Every finding on record at Adept Nursing & Rehab of South Sioux City

LICENSURE REFERENCE 175 NAC 12-006.04(F)(i)(5) Based on interview and record review; the facility failed to notify Resident 3's physician of a change in condition related to cellulitis to the resident's left stump and a significant weight gain. The sample size was 7 and the facility census was 40. Findings are: A.Review of the facility policy Notification of Changes with a revised date of 2/23/26, revealed the purpose of the policy was to ensure the facility promptly informed the resident, consulted the resident's physician, and notified the resident's representative when there was a change requiring notification. Circumstance which required notification included:-accidents resulting in an injury and which had the potential to require physician intervention.-significant change in the resident's physical, mental, or psychosocial condition such as a deterioration in health, mental and psychosocial status.-circumstances which could require a need to alter treatment which could include a new treatment or discontinuation of a current treatment based on adverse consequences, an acute condition or exacerbation of a chronic condition. B.Review of Resident 3's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/18/26 revealed diagnoses of alcohol cirrhosis of the liver, anemia, end stage renal disease, depression, cellulitis (skin infection), hepatic encephalopathy (decline in brain function caused by sever liver disease), morbid obesity, and heart failure. The assessment identified the following regarding Resident 3:-cognition was intact.-reported feeling down, depressed, or hopeless.-weight of 411 pounds with a weight gain of 5% or more in the last month or a gain of 10% or more in the last 6 months. The resident was not on a prescribed weight gain regimen. Review of Nursing Progress Notes revealed the following:-11/28/25 at 10:45 AM the staff reported the resident did not look good. The resident had loss of appetite, did not eat breakfast and was very drowsy.-11/28/26 at 2:54 PM the resident refused to eat the noon meal due to appetite loss and reported feeling tired with little energy. The resident refused when staff recommended hospitalization.-11/28/25 at 5:39 PM the resident continued with poor appetite and lethargy.-11/28/25 at 9:34 PM the resident refused the evening meal and the resident remained very tired and weak. The resident continued to refuse hospitalization.-11/28/25 at 9:53 PM the resident's oxygen saturation (amount of hemoglobin in your blood carrying oxygen) was 88% and the resident remained lethargic.-11/29/26 at 10:30 AM (12 hours and 37 minutes later) the resident was pale, cheeks were flushed and the resident's left stump (leg) was bright red, edematous, warm, and tender to the touch. The resident's physician was notified of the resident's change of condition and an order was received to send the resident to the emergency room for evaluation.-11/29/26 at 4:30 PM the hospital notified the facility the resident was admitted for cellulitis. Review of the resident's electronic medical record revealed no evidence the resident's physician was notified of the residents change of condition on 11/28/25 with loss of appetite, increased lethargy/weakness, and decreased oxygen saturation until 11/29/26, when the resident was hospitalized for cellulitis. Review of Resident 3's Weights and Vitals Summary Report revealed the following weights for Resident 3:-2/3/26 the residents' weight was 390 pounds.-2/10/26 the residents' weight was 412 pounds (up 22 pounds or a gain of 6% in 1 week).-2/12/26 the residents' weight was 415 pounds up another 3 pounds. During an interview on 3/17/26 at 1:30 PM the Director of Nursing (DON) confirmed the following:-11/28/25 the staff reported the resident did not look good and had no appetite. The resident had refused all meals and was lethargic and weak. The residents' oxygen saturation dropped to 88%. The staff asked the resident about going to the hospital but the resident refused.-the last documented assessment for Resident 3 on 11/28/26 was at 9:53 PM.-11/29/25 at 10:30 AM the resident's stump to the left leg was bright red, edematous and warm to the touch.-there was no documented assessment of the resident since 9:53 PM (12 hours and 37 minutes prior) on 11/28/26. The resident's physician was notified at this time and an order was received to send the resident to the emergency room for evaluation. The resident was admitted to the hospital with diagnosis of cellulitis to the resident's left stump.-Resident 3's weight on 2/3/26 was 390 pounds and on 2/10/26 the resident's weight was 412 pounds (up 22 pounds or a 6% weight gain in one week). There was no evidence the facility staff had notified the physician of the residents' significant weight gain.

Licensure Reference Number 175 NAC 12-006.09Based on record review and interview; the facility failed to follow physician's orders for Resident 1's daily weights. The sample size was 4 and the facility census was 41. Findings are: A record review of Resident 1's Minimum Data Set (MDS-federally mandated comprehensive assessment used to create resident care plans) dated 8/21/25 revealed the resident had debility with cardiorespiratory (heart and lung) conditions including atrial fibrillation (abnormal heart rhythm), Congestive Heart Failure (CHF-failure of the heart to beat effective and having the potential for buildup of excess fluid lungs, legs, and other parts of the body), Hypertension (high blood pressure) and Renal insufficiency (declined in or non-optimal kidney function), and was taking insulin, antipsychotic, antibiotic, and diuretic (reduces fluid volume by increasing urine output) medications. The resident's weight was 216 pounds with no significant loss or gain.A record review of Resident 1's Care Plan dated 8/15/25 revealed the resident took a diuretic medication for CHF.A record review of Resident 1's admission orders dated 8/15/25 revealed an order for daily weights for 4 days and then weekly weights for 4 weeks. A record review of Resident 1's Medication Administration Record dated August 2025 revealed the resident's scheduled daily weights for 8/16/25 and 8/17/25 were not completed. During an interview on 9/23/25 at 11:30 AM the Assistant Director of Nursing confirmed that the daily weight orders on 8/15/25 at the time of admission were not completed on 8/16/25 or 8/17/25 as ordered to ensure monitoring of the effects of the resident's diuretic medication to treat the resident's heart failure. During an interview on 9/23/25 at 1:00 PM the Director of Nursing confirmed Resident 1 was not weighed as ordered on 8/16/25 and 8/17/25.

Licensure Reference Number 175 NAC 12-006.05Based on record review and interviews, the facility failed to ensure gradual dose reductions were attempted or documented clinical contraindications were completed for Resident 1's antipsychotic and antianxiety medications, and Resident 2 and 23's antidepressant medications. The sample size was 5 and the facility census was 44. Findings are: A. Review of the facility policy Use of Psychotropic Medication with a revision date of 8/25 revealed the following;-It was the intent of the policy to ensure residents only received psychotropic medications when other nonpharmacological interventions were clinically contraindicated. Additionally, those medications were only used to treat resident's medical symptoms and not used for discipline or staff convenience. -adequate indications for use referred to the identified, documented clinical rationale for administering a medication based on assessment of the resident's condition and therapeutic goals and after other treatments were deemed inadequate.-Psychotropic medications were used only when a practitioner determined the medication was appropriate to treat a resident's specific diagnosed, and documented condition, and the medication was beneficial to the resident as demonstrated by monitoring and documentation of the resident's response. -Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative were informed of the risks, benefits, and alternatives for the medication including warnings for antipsychotic medications in advance of such initiated increases. -Residents had the right to accept or decline the initiation or increase of a psychotropic medication.-The facility documented the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deemed. -Residents who received psychotropic medications received gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the drugs. B. Review of Resident 1's Minimum Data Set (MDS-federally mandated assessment used to develop resident care plans) dated 5/20/24 revealed the resident took antipsychotic and antianxiety medications 7 out of 7 of the preceding days. In addition, the resident had diagnoses of dementia, anxiety, and depression. Review of Resident 1's Consultant Recommendation to Physician dated 11/20/24 revealed the resident had been taking the antianxiety medication Buspar 5 mg daily since 5/31/24. The provider chose not to attempt a gradual dose reduction of the medication, however there was no documented clinical rationale. Review of Resident 1's Consultant Recommendation to Physician dated 11/20/24 revealed the resident had been taking the antipsychotic medication Quetiapine 25 milligrams (mg) daily since 7/17/24. The provider chose not to attempt a gradual dose reduction of the medication, however there was no documented clinical rationale. Review of Resident 1's Consultant Recommendation to Physician dated 2/10/25 revealed the resident had been taking the antipsychotic medication Quetiapine 25 milligrams (mg) daily since 7/17/24. The provider chose not to attempt a gradual dose reduction of the medication, however there was no documented clinical rationale Review of Resident 1's Consultant Recommendation to Physician dated 6/13/25 revealed the resident had been taking the antianxiety medication Buspar 5mg daily since 5/31/24. The provider chose not to attempt a gradual dose reduction of the medication, however there was no documented clinical rationale. Review of Resident 1's Care Plan with a revision date of 8/15/25 revealed the resident took the psychotropic medications due to an anxiety disorder and staff were to evaluate effectiveness and side effects routinely to consider decreasing or eliminating those medications. During an interview on 8/19/25 at 2:55 PM Director of Nursing (DON) confirmed that Resident 1 did not a documented clinical rationale for not attempting a dose reduction for the psychotropic medications quetiapine and buspirone despite the pharmacist recommendations to the physician. C. Review of Resident 2's MDS dated [DATE] revealed the resident had diagnoses of dementia and bipolar disorder and took antidepressant medication 7 out of 7 of the preceding days. Review of Resident 2's Care Plan with a revision date of 8/23/23 took the antidepressant Effexor/Venlafaxine for Bipolar disorder and staff were to monitor effects and for adverse effects. Review of Resident 2's Consultant Recommendation to Physician dated 10/21/24 revealed the resident had been taking Effexor XR 75mg daily since 10/19/23. The provider chose not to attempt a gradual dose reduction, however, did not document a clinical rationale for not attempting a reduction. During an interview on 8/19/25 at 10:05 AM The Director of Nursing Confirmed the facility did not have documented rationale or clinical indication from the provider as to why a gradual dose reduction was contraindicated for Resident 2's antidepressant medication Venlafaxine. D. Review of Resident 23's MDS dated [DATE] revealed the resident was cognitively intact, required assistance from staff with toileting, dressing, and personal hygiene; had diagnoses of Renal Disease, Diabetes, Non-Alzheimer's Disease Dementia; Parkinson's Disease, Anxiety, Depression, and Schizophrenia; and received Antipsychotic and Antidepressant medications. Review of Resident 23's Care Plan last revised 8/5/25 revealed the resident required assistance with dressing and toileting; had a history of mental illness; had a mood disorder;; diagnoses included Parkinson's Disease, history of other diseases of the nervous system, Chronic Kidney Disease, Diabetes, Major Depressive Disorder, Anxiety, Dementia without behaviors, Schizophrenia (a brain disorder that affects how a person thinks, feels, and behaves); and received psychotropic medications. Review of Resident 23's Medication Review Report revealed an order for Sertraline (an antidepressant medication) 50 milligrams (mg) daily for Major Depressive Disorder with an original order date of 1/3/24. Review of the facility form Consultant Recommendation to Physician dated 9/2/24 revealed there was no documented rationale for the continued use of the Sertraline and the Physician should have documented a rationale. Interview with the DON on 8/19/25 at 12:00 PM confirmed there was no rationale documented for the continued use of Sertraline.

Licensure Reference Number 175 NAC 12.006.04(D) Licensure Reference Number 175 NAC 12-006.04(G)Based on observation, record review, and interview; the facility failed to ensure adequate staffing related to call light response times. This had the potential to affect all residents who were able to activate use of their call light. Findings are:A. Review of the Facility Assessment for The Palms at Regency Square with a revised date of 6/6/25 revealed:-The facility assessment was used to make staffing decisions to ensure that there were sufficient number of staff to care for the residents as identified through resident assessments and plans of care. B. An observation on 8/17/25 revealed Resident 53's call light was turned on at 9:04 AM. The resident was hollering out for help at 9:20 AM and the call light was answered at 9:31 AM, (the call light was on for 26 minutes).An interview with Resident 53 on 8/17/25 at 10:25 AM revealed Resident 53 reported staff take over 15 minutes to answer the call light many times. Review of the facility Device Activity Report (record of call light activations and responses) for Resident 53 from 8/10/25 through 8/17/25 revealed the following call light response times greater than 15 minutes:-8/15/25 at 2:56 PM answered at 15 minutes 33 seconds,-8/15/25 at 6:48 PM answered at 17 minutes 31 seconds, -8/15/25 at 9:20 PM answered at 26 minutes 33 seconds, -8/16/25 at 9:34 AM answered at 26 minutes 30 seconds, -8/17/25 at 9:31 AM answered at 26 minutes 46 seconds,-8/17/25 at 1:59 PM answered at 22 minutes 55 seconds. C. Review of the Device Activity Report from 8/18/25 through 8/20/25 revealed the following call light response times greater than 15 minutes random rooms:-8/18/25 at 7:23 AM answered at 37 minutes 11 seconds,-8/18/25 at 8:04 AM answered at 39 minutes 19 seconds, -8/18/25at 8:10 AM answered at 28 minutes 8 seconds, -8/18/25 at 8:52 AM answered at 16 minutes 54 seconds, -8/18/25 at 9:15 AM answered at 27 minutes 21 seconds,-8/18/25 at 9:16 AM answered at 27 minutes 25 seconds,-8/18/25 at 10:33 AM answered at 17 minutes 1 second,-8/18/25 at 11:16 AM answered at 17 minutes 42 seconds, -8/18/25 at 11:38 AM answered at 20 minutes 30 seconds,-8/18/25 at 1:47 PM answered at 21 minutes 58 seconds, -8/18/25 at 2:08 PM answered at 39 minutes 7 seconds, -8/18/25 at 2:09 PM answered at 16 minutes 32 seconds,-8/18/25 at 2:53 PM answered at 21 minutes 7 seconds, -8/18/25 at 4:02 PM answered at 22 minutes 57 seconds,-8/18/25 at 4:02PM answered at 29 minutes 29 seconds,-8/18/25 at 4:45 PM answered at 17 minutes 36 seconds, -8/18/25 at 4:57 PM answered at 17 minutes 56 seconds,-8/18/25 at 6:44 PM answered at 26 minutes 32 seconds, -8/18/25 at 6:47 PM answered at 21 minutes 28 seconds,-8/18/25 at 7:26 PM answered at 15 minutes 51 seconds, -8/18/25 at 7:38 PM answered at 56 minutes 25 seconds,-8/18/25 at 7:45 PM answered at 29 minutes 5 seconds, -8/18/25 at 7:48 PM answered at 31 minutes 31 seconds, -8/18/25 at 7:58 PM answered at 28 minutes 23 seconds, -8/18/25 at 8:07 PM answered at 35 minutes, -8/18/25 at 8:26 PM answered at 17 minutes 56 seconds, -8/18/25 at 8:55 PM answered at 15 minutes 44 seconds, -8/19/25 at 6:26 AM answered at 22 minutes 41 seconds, -8/19/25 at 7:44 AM answered at 20 minutes 51 seconds, -8/19/25 at 8:30 AM answered at 15 minutes 50 seconds-8/19/25 at 8:39 AM answered at 22 minutes 4 seconds, -8/19/25 at 2:53 PM answered at 34 minutes 28 seconds, -8/19/25 at 3:17 PM answered at 19 minutes 50 seconds, -8/19/25 at 5:18 PM answered at 20 minutes 13 seconds,-8/19/25 at 6:55 PM answered at 17 minutes 35 seconds,-8/19/25 at 6:57 PM answered at 26 minutes 47 seconds, -8/19/25 at 7:32 PM answered at 21 minutes 56 seconds, -8/19/25 at 7:11 PM answered at 15 minutes 28 seconds,-8/19/25 at 7:33 PM answered at 59 minutes 6 seconds,-8/19/25 at 7:52 PM answered at 26 minutes 47 seconds, -8/19/25 at 8:20 PM answered at 45 minutes 59 seconds,-8/19/25 at 8:45 PM answered at 17 minutes 38 seconds, -8/19/25 at 9:07 PM answered at 19 minutes 27 seconds. D. Resident Council Meeting on 8/20/25 at 9:57 AM revealed the residents in attendance voiced call lights were not answered in an acceptable time frame. E. Interview on 8/19/25 at 2:10 PM with the Director of Nursing revealed that the facility expected staff to answer the call lights within 15 minutes. The facility does not have a policy related to answering call lights. Interview on 8/19/25 at 2:50 PM with the Administrator confirmed there were call lights on longer than 15 minutes on 8/17/25 through 8/19/25 and staff were expected to answer call lights within 15 minutes.

Licensure Reference Number 175 NAC 12-006.09(H)Based on record review and interview; the facility failed to ensure Resident 16 had a documented duration of use for an antibiotic. The sample size was 23 and the facility census was 44. Findings are: Review of the facility policy Antibiotic Stewardship Program last revised 6/1/25 revealed the purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The program included antibiotic use protocols and a system to monitor antibiotic use. Antibiotic use protocols included:-nursing staff were to assess residents who were suspected to have an infection and notify the physician, -laboratory testing would be in accordance with current standards of practice, and -all prescriptions for antibiotics would specify the dose, duration, and indication for use. Monitoring antibiotic use included:-staff would monitor responses to antibiotics to determine if the antibiotic was still indicated, -antibiotic orders obtained upon admission-whether new or a readmission would be reviewed for appropriateness, and -antibiotic orders obtained from consulting, specialty, or emergency providers would be reviewed for appropriateness. Review of Resident 16's Minimum Data Set (MDS- a federally mandated assessment tool used in care planning) dated 7/16/25 revealed the resident was admitted on [DATE] with End Stage Kidney Failure, Stroke, Depression, and Asthma; was dependent with dressing, and toileting, and needed assistance with personal hygiene; was always incontinent; and was cognitively intact. Review of Resident 16's Care Plan last updated 8/19/25 revealed the resident was at risk for recurrent Urinary Tract Infections (UTI); required assistance with transfers, toileting, dressing, and personal hygiene; was always incontinent due to a history of a stroke; and had diagnoses of paralysis due to a stroke, Diabetes, Chronic Kidney Disease, End Stage Renal Disease, and Dependence on Dialysis. Review of Resident 16's Medication Administration Record for August 2025 revealed an order for Nitrofurantoin (an antibiotic) 100 milligrams (mg) orally 1 time per day for a history of UTI's and for prophylaxis (taken to prevent an infection) ordered 6/28/25 with no stop date and Cefdinir (an antibiotic) 300mg twice daily for 7 days for a UTI ordered 8/18/25. An interview on 8/19/25 at 12:50 PM with Licensed Practical Nurse (LPN)-P confirmed the Nitrofurantoin did not have a stop date and the Resident 16 was taking the antibiotic for prophylaxis. Further interview confirmed that antibiotics should have a stop date and the resident had a current UTI and was started on an additional antibiotic to treat it. An interview with the Director of Nursing on 8/19/25 at 2:45 PM confirmed antibiotics should have a stop date. Further interview confirmed Resident 16 had a current UTI and was started on an additional antibiotic.

Licensure Reference Number 175 NAC 12-006.12Based on record review and interview; the facility failed to obtain signed consent for the use of psychotropic (affects the brain and nervous system, altering mood, perception, cognition, and behavior) medications prior to use to ensure the resident's responsible party was educated on the benefits and risks prior to the medication being used for Resident 1. The sample size was 5 and the facility census was 44. Findings are: Review of the facility policy Use of Psychotropic Medication with a revision date of 8/25 revealed the following;-It was the intent of the policy to ensure residents only received psychotropic medications when other nonpharmacological interventions were clinically contraindicated. Additionally, those medications were only used to treat resident's medical symptoms and not used for discipline or staff convenience. -adequate indications for use referred to the identified, documented clinical rationale for administering a medication based on assessment of the resident's condition and therapeutic goals and after other treatments were deemed inadequate.-Psychotropic medications were used only when a practitioner determined the medication was appropriate to treat a resident's specific diagnosed, and documented condition, and the medication was beneficial to the resident as demonstrated by monitoring and documentation of the resident's response. -Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative were informed of the risks, benefits, and alternatives for the medication including warnings for antipsychotic medications in advance of such initiated increases. -Residents had the right to accept or decline the initiation or increase of a psychotropic medication.-The facility documented the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deemed. Review of Resident 1's Minimum Data Set (MDS-federally mandated assessment used to develop resident care plans) dated 5/20/24 revealed the resident took antipsychotic and antianxiety medications 7 out of 7 of the preceding days. In addition, the resident had diagnoses of dementia, anxiety, and depression. Review of Resident 1's Medication Administration Record date May 2025 revealed the resident was receiving the antipsychotic medication Quetiapine 25 milligrams (mg) daily and the anti-anxiety medication Buspirone 5mg daily starting on 5/6/25. Review of Resident 1's Care Plan with a revision date of 8/15/25 revealed the resident took the psychotropic medications due to an anxiety disorder and staff were to evaluate effectiveness and side effects routinely to consider decreasing or eliminating those medications. Review of Resident 1's Psychotropic Medication Informed Consent dated 5/20/25 revealed the facility obtained consent for the use of psychotropic medications (buspirone, and quetiapine) on 5/20/25 (15 days after the readmission orders for the medications were started/given. During an interview on 8/18/25 at 11:00 AM Registered Nurse -V revealed the facility was requesting consent from residents or their responsible parties for the use of psychotropic medications but were not waiting to obtain that consent prior to starting the medications. During an interview on 8/20/25 at 10:28 AM the Director of Nursing confirmed the facility had no evidence the facility obtained informed consent prior administering psychotropic medication (quetiapine, and buspirone) to Resident 1.

Licensure Reference Number 175 NAC 12-006.18Based on observation, record review, and interview; the facility failed to utilize the required Personal Protective Equipment (PPE-gowns and gloves) during the provision of cares for Resident 23 who was on Enhanced Barrier Precautions (EBP). The sample size was 3 and the facility census was 44. Findings are: Review of the facility policy Enhanced Barrier Precautions last revised on 5/30/25 revealed the facility was to implement EBP for the prevention of transmission-based Multidrug-Resistant Organisms (MDRO's). EBP referred to an infection control intervention designed to reduce transmission of MDRO's that employed targeted gown and glove use during high-contact resident care activities. An order for EBP would be obtained for residents with wounds (chronic wounds, diabetic foot ulcers, unhealed surgical wounds) or indwelling medical devices (such as catheters).Implementation of EBP: gowns and gloves available immediately near or outside of the resident's room and PPE for EBP was necessary when performing high-contact care activities. High-contact care activities included: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, and wound care. Review of Resident 23's Minimum Data Set (MDS-a federally mandated assessment tool used in Care Planning) dated 7/30/25 revealed the resident was cognitively intact; required assistance with toileting, dressing, and hygiene; diagnoses included Renal Disease, Diabetes, Non-Alzheimer's Dementia, Parkinson's Disease, Anxiety, and Depression; and the resident had open lesions to at least 1 foot. Review of Resident 23's Care Plan last revised 8/5/25 revealed the resident received assistance with dressing and toileting; had chronic open areas to feet and toes which included numerous wounds on feet and toes that were diabetic ulcers; required EBP due to an MDRO; and had diagnoses of paralysis due to a stroke, Diabetes, Chronic Kidney Disease, End Stage Renal Disease, Dependence on Dialysis, and non-pressure chronic ulcer of part of right foot. Review of Resident 23's Medication Review Report revealed an order for EBP due to wounds. Staff were to ensure appropriate PPE was used during resident cares. The following observations were made with Resident 23:-on 8/17/25 at 10:05 AM the resident was in the resident room resting on the bed watching tv. The resident had a sign for EBP precautions next to the resident's name on the wall outside of the resident room. A caddy for PPE was noted to be on the back of the resident's room door.,-on 8/18/25 at 2:00 PM the resident was laying on top of the resident bed watching tv. An EBP sign was located on the wall next to the resident's name plate.,-on 8/19/25 at 9:30 AM the resident was in the resident room watching tv. An EBP sign was located next to the resident's name on the wall and a PPE caddy was noted behind the door with supplies inside.,-on 8/19/25 a 9:55 AM Registered Nurse (RN)-K and Nursing Assistant (NA)-R performed hand hygiene, applied gloves, and entered the resident's room. RN-K, not wearing a gown completed the treatments to the open wounds on the resident's feet. NA-R, not wearing a gown, assisted by holding the resident's leg up. When the treatment was completed, RN-K and NA-R removed their gloves and performed hand hygiene. An interview on 8/19/25 at 10:15 AM with RN-K confirmed the resident had EBP in place with a caddy of PPE behind the resident's room door. Further interview confirmed RN-K and NA-R should have worn PPE during the dressing change and when providing cares to the resident. On 8/19/25 at 10:55 AM an interview with the Director of Nursing confirmed the resident was on EBP and PPE should have been worn during the treatment to the resident's open areas on the feet.

Licensure Reference Number 12.006.04(F)(i)(5) Based on record review and interview the facility failed to notify the physician of a change in condition for 1 (Resident 3) of 3 residents sampled. The facility census was 56. The findings are: Record review of Resident 3's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 09-12-2024 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as a 4. According to the MDS Manual a score of 0-7 indicate a person has severe cognitive impairment. -Required extensive assistance with hygiene, bathing, toileting, dressing and transfers. Record review of the facility's undated list of residents with infections in the last 3 months revealed Resident 3 had an ear infection on 10-10-2024. Record review of Resident 3's progress notes dated 10-07-2024 revealed Resident 3 had a fever of 101.5 with tenderness and drainage from the left ear. Furthermore, the progress note dated 10-07-2024 indicated the medical practitioner was called and the facility was awaiting a call back. Record review of Resident 3's progress notes dated 10-07-2024 revealed the medical practitioner for Resident 3 was out of the office and to contact an alternate practitioner. Record review of Resident 3's progress notes dated 10-08-2024 revealed no documentation about Resident 3's ear. Record review of Resident 3's progress notes dated 10-09-2024 revealed the facility received no response from the alternate practitioner since 10-07-2024, and a fax was sent to Resident 3's medical practitioner. Record review of Resident 3's fax communication with medical practitioner dated 10-09-2024 revealed the facility did not receive a response from updating the alternate practitioner on 10-07-2024 and resident continued to have drainage from the left ear. Record review of Resident 3's progress note dated 10-10-2024 revealed the medical practitioner had given an order for an antibiotic for the left ear. An interview with the facility Administrator (ADM) on 11-12-2024 at 1:15 PM confirmed there was a delay in treatment and the facility should have contacted the practitioner the next day if no response was received from the alternate practitioner.

Licensure reference: 175 NAC 12-007.04(G) Based on observations, interviews, and record reviews, the facility failed to ensure staff were notified to residents calls for assistance within facility. This has the potential to affect all 52 residents of the facility. Findings are: A. A review of Resident 3's Admission Record revealed Resident 3 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction [stroke] and fracture of the shaft of the left fibula [a break in the outside bone of the lower leg]. A review of Resident 3 MDS [Minimum Data Set; a comprehensive assessment used for care planning] dated 9/2/24 identified Resident 3 as having a score of 15 on the Brief Interview for Mental Status indicating Resident 3 is cognitively intact. In an interview on 9/24/24 at 9:41 AM, Resident 3 reported that Resident 3 had woke up at 6:00 AM and noted blood on the bed from the scratch on Resident 3's arm. Resident 3 reported they put on the call light and waited for 2 hours, no one answered and then Resident 3 called a family member. According to Resident 3, Resident 3's family member came to the facility at 8:30 AM and found a staff member to assistance Resident 3 with the bleeding from the scratch. A review of Grievance Form dated 9/9/24 revealed Resident 3's call light had been on for 2 plus hours. A review of Resident 3's Device Activity Report [call light log] revealed the following: -Resident 3's call light was activated on 9/9/24 at 6:27 AM and cleared at 8:21 AM for total time of 114 minutes and 22 seconds -Resident 3's call light was activated on 9/924 at 8:37 AM and cleared at 9:32 AM for a total time of 55 minutes and 47 seconds In an interview on 9/24/24 at 12:37 PM, LPN A [Licensed Practical Nurse] reported Resident 3's family member found LPN A while LPN A was passing medications. LPN A was not aware that Resident 3's call light had been on. LPN A acknowledged that LPN A did not have a pager or walkie and had to check the monitor in the hallway to know that a call light was on. B. A review of Resident 3's Device Activity Report for 9/20/24 to 9/24/24 revealed the following: -Resident 3's call light was activated on 9/24/24 at 9:17 AM and cleared at 9:52 AM for a total time of 24 minutes and 26 seconds -Resident 3's call light was activated on 9/23/24 at 6:52 PM and cleared at 7:33 PM for a total time of 40 minutes -Resident 3's call light was activated on 9/23/24 at 12:07 PM and cleared at 12:53 PM for a total time of 45 minutes and 52 seconds -Resident 3's call light was activated on 9/22/24 at 6:43 PM and cleared at 7:18 PM for a total time of 35 minutes and 3 seconds -Resident 3's call light was activated on 9/21/24 at 8:51 AM and cleared at 9:14 AM for a total time of 22 minutes and 57 seconds -Resident 3's call light was activated on 9/21/24 at 6:38 PM and cleared at 7:17 P for a total time of 38 minutes and 54 seconds -Resident 3's call light was activated on 9/20/24 at 7:40 AM and cleared at 8:20 PM for a total time of 40 minutes and 8 seconds -Resident 3's call light was activated on 9/20/24 at 1:22 PM and cleared at 2:01 PM for a total time of 38 minutes and 56 seconds -Resident 3's call light was activated on 9/20/24 at 4:22 AM and cleared at 4:46 AM for a total time of 23 minutes and 19 seconds C. A review of Resident 2's Device Activity Report for 9/12/24 to 9/24/24 revealed the following: -Resident 2's call light was activated on 9/23/24 at 4:32 PM and cleared at 5:05 PM for a total time of 32 minutes and 27 seconds -Resident 2's call light was activated on 9/21/24 at 1:40 PM and cleared at 2:02 PM for a total time of 22 minutes and 43 seconds -Resident 2's call light was activated on 9/15/24 at 9:11 AM and cleared at 10:12 AM for a total time of 60 minutes and 33 seconds -Resident 2's call light was activated on 9/13/24 at 7:12 PM and cleared at 7:37 PM for a total time of 25 minutes and 24 seconds -Resident 2's call light was activated on 9/12/24 at 12:40 PM and cleared at 1:45 PM for a total time of 65 minutes and 21 seconds D. A review of Resident 1's Device Activity Report for 9/13/24 to 9/24/24 revealed the following: -Resident 1's call light was activated on 9/13/24 at 2 PM and reset 34 minutes and 19 seconds later -Resident 1's call light was activated on 9/14/24 at 8:11 AM and reset 43 minutes 2 seconds later -Resident 1's call light was activated on 9/19/24 at 10:43 AM and reset 44 minutes and 56 seconds later -Resident 1's call light was activated on 9/19/24 at 3:57 PM and reset 28 minutes and 56 seconds later E. Observations on 9/24/24 at 11:01 AM revealed no call light monitor located on the 100 hallway. F. Observations on 9/24/24 at 2:10 PM revealed 2 monitors that were used to identify call lights that were currently activated in the facility. One monitor was located near the front nurses' station and was located between the 200 and 300 hallways. The monitor could not be seen by staff working on the 100, 200, or 300 hallways. A second monitor was located near the back nurses' station and was located between the 400 and 500 hallway and was not viewable from the 400 or 500 hallways. G. In an interview on 9/24/24 at 10:20 AM, Agency LPN E confirmed that Agency LPN E did not have a pager or walkie talkie that day. LPN E reported that LPN E would have to check the call light monitor to know if call lights were activated which can be hard when getting residents up for the day. H. In an interview on 9/24/24 at 10:39 AM, Bath Aide C confirmed that Bath Aide C did not have a pager or walkie talkie that day and would check the hallway screens to find out if call lights were activated. I. In an interview on 9/24/24 at 11:15 AM, Nurse Aide B confirmed that Nurse Aide B did not have a pager or walkie talkie and would need to check the call light was activated. J. In an interview on 9/24/24 at 10:53 AM, the ADON [Assistant Director of Nursing] reported that pagers and walkies have disappeared. Currently, the ADON has 3 pagers and walkies and is collecting pagers and walkies from staff. The ADON confirmed that pagers are not being handed out to staff members and staff members would need to check the monitors to know that a call light had been activated. K. In an interview on 9/24/24 at 1:18 PM, the DON reported the facility was working on ordering more pagers and walkies and confirmed having more pagers and walkies would help with call light response times. L. In an interview on 9/24/24 at 2:11 PM, the Administrator reported an expectation that call lights be answered within 15-20 minutes. The Administrator reported being unaware of the pager shortage. The Administrator confirmed that staff members would have to come off of the hallway to check the call light monitors and that call lights is an issue for the facility.

Licensure reference: 175 NAC 12-006.09 Based on record review and interview, the facility staff failed to ensure care was provided without delay for a changes in condition of a wound for 1 [Resident 3] of 3 sampled residents. The facility had a total census of 52 residents. Findings are: A review of Resident 3's Admission Record revealed Resident 3 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction [stroke] and fracture of the shaft of the left fibula [a break in the outside bone of the lower leg]. A review of Resident 3 MDS [Minimum Data Set; a comprehensive assessment used for care planning] dated 9/2/24 identified Resident 3 as having a score of 15 on the Brief Interview for Mental Status indicating Resident 3 is cognitively intact. A review of Resident 3's Care Plan with a focus area dated 9/10/24 revealed Resident 3 had a cat scratch on right forearm with the following interventions identified: -Encourage good nutrition and hydration in order to promote healthier skin dated 9/11/24 -Keep nails short to reduce risk of scratching or injury from picking at skin dated 9/11/24 -Keep skin clean and dry. Use lotion on dry skin dated 9/11/24 -Monitor/document location, size, and treatment of skin tear. Report abnormalities, failure to heal, sign/symptoms of infection, maceration etc. to doctor dated 9/11/24 -Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface dated 9/11/24 A review of Weekly Skin Evaluation dated 9/1/24 revealed Resident 3 had a cat scratch/bite on top of right forearm/wrist area in an L shape 2.5 cm [centimeters] x 2 cm. In an interview on 9/24/24 at 9:41 AM, Resident 3 reported Resident 3 had woke up at 6:00 AM and noted blood on the bed from the scratch on Resident 3's arm. Resident 3 had put on call light waited for 2 hours, no one answered and then call a family member. According to Resident 3, Resident 3's family member came to the facility at 8:30 AM and found a staff member to assistance Resident 3 with the bleeding from the scratch. A review of Weekly Skin Evaluation dated 9/9/24 revealed the following: -Right forearm-scratch in L shape around what appears to be [NAME]. Continues to have periods of bleeding. -Drsg [dressing] saturated with sero/sang [serosanguineous] drainage this am. Some clotting noted on drsg, and bedding. Tx [treatment] completed. Area continued to bleed. Coban applied to area of dressing. Instructed resident to keep arm above head for about 15-20 min [minutes]. Bleeding stopped. A review of Resident 3's call light log revealed the following: -Resident 3's call light was activated on 9/9/24 at 6:27 AM and cleared at 8:21 AM for total time of 114 minutes and 22 seconds A review of Resident 3's MAR [Medication Administration Record] 9-2024 revealed the following orders for treatment to Resident 3's right forearm and order for blood thinner medication as follows: -Order dated 9/1/24 Soak off dressing with NS [normal saline]/sterile water if needed. Cleanse wound with saline. Pat dry. Place Xeroform dressing [a find mesh gauze occlusive dressing] over wound cover with gauze or ABD [a highly absorbent sterile dressing]. Wrap with Kerlix [a bandage made of woven gauze]. -Order dated 8/31/24 Apixaban [blood thinner] 5 mg, 1 tablet by mouth 2 times per day A review of Resident 3's Progress Notes revealed the following documentation regarding the scratch on right forearm: -9/7/24 at 6:44 PM , Resident has been having some bleeding from the cat scratch right forearm, got dressing change twice today,applied pressure on it for about 15 mins [minutes], but it won't stop bleeding, so nurse used a Cuban dressing and a 4x4 (dressing), which helped to relief the bleeding. -9/8/24, a review of Resident 3's Progress note revealed no documentation regarding Resident 3's scratch on the right forearm -9/9/24 3:15 PM Telephone order obtained from provider with referral for patient to go to MWC [Wound Care] to be seen for wound on rt [right] forearm. -9/10/24 11:26 AM This nurse assessed residents wound on right arm with assistance of second nurse. This nurse decided to call provider as resident is on blood thinners and has had dressing changed multiple times due to saturation. Provider gives T.O. [telephone order] to send resident to ER [emergency room ] to evaluate and tx [treat] then tomorrow at her appt [appointment] it would be assessed. Family called per resident request to update on current plan of care and facility transport will take her to ER when returned to facility. -9/10/24 5:12 PM Resident returns to facility from E.D. [Emergency Department] via facility transport. New orders received from Provider to start azithromycin [antibiotic] and cephalexin [antibiotic] for cellulitis [a skin infection affecting skin's deeper layers and underlying tissue] of right arm wound. Residents MWC clinic was also moved to tomorrow at @0845. Resident and all of emergency contact list (per resident request) was notified and agree with plan of care. -9/11/24 12:16 AM Resident's dressing to rt. [right] arm noted to have moderate amount of blood and small amount of active bleeding noted. This nurse discards old dressing, applies pressure and reinforces w/ [with] clean dressing and wraps w/ ACE bandage to help control bleeding. Bleeding is well controlled and resident tolerates well. Will continue to monitor. Call light [within] reach. -9/11/24 2 AM At about 2205 [10:05 PM] on 9/10/24, resident's dressing to rt. Arm noted to be saturated w/ a moderate amount of blood. Small amount of active bleeding noted. Pressure applied as nurse changes/discards old dressing and reinforces it w/clean dressing. Resident tolerates well. Bleeding under control. Will continue to monitor. A review of Resident 3's Discharge Instructions from Wound Clinic dated 9/11/24 revealed Surgicel [a hemostat to help control bleeding] was placed in Resident 3's wound for hemostasis [stop bleeding after vascular damage]. In an interview on 9/24/24 at 12:37 PM, LPN A [Licensed Practical Nurse] reported Resident 3's family member found LPN A while LPN A was passing medications. LPN A reported Resident 3 was in bed with blood on the bandage and pad in bed. LPN A had cleaned the wound,using compression to get out some of the extra fluid, cleaned the wound again, and rewrapped it. LPN A reported being approached by Resident 3's family member about a half hour later as wound was bleeding again. LPN A reported applying pressure and re-wrapping the wound again and encouraging Resident A to hold arm above the head. LPN A reported that LPN A did not have to re-wrap Resident 3's wound the rest of the shift. LPN A reported not being aware Resident 3's call light had been on. LPN A acknowledged that LPN A did not have a pager or walkie and had to check the monitor in the hallway to know that a call light had been on. In an interview on 9/24/24 at 10:20 AM, Agency LPN E reported being informed that Resident 3's bleeding wouldn't stop over the weekend. LPN E reported taking off the dressing, putting a new dressing on it, and it bled through it right away. LPN E wrapped it with Coban [self-adherent wrap] and call Resident 3's provider and received orders for Resident 3 to be seen in the emergency room . In interviews on 9/24/24 at 12:02 PM and 2:11 PM, the Administrator reported an expectation that call lights be answered within 15-20 minutes and acknowledged that the call light time for Resident 3 was too long for a resident with bleeding. In interviews on 9/24/24 at 3:37 PM, the DON confirmed that Resident 3's provider should have been contacted and additional monitoring/evaluation should have been completed after notation in Resident 3's Progress Note on 9/7/24 regarding bleeding from Resident 3's wound.

Licensure Reference Number 175 NAC 12.006.11(E) Based on observations and interviews, the facility failed to a) ensure food products were disposed of prior to expiration dates, b) failed to implement and maintain the cleaning of food preparation equipment and surfaces to prevent the potential for food borne illness. This had the potential to affect 48 of 49 residents who eat from the kitchen. The facility census was 49. Finding are: During the initial kitchen tour on 06/24/24 from 9:05AM to 9:30 AM revealed the following: The walk-in refrigerator: -Gallon of 2% milk found in the walk-in refrigerator was open and only had 1/2 contents left was undated. In the walk-freezer: -Walk-in freezer had visible frost/ice buildup on the outside of the freezer door on the lower portion near the floor. The ice build-up covered the full length of the freezer door and approximately 8 inches high. -Unlabeled, undated bag of what appeared to be frozen egg patties or waffles observed inside walk-in freezer. In the reach-in refrigerator: -Three sandwiches wrapped in clear plastic wrap were not labeled or dated. -1 1/2 quart of unknown meat salad was not labeled or dated. -One tub of opened sour cream was not labeled or dated. The Dry Storage Area: -12 boxes sitting on the floor in the Dry Storage Area. -One open bag of Lemonade Drink Mix was tied shut with a twisty tie but was not dated. -One bag of Cocoa Powder was dated but was open (not securely closed). In the Dishwashing Area: -Steel metal grate hatch (approximately 3 feet by 3 feet) located in the dishwashing room was what resembles dust, and food debris build up around the edges. Duct tape covering the seam opening of the metal grate [NAME] and not intact with a large amount of what appears to be dust, food debris and grease buildup. Food service worker in the kitchen stated that they have tripped on this raveled duct tape several times. Grate on the floor was visibly dirty with rust buildup was not clean and was an uncleanable surface. -Oxidizes white/brown substance resembling hard water deposits, observed on the top of the dishwasher near both dishwasher drop down doors. In the Kitchen Preparation Area: -Numerous areas of what resembled dust, dirt, and grease build up observed in the seams of the kitchen linoleum flooring. -Small amount of oxidized white, dry, flakey substance noted on the outside, left-hand side of the ice machine lid. Observation of kitchen tour on 06/26/2024 at 08:05AM with the Certified Dietary Manger (CDM) revealed the following: -One tub of opened sour cream in the reach in refrigerator was not labeled or dated. -Large amount of dusty, sticky substance located on the outside of Cream of Tarter Seasoning plastic container. -Small amount of oxidized white, dry, flakey substance noted on the outside, left-hand side of the ice machine lid.--Open, undated bag of hot dogs loosely wrapped in clear plastic wrap observed in walk-in freezer. -1/4 container of low-fat cottage cheese in the walk-in refrigerator was undated. -1/2 container of opened sour cream in the reach in refrigerator was not labeled or dated. -Yellow, dried residue with 3-inch circular dark marks and scratches located on the kitchen linoleum flooring in the dry storage room where the wheels of a 6-metal storage rack rests. Dried food debris, resembling onion and cabbage leaves noted on the floor under the metal storage rack. -Unsealed linoleum patches located on kitchen flooring in front of the griddle stove, preparation table, and ovens not sealed. Previous sealant/caulking was broken revealing bottom floor surface; the area was not sealed and not a cleanable surface. A interview with CDM on 06/24/24 at 9:05 AM the CDM confirmed the above listed items from the kitchen tour on 06/26/2024 at 8:05 AM needed to be cleaned, repaired and/or corrected. Record Review of Nebraska Food Code reveals a regulation at 4-202.16 states that Nonfood-contact surfaces shall be free of unnessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. Record Review of Nebraska Food Code reveal a regulation at 3-305.11 States that Food shall be protected from contamination by storing the food 1) In a clean, dry location, 2) Where it is not exposed to splash, dust, or other contamination; and 3) At last 15 cm (6 inches) above the floor.

Licensure Reference Number 175 NAC 12.006.18 Based on observation, interview and record review: the facility staff failed to ensure hand hygiene was performed after glove changes during peri care, catheter care, and wound care and failed to prevent potential cross contamination during these cares by placing the washcloths in the sink basins and on the bed covers without a barrier for 2 of 2 residents surveyed (Residents 1 and 21). The facility claimed a census of 49. Findings are: 49164 A. Record Review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 05-25-2024 revealed Resident 1 admitted to the facility on [DATE] with the diagnosis of Heart Failure, Diabetes Mellitus Type 2, Schizophrenia, and Morbid Obesity. The MDS indicated Resident 1 had an indwelling catheter and required maximal assistance from staff to roll in bed, perform upper body dressing and personal hygiene and was dependent on staff to perform transfers, bathing, lower body dressing, and toileting hygiene. An observation on 06-26-2024 at 10:15 AM revealed Nurse Assistant (NA) D and NA E entered Resident 1's room to perform urinary catheter care and perineal care, wearing a gown and gloves. NA D placed a stack of washcloths in the bottom of the sink and turned on the water. After the washcloths were wet, NA D took the washcloths out of the sink and placed them onto Resident 1's bedside table without a barrier. Using one of the washcloths from the bedside table, NA D washed the right groin and the left groin, then using another washcloth from the bedside table, washed the urinary catheter tubing. Both NAs rolled Resident 1 to a side lying position, and NA D removed the incontinence brief that was soiled with feces. NA D removed soiled gloves and applied clean gloves without hand hygiene and used toilet paper to remove fecal matter from the resident's buttocks. After discarding the toilet paper, NA D used another washcloth from the bedside table and washed Resident 1's buttocks, then proceeded without changing gloves or performing hand hygiene to place a clean brief under the resident, apply barrier cream to the resident's skin, and place the catheter tubing into the securement device. NA D then removed gown and gloves and left the room without performing hand hygiene. NA E wearing the same soiled gloves throughout the procedure, covered Resident 1 with a sheet and went to the bathroom and returned with a paper towel, a graduate and alcohol wipes. NA E placed the paper towel on the floor and set the graduate on top of the towel and proceeded to empty the urinary catheter bag into the graduate. Once completed, NA E discarded urine into the toilet, removed gown and gloves and left the room without performing hand hygiene. An interview was conducted with NA D on 06-26-2025 at 10:35 AM confirmed the washcloths were placed in the bottom of the sink and hand hygiene should have been done after glove changes. An interview with NA E on 06-26-2024 at 10:45 AM confirmed NA E did not perform hand hygiene after removing gloves and should have. An interview with the Director of Nursing (DON) on 06-27-2024 at 12:02 PM confirmed hand hygiene should have been performed after glove changes, and using the bottom of the sink instead of a basin could cause cross contamination. Record Review of the facility policy Perineal Care (refers to the care of the external genitalia and the anal area) dated 11-28-2024 revealed it is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. The policy also revealed a basin of warm water was to be used to wet washcloths. B. Record review of Resident 21's MDS dated [DATE] revealed Resident 21 admitted to the facility on [DATE] with diagnosis of morbid obesity, alcoholic cirrhosis of the liver, left above the knee amputation and was a carrier of Methicillin Resistant Staph Aureas (MRSA, is a staph bacteria that does not get better with the type of antibiotics that usually cure staph infections). The MDS indicated Resident 21 required maximal assistance of staff to perform toileting hygiene and bathing and was completely dependent on staff for toilet and shower transfers. An observation on 6-26-2024 at 3:40 PM revealed NA E entered the room wearing a gown and gloves, to assist Registered Nurse (RN) A with personal care and wound care for Resident 21. NA E placed a stack of washcloths in the bottom of the sink and turned the water on. Once wet, the washcloths were hung on the inside of the sink basin. RN A entered Resident 21's room wearing a gown and gloves to provide a treatment to Resident 21. Resident 21 was lying on the bed, RN A lifts the resident's left breast, which was red and took a washcloth from inside the sink basin and washed the area and then applied powder to the area. RN A then removed soiled gloves and applied clean gloves without hand hygiene and then assisted NA E with positioning Resident 21 onto the right side. Resident 21's skin in the gluteal cleft was red with a yellow substance at the bottom of the cleft. RN A took one of the washcloths that were hanging in the sink basin and used it to wipe the buttocks and the gluteal cleft which began to bleed revealing an open slit in the skin. RN A applied powder to the area and placed a clean bottom sheet under Resident 21. After securing the bottom sheet to the bed, RN A rolled Resident 21 onto (gender) back, removed gloves and placed more washcloths in the bottom of the sink. RN A applied new gloves without performing hand hygiene and washed both armpits using washcloths out of the sink basin. After applying powder to the armpits, RN A removed the gloves and applied clean gloves and used a 4 by 4 inch gauze pad to cleanse the skin folds on Resident 21's left amputation site that was reddened with yellow drainage. After applying powder to the area, RN A removed gloves and gown and performed hand hygiene with soap and water for 30 seconds, then left the room. An interview conducted with RN A on 6-26-2024 at 4:45 PM confirmed that RN A did not perform hand hygiene in between glove changes and the placement of washcloths in the bottom of the sink could cause cross contamination. Record review of the facility policy Hand Hygiene dated 04-01-2024 revealed under Policy All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff in all locations within the facility. Under Policy Explanation and Compliance Guidelines 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 6. Additional considerations revealed the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to applying gloves and immediately after removing gloves. Under the attached Hand Hygiene Table situations are described that would require hand hygiene included -after handling contaminated objects -before and after removing personal protective equipment including gloves. -before and after handling clean or soiled dressings and linens -after handling items potentially contaminated with blood, body fluids, secretions or excretions -when during resident care, moving from a contaminated body site to a clean body site -after assistance with personal body functions (e.g.,elimination, hair grooming, smoking) An interview conducted with the Director of Nursing (DON) on 06-27-2024 at 12:02 PM confirmed that hand hygiene should have been done after glove changes and using the bottom of the sink instead of a basin could cause cross contamination.

Licensure Reference Number 175 NAC 12-006.19 Based on observations and interviews: the facility staff failed to maintain hallyway carpets in the center hallway, south hallway and the common area between 400 north and south hallways with the potential to effect 35 residents, failed to ensure2 (room [ROOM NUMBER], 402 and 405) ventilation covers were clean and failed to ensure a privacy curtain was in 1 residents room, room [ROOM NUMBER]. The facility staff identified a census of 49. Findings are: Observations on 6/24.2024 between 8:40 AM and 9:30 AM of the environmental tore revealed the following: - A shared toilet between rooms [ROOM NUMBERS] that lacked doors on both sides of the toilet. -Lingering strong urine smell in room [ROOM NUMBER]. -Bathroom ventilation's covers in rooms 310, 402, 405 covered with a gray fuzzy substance, resembling dust. -Stains (irregular shaped discolored blotches significantly darker than the surrounding carpet) down the Center, and South Hallways, and in the common area between 400 North and South Hallways). Carpet down the Center Hallway shows visible streaked linear lines. On 6/26.24 betwwen 1:45 PM and 2:15 PM of a environmental tour with the Maintenance Director (MD) revealed the following. -There was a lingering, strong urine smell in room [ROOM NUMBER]. MD reported that the urine smell was coming from the floor. -There was no privacy curtain of the shared toilet on side of room [ROOM NUMBER]. MD reported that there should be a privacy curtain on both sides of the shared toilet and that a privacy curtain was missing on the side of room [ROOM NUMBER]. -There was gray, fuzzy substance, resembling dust covering the bathroom vent in room [ROOM NUMBER] and room [ROOM NUMBER]. -Carpet flooring down the South Hallways showed visible stains of various, irregular shaped discolored blotches significantly darker than the surrounding carpet. -Carpet flooring down the Center Hallway was streaked with stained linear lines, resembling high volume traffic use. Large carpet stain irregularly shaped approximately 2 inches by 6 inches located three (3) feet inside Center Hallway near the Area 1 Nurse's Station (closest to the front entrance). A interview on 06/26/24 at 2:15 PM with Maintenance Director confirmed the above listed environmental concerns.

Based on record review and interview, the facility failed to provide a written notice of a bed hold for 2 (Resident 252 and 1) of 2 sampled residents. The facility census was 49. Findings are: A. A review of medical record for Resident 252 revealed Resident 252 had a fall on 05/25/24 and was transferred by ambulance to the hospital at 11:45 PM and returned to the facility on [DATE] at 02:31 AM. No bed hold notice was given to the resident or responsible party at time of transfer. On 05/26/24 at 12:30 PM Resident 252 was transferred by ambulance to the hospital. No bed hold notice was given to the resident or responsible party at time of transfer. Facility's Bed Hold Notice Upon Transfer Policy dated 8/1/23 revealed the following: At time of emergency transfer the resident and/or resident representative will be informed of bed hold option. The details of the bed hold will be provided in writing to the resident and/or resident representative soon as possible. An interview with Social Services Director (SSD) on 06/26/24 at 10:50 AM confirmed that the facility did not give timely notification of bed hold policy at time of transfer or discharge to Resident 252 or their representative on 05/25/24 at 11:45 PM or on 05/26/24 at 12:30 PM. 49164 B. Record Review of Resident 1's Electronic Health Record (EHR, is a digital version of a patient's paper chart)revealed Resident 1 was admitted on [DATE] and had been transferred to the hospital on 11-16-2023, 12-09-2023, 02-23-2024, and 05-19-2024. Record Review of Resident 1's medical record revealed there was no indications the facility provided a bed hold notice on 11-16-2023 and 12-09-2023. An interview conducted on 06-27-2024 at 10:25 AM with the SSD confirmed a bed hold notice was not issued to Resident 1 or Resident 1's representative for the hospital transfers on 11-16-2023 and 12-09-2023. Record Review of the facility policy Bed Hold Notice Upon Transfer dated 08-01-2023 revealed Policy: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. At the time of emergency transfer the resident and/or the resident representative will be informed of bed hold option. The details of the bed hold will be provided in writing to the resident and/or resident representative as soon as possible.

Based on record review and interview, the facility failed to provide a written notice of transfer for 1 (Resident 252) and/or their representative upon transfer to the hospital and failed to notify a representative of the Office of the State Long-Term Care Ombudsman for 2 of 2 (Resident 1 and 252) residents sampled for hospitalization s. The facility census was 49. Findings are: A. Review of a Electronic Health Record (EHR,, is a digital version of a patient's paper chart)) for Resident 252 revealed Resident 252 had a fall on 05/25/24 and was transferred by ambulance to the hospital at 11:45 PM and returned to the facility on [DATE] at 2:31 AM. No bed hold notice was given to the resident or responsible party at time of transfer. On 05/26/24 at 12:30 PM Resident 252 was transferred by ambulance to the hospital. No bed hold notice was given to the resident or responsible party at time of transfer. An interview with the Social Services Director (SSD) on 06/26/24 at 10:50 AM confirmed that the facility did not give the notification of bed hold policy at time of transfer or as soon after to Resident 252 or their representative. An interview with the SSD on 06/26/24 at 10:50 AM confirmed that the facility did not send a copy of the notice of resident transfer out of the facility to a representative of the Office of the State Long-Term Care Ombudsman. Facility's Bed Hold Notice Upon Transfer Policy dated 8/1/23 revealed the following: At time of emergency transfer the resident and/or resident representative will be informed of bed hold option. The details of the bed hold will be provided in writing to the resident and/or resident representative as soon as possible. 49164 B. Record Review of Resident 1's EHR revealed an admitted [DATE]. Resident 1 had two hospitalization s one on 11-16-2023 and one on 12-09-2023. Record Review of Resident 1's progress notes dated 11-16-2023 revealed Resident 1 was transferred to hospital via Emergency Medical Services (EMS, also known as ambulance services or paramedic services, are emergency services that provide urgent pre-hospital treatment and stabilization for serious illness and injuries and transport to definitive care) and did not have indications the Ombudsman was notified. Record Review of Resident 1's progress notes dated 12-09-2024 revealed Resident 1 was transferred to the hospital via EMS. An interview conducted on 06-27-2024 at 10:25 AM with the Social Service Designee (SSD) confirmed that the facility had not notified the ombudsman of the transfers to the hospital on 11-16-2023 and 12-09-2023.

Licensure Reference Number 175 NAC 12.006.09(J) Based on observation, interview and record review, the facility failed to follow physicians' orders for the administration of tube feeding for 1 (Resident 42) of 1. The facility identified a census of 49. Findings are: Record review of Resident 42's Minimum Data Set (MDS - a federally mandated assessment tool for Medicare and Medicaid residents) dated 2/22/2024 revealed Resident 42 had a Brief Interview for Mental Status (BIMS) score of a 8. According to the MDS [NAME] a score of 8 to 12 indicates a persons cognition is moderately impaired. Record review of Resident 42's MDS dated [DATE] revealed Resident 42 was receiving tube feeding. Record review of a practitioners order dated 6-21-2024 revealed Resident 42's practitioner order Novasource renal ( a feeding formula) to be given at 65 milliliters (ml) per hour for 12 hours. An observation on 06/26/2024 at 7:1 5 AM of Resident 42 revealed Resident 42's tube feeding was being administered via gravity (a method to administer formula from the feeding bag into the feeding tube by the force of gravity) through a gravity set bag ( a device that uses gravity to deliver a prescribed amount of formula feed to a patient through a feeding tube). The gravity set bag was dated 6/25/2024 and had the residents name on it with 50 milliliters (ml) of unidentified formula remained in the bag. The gravity set did not indicate what rate the formula was running at or how long it had been running. An interview with Licensed Practical Nurse B (LPN-B) on 06/26/2024 at 7:30 AM revealed LPN-B did not know what formula was being used or what rate it should be running at. LPN-B stated, it should be on the order. LPN-B did not know what amount of flush should be used when the tube feeding was finished or how to identify the amount of formula the resident received. LPN-B confirmed they did not know how to set up and administer tube feeding by gravity and further confirmed they could not find a physicians' order to administer the tube feeding by gravity. An interview with Registered Nurse-A (RN-A) on 06/26/2024 at 7:40 AM revealed RN-A was unable to find a physician's order to administer the tube feeding by gravity. RN-A confirmed they were unaware the tube feeding was being administered by gravity. An interview on 06/26/2024 at 9:15 AM with the Director of Nursing (DON) confirmed the DON was not aware that Resident 42's tube feeding was being administered by gravity. The DON confirmed a physicians' order was required prior to administering tube feeding via gravity.

Licensure Reference Number 175 NAC 12.006.09(l) Based on observation, interview and record review the facility failed to implement interventions to prevent reoccurring falls for 1 of 4 residents (Resident 40). The facility census was 49. Findings are: Record Review of Resident 40's most recent Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 05-14-2024 revealed Resident 40 had a Brief Interview of Mental Status (BIMS, an assessment that aids in detecting cognitive impairment. A score of 0-7 equals severe impairment, 8-12 indicates moderate impairment and 13-15 indicates cognitively intact) score of 7 indicating severe impairment. The MDS also revealed Resident 40 had the diagnosis' of End Stage Renal Disease, Heart Failure, Diabetes Mellitus and Depression. According to the MDS Resident 40 needed partial assistance from staff for bed mobility, transfers, oral hygiene and upper body dressing and maximal assistance from staff for lower body dressing, bathing and personal hygiene. Record Review of Resident 40's Progress Notes dated 06-13-2024 revealed Resident 40 slid out of their wheelchair in the transportation van and the immediate intervention was to make sure Resident 40 was positioned correctly in wheelchair after dialysis. Record Review of Resident 40's Progress Notes dated 06-14-2024 revealed the interdisciplinary team had reviewed the fall on 06-13-2024 and determined the cause of the fall was related to Resident 40 sitting on a lift sling during transport to and from dialysis. The intervention was facility staff would put Resident 40 in the wheelchair with Dycem (Dycem(R) non-slip material is used to help stabilize objects, hold objects firmly in place, or to provide a better grip) on the cushion as well as Dycem between the sling and the resident on dialysis days or when the hoyer is used. An observation on 06-27-2024 at 10:40 AM of Nurse Aid (NA) C and Licensed Practical Nurse (LPN) B transferring Resident 40 into the wheelchair to go to dialysis revealed NA C obtained Resident 40's wheelchair and places it next to Resident 40 who was sitting in the recliner. Observation of the wheelchair revealed a cushion was present in the seat of the wheelchair. NA C places a hoyer lift sling in wheelchair on top of the wheelchair cushion There was no Dycem placed on the cushion or between the sling Resident 40 was transferred to the wheelchair with a sit to stand lift with the assistance of both NA C and LPN B. An interview with NA C on 06-27-2024 at 10:55 AM revealed NA C did not know the intervention of placing a Dycem in between the hoyer sling and the resident, and under the wheelchair cushion. An interview with LPN B on 6-27-2024 at 11:00 AM revealed LPN B did not know the intervention of placing a Dycem underneath the wheelchair cushion and in between the hoyer sling and the resident and LPN B confirmed the Dycem had not been applied. An interview with the Director of Nursing (DON) on 06-27-2024 at 12:00 PM confirmed the interventions were on Resident 40's Kardex (a nursing worksheet which includes a summary of patient information such as clinical follow-ups and daily care schedules) and the staff should have placed Dycem under the wheelchair cushion and between the hoyer sling and Resident 40.

Licensure Reference Number NAC 175 12-06.09(H)(iii)(2) Based on observation, interview and record review, the facility failed to implement a ordered treatment for 1 (Resident 37) of 3 sampled residents for wound care. The facility identified a census of 49. Findings are: Record review of Resident 37's (Treatment Administered Record) TAR for June 2024 revealed a treatment order for Resident 37's left heel ,was Skin Prep daily with an order date of 6/5/2024. An observation on 6/26/24 at 6:56 AM revealed (Registered Nurse) RN-A came into Resident 37's room to complete the residents wound care. RN-A had poured Betadine in a medication cup outside of the room and brought this medication cup into the room and reported the Betadine was for Resident 37's left heel ulcer. Further observation revealed RN-A using a cotton ball applied the Betidine to Resident 37's left heel. On 06/26/24 at 10:56 AM a interview was conducted with the (Director of Nursing) DON. During the interview the DON reported the treatment should have been performed as ordered. The DON confirmed the treatment order to Resident 37's left heel was skin prep. On 06/26/24 at 10:57 AM a Interview was conducted with RN-A. During the interview RN-A reported not being aware of what the current order for Resident 37's left heel.

Licensure Reference Number 175 NAC 12.006.09(H)(iii)(3) Based on observation, interview and record review;the facility staff failed to conduct skin evaluations and failed to provide wound treatments in the order time frames for 1( Resident 21) of 1 Residents. The facility census was 49. Findings are: A. Record review of Resident 21's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 05-21-2024 revealed Resident 21 admitted to the facility on [DATE] with diagnosis of morbid obesity, alcoholic cirrhosis of the liver, left above the knee amputation and was a carrier of Methicillin Resistant Staph Aureas (MRSA, is a staph bacteria that does not get better with the type of antibiotics that usually cure staph infections). The MDS also revealed Resident 21 had a Brief Interview of Mental Status (BIMS, an assessment that aids in detecting cognitive impairment. A score of 0-7 equals severe impairment, 8-12 indicates moderate impairment and 13-15 indicates cognitively intact) score of 15 indicating intact cognition. The MDS indicated Resident 21 required maximal assistance of staff to perform toileting hygiene and bathing, and was completely dependent on staff for toilet and shower transfers. Record review of Resident 21's Electronic Health Record (EHR, is a digital version of a patient's paper chart) revealed orders to perform a weekly skin assessment every Saturday on the evening shift and to document the assessment in Point Click Care (the name of the cloud based software used by the facility). Further review of Resident 21's EHR revealed there was not information in Resident EHR that indicating skin assessments were completed on 06-01-2024 and 06-22-2024 Record Review of Resident 21's weekly skin evaluations revealed a skin evaluation dated 06-08-2024 identifying a macerated (maceration is defined as the softening and breaking down of skin resulting from prolonged exposure to moisture) area to the left gluteal fold (the horizontal skin crease that forms below the buttocks, separating the upper thigh from the buttocks). Record Review of Resident 21's weekly skin evaluation dated 06-16-2024 revealed revealed Resident 21 had maceration to both the right and left gluteal folds. An observation on 06-26-2024 at 3:40 PM of Registered Nurse (RN) A performing wound care for Resident 21 revealed Resident 21 had skin maceration to skin under left breast, bilateral arm pits, the gluteal cleft (the groove between the buttocks) and in the folds of a left stump (the portion of the leg remaining after an amputation). An interview with the Director of Nursing (DON) conducted on 06-27-2024 at 12:00 PM confirmed that no other skin assessments were conducted after 06-16-2024 for Resident 21. B. Record Review of Resident 21's Treatment Administration Record (TAR) dated 06-24-2024 revealed an order to Clean, dry and apply house powder to all folds twice a day at 8:00 AM and 8:00 PM for skin breakdown. In addition staff were to use Nystatin External Powder and to be apply to stump folds topically twice a day at 8:00 AM and 8:00 PM to prevent fungal infection and soreness. An observation on 6-26-2024 at 3:40 PM of RN A administering treatments to Resident 21's skin revealed RN A applied a house powder to all folds and Nystatin powder to Resident 21's stump. An interview was conducted on 06-26-2024 at 3:45 PM with RN A. During the interview RN A confirmed the ordered treatment for Resident 21's skin breakdown was followed. Record review of the facility's Wound Treatment Management policy dated 11-29-2023 revealed: -Policy: to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. - Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician's orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of of treatment orders, the licensed nurse will notify physician to obtain treatment orders. 3. Dressing changes may be provided outside the frequency parameters in certain situations: -feces seeped underneath the dressing, the dressing had dislodged ,the dressing is soiled otherwise, or wet. 4. Dressings will be applied in accordance with manufacturer recommendations. 5. Treatment decisions will be based on: -etiology of the wound -characteristics of the wound -location of the wound -goals and preferences of the resident/representative 6. Guidelines for dressing selection may be utilized in obtaining physician orders 7. Treatments will be documented on the TAR or in the EHR. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound.

Based on record review and interview, the facility failed to ensure a Preadmission Screening Resident Review (PASARR, a federally mandated screening process to ensure Nursing Home residents with mental illness and/or developmental disabilities receive the care and services they need in the most appropriate setting) was accurately completed for 1 (Resident 34) of 2 sampled residents. The facility sample was 49. Finding are: Record review of Resident 34's admission Minimum Date Set ( MDS, a federally mandatory assessment tool used for care planning) dated 07/14/2023 was admitted to the facility on [DATE] with the diagnoses of Unspecified Dementia, Generalized Anxiety Disorder, Major Depressive Disorder, and Delusional Disorder. Record review of PASARR Level 1 screening form dated 07-12-2023 revealed Resident 34 was assessed as having no diagnosis or suspicion of Serious Mental Illness (SMI) or Intellectual Disability or Related Condition (ID/RC). Interview with the Social Services Director on 06/26/24 at 10:00 AM confirmed that the PASARR Level Screen for Resident 34 completed on 07/12/2023 was inaccurate. The SSD reported based on the Resident 34's Admission Diagnosis of Dementia, Major Depression, Delusional Disorder and Anxiety that a PASARR Level 2 screen should have been completed. A review of the facility's policy titled Resident's Assessment- Coordination with PASARR Program Date Implemented 8-1-23 and Date Reviewed/Revised 9-18-23 revealed the following: -Policy: -The facility coordinated assessment with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated stetting appropriate to their needs.

Licensure Reference Number 175 NAC 12-006.12 Based on interview and record review, the facility failed to ensure that anti-seizure medications (medication to prevent seizures) was provided for Resident 1 to prevent potential seizures (a burst of uncontrolled electrical activity between brain cells stiffness, twitching, or limpness) and pain-relieving medication were provided for Resident 2. This affected 2 (Resident 1 and 2) of 3 sampled residents. The total facility census was 49. Findings are: A record review of the undated Pharmacy Services policy revealed the pharmacist along with the facility and medical director should have strived (tried) to assure that medications were requested, received, and administered in a timely manner as ordered by the prescriber (doctor, nurse practioner, physician assistant, etc.). A record review of the Form of Pharmaceutical Services Contract dated 09/01/2023 revealed the pharmacy would deliver medications to the facility 7 days per week, 365 days per year on a daily delivery schedule mutually agreed on by the facility and pharmacy. The Pharmacy should have established an emergency system for backup/or interim order dispensing. The contract did not reveal the daily delivery schedule mutually agreed on by the facility and the pharmacy. A record review of the facility's contract pharmacy's Iowa Pharmacy Information dated 09/28/2023 revealed Monday - Friday New Orders delivery times were 11:00 AM and 11:00 PM, Saturday, Sunday, and Holidays New Orders delivery times were 11:00 AM and 4:30 PM. New order requests received before 11:00 AM will arrive with the first scheduled delivery. New orders received after 11:00 PM Monday - Friday and after 4:30 PM Saturday, Sunday, and Holidays will arrive on the first scheduled delivery the following day. A record review of the facility's Azria Administering Medications policy dated 04/2019 revealed medications were to be administered (given) as the prescriber ordered in the required timeframe. Medications were to be administered with 1 hour of the prescribed time. A. A record review of Resident 1's Clinical Census dated 10/31/2023 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 1's Medical Diagnosis dated 10/31/2023 revealed the resident had a primary diagnosis of Acute and Chronic Respiratory Failure with Hypoxia (sudden and long-term respiratory failure with low oxygen). Other diagnoses include Epilepsy (a neurological disorder with recurrent episode of sensory disturbance, loss of consciousness, or convulsions), Other Seizures, Impaired Fasting Glucose (blood sugar). A record review of Resident 1's Discharge Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 10/22/2023 revealed the resident needed set up assistance for personal and oral hygiene (cleaning), supervision with dressing, and partial assistance with toileting and footwear. The MDS did not reveal that the Brief Interview for Mental Status (BIMS) (a score of a residents cognitive abilities) had been completed. A record review of Resident 1's Care Plan with an admitted [DATE] did not reveal interventions for Epilepsy or Other Seizures. A record review of Resident 1's Medication Administration Record (MAR) dated October 2023 revealed Resident 1 had an order for Lamotrigine (a medication used to treat Epilepsy) 200 milligram (mg) tablet 1 time per day for the resident's seizure diagnosis to be administered at 8:00 AM. The MAR revealed the resident had an order for Gabapentin (a medication used to treat Epilepsy) 600 mg tablet 3 times per day related to Other Seizures to be given at 8:00 AM, 2:00 PM, and 8:00 PM. The MAR revealed several other medications to be administered as ordered. The MAR did not reveal any of Resident 1's medications were administered while the resident was at the facility. A record review of Resident 1's Progress Notes dated 10/20/2023 - 10/24/2023 revealed: -10/22/2023 at 8:24 AM, RN-B charted: resident was found the morning (AM) by the cleaning staff. [Gender] was trying to talk to [gender] and noticed [gender] was unresponsive and looked like [gender] was choking. Went in there and resident was foaming at the mouth and having a seizure. Ran and got the nurse (RN-A) to help with resident as well. Turned resident on [gender] side and applied oxygen. Ran to call 911. Emergency Medical Services (EMS) arrived and gave her medications and started an IV. Resident would go in and out of seizure. Resident was coming out of seizure as EMS was leaving with (gender). Not able to answer questions but, would kind of groan. Sounds like she might have aspirated (inhaled food or fluids) as she was making gurgling sounds. Called report to the hospital. Let them know we currently do NOT have her medications (meds) in yet. RN-B called multiple times yesterday as medications were e-scribed (sent via electronic format) to pharmacy before [gender] hospital discharge on Friday per discharge papers. RN-B was told yesterday that they would be here as they could see [gender] profile in the system and [gender] meds. No meds arrived when RN-B took over this morning (AM) again. Called pharmacy and representative (rep) said they would come on morning run but, [gender] would transfer RN-B to the pharmacist to make sure. RN-B told the pharmacist that RN-B don't trust that they are really coming because they have been saying that since yesterday. Called the son to let the son know that the facility didn't have the medications yet and RN-B had been trying multiple times since yesterday to get them. -10/22/2023 at 9:00 AM, RN-A charted: At 8:24 AM the south hall nurse RN-B came to this writer and asked for assistance with resident as she was having a seizure. Upon entry to room [ROOM NUMBER] resident was having a tonic clonic seizure (stiffening and twitching or jerking of a person's muscles) and frothing at the mouth. Resident's pillow was very wet, [gender] was incontinent (lack of voluntary control over urination or bowels) and diaphoretic (sweating). RN-A rolled the resident to the side and started timing. RN-B exited the room and called EMS. At 8:36 AM 1 paramedic (EMS) arrived to assist. EMS gave rescue medication to the resident and got vital signs. Medication was unsuccessful and seizure continued. At 8:42 AM the paramedic called for more help and gave a second dose of rescue medication. Resident then relaxed but was still not responding to words but had a startle reflex. At 8:51 AM the fire department arrived, and the resident went back into a tonic clonic seizure and the resident was transferred at 8:56 AM. -10/22/2023 at 10:04 AM, RN-C charted: resident had a seizure this morning (AM) and medication (meds) were not here from pharmacy yet. -10/22/2023 at 2:30 PM, RN-B charted: Called emergency room and resident was going to be admitted to the Intensive Care Unit (ICU) and the resident was currently on a ventilator (a machine used to give breaths). -10/22/2023 at 7:09 PM, RN-B charted: Meds finally delivered on 10/22/2023 at 6:30 PM after they were supposed to deliver them yesterday! Resident at hospital. Called the change of command of pharmscript and no answer by anyone. In a telephone interview on 10/31/2023 at 12:57 PM, Registered Nurse (RN)-A confirmed that during report at the start of the shift on 10/21/2023, RN-A was told Resident 1 was admitted on [DATE] at about 6:00 PM and the resident had a history of seizures. RN-A confirmed that during the shift the resident's medications did not arrive. RN-A confirmed RN-A discussed the situation with RN-B and RN-B confirmed RN-B had called the pharmacy at least 5 times during the shift to find out when Resident 1's medications would be delivered. RN-B was told by the pharmacy that the resident and the resident's medication were in the pharmacy's system and would be on the next delivery. RN-A confirmed that RN-A was told in report on 10/22/2023 that Resident 1's medication had still not arrived. On 10/22/2023 at about 8:30 AM RN-A heard loud voices coming from Resident 1's room so RN-A and RN-B went to Resident 1's room and observed the resident having a seizure and frothing (white, small bubbles) at the mouth. RN-A began to treat the resident and RN-B went to call 911. Emergency services arrived, quickly loaded the resident, and left the facility at 8:56 AM. RN-A confirmed that Resident 1's prescriptions were sent to the pharmacy by the discharging hospital on 10/20/2023. RN-A confirmed the prescriptions had to be received by the pharmacy by a certain time to be delivered that day due to the pharmacy would only do 1 run per day on the weekends, but they were sent prior to that cutoff time. RN-A confirmed that Resident 1's medications were not delivered to the facility until 10/22/2023 at about 6:00 PM after the resident had a seizure and that was unacceptable. In an interview on 10/31/2023 at 4:45 PM, RN-B confirmed Resident 1 was admitted to the facility later Friday evening on 10/20/2023. When RN-B worked the 6:00 AM to 6:00 PM shift on 10/21/2023, the resident had not got medications yet. RN-B confirmed RN-B called the pharmacy and the pharmacy said they could see everything for the resident and the medications would be delivered, but they did not come. RN-B faxed everything to the pharmacy on 10/21/2023. When RN-B came in to work on 10/22/2023, the medications were still not there for Resident 1. RN-B called the pharmacy again, was transferred to the pharmacist, and was told by the pharmacist that everything for the resident was in the system, but for some reason the pharmacist had to enter each medication in, that was the reason for the delay. At about 8:30 AM the resident had a seizure and was transferred to the hospital. In an interview on 11/01/2023 at 06:50 AM, Licensed Practical Nurse (LPN)-D confirmed LPN-D worked the 06:00 PM - 06:00 AM shift on 10/21/2023. LPN-D confirmed that the pharmacy had not been called about Resident 1's medications not being at the facility on that shift because the day shift had reported they called the pharmacy. LPN-D confirmed the medications did not arrive at the facility until 6:00 PM Sunday (10/22/2023) and confirmed the facility staff was never sure what time the pharmacy would deliver medications. LPN-D confirmed that the facility did not attempt to call the doctor and should have. LPN-D confirmed this had been on ongoing issue with the pharmacy and LPN-D was unsure if management had discussed the issues with the pharmacy. A record review of Resident 1's Un-named facility incident timeline dated 10/20/2023 - 10/23/2023 revealed: -10/20/2023 Late evening resident arrived at the facility and the Assistant Director of Nursing (ADON) entered orders and notified the nurse they needed completed before 11:00 PM and needed faxed to the pharmacy at STAT (quickly) with a phone call telling the pharmacy to look for the new admission orders. -10/20/2023 at 11:05 PM - Nurse faxed orders to the pharmacy. -10/21/2023 at 6:00 AM - RN-B received report that the meds were not in but were faxed. -10/21/2023 at 4:00 PM - Day nurse reported to ADON that the pharmacy did not send the meds and verbalized the nurse called the pharmacy. -10/21/2023 at 5:00 PM - Pharmacy there with a delivery, but it did not include Resident 1's meds. The ADON told the nurse to call the pharmacy representative to resolve the problem. -10/22/2023 at 5:29 AM - LPN-D documented on the MAR not available, ordered. -10/22/2023 at 9:00 AM - Day nurse documented 8:24 AM seizure. -10/22/2023 at 9:00 AM - RN-A documented observations of the time of the seizure to time of departure with EMS. -10/22/2023 at 2:00 PM - RN- B documented call to hospital, resident would be admitted . -10/22/2023 at 7:09 PM - RN-B documented meds finally arrived and that the pharmacy chain of command was called with no answer. -10/22/2023 day - Nurse notified ADON by phone that the resident was admitted and ADON informed nurse not to accept resident back to the facility if meds had not arrived. -10/23/2023 at 9:00 AM Noted at stand up pharmacy issues and resident admitted to hospital. A record review of the facility's Abuse Investigation Tool dated 10/20/2023 revealed Resident 1 was admitted to the facility 10/20/2023 at 7:00 PM and was discharged to the emergency room [DATE] at 8:22 PM. The nurse documented the meds were ordered and did not arrive timely. The Administrator contacted the Corporate Regional Team and it was decided that the incident was not reportable to the State of Nebraska. The pharmacy was contacted, the process was reviewed and the medication ordering process was changed. The Administrator documented the incident was a Perfect Storm due to the facility received 2 new admissions that day, it was a weekend/Friday late admission, the staff was focused on a machine the facility did not have, the ADON did not receive the email with medications and the Director of Nursing was on vacation, and the incident was not put into Risk Management. The physician and resident 1's representative were not contacted until after the resident had a seizure. In an interview on 11/01/2023 at 12:15 PM, the facility's contract pharmacy's pharmacist confirmed the pharmacy did not get the orders from the facility until 10/20/2023 at 11:10 PM which was past the cutoff time for the orders to be delivered and there was no insurance information for the resident. The cutoff time should be 11:00 PM. The pharmacy then did get the insurance information, but the processing of the orders did not get completed until 10/21/2023 at 1:35 PM. The orders were then sent to the entry department 10/21/2023 at 11:40 PM. The orders where then process and delivered to the facility on [DATE] at 6:03 PM. The pharmacist confirmed the delay from getting the insurance information to being sent to the entry department was an internal error and could not give the reason. The expectation of the pharmacy was that the medications would be delivered to the facility on the next scheduled delivery, but the cutoff times were different because it was a Saturday. The pharmacist confirmed that not receiving medications of Lamotrigine and Gabapentin could have resulted in Resident 1 having a seizure. In an interview on 10/31/2023 at 1:40 PM, Resident 1's representative confirmed the resident was at a hospital and was transferred to a different hospital due to needing a higher level of care. Resident 1's represetnative revealed Resident 1 was placed on a ventilator and had a feeding tube placed upon admission to the hospital. The resident's representative confirmed the first time the facility contacted them was on 10/22/2023 at about 8:30 AM to notify the family that the resident had been transported to the hospital due to a seizure. The representative confirmed the nurse that contacted them started out the conversation with an apology as Resident 1's medications had not arrived since admission. The representative stated that if the family had been notified before they had medications at home they could have brought medications in for the resident until the resident's meds arrived. In an interview on 11/01/2023 at 9:02 AM, the ADON confirmed Resident 1 was a late admission on Friday 10/20/2023, the orders were entered into the EMR by 10:00 PM, and they were faxed to the pharmacy before 11:00 PM. The ADON confirmed the nurse that was on the following day was an agency nurse and the ADON did not know if the agency nurse knew the process, so the nurse resent the medications and called the pharmacy before 11:00 AM on 10/21/2023. The ADON revealed the medications did not arrive on 10/21/2023. The ADON confirmed the medications were not administered per policy and should have been. The ADON confirmed that RN-A and RN-B knew the pharmacy process and knew the nurses could get medications out of the Medbank (a storage system of medications to be used in emergency situations), but RN-A and RN-B did not use the Medbank. The ADON confirmed that Lamotrigine was not in the Medbank but Gabapentin was. A record review of Resident 1's Emergency Department (ED) to Hospital (Hosp) Admission (discharged ) in SCS ICU (continued) Service: Emergency Medicine note, page 32, dated 10/23/2023 revealed the physician confirmed on the Differential Diagnoses: Seizure, Status Epilepticus (seizure lasting greater than 5 minutes), and Acute Medication Withdrawal (new symptoms after sudden medication stoppage). A record review of Resident 1's Emergency Department (ED) to Hospital (Hosp) Admission (discharged ) in SCS ICU (continued) Service: Neurology note, dated 10/23/2023 revealed the physician confirmed in the History of Present Illness (HPI) that the resident presented yesterday with seizures in the setting of not getting Lamictal (Lamotrigine) for several days. In the physician's Impression, the physician confirmed the resident had seizures likely secondary to missed medications. B. A record review of Resident 2's Clinical Census dated 11/01/2023 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 2's Medical Diagnosis dated 11/01/2023 revealed the resident had a primary diagnosis of Fracture of Superior Rim of Left Pubis (left pubic bone break). Other diagnoses include Fracture of 1 Rib Unspecified Side, Pathological Fracture, Hip, unspecified (break caused by disease not trauma), Dementia (confusion). A record review of Resident 2's MDS with an admitted [DATE] revealed the resident had a BIMS of 9 of 15 which indicates moderate cognitive impairment. The resident needed substantial assistance for personal and oral hygiene, toileting, bathing, and dressing. A record review of Resident 2's Care Plan with an admitted [DATE] did not reveal focus area, goals, or interventions for pain. In an interview on 10/31/2023 at 12:57 PM. RN-A confirmed Resident 2 was admitted [DATE] in the late morning with a broken pelvis and none of the pain medications were delivered to the facility until the night of 10/21/2023. RN-A confirmed the resident was yelling out in pain and had increased behaviors due to his uncontrolled pain. The staff gave the resident another resident's Acetaminophen in the morning of 10/21/2023 and the ADON assisted the nurse in getting and Oxycodone 5 mg tablet out of the Medbank at about 5:30 PM due to the resident's left hip pain was a 10. RN-A confirmed it is an ongoing issue with the pharmacy delaying resident's medication, especially on the weekends. A record review of Resident 2's MAR dated October 2023 revealed Resident 2 had an admission order for Acetaminophen (a medication used to treat pain) 500 mg tablet 2 times per day for the resident's diagnosis of Fracture of the Superior Rim of the Left Pubis to be administered at 8:00 AM and 8:00 PM. The MAR revealed the Resident 2 had an order for Aspirin 81 (a medication used to treat pain) 1 tablet 2 times per day for the resident's diagnosis of Fracture of the Superior Rim of the Left Pubis to be administered at 8:00 AM and 8:00 PM. Acetaminophen 650 mg tablet every 4 hours as needed for pain. Hydrocodone-Acetaminophen (a medication used to treat pain) 7.5-325 mg tablet as needed for moderate pain. Oxycodone Hydrochloride (HCL)(a medication used to treat pain) 5 mg tablet as needed for pain. The MAR did not reveal any of Resident 1's pain medications were administered until 10/21/2023 Acetaminophen 500 mg tablet was administered at 8:00 AM for a pain of 10 out of 10 which is severe. The MAR had Chart Code 9 listed which was Other / See Nurse Notes. The MAR did reveal: -10/20/2023 and 10/21/2023 Scheduled Acetaminophen 650 mg tablet was not administered. -10/21/2023 at 5:18 PM Oxycodone 5 mg as needed tablet was administered for a pain level of 10 and was ineffective. -10/21/2023 at 9:09 PM Hydrocodone-Acetaminophen 7.5-325 mg tablet was administered, but it was ineffective. A record review of Resident 2's Clinical Physician Orders dated 10/31/2023 revealed an order to complete a pain evaluation every shift. A record review of Resident 2's Pain Level Summary dated 11/01/2023 did not reveal a pain level was documented until 10/21/2023 at 8:04 AM at which time the resident had a pain level of 10 out of 10 which indicated severe pain, 10/21/2023 at 2:07 PM revealed a pain level of 6 out of 10 which indicated moderate pain, 10/21/2023 at 5:18 PM revealed a pain level of 10 out of 10 which indicated severe pain, and 10/21/2023 at 6:07 PM revealed a pain level of 8 out of 10 which indicated severe pain. A record review of Resident 2's Progress Notes dated 10/20/2023 - 10/31/2023: -Did not reveal a pain evaluation completed every shift. -Did not reveal Nurse Notes as to why the pain medication were not administered as ordered. -10/21/2023 2:07 PM did reveal Acetaminophen 650 mg tablet was administered. -10/21/2023 5:18 PM Oxycodone 5 mg tablet was given for left hip pain of 10 out of 10. -10/21/2023 at 5:36 PM revealed a Pharmacy Note of the nurse had tried multiple times since 7:00 AM to get the residents medications to the facility from the pharmacy. At 7:00 AM the pharmacy said they did not have orders for Resident 2. The nurse faxed the pharmacy of the discharge medications and the 2 intravenous (IV) antibiotics and wrote STAT on all 4 pages. Then the pharmacy said they did not have the resident's insurance, so the nurse faxed a copy of the resident's insurance card. The nurse contacted the physician, and the physician confirmed the meds were sent to the facility's previous pharmacy. The nurse called the pharmacy again at 11:30 AM - 12:00 PM and the nurse was told the pharmacy had everything they needed and the STAT meds for narcotics would be at the facility between 4:30 PM to 5:00 PM, but the rest of the medications would be on the overnight run. The nurse was able to pull Oxycodone out of the Medbank with the ADON for the resident to get some pain relief. The Oxycodone was pulled out of the Medbank with the ADON. -10/21/2023 at 6:05 PM revealed Aspirin 81 was not administered due to meds were not at the facility from the pharmacy. -10/21/2023 at 6:07 Acetaminophen 650 mg tablet was administered for a pain level of 8 out of 10, and was ineffective. -10/22/2023 at 1:45 AM revealed the resident was very restless and agitated at times. Yelling out frequently, sitting on the edge of the bed. As needed Ativan (anxiety medication) and Hydrocodone (pain medication) was given earlier in the shift and it was ineffective. Resident pulled the Peripherally Inserted Central Catheter (PICC line)(a tube used to administer liquid medications into the bloodstream) out of the resident's arm. -10/22/2023 at 2:42 AM revealed the resident was transported to the hospital to have the PICC line re-inserted. -The Progress Notes did not reveal when the resident's medications arrived at the facility. In an interview on 11/01/2023 at 6:50 AM LPN-D confirmed LPN-D worked the 6:00 PM - 6:00 AM shift on 10/21/2023. LPN-D confirmed that the pharmacy had not been called about Resident 2's medications not being at the facility on that shift because the day shift had reported they called the pharmacy. LPN-D confirmed the medications did not arrive at the facility until after 10/22/2023 after midnight and confirmed the facility staff was never sure what time the pharmacy would deliver medications. LPN-D confirmed this had been on ongoing issue with the pharmacy and LPN-D was unsure if management had discussed the issues with the pharmacy. LPN-D confirmed not having the scheduled and as needed (PRN) pain medications could have caused increased pain and agitation. In an interview on 11/01/2023 at 9:02 AM, the ADON confirmed Resident 2's medications were not administered within the required timeframe per the policy and should have been. The ADON confirmed that RN-A and RN-B knew the pharmacy process and knew the nurses could get medications out of the Medbank, but RN-A and RN-B did not use the Medbank until the resident had a pain of 10 out of 10. In an interview on 11/01/2023 at 12:15 PM, the facility's contract pharmacy's Pharmacist confirmed the pharmacy did not get Resident 2's orders and admission information from the facility until 10/21/2023 at 8:37 AM, but the pharmacy still needed the insurance information. The pharmacy got the insurance information, and it was entered right away and sent to order entry on 10/21/2023 at 2:00 PM. The orders were then processed and Resident 2's medications were delivered 10/22/2023 at 6:03 PM. The Pharmacist did confirm that Resident 2 missing their medications would cause pain and agitation. ] In an interview on 10/31/2023 at 4:35 PM, RN-B confirmed Resident 2 was admitted to the facility Friday 10/20/2023 at about 11:30 AM. RN-B confirmed the resident's medications were supposed to be STAT and delivered within 3-4 hours. RN-B confirmed the pharmacy's driver came at 4:30 - 5:00 PM Saturday 10/21/2023 and Resident 2's medications were not delivered. RN-B called the pharmacy again and was told due to the medications being STAT the pharmacy had to send with a different driver. RN-B confirmed at that point the ADON was at the facility and was able to get RN-B in the Medbank to get Resident 2 some pain medications due to the resident was in severe pain. RN-B confirmed the medications did not get to the facility until late Saturday night 10/21/2023, and the first dose was given Sunday morning 10/22/2023. RN-B confirmed the resident would not have been in pain if the resident would have had the scheduled and PRN pain medication as ordered. C. The Immediate Jeopardy (IJ) was identified on 10/20/2023 and the IJ template was presented to the facility 11/01/2023 at 2:53 PM. The facility submitted the following abatement statement: -the facility was to educate the current staff 11/01/2023 in a mandatory meeting related to processes when medications are not available as outlined below. These processes have also been sent to all currently utilized agencies that explains the facility's expectation. -Cubex (Pyxis, Medbank) was to be used when medication was not available. -Nurse is to call pharmacy notifying them of STAT order by fax. Nurse is to ask pharmacy for expected estimated time of arrival (ETA). If the ETA is beyond four hours, Nurse is to advise pharmacy to utilize local pharmacy to fulfil the need. -After the fax is sent, nurse to call pharmacy again to verify order received, fax is to include resident face sheet and orders. -Nurse is to document in PointClickCare time fax was received by the pharmacy and with whom at the pharmacy they spoke. -New and current RN/LPN staff, including agency staff, will receive education on this process by Nursing Leadership prior to working independently. -Escalation process will be posted at the nurse's stations to include calling Nurse Leadership for further direction in the event pharmacy is unable to fulfill medications. -To monitor, the Director of Nursing (DON) or designee will review all new hire and new agency documentation of education to ensure pharmacy ordering compliance as outlined above is completed 5 times per week for 2 weeks. Then 3 times per week for 2 weeks. Then 1 time per week for 8 weeks. This will be reviewed through the facility's Quality Assurance program monthly for 3 months to assure compliance. -The Abatement Statement was signed by the Administrator.

Licensure Reference Number 175 NAC 12-006.09D8b Based on observation, interview and record review; the facility failed to assist with nutritional intake or deliver meals to a resident (Resident 1) to avoid continued significant weight loss resulting in hospice admission and failed to implement intervention to prevent the potential for weight loss for 2 residents (Resident 3 and 4) of 6 sampled residents. The facility census was 56. Findings are: A. Record review of the Admission Record revealed Resident 1 was admitted on [DATE]. Resident 1 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 1's Care Plan revealed: o The resident has nutritional problem or potential nutritional problem Self-Feeding Difficulty Date Initiated: 04/02/2021 o Nutrition status will maintain / improve as evidenced by adequate oral intake and stable weight. Date Initiated: 04/02/2021 Target Date: 09/07/2021 o Assist Resident w/ all meals. Date Initiated: 04/02/2021 o Diet as ordered: Regular diet w/ his food preferences. Date Initiated: 04/02/2021 o Monitor and record meal intakes Date Initiated: 04/02/2021 o Monitor and record weights Date Initiated: 04/02/2021 o Monitor nutrition indicative labs Date Initiated: 04/02/2021 Record review of Resident 1's weights revealed the following weights: admitted d 03/31/21 weight 143 4/3/21 weight 141 4/4/21 weight 142 4/5/21 weight 140 4/15/21 weight 140 5/3/21 weight 139 5/23/21 weight 131 7/8/21 weight 111. Record review of meal intake records from 05/05/2021-07/12/2021 or 69 days for Resident 1 revealed; Resident 1 had no documentation of meals for 40 of the 69 days. Record review of Hospice Physician Plan of Care dated 5/26/21 revealed, the admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Nutrition Progress note dated 6/2/21 revealed, Change of condition: nutrition assess: Hospice care initiated. Weight. 131#, shows a loss of 6% or9# near 30 days; and down 12# from admission weight of 143# on 3.31.21. Resident eating variably; refusals to 100% and sips to 1400 cc average in observation period per records available. Has 2 Cal Med Pass supplement 60 cc TID (Three times a day) and takes 100% per MAR (Medication Administration Record). Can increase that amount for added nutrition; will follow family and Hospice directives on any further nutrition. Nutrition needs are unmet currently placing resident at risk for further weight loss, dehydration and overall nutrition declines. Record review of MDS Significant Change in Condition assessment dated [DATE] revealed, Section B Vision: Resident 1 was severely impaired. Section G Functional Status: Resident 1 requires extensive assistance of 1 person for transfers, walking in room, dressing, eating, toilet use, personal hygiene, and bed mobility. Section I Active Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Section K Swallowing/Nutrition Status: Weight loss 5% or more in the last month or loss of 10 percent in more than 6 months not physician prescribed An interview on 7/13/21 at 6:36 PM with NA-A reported that Resident 1 preferred to lay on their stomach and would reposition self when staff was not present. NA-A reported that they did turn the resident to assist with eating. Resident was resistive to eating at times when they attempted to feed the resident. NA confirmed that the staff would document the food intake in the EMR (Electronic Medical Record) even if the resident refused it would be documented in the EMR as a refusal. An interview on 7/14/21 at 11:20 AM with NC (Nurse Consultant) confirmed the facility was unable to provide documentation of the 40 days missing meal intakes for Resident 1. The NC confirmed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 7/14/21 at 11:26 AM with the Dietician. The Dietician confirmed they had sent reports weekly to the DON (Director of Nurses) related to missing documentation for meals. The Dietician confirmed there had not been a significant amount of correction with the documentation related to meal intake. The Dietician reported if the meal intakes are not documented then they would ask the staff about meal intakes for residents. The Dietician confirmed the lack of documentation could affect the ability to accurately assess intakes. The Dietician confirmed on 6/2/21 a change in condition had been completed related to weight loss for Resident 1. The Dietician reported they had placed Resident 1 on a supplement that was discontinued by hospice. B. Record review of Admission Record revealed, Resident 3 was admitted on [DATE]. Resident 3 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Care Plan for Resident 3 revealed NUTRITION: The resident has nutritional problem or potential nutritional problem (confused) r/t (related to) leaves 25% plus of most meals uneaten. 11/3/20 - Chewing problems, is on mechanical altered diet 3/15/21 - needs assist w/ (With) meals. Date Initiated: 01/22/2020 Revision on: 03/15/2021 Nutrition status will maintain /improve as evidenced by adequate oral intake and stable weight. Date Initiated: 01/22/2020Target Date: 08/31/2021 o 2/26/2020 - Provide 8oz. Glucerna BID (Twice Daily) 10am & 3pm3/20/20 - Glucerna BID w/ breakfast & lunch. Date Initiated: 02/28/2020Revision on: 05/05/2021 o Diet as ordered: Provide Cardiac diet w/ (with) her food preferences. 2/21/2020 - Diet changed to Regular. 11/3/20 - Mechanical soft diet w/ ground meat. 2/3/21 - Consistency changed to puree per ST (Speech Therapy) rec. trial 2/3 through 2/9.2/9/21 - ST sent fax to doctor for a puree diet order.4/20-21-Puree consistency diet Date Initiated: 01/22/2020 o Monitor and record meal intakes Date Initiated: 01/22/2020 o Monitor and record weights Date Initiated: 01/22/2020 o Monitor nutrition indicative labs Date Initiated: 01/22/2020 o RD to evaluate and make diet change recommendations PRN. Date Initiated: 01/22/2020 o Resident eats independently - assist with set up as needed. May need cueing and encouragement. All meals in dining room, offer clothing protector. 3/15/21 - Assist resident w/ all meals. Date Initiated: 01/22/2020 Record review of Resident 3's weights revealed; 07/07/2021 14:11 148 Lbs (Pounds) (Bath) 06/30/2021 11:17 151 Lbs (Bath) 06/23/2021 18:31 155.5 Lbs (Mechanical Lift) 06/23/2021 13:48 153 Lbs (Bath) 06/18/2021 15:35 151 Lbs (Bath) 06/16/2021 10:50 154 Lbs (Bath) 06/09/2021 13:59 146 Lbs (Bath) -3.0% change from last weight [Comparison Weight 06/02/2021, 151.0 lbs, -3.3%, -5.0 lbs] 06/09/2021 10:44 146 Lbs (Bath) 06/02/2021 10:10 151 Lbs (Bath) 05/30/2021 00:28 151.5 Lbs (Bath) 05/26/2021 10:46 151 Lbs (Bath) 05/19/2021 10:33 152 Lbs (Bath) 05/19/2021 10:15 152 Lbs (Bath) 05/12/2021 10:43 151 Lbs (Bath) 05/05/2021 11:27 151 Lbs (Bath) 04/28/2021 10:32 149 Lbs (Bath) -10.0% change [Comparison Weight 11/11/2020, 167.0 lbs, -10.8%, -18.0 lbs] Record Review of Meal intakes for Resident 3 from 5/18/21 through 7/13/21 revealed; there was no meal documentation for 19 of 57 days. Record review of PO (Physician Order) for Resident 3 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of MDS Quarterly assessment for Resident 3 dated 6/2/21 revealed, Section G Functional Status: Resident 3 requires extensive assistance of 1 person for transfers, walking in room, dressing, eating, toilet use, personal hygiene, and bed mobility. Section I Active Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Section K Swallowing/Nutrition Status: no weight loss of 5% or more in the last month or loss of 10 % in 6 months An interview on 7/14/21 at 11:22 AM with NC (Nurse Consultant) confirmed the facility was unable to provide documentation of the 19 days missing meal intakes for Resident 3. The NC confirmed Resident 3 required assistance with meals, the resident should be placed on the South wall of the dining area so they can receive assistance. The NC reported the facility will be implementing a plan going forward to address documentation of meals to include education to staff regarding alternative meals and residents that require assist with eating. C. Record review of Admission record revealed Resident 4 admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The resident has nutritional problem or potential nutritional problem (poor intake). Has many food dislikes. 2/5/21 Returned from hospital on puree diet w/ nectar liquids. Resident and POA signed a Negotiated Risk Agreement 2/16/21 to have regular diet/thin liquids. 6/22/21-Intakes are very poor Date Initiated: 01/11/2021 Revision on: 06/22/2021 o Nutrition status will maintain / improve as evidenced by adequate oral intake and gradual weight gains Target Date: 09/14/2021 o 4/23/21-Med Pass 30 ml TID Date Initiated: 04/23/2021 o Monitor and record meal intakes Date Initiated: 01/11/2021 o Monitor and record weights Date Initiated: 01/11/2021 o Monitor nutrition indicative labs Date Initiated: 01/11/2021 o Provide and serve supplements as ordered: 2/5/21 - Ensure TID Date Initiated: 01/11/2021 Revision on: 06/17/2021 o RD (Registered Dietician) to evaluate and make diet change recommendations PRN. Date Initiated: 01/11/202 07/08/2021 14:57 103 Lbs (Bath) 07/03/2021 13:59 103 Lbs (Bath) 07/02/2021 18:01 103.5 Lbs (Mechanical Lift) 07/01/2021 13:29 103 Lbs (Bath) 06/28/2021 13:29 103 Lbs (Bath) 06/20/2021 12:32 103.5 Lbs (Bath) 06/19/2021 13:59 103 Lbs (Bath) 06/11/2021 18:47 107 Lbs (Mechanical Lift) -3.0% change from last weight [Comparison Weight 06/04/2021, 103.5 lbs, -3.4%, -3.5 lbs] MDS: -10.0% change over 180 day(s) [Comparison Weight 12/11/2020, 125.0 lbs, -20%, -25.0 lbs] 06/05/2021 13:58 100 Lbs (Bath) MDS: -10.0% change over 180 day(s) [Comparison Weight 12/11/2020, 125.0 lbs, -17.2%, -21.5 lbs] 06/04/2021 19:09 103.5 Lbs (bed scale) MDS: -10.0% change over 180 day(s) [Comparison Weight 12/04/2020, 125.0 lbs, -19.2%, -24.0 lbs] 05/28/2021 11:08 101 Lbs (Bath) MDS: -10.0% change over 180 day(s) [Comparison Weight 11/27/2020, 125.0 lbs, -20%, -25.0 lbs] 05/21/2021 13:59 100 Lbs (Bath) MDS: -10.0% change over 180 day(s) [Comparison Weight 11/27/2020, 125.0 lbs, -20%, -25.0 lbs] 05/21/2021 09:30 100 Lbs (Sitting) -MDS: -10.0% change over 180 day(s) [Comparison Weight 11/20/2020, 124.0 lbs, -18.5%, Record review of Meal Intakes from 5/15/21 through 7/9/21 revealed, no meal documentation on 31 of 60 days. Record review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 7/14/21 at 11:22 AM with NC (Nurse Consultant) confirmed the facility was unable to provide documentation of the 31 days missing meal intakes for Resident 4.

Licensure Reference: 175 NAC 12-006.09D7b Based on record reviews, observations, and staff interviews; the facility failed to assess residents' risk for burns from hot liquids and implement interventions to prevent burns from spilling hot liquids for 2 residents (Resident 1 and 3) of 5 sampled residents. The facility identified a total of 15 residents at risk for burns from hot liquid out of a total census of 61 residents. Findings are: A. On 1/9/12 at 12:50 PM, a cup of coffee was obtained from facility coffee machine in dining room of the facility. Coffee was poured into a thermal cup that the facility utilized to serve to coffee to residents of the facility. The following temperatures were recorded from facility thermometer in the presence of the Dietary Manager: -12:50 PM, just poured, 165 degrees Fahrenheit (F) -12:55 PM 156 degrees F -1 PM 144 degrees F -1:05 PM 138 degrees F -1:10 PM, 20 minutes after coffee was poured, 132 degrees F In an interview on 1/9/12 between 12:05-12:30 PM, the Dietary Manger reported the coffee machine temperature was set at 175 degrees F with coffee to be between 160-165 degrees F when poured into a cup. The coffee machine had been installed at the facility in 11/11 according to the Dietary Manager. In a follow-up interview on 1/10/12 at 8 AM, the Dietary Manager reported the facility started using the thermal cups at the about the same time as the facility installed the new coffee machine due to receiving complaints about the coffee being cold. A review of Equipment Service Invoice revealed coffee machine was installed on 11/17/11. Observations in the dining room at 2 PM on 1/9/12 revealed the coffee was on and accessible to residents. A visitor but no staff members or residents were observed in the dining room. In an interview on 1/10/12 at 8 AM, the Dietary Manager confirmed the coffee machine was on and coffee was available in the dining room at all times. B. Resident 1 was admitted to the facility on [DATE] according to Record of Admission. Resident 1's Client [DIAGNOSES REDACTED]. A review of Resident 1's MDS (Minimum Data Set; a comprehensive assessment used for care planning) dated 11/9/11 revealed the following: -Resident 1 scored 12 out of 15 points on Brief Interview for Mental Status (BIMS). -Resident 1 required supervision and setup assistance for eating Resident 1's Care Plan did not include a problem related to burns for spilled hot liquids but did include the following interventions related to potential hot liquid burns. -Resident 1 to have all meals in dining room. -Offer Resident 1 a clothing protector at each meal. Resident 1 wants a clothing protector at times. -Cool coffee with water before serving to Resident 1 (This intervention was dated 1/5/12. 5 days after Resident 1 sustained a burn from spilling hot coffee.) Therapy Screen Form for Resident 1 dated 11/21/11 stated "Nursing reports decrease function, increased frequency of falling, only eating 25%, no longer ambulating to dine." The Therapy Screen Form concluded therapy evaluation indicated for occupational therapy, physical therapy, and speech therapy. physician's orders [REDACTED]. Incident Report for Resident 1 for incident on 12/31/11 at 5 PM stated the following: "Resident was sitting at the table in the dining room waiting for supper when this med (medication) aide notice resident spilled (Resident 1) hot coffee on (Resident 1) lap. CNA (Certified Nurse Aide) and med aide took resident to (Resident 1) room. Notice redness on both thighs cool rag was applied." Non-Decubitus Skin Conditions report form for Resident 1 dated 12/31/11 identified a large blister on left inner thigh and 2-3 larger blister and several smaller blisters on right thigh. A review of physician's orders [REDACTED]. -1/1/12 Slivadene cream to blisters twice a day cover with dressing -1/3/12 Cephalexin (an antibiotic) 500 mg caps 1 orally three times per day for 10 days Non-Decubitus Skin Conditions report entry for Resident 1 dated 1/10/12 identified the following: -Area A-Resident 1's left thigh had 4 cm (centimeter) x .7 cm drying blister linear, yellow/greenish in color with no dressing, no periwound redness, no odor, and no warmth. -Area B-Resident 1's right thigh had 12.5 cm x 2 cm linear areas with bridging present. Area has 50% dry intact blister and 50% moist yellow with red flecks. -Area C-Resident 1's right thigh had 9.5 cm x 1.7 cm linear drying blister, with no warmth, no periwound odors, or drainage. Observation of and interview with Dietary Manager at 5:35 PM on 1/9/12 revealed Resident 1's coffee was cooled with water prior to service to Resident 1. Observations at 7:30 AM on 1/10/12 revealed Resident 1's coffee cooled with ice prior to service. A check of coffee temperature for coffee prepared for Resident 1 revealed a temperature of 65 degrees. A review of Resident 1's medical record did not reveal an assessment for safety with hot liquids. C. Resident 3 was admitted to the facility on [DATE] according to Record of Admission. Resident 3's Client [DIAGNOSES REDACTED]. A review of Resident 3's 12/7/11 MDS revealed the following: -Resident 3 scored 14 out of 15 on BIMS. -Resident 3 required extensive assist of one person with eating. Resident 3's Care Plan, dated 10/8/09, identified Resident 3 as eating slow and needing assist with meals. The intervention listed related to potential for spilling hot liquid was assist (Resident 3) with clothing protector for all meals per (Resident 3) request." Observations between 12:45 PM-12:56 PM on 1/9/12 revealed Resident 3 at the table in the dining room. Resident 3 was served a cup of coffee from the coffee machine with powdered creamer mixed into it. The coffee cup had no lid and a straw was placed into the cup of coffee. Resident 3 was observed with head tilted back holding cup of coffee at an angle drinking coffee from the straw. No staff members were observed to assist Resident 3 or be present at Resident 3's table at the time Resident 3 was drinking the coffee. Observations between 5-5:15 PM on 1/9/12 revealed Resident 3 being fed pureed food. Resident 3 was observed to drink pink liquid from a glass independently and spill pink liquid onto Resident 3's clothing protector. Hot Liquids Safety Evaluation dated 1/10/12, after observation of Resident 3 drinking hot liquid independently, identified Resident 3 as being at risk for injury from spills of hot liquids due to contractures of fingers/hands/wrists/elbows or shoulders and loss of mobility/reduced movement in upper extremities. New interventions to be implemented on 1/10/12 due to the evaluation included: temperature of hot liquid not to exceed 180 degrees; hot liquids drank while sitting at table only; coffee cooled with cream; wear clothing protector/lap protector; staff to assist resident with all hot liquids and resident to be seated at an assisted table. D. In an interview on 1/9/12 at 2:50 PM, the ADON reported the facility did not screen residents for safety with hot liquids. In an interview on 1/9/2012 at 3:50 PM, the DON (Director of Nursing) reported the facility did not screen residents for safety with hot liquids but that therapy did screen all new residents at the facility. In an interview on 1/9/12 at 4:12 PM, PTA (Physical Therapy Assistant) Therapy Department Head reported therapy did not do an evaluation of resident's safety with hot liquids. A review of the facility investigation revealed in-service education regarding first aide for burns would be provided to nurse aides on 1/5/12 and nurses on 1/12/12. The facility investigation stated Dietary Staff would be educated as well. In an interview on 1/9/12 at 3:50 PM, the DON confirmed an in-service would be held regarding burns on 1/12/12 for nurses. In an interview on 1/9/12 at 4 PM, the Dietary Manager reported Dietary staff would be attending an in-service regarding burn on 1/12/12. E. The following interventions were implemented by the facility on 1/10/12 to abate the immediacy of the situation and protect residents from hot liquid burns: -The coffee machine located in the dining room was shut off and no coffee was served at the lunch meal on 1/10/12. -A Hot Liquids Safety Evaluation was completed on all residents of the facility with 15 residents being identified at risk for injury from spills of hot liquids. The care plans for the 15 residents identified at risk for injury from spills of hot liquids were updated to include interventions to protect residents from injuries related to spills of hot liquids. -Staff education with an in-service at 2 PM on 1/10/12 was completed. -A list of Residents at Risk with Hot Liquids was posted in the kitchen. The following additional interventions were planned: -Coffee Machine would be moved into the kitchen where only kitchen staff would have access to it. -Lap pads were to be made available for residents at risk. -All staff members were required to read and sign "Hot Liquid Safety Guidelines" prior to staff working. -Coffee for residents at risk for injuries from hot liquids would be poured in to a carafe and cooled to a temperature between 120-140 degrees F before service to residents.