to try to promote weight gain and prevent weight loss from occurring. In addition, the dietary meal card indicated that Resident 06 was to be served small portions. Review of Resident 06's readmission orders [REDACTED]. Review of the NUTRITIONAL PROGRESS NOTES dated 12/8/2010 revealed that the DM had written that Resident 06's weight was down 4 lbs. However, there were no recommendations for nutritional interventions made at that time to prevent further weight loss from occurring. On 1/5/2011, the DM had made a note that cereal was power packed and the facility offered supplements if the resident was not eating well; however, a definitive plan had not been established to ensure that Resident 06 was receiving those interventions to prevent further weight loss from occurring. Review of Resident 06's comprehensive care plan dated 10/6/2010 did not contain information that the resident had experienced significant weight loss. An approach for "risk of nutritional impairment due to leaving 25% or more of meal uneaten" stated to provide supplements as ordered per MAR and dietary intervention but did not give instructions on who was to provide the supplement, when it was to be provided or how much was to be provided at what time. D. Resident 15 was admitted to the facility on [DATE] according to the ADMISSION RECORD on the medical record. The following [DIAGNOSES REDACTED]. Review of Resident 15's VITAL SIGNS AND WEIGHT FLOW RECORD from August 2010 to February 2011 revealed the following weights: 8/9/2010 - 174 lbs 9/6/2010 - 175 lbs 10/6/2010 - 176 lbs 11/1/2010 - 175.5 lbs 11/17/2010 - 155 lbs 12/1/2010 - 153.5 lbs 1/5/2011 - 148 lbs 2/2/2011 - 154 lbs From 8/9/2010 to 2/2/2011, Resident 15 lost 20 lbs, representing an 11% significant weight loss in 6 months. From 11/1/2010 to 11/17/2010, Resident 15 lost 20.5 lbs, representing an 11% significant weight loss in 16 days. From 11/1/2010 to 2/2/2011, Resident 15 lost 21.5 lbs, representing a 12% significant weight loss in 3 months. Review of Resident 15's current physician's orders [REDACTED]. Review of the MEDICAL NUTRITION THERAPY RECOMMENDATIONS from 7/9/10 to 1/20/2011 documented by the Consulting Dietitian revealed that the only review performed for Resident 15 was conducted on 11/23/2010 after the resident had lost 20.5 lbs. The Consulting Dietitian had documented the following: "Weight loss - Resident's weight is down from 175 and lost 18 pounds from 11-1-10 to 11-23-10 to 157. Tongue was treated for [REDACTED]. Weight loss is actually beneficial due to obesity, however there may be an underlying cause. Resident is being offered super cereal at breakfast to increase nutritional intake. Will continue to follow weight for stability. No labs or med changes". There were no recommendations made on 11/23/2010 by the Consulting Dietitian to prevent further weight loss from occurring. Review of Resident 15's INDIVIDUAL MEAL INTAKE RECORD for January and February 2011 did not reveal any evidence that super cereal was being offered or consumed by the resident to evaluate the effectiveness of the intervention. Observation on 2/8/2011 at 8:30 AM revealed that Resident 15 was not served any hot cereal for the breakfast meal. Review of the menu for 2/8/2011's breakfast meal revealed that hot cereal was to be served. Observation on 2/9/2011 at 8:15 AM revealed that Resident 15 was not served any hot cereal for the breakfast meal. Review of the menu for 2/9/2011's breakfast meal revealed that hot cereal was to be served. Interview on 2/9/2011 at 8:46 AM with Resident 15 revealed that the resident did not know why (gender) did not receive any hot cereal for breakfast. Resident 15 stated that (gender) "just got served what was in front of (gender)". Review on 2/9/2011 of Resident 15's dietary meal card revealed that cereal was circled with a "NO" beside it; however, there were no substitutions documented on the serving card to direct Dietary staff on what to give to the resident to replace the hot cereal. In addition, the Consulting Dietitian had documented in the NUTRITIONAL PROGRESS NOTE on 11/23/2010 that the resident was "being offered super cereal at breakfast to increase nutritional intake and continue to follow weight for stability". Interview on 2/9/2011 at 10:45 AM with the Consulting Dietitian, DM and the DON confirmed that Resident 15 had experienced significant weight loss from November 2010 to December 2010. The Consulting Dietitian confirmed that no new interventions had been initiated for Resident 15 since November 2010 to prevent further weight loss from occurring. The Consulting Dietitian also confirmed that (gender) had been in the facility on 1/5/2011 and documented in the NUTRITIONAL PROGRESS NOTE indicating that meals were supplemented; however, there was no documentation in the NUTRITIONAL PROGRESS NOTE to indicate what was being supplemented or to indicate the amounts consumed by Resident 15 for further evaluation for the effectiveness of the intervention. Further review of Resident 15's medical record revealed that on 12/7/2010, blood work had been performed showing that Resident 15 had a low blood serum [MEDICATION NAME] of 3.3 (normal was 3.7-5.1) g/dL (grams per deciliter). The Consulting Dietitian confirmed that Resident 15 had not been reviewed in December 2010, even though Resident 15 had a low serum [MEDICATION NAME] and had experienced significant weight loss the previous month. Observation on 2/7/2011 at 11:59 AM revealed that Resident 15 also had a new open area on the coccyx that measured 1.8 cm (centimeters) by .5 cm. Further review of Resident 15's medical record revealed that the resident had had an open area on the right great toe and a Stage II pressure sore on the left inner gluteal area since the middle of January 2011. Interview on 2/9/2011 at 10:45 AM with the Consulting Dietitian confirmed that (gender) had not been made aware of the skin breakdown on Resident 15 and there had not been any interventions implemented to assist with healing of the skin issues. Further interview on 2/9/2011 at 10:45 AM with the DM and the DON revealed that 120 cc (cubic centimeters) of house supplement was being provided to Resident 15 BID (two times a day) with the resident taking usually 100% of the supplement. This intervention had been implemented on 12/27/2010; however, there had been no attempt to increase the amount given to try to prevent further weight loss from occurring. In addition, Resident 15 was not on the list to receive a high calorie/high protein snack to try to prevent further weight loss from occurring.