Every finding on record at Adept Nursing & Rehab of Sutherland

Licensure Reference Number 175 NAC 12-006.09(I) Based on observations, interviews, and record review; the facility failed to ensure water temperatures in resident restroom sinks and a resident accessible dining room sink were 120 degrees or below, placing 6 (Residents 9, 15, 26, 29, 38, and 40) of 6 sampled residents at risk for burns. The facility census was 42. Findings Are: The facility was notified on 3/2/2026 at 2:30 PM of an Immediate Jeopardy (IJ) which began on 4/15/2025. The IJ was removed on 3/2/2026, as confirmed by surveyor onsite verification. A record review of facility policy Safe Water Temperatures with a revision date of 4/2/2025 revealed water temperatures will be set to a temperature of no more than 120 degrees Fahrenheit (F). Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed. A record review of a Burn Exposure Chart on the antiscald.com website dated 2026, revealed a 2nd degree burn can occur within 2 minutes of exposure to a water temperature of 124 degrees F, within 17 seconds of exposure to a water temperature of 131 degrees F, and within 3 seconds of exposure to a water temperature of 140 degrees F. A.A record review of Resident 15's admission Record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of Hemiplegia (total or partial paralysis on one side of the body that results from disease or injury to the motor centers of the brain). The resident resided in the facility's Special Care Unit (SCU). A record review of Resident 15's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 2/10/2026 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 3/15, which indicated the resident had severe cognitive impairment. The resident utilized a wheelchair for mobility and was independent with wheeling self at least 150 feet. An observation on 3/2/2026 at 1:46 PM in Resident 15's room (room [ROOM NUMBER]), revealed the bathroom sink water temperature was 132.1 degrees F. An interview on 3/2/2026 at 1:42 PM with Nurse Aide (NA)-A revealed Resident 15 was independently mobile and did go into their bathroom at times without staff assistance. An interview and observation on 3/2/2026 at 1:57 PM with Maintenance revealed they checked the water temperatures in random rooms throughout the facility Monday through Friday each week. Maintenance was observed turning on the water in room [ROOM NUMBER]'s bathroom sink and obtaining a temperature reading of 132 degrees F with their temperature gauge. An observation on 3/3/2026 at 11:24 AM revealed Resident 15 wheeling self from the dining room and down the hallway independently. B.A record review of Resident 26's admission Record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of dementia (a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior). The resident resided in the facility's SCU. A record review of Resident 26's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 0/15, indicating the resident had severe cognitive impairment. The resident utilized a walker for ambulation, required supervision with toileting hygiene, and was able to ambulate at least 150 feet independently. A record review of Resident 26's undated Care Plan revealed the resident required set up assistance with hygiene and was independent with toileting and ambulation. An observation on 3/2/26 at 1:39 PM revealed the bathroom sink water temperature in Resident 26's room (room [ROOM NUMBER]) was 137.8 degrees F. An interview on 3/2/26 at 1:42 PM with NA-A revealed Resident 26 was independently ambulatory and did go into their bathroom independently at times. An observation on 3/2/26 at 2:07 PM revealed Maintenance turning on the water in room [ROOM NUMBER]'s bathroom sink and obtaining a temperature reading of 137.4 degrees F with their temperature gauge. C.A record review of Resident 29's admission record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of dementia. The resident resided in the facility's SCU. A record review of Resident 29's admission MDS dated [DATE] revealed a BIMS score of 0/15, indicating the resident had severe cognitive impairment. The resident utilized a walker for mobility and required supervision for walking up to 50 feet. A record review of Resident 29's undated Care Plan revealed the resident required supervision for ambulation and toileting. An observation on 3/2/2026 at 1:35 PM revealed Resident 29 resided in room [ROOM NUMBER] and their bathroom sink water temperature was 136 degrees F. An interview on 3/2/26 at 1:42 PM with NA-A revealed Resident 29 was independently mobile and did go into their bathroom independently at times. D.A record review of Resident 9's admission Record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of dementia. The resident resided in the facility's SCU in room [ROOM NUMBER]. A record review of Resident 9's Quarterly MDS dated [DATE] revealed a BIMS score of 0/15, which indicated the resident had severe cognitive impairment. The resident did not utilize any mobility devices, required supervision with toileting hygiene, and was able to walk at least 150 feet independently. An observation on 3/2/2026 at 1:32 PM revealed Resident 9's bathroom sink water temperature was 133 degrees F. An interview on 3/2/26 at 1:42 PM with NA-A revealed Resident 9 was independently ambulatory and frequently wandered throughout the SCU. An observation on 3/2/26 at 2:04 PM revealed Maintenance turning on the water in room [ROOM NUMBER]'s bathroom sink and obtaining a temperature reading of 133.1 degrees F with their temperature gauge. E.A record review of Resident 40's admission Record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of Alzheimer's disease (a degenerative brain disease of unknown cause that usually starts in late middle age or in old age, that results in progressive memory loss, impaired thinking, disorientation, and changes in personality and mood). The resident resided in the facility's SCU in room [ROOM NUMBER]. A record review of Resident 40's Annual MDS dated [DATE] revealed a BIMS score of 10/15, which indicated the resident had moderate cognitive impairment. The resident utilized a wheelchair for mobility and was independent with wheeling self at least 150 feet. A record review of Resident 40's undated Care Plan revealed the resident required substantial assistance with toileting and supervision for personal hygiene. An observation on 3/2/2026 at 1:32 PM revealed Resident 40's bathroom sink water temperature was 133 degrees F. An interview on 3/2/26 at 1:42 PM with NA-A revealed Resident 40 was independently mobile and did go into their bathroom independently at times. An observation on 3/2/26 at 2:04 PM revealed Maintenance turning on the water in room [ROOM NUMBER]'s bathroom sink and obtaining a temperature reading of 133.1 degrees F with their temperature gauge. F.A record review of Resident 38's admission Record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of degeneration of nervous system due to alcohol. The resident resided in the facility's SCU in room [ROOM NUMBER]. A record review of Resident 38's Quarterly MDS dated [DATE] revealed a BIMS score of 8/15, which indicated the resident had moderate cognitive impairment. The resident was independent with toileting, required set up/clean up assistance with personal hygiene, and was able to ambulate at least 150 feet independently. An observation on 3/2/2026 at 1:50 PM revealed Resident 38's bathroom sink water temperature was 121 degrees F. An interview on 3/2/26 at 1:42 PM with NA-A revealed Resident 38 was independently ambulatory and did go into their bathroom without staff assistance. An observation on 3/2/26 at 1:59 PM revealed Maintenance turning on the water in room [ROOM NUMBER]'s bathroom sink and obtaining a temperature reading of 124.3 degrees F with their temperature gauge. G.An observation on 3/2/2026 at 2:08 PM revealed Maintenance turning on the water in the SCU dining room sink and obtaining a temperature reading of 136.6 degrees F with their temperature gauge. An interview on 3/2/26 at 2:08 PM with Maintenance revealed the lowest water temperature for the facility sinks was to be 120 degrees F and that Maintenance ensured the temperatures were not above 140 degrees F as they did not want anyone to get burned. Maintenance also stated that the entire building's water was heated by the same water heater. H.A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of April 14th-18th, 2025 revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In room [ROOM NUMBER], 113, 104, 123 the temperature was 125.3 degrees F on 4/15/2025, 128 degrees F on 4/16/2025, 122.3 degrees F on 4/17/2025, and 124.2 degrees F on 4/18/2025.-In room [ROOM NUMBER], 119, 111, and 125 the temperature was 126 degrees F on 4/15/2025, 134.4 degrees F on 4/16/25, and 122.2 degrees F on 4/18/2025.-In room [ROOM NUMBER], 105, 130, and 103 the temperature was 129.5 degrees F on 4/15/2025 and 131.8 degrees F on 4/16/2025.A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of April 28th-May 18th, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 127.5 degrees F on 4/28/2025, 127.9 degrees F on 4/29/2025, 124.2 degrees F on 4/30/2025, 124.2 degrees F on 5/1/2025, and 122.4 degrees F on 5/2/2025.-In SCU Rooms 108, 110, 105, and 112 the temperature was 125.3 degrees F 4/28/2025, 128.9 degrees F on 4/29/2025, 125.8 degrees F on 4/30/2025 and 121.5 degrees F on 5/1/2025. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of May 5th-May 8th, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 124.6 degrees F on 5/7/2025.-In SCU Rooms 105, 107, 111, and 106 the temperature was 125.5 degrees F on 5/5/2025, 123.5 degrees F on 5/6/2025, and 125.3 degrees F on 5/7/2025. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of May 12th-May 15th, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 123.6 degrees F on 5/12/2025, 123.7 degrees F on 5/13/2026, and 126 degrees F on 5/14/2026.-In SCU Rooms 105, 106, 107, and 108 the temperature was 126.4 degrees F on 5/12/2025, 122.8 degrees F on 5/13/2025, and 127.2 degrees F on 5/14/2025. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of May 19th-May 23rd, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 125.3 degrees F on 5/19/2025, 123.5 degrees F on 5/20/2025, 124.3 degrees F on 5/21/2025, 127 degrees F on 5/22/2025, and 123.2 degrees F on 5/23/2025.-In SCU Rooms 112, 106, 111, 110, and 108 the temperature was 130.4 degrees F on 5/19/2025, 125 degrees F on 5/20/2025, 125.6 degrees F on 5/21/2025, 126.3 degrees F on 5/22/2025, and 121.6 degrees F on 5/23/2025.A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of May 27th-May 30th, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 122.1 degrees F on 5/27/2025, 125.4 degrees F on 5/28/2025, and 123.3 degrees F on 5/29/2025.-In SCU room [ROOM NUMBER], 106, 107, and 108 the temperature was 122.7 degrees F on 5/27/2025, 127.1 degrees F on 5/28/2025, and 125.5 degrees F on 5/29/2025. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of June 2nd -June 6th, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 124 degrees F on 6/2/2025, 124.9 degrees F on 6/4/2025, 122.4 degrees F on 6/5/2025, and 124.8 degrees F on 6/6/2025.-In SCU room [ROOM NUMBER], 111, 110, 105, and 106 the temperature was 127.6 degrees F on 6/2/2025, 120.9 degrees F on 6/3/2025, 123.2 degrees F on 6/4/2025, 123.4 degrees F on 6/5/2025, and 123.6 degrees F on 6/6/2025. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of July 7th -July 11th, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 124.4 degrees F on 7/8/2025, 125 degrees F on 7/9/2025, 120.8 degrees F on 7/10/2025, and 122.2 degrees F on 7/11/2025.-In SCU room [ROOM NUMBER], 105, 106, 107, and 108 the temperature was 129 degrees F on 7/8/2025, 127 degrees F on 7/9/2025, 120.1 degrees F on 7/10/2025, and 124 degrees F on 7/11/2025. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of July 14th -July 18th, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 121.9 degrees F on 7/14/2025, 123.9 degrees F on 7/16/2025, 131.6 degrees F on 7/17/2025, and 131.8 degrees F on 7/18/2025.-In SCU room [ROOM NUMBER],107, 106, 110, and 108 the temperature was 124.6 degrees F on 7/14/2025, 122.7 degrees F on 7/16/2025, 131.1 degrees F on 7/17/2025, and 128.5 degrees F on 7/18/2025. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of July 21st -July 25th, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 131.7 degrees F on 7/21/2025, 130.3 degrees F on 7/22/2025, 124.3 degrees F on 7/23/2025, 132.1 degrees F on 7/24/2025, and 131.2 degrees F on 7/25/2025.-In SCU room [ROOM NUMBER], 108, 107, 106, and 105 the temperature was 128.9 degrees F on 7/21/2025, 130.3 degrees F on 7/22/2025, 122.6 degrees F on 7/23/2025, 129 degrees F on 7/24/2025, and 130.3 degrees F on 7/25/2025.A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of July 28th -August 1st, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 124.3 degrees F on 7/28/2025, 132.1 degrees F on 7/29/2025, 126.3 degrees F on 7/31/2025, 126.3 degrees F on 8/1/2025.-In SCU Rooms 112, 110, 111, and 105 the temperature was 130.2 degrees F on 7/28/2025, 132 degrees F on 7/29/2025, 129.3 degrees F on 7/31/2025, and 129.3 degrees F on 8/1/2025. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of August 4th -August 8th, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 126.5 degrees F on 8/4/2025, 139.6 degrees F on 8/5/2025, 130.7 degrees F on 8/7/2025, and 137.7 degrees F on 8/8/2025.-In SCU Rooms 112, 105, 106, and 107 the temperature was 130.1 degrees F on 8/4/2025, 139.4 degrees F on 8/5/2025, 138.1 degrees F on 8/7/2025, and 139.4 degrees F on 8/8/2025. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of August 11th -August 15th, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 127.3 degrees F on 8/11/2025, 135.4 degrees F on 8/12/2025, 135.4 degrees F on 8/13/2025, 138.1 degrees F on 8/14/2025, and 138.9 degrees F on 8/15/2025.-In SCU Rooms 111, 110, 108, 107, and 106 the temperature was 137.4 degrees F on 8/11/2025, 138.1 degrees F on 8/12/2025, 137.1 degrees F on 8/13/2025, 135.4 degrees F on 8/14/2025, and 135.2 degrees F on 8/15/2025. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of August 18th -August 22nd, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 136.6 degrees F on 8/18/2026, 133.8 degrees F on 8/19/2025, 135.4 degrees F on 8/20/2025, 131.5 degrees F on 8/21/2025, and 134.1 degrees F on 8/22/2025.-In SCU room [ROOM NUMBER], 105, 110, 106, and 107 the temperature was 138.5 degrees F on 8/18/2025, 138.7 degrees F on 8/19/2025, 137.5 degrees F on 8/20/2025, 135.7 degrees F on 8/21/2025, and 135.6 degrees F on 8/22/2025. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of September 1st -September 5th, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 123.1 degrees F on 9/1/2025, 126.8 degrees F on 9/2/2025, 134.2 degrees F on 9/3/2025, 131 degrees F on 9/4/2025, 135.6 degrees F on 9/5/2025.-In SCU room [ROOM NUMBER], 110, 111, 112, and 107 the temperature was 129.3 degrees F on 9/1/2025, 134.3 degrees F on 9/2/2025, 135 degrees F on 9/3/2025, 135.8 degrees F on 9/4/2025, and 126.7 degrees F on 9/5/2025. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of September 8th -September 12th, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 130.8 degrees F on 9/8/2025, 136.4 degrees F on 9/9/2025, and 133.3 degrees F on 9/10/2025.-In SCU room [ROOM NUMBER], 105, 106 the temperature was 130.6 degrees F on 9/8/2025, 132.7 degrees F on 9/9/2025, and 136.5 degrees F on 9/10/2025. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of September 22nd -September 26th, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 126.4 degrees F on 9/22/2025, 122.2 degrees F on 9/23/2025, 130.4 degrees F on 9/24/2025, 132.6 degrees F on 9/25/2025, and 130.1 degrees F on 9/26/2025.-In SCU room [ROOM NUMBER], 105, 106, 107, and 108 the temperature was 135.4 degrees F on 9/22/2025, 140.4 degrees F on 9/23/2025, 136.2 degrees F on 9/24/2025, 136.8 degrees F on 9/25/2025, and 135.7 degrees F on 9/26/2025. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of September 29th -October 3rd, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 139.8 degrees F on 9/29/2025, 132.6 degrees F on 10/1/2025, 128.9 degrees F on 10/2/2025, and 133.1 degrees F on 10/3/2025.-In SCU room [ROOM NUMBER], 111, 110, and 108 the temperature was 138.7 degrees F on 9/29/2025, 135.6 degrees F on 10/1/2025, 138 degrees F on 10/2/2025, and 134.8 degrees F on 10/3/2025. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of October 6th -October 10th, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 121.6 degrees F on 10/6/2025, 124.3 degrees F on 10/7/2025, 130.1 degrees F on 10/8/2025, 126.0 degrees F on 10/9/2025, and 123.4 degrees F on 10/10/2025.-In SCU room [ROOM NUMBER], 105, 106, 107, and 108 the temperature was 136.9 degrees F on 10/6/2025, 134.5 degrees F on 10/7/2025, 134.6 degrees F on 10/8/2025, 132.6 degrees F on 10/9/2025, and 126.4 degrees F on 10/10/2025. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of October 20th -October 23rd, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 131.2 degrees F on 10/20/2025, 133.3 degrees F on 10/21/2025, 136.1 degrees F on 10/22/2025, and 135.4 degrees F on 10/23/2025.-In SCU room [ROOM NUMBER], 112, 111, and 106 the temperature was 131 degrees F on 10/20/2025, 125.1 degrees F on 10/21/2025, 131.6 degrees F on 10/22/2025, 124.6 degrees F on 10/23/2025. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of October 27th -October 31st, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 128.6 degrees F on 10/27/2025, 126.1 degrees F on 10/28/2025, 130.6 degrees F on 10/29/2025, 131 degrees F on 10/30/2025, and 129.8 degrees F on 10/31/2025.-In SCU room [ROOM NUMBER], 111, 110, 108, and 107 the temperature was 126.1 degrees F on 10/27/2025, 130.6 degrees F on 10/28/2025, 129.7 degrees F on 10/29/2025, 130.6 degrees F on 10/30/2025, and 129.6 degrees F on 10/31/2025. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of November 3rd -November 7th, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 122.6 degrees F on 11/3/2025, 120.6 degrees F on 11/4/2025, 122.4 degrees F on 11/5/2025, 125.1 degrees F on 11/6/2025, and 128.7 degrees F on 11/7/2025.-In SCU room [ROOM NUMBER], 107, 108, 105, and 110 the temperature was 133 degrees F on 11/3/2025, 130.7 degrees F on 11/4/2025, 137.2 degrees F on 11/5/2025, 131.4 degrees F on 11/6/2025, and 129.6 degrees F on 11/7/2025. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of November 10th -November 14th, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 135.1 degrees F on 11/10/2025, 132.2 degrees F on 11/11/2025, 131.5 degrees F on 11/12/2025, 135.4 degrees F on 11/13/2025, and 133 degrees F on 11/14/2025.-In SCU room [ROOM NUMBER], 112, 106, 107, 108 the temperature was 134.6 degrees F on 11/10/2025, 135.6 degrees F on 11/11/2025, 133.7 degrees F on 11/12/2025, 130.4 degrees F on 11/13/2025, and 137.6 degrees F on 11/14/2025. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of November 17th -November 21st, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 136.4 degrees F on 11/17/2025, 133 degrees F on 11/18/2025, 135.4 degrees F on 11/19/2025, 130.6 degrees F on 11/20/2025, 133.4 degrees F on 11/21/2025.-In SCU room [ROOM NUMBER], 105, 111, 107, and 108 the temperature was 133.3 degrees F on 11/17/2025, 129.1 degrees F on 11/18/2025, 136.5 degrees F on 11/19/2025, 127.4 degrees F on 11/20/2025, and 133.3 degrees F on 11/21/2025. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of December 8th -December 12th, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 132.6 degrees F on 12/8/2025 and 127.1 degrees F on 12/9/2025.-In SCU the temperature was 130.1 degrees F on 12/8/2025 and 132.3 degrees F on 12/9/2025. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of December 22nd -December 26th, 2025, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 134.6 degrees F on 12/22/2025, 132.1 degrees F on 12/23/2025, 131.6 degrees F on 12/24/2025, and 129.1 degrees F on 12/26/2025.-In SCU 105, 106, 107, and 108 the temperature was 128.1 degrees F on 12/22/2025, 130.1 degrees F on 12/23/2025, 129.6 degrees F on 12/24/2025, and 131.6 degrees F on 12/26/2025. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of December 29th, 2025 -January 2nd, 2026, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 129.6 degrees F on 12/29/2025, 132 degrees F on 12/30/2025, 126.3 degrees F on 12/31/2025, 127.6 degrees F on 1/1/2026, and 130.1 degrees F on 1/2/2026.-In SCU 112, 111, 110, and 108 the temperature was 130.1 degrees F on 12/29/2025, 128.7 degrees F on 1/30/2025, 130 degrees F on 12/31/2025, 125.4 degrees F on 1/1/2026, and 125.1 degrees F on 1/2/2026. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of January 5th -January 9th, 2026, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 134.4 degrees F on 1/5/2026, 136.1 degrees F on 1/6/2026, 132.1 degrees F on 1/7/2026, 129.6 degrees F on 1/8/2026, and 131.6 degrees F on 1/9/2026.-In SCU 105, 106, 107, 108, and 110 the temperature was 126.7 degrees F on 1/5/2026, 128.1 degrees F on 1/6/2026, 130.1 degrees F on 1/7/2026, 129.6 degrees F on 1/8/2026, and 130.1 degrees F on 1/9/2026. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of January 10th -January 16th, 2026, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 134.2 degrees F on 1/10/2026, 133.6 degrees F on 1/11/2026, 131.4 degrees F on 1/12/2026, and 129 degrees F on 1/13/2026.-In SCU 105, 106, 107, and 108 the temperature was 130.1 degrees F on 1/10/2026, 133.1 degrees F on 1/11/2026, 128.6 degrees F on 1/12/2026, and 129.6 degrees F on 1/13/2026. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of January 19th -January 23rd, 2026, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 137.5 degrees F on 1/19/2026, 134.6 degrees F on 1/20/2026, 132.6 degrees F on 1/21/2026, 128.1 degrees F on 1/22/2026, and 126.1 degrees F on 1/23/2026.-In SCU 110, 111, 112, 105, and 106 the temperature was 138.9 degrees F on 1/19/2026, 131 degrees F on 1/20/2026, 130.1 degrees F on 1/21/2026, 128.1 degrees F on 1/22/2026, and 126.1 degrees F on 1/23/2026. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of January 27th -January 30th, 2026, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 132.1 degrees F on 1/27/2026, 130.6 degrees F on 1/28/2026, 131 degrees F on 1/29/2026, and 130.6 degrees F on 1/30/2026.-In SCU 112, 111, 110, and 108 the temperature was 131 degrees F on 1/27/2026, 130.4 degrees F on 1/28/2026, 128.4 degrees F on 1/29/2026, and 126.2 degrees F on 1/30/2026. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of February 2nd -February 6th, 2026, revealed the water temperature was greater than 120 degrees Fahrenheit (F):-In SCU Dining room the temperature was 126.1 degrees F on 2/2/2026, 123.6 degrees F on 2/3/2026, 129.4 degrees F on 2/4/2026, 131.2 degrees F on 2/5/2026, and 130.4 degrees F on 2/6/2026.-In SCU 112, 111, 110, 105, and 106 the temperature was 129.6 degrees F on 2/2/2026, 130.1 degrees F on 2/3/2026, 127.2 degrees F on 2/4/2026, 130.4 degrees F on 2/5/2026, and 127.4 degrees F on 2/6/2026. A record review of the facility's Direct Supply TELS Logbook Documentation Water Temps for the week of February 23rd -February 27th, 2026, revealed a comment Thursday the 19th I was stripping a room floor and that Friday I was out sick and all this week just as well. There were no temperatures recorded on the document. An interview on 3/3/36 at 8:45 AM with the Regional Director of Operations (RDO) confirmed that the TELS water temperature logs indicated the IJ started in April 2025. Abatement Statement:1. Correction to the residents affected #26, 29, 9, 40, 15, and 38:-Hot water heaters were turned down to 120 degrees.-All hot water usage was ceased for resident usage.-All resident sinks hot water was turned on and monitored by a staff member until temperature was under 120 degrees.-Baths were stopped until bathroom water temperatures were under 110 degrees.-Education to all staff to not use resident care area water without taking a temperature and to not use the sink for hand washing if the temperature is over 120 degrees. Staff educated on how to take water temperatures.-Maintenance Director educated on safe temperature range. 2. System Changes: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 3-2-26)-Safe Water Temperature Policy was educated to all staff that are working and will continue to be reviewed with all staff prior to their next shift until everyone has completed the education.-Utilize TELs to educate maintenance staff or designated staff doing water temperatures on what are acceptable water temperatures and document water temperatures in TELs and review what acceptable water temperatures are and that no temperatures that were taken exceed the acceptable safe water temperatures of 100 degrees to 120 degrees in resident care areas. -If any temperatures exceed the acceptable safe water temperature of 120 degrees the water source will be shut down until temperature can be within acceptable range. Nursing staff and Administrator will be notified of out of range temperatures immediately and hot water heater will be adjusted to bring temperatures down. 3. Monitoring:-Performance Improvement Project (PIP) was implemented and presented to all Department Heads on 3-2-26. Monitoring will be completed by Administrator by reviewing water temperature logs 5 x a week for 2 weeks 3 x a week for 2 weeks then monthly for 2 months. All findings will be discussed at the monthly QAA meeting for a minimum of three months or until the pattern of compliance is maintained for accuracy. At the time of the survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level.

The facility failed to prepare foods according to the recipe, including pureed foods, to ensure the nutritive value was maintained. This had the potential to affect all 42 residents.Pureed residents were 1, 5, 22Licensure Reference Number 175 NAC 12-006.09(J)(i) Based on observation, record review, and interviews, the facility failed to prepare foods according to the recipe, including pureed foods for Residents 1, 5, and 22, to ensure nutritive value was maintained. This had the potential to affect all residents.Findings are: A continuous observation in the kitchen on 3/4/26 from 9:05 AM through 10:45 AM revealed Cook-B performed the following:At 9:15 AM, Cook-B removed 1.5 pounds (lbs) of sliced raw bacon from a package, then chopped the bacon into small pieces. The bacon was added to a skillet and cooked on the stove until 9:23 AM.At 9:25 AM, Cook-B measured 32 ounces (oz) of sour cream into a measuring cup.At 9:28 AM Cook-B cracked 30 uncooked eggs into a bowl, then whisked them.At 9:46 AM, Cook-B removed 12 pounds of spinach from a colander which had been draining over the sink, then transferred it into a mixing bowl.The bacon, sour cream, and eggs were mixed with salt, pepper, and sauteed onions in a bowl, then combined with the spinach. All ingredients were placed in a stainless-steel pan and put into the oven.A record review of a facility document dated 2026, titled Dining Manager, Spinach bake, revealed a list of ingredients and cooking instructions for that dish, and included the following ingredient amounts calculated for 46 servings:Spinach, chopped frozen, 7 pounds 10 oz.Bacon, raw, 3 pounds 11 oz.Sour cream, 4 lbs, 10 oz. (74 oz total).Eggs, large, 1 3/4 each serving, with 46 servings requiring 80.5 eggs.Other ingredients were measured in accordance with the recipe.An interview on 3/04/2026 at 1:43 PM with the Dietary manager (DM) confirmed that Cook-B did not prepare the spinach bake according to the recipe as written and should have.B.A continuous observation in the kitchen on 3/4/26 from 9:05 AM through 10:45 AM revealed the following:At 10:04 AM, Cook-B removed a 16-ounce container of Sysco pork base from the refrigerator, then filled a pitcher with hot tap water.Cook-A added 1 tablespoon of pork base into the pitcher which held 1 gallon (128 oz) of water.At 10:26 AM, Cook-B added the pork base water to the stainless-steel pan which held the pork tenderloin that was prepared for the lunch meal.At 10:27 AM, Cook-B put three scoops of meat in the blender, added some pork base water then pureed the meat. Cook-A stopped the blender, checked the texture of the meat mixture, added an unmeasured amount of thickener, then blended again.At 10:39 AM, Cook-B transferred the pork mixture into a small stainless-steel pan, covered with foil and placed in the steam table.A record review of the 16-oz Sysco pork base container revealed directions to add 1 teaspoon of base to 8 oz of boiling water, or add entire container to 5 gallons of boiling water.A record review of medical records in Point Click Care revealed that Residents 1, 5, and 22 were prescribed a pureed diet.An interview with Cook-B on 3/4/26 at 10:26 AM revealed there are 3 residents who receive the pureed diet.An interview on 3/04/2026 at 1:43 PM with the DM confirmed that Cook-B did not add enough pork base to the pitcher of water, which was then added in the pureed meat and later thickened, diluting the nutritive value for those three residents.

Based on observation, record review, and interviews, the facility failed to ensure the freezers were maintained at 0 degrees or below, failed to prevent the potential for cross contamination when handling raw meat, and failed to use or dispose of foods prior to expiration date, This had the potential to affect all 42 residents.Findings are:A.Record review of facility-provided documents of temperature records/documents from the walk-in freezer, the upright deep-freeze, and the refrigerator/freezer combination (records did not identify which freezer the temperature logs were related to) revealed the following measurements documented above 0 degrees Fahrenheit:September 2025, AM shift measurements -30 days with data listed, and 11 of 30 days (September 19th-30th) ranged from 6-20 degrees. (The PM shift had 25 of 30 days with documented temperatures, all below zero).September 2025, AM measurements listed 30 days of data that ranged from 2-11 degrees. PM measurements 24 days had data recorded, and all 24 ranged from 2-10 degrees .September 2025, AM measurements listed 30 days of data that ranged from 9-19 degrees. PM measurements 23 days had data recorded, and all 23 ranged from 8-12 degrees.October 2025, AM measurements 23 of 31 days with data, 20 out of 23 were above 0 degrees F (range 8-12 degrees). PM - 11 days with data, 7 days were above 0 degrees and ranged from 8-11 degrees.October 2025, AM - 25 days with data, 22 days temps ranged from 8-14 degrees, and three days marked, defrosting. PM - 10 of 31 days with data, all 10 ranged from 8-14 degrees.October 2025, AM - 25 days with data, 23 days temps ranged from 2-12 degrees. PM - 11 days with data, all 11 ranged from 2-10 degrees.October 2025, AM - 23 of 31 days with data, 20 out of 23 ranged 8-12 degrees. PM - 11 days with data, 7 days were above 0 degrees and ranged from 8-11 degrees.November 2025, AM - 27 of 30 days with data, 26 out of 27 ranged from 2-9 degrees. PM - 16 days with data, 11 days ranged from 2-4 degrees.November 2025, AM - 26 of 30 days with data, all 26 ranged from 8-20 degrees. PM - 18 days with data, all 18 days ranged from 8-11 degrees.November 2025, AM - 27 of 30 days with data, all 27 ranged from 4-10 degrees. PM - 21 days with data, all 21 days ranged from 4-12 degrees.December 2025, AM - 28 of 31 days with data, all 28 ranged from 6-15 degrees. PM - 11 days with data, all 11 days ranged from 9-11 degrees.December 2025, AM - 28 of 31 days with data, all 28 ranged from 2-10 degrees. PM - 12 days with data, 11 days ranged from 1-11 degrees.December 2025, AM - 28 of 31 days with data, all 28 ranged from 8-12 degrees. PM - 12 days with data, all 12 days ranged from 8-11 degrees.January 2026, AM - 31 days with data, which ranged from 8-21 degrees. PM - 12 days with data, all 12 days ranged from 8-11 degrees.January 2026, AM - 31 days with data, with 28 days which ranged from 2-10 degrees. PM - 21 days with data which ranged from 1-10 degrees.January 2026, AM - 29 days with data, with 23 days which ranged from 2-12 degrees, and three days marked defrost. PM - 21 days with data with 16 days which ranged from 1-15 degrees and three days marked defrost.February 2026, AM - 28 days with data, which ranged from 8-12 degrees. PM - 1 day with data, 9 degrees above zero.February 2026. AM - 28 days with data, 18 days which ranged from 2-18 degrees. PM - 2 days with data, 1 day at 1 degree.February 2026. AM - 28 days with data, with 23 days which ranged from 2-16 degrees. PM - 2 days with data, 1 day at 2 degrees.An observation on 3/2/26 at 11:30 AM of the upright deep-freezer revealed contents including ice creams, pies, and a cake. The ice cream containers were able to have the sides depressed/squished. The freezer portion of the refrigerator/freezer in the kitchen revealed more food containers that were able to have the sides squished.An interview on 3/2/26 at 11:40 AM with the Dietary manager (DM) revealed that the freezer temperature logs for February recorded temperatures for three different freezers: the walk-in freezer, the upright deep-freeze, and the refrigerator/freezer combination, and confirmed the logs did not specify which freezer each log belonged to, and this was the routine practice. The interview confirmed that the freezers should have been at zero degrees Fahrenheit or below. The interview also revealed that no logs were available prior to September 2025, as the DM initiated the temperature monitoring after they were hired. An interview on 3/4/26 at 1:43 PM with the DM confirmed that all three freezers were not zero degrees Fahrenheit for most days recorded between September 2025 and the time of survey (as stated above) as required, and should have been.B.A continuous observation in the kitchen on 3/4/26 beginning at 11:54 AM through 12:05 PM revealed the following actions:At 11:54 AM Cook-B was wearing a glove on their left hand and had a bare right hand, entered the walk-in freezer then exited with three meat patties in their gloved hand. Cook-B put the patties in a skillet on the stove.Cook-B removed clear plastic film from the top of a large stainless-steel bowl containing Hawaiian dinner rolls. Cook-B picked up several packages of Hawaiian dinner rolls from a shelf and put them on the prep counter. Cook-B put a glove on the non-gloved hand. Cook-B removed the rolls from the packaging, broke them apart with both hands into single rolls and placed them in the large bowl. Cook-B obtained another piece of clear plastic film from the dispenser, touching the dispenser and film with both gloved hands. Cook-B picked up the empty roll packages and put them into a trash can.At 11:59 AM Cook-B opened a drawer under the prep counter, removed a spatula, walked to the stove and used the spatula to flip the meat patties while wearing the same gloves. Cook-B then obtained a bag of hamburger buns from a shelf and put them on the counter.At 12:00 PM Cook-B removed their gloves, put them in a trash can, and performed hand hygiene with soap and water.An interview on 3/4/26 at 1:43 PM with the DM confirmed that the meat patties were made of uncooked hamburger. The interview also confirmed that Cook-B did not remove their gloves or perform hand hygiene after handling raw meat and should have.C.An observation on 3/2/2026 at 11:24 AM in the dry storage room of the kitchen revealed the following:5, 46-ounce containers of ready-to-drink tomato juice with an expiration date of 2/16/26.3, 46-ounce containers of ready-to-drink prune juice with an expiration date of 2/15/26.1 undated 1-gallon zip lock bag of bananas cut in half with peels still on and tips cut off and moisture collected in the bag.An observation on 3/2/26 at 11:40 AM in the kitchen refrigerator revealed the following:One opened undated bag with 2 hard-boiled eggs partly liquefied.One 1-quart container of [NAME] latte liquid mix, expiration date February 2026.An interview on 3/2/26 at 11:50 AM with the DM confirmed that the tomato and prune juice containers were beyond their expiration dates, bananas, eggs, and [NAME] latte mix were no longer suitable for consumption, and that all should have been discarded.

Licensure Reference Number 175 NAC 12-006.05Based on record review and interview, the facility failed to ensure informed consent was obtained for 1 (Resident 1) of 5 sampled residents' psychotropic medications. The facility identified a census of 42.Findings:Resident 1 was admitted on [DATE] and had diagnoses of chronic obstructive pulmonary disease (a progressive lung disease that restricts breathing, often caused by smoking), Type 2 diabetes mellitus (a metabolic disorder when the body cannot regulate levels of sugar in the blood), schizophrenia (a mental disorder that affects how a person thinks, feels, and behaves), bipolar disorder (a mental illness with episodes of extreme mood changes), depression, and anxiety.A record review of Resident 1's medication orders in Point Click Care (PCC, an electronic medical record system), revealed that Resident 1 had physician orders for clonazepam (an antianxiety medication) 0.5 mg by mouth every 12 hours as needed for symptoms of anxiety with a order date of 01/28/2026, and lamotrigine (used to treat bipolar and epilepsy, a seizure disorder) 200 mg by mouth at bedtime for bipolar disorder with a order date of 1/12/26.A record review of Resident 1's progress notes on 12/7/25 and 12/8/25 at 1:28 PM revealed Resident 1 was noted to be taking clonazepam at that time.A record review of Resident 1's electronic medical record revealed no evidence of consent obtained or benefits and side effects explained for clonazepam or lamotrigine.An interview on 3/05/2026 at 10:22 AM with the Assistant Director of Nursing (ADON) revealed there was no consent in Resident 1's medical record for the psychotropic medications clonazepam and lamotrigine and there should have been.

Licensure Reference Number 175 NAC 12-006.05 (G)Based on record review and interview, the facility failed to ensure there was a duration for psychotropic medication for 1 (Resident 1) of 5 sampled residents. The facility identified a census of 42.Resident 1 was admitted on [DATE] and had diagnoses of chronic obstructive pulmonary disease (a progressive lung disease that restricts breathing, often caused by smoking), Type 2 diabetes mellitus (a metabolic disorder when the body cannot regulate levels of sugar in the blood), schizophrenia (a mental disorder that affects how a person thinks, feels, and behaves), bipolar disorder (a mental illness with episodes of extreme mood changes), depression, and anxiety.A record review of Resident 1's medication orders in Point Click Care (PCC, an electronic medical record system), revealed that Resident 1 had physician orders for clonazepam (an antianxiety medication) 0.5 mg by mouth every 12 hours as needed for symptoms of anxiety with an order date of 01/28/2026 and no end date.A record review of a facility document Pharmacist's recommendation to prescriber, with a recommendation date of 1/30/26, revealed the pharmacist recommended the provider give a stop date for the 1/28/26 clonazepam order, not to exceed 6 months for the last year for Resident 1. The document also revealed the pharmacist communicated that the there was a 14 day stop on all PRN (when a medication is given on as-needed basis and not on a schedule) psychotropic medications unless the provider documents a clinical rationale and a new duration for use on the order. The same document included the provider's response, which was marked, disagree, and the clinical rationale given as anxiety, and was documented on 2/10/26.An interview on 3/05/2026 at 9:35 AM with the Assistant Director of Nursing (ADON) revealed there was no end date for Resident 1's medical record for the as needed psychotropic medication clonazepam and there should have been.

Based on record review and interview; the facility failed to ensure the attending physician reviewed and acted upon, or provided rationale for not acting upon, recommendations made by the pharmacist during their monthly medication regimen reviews for 1 (Resident 33) out of 5 sampled residents. The facility census was 42.Findings are:A.Record review of Resident 33's admission record dated 3/5/2026 revealed an admission date of 8/3/2023 with listed diagnoses:-Major Depressive Disorder, Recurrent-Post-Traumatic Stress Disorder-Alzheimer's Disease with Late Onset -Cerebral Infarction (Stroke) -Paranoid Schizophrenia (a chronic mental disorder with intense, irrational delusions and/or hallucinations, such as believing they are being plotted against or monitored) -Conversion Disorder with Seizures or ConvulsionsRecord Review of Resident 33's order summary dated 3/4/2026 revealed the following medication orders:Desvenlafaxine (a serotonin-norepinephrine reuptake inhibitor (SNRI) used to treat major depressive disorder in adults) ER (extended release) oral tablet extended release 24-hour 50 milligram (mg), Give 1 tablet by mouth one time a day related to Major Depressive DisorderQuetiapine ( an atypical antipsychotic used to treat schizophrenia, bipolar disorder, and major depressive disorder) Fumarate Tablet 25mg, Give 0.5 tablet by mouth at bedtime for Paranoid Schizophrenia related to other schizoaffective disordersRecord review of Medication Regimen Review's from 12/24/2024, 1/27/2025, and 2/25/2025 revealed recommendations for a gradual dose reduction (GDR) from the Pharmacist, with no response from a physician until 3/29/2025Record review of facility policy Medication Regimen Review Policy implemented on 8/1/2023 states The consulting pharmacist shall review each residents medication regimen monthly. Any recommendations made regarding changes to medication regimen will be put in writing and sent to the DON(Director of Nursing). The DON is responsible for forwarding these recommendations to the prescribing practitioner and providing the facility's Medical Director a copy of all irregularities found by the consultant pharmacist. If the pharmacist's recommendation is not addressed and a response if not received in 14 days from when they were provided to DON, the facility will refax all remaining letters. After two attempts at reaching the prescriber, the facility may request the medical director review the recommendation. In this case the facility is to provide a copy of any new order generated to the original prescriber's office.Interview at 11:30AM on 3/5/2026 with the Assistant Director of Nursing (ADON) confirmed that nursing is responsible for faxing pharmacy recommendations to the prescribing physician. If there is no response from the first fax, staff would fax the pharmacy recommendation to the prescribing physician a second time. the ADON was unable to provide next steps if the prescribing physician did not respond to the second fax.

Licensure Reference Number 175 NAC 12-006.09(H)(iv) Based on record review and interview, the facility failed to follow their bowel protocol to prevent constipation for 1 (Resident 29) of 5 sampled residents. The facility census was 42.Findings Are: A record review of a facility document BM (bowel movement) List revealed Bowel Routine as per facility protocol with the following guidance:-Give Prune Juice if no BM in 2 days.-Give MOM (milk of magnesia) if no BM in 3 days -Must document bowel sounds daily starting day 3 until BM occurs.-Give suppository if no BM in 4 days.-Notify MD (physician) if refused or no results from suppository on day 4. A record review of Resident 29's admission Record revealed the resident was admitted to the facility on [DATE] and had a diagnosis of chronic idiopathic constipation. A record review of Resident 29's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 12/29/2025 revealed the resident had no constipation present at the time of the assessment. A record review of Resident 29's Order Summary dated 3/3/2026 revealed the following orders:-Stool Softener oral capsule (Docusate Sodium) 100 milligrams once a day for the prevention of constipation. This order had a start date of 12/20/2025.-Polyethylene Glycol powder (a laxative medication), give 17 grams every 24 hours as needed for constipation. This order had a start date of 12/19/2025. A record review of Resident 29's Task- B&B Bowel Movements documentation for 2/2/2026 through 2/28/2026 revealed the resident had no bowel movements:-From 2/5/2026 through 2/10/2026, 6 days total.-From 2/15/2026 through 2/18/2026, 4 days total. A record review of Resident 29's Medication Administration Record for February 2026 revealed no evidence of their as needed polyethylene glycol being administered. A record review of Resident 29's Progress Notes for the month of February 2026 revealed no evidence of the resident being assessed or interventions being implemented related to their bowels. An interview on 3/5/2026 at 10:12 AM with the Assistant Director of Nursing (ADON) confirmed the facility did not assess Resident 29 nor provide their as needed medication to treat their constipation during the month of February.

Based on record review and interviews, the facility failed to evaluate resources related to decision-making for 1 sampled resident (Resident 1) with cognitive impairment. The facility identified a census of 42. A record review of Resident 1's face sheet revealed that Resident 1 was admitted on [DATE] and had diagnoses of chronic obstructive pulmonary disease (a progressive lung disease that restricts breathing, often caused by smoking), Type 2 diabetes mellitus (a metabolic disorder when the body cannot regulate levels of sugar in the blood), schizophrenia (a mental disorder that affects how a person thinks, feels, and behaves), bipolar disorder (a mental illness with episodes of extreme mood changes), depression, and anxiety. The record also revealed that Resident 1 made decisions on their own behalf and that there was not a power of attorney (a legal document that allows one person to act on behalf of another) or guardian (a court-appointed person who has legal authority over someone who can no longer make sound decisions about themselves). The face sheet also revealed Resident 1 had a diagnosis of cognitive communication deficit.An interview on 3/2/26 at 4:27 PM with Resident 1's family member revealed Resident 1 had two family members who served as co-guardians of Resident 1 for 14 years due to their severe mental illness. The interview also revealed the guardianship was legally dissolved in 2017 or 2018 after the family member could not find a substitute guardian while they were unable to continue due to the family member's medical reasons. The interview revealed that the family member still did not make decisions for Resident 1, and that they have not been a decision-maker since the guardianship was dissolved.A record review of Resident 1's electronic medical record in Point Click Care (PCC) revealed a BIMS assessment (Brief Interview for Mental Status, a 15-point cognitive screening tool that tests orientation and memory) was completed several times with the resident with the following results: (13-15 normal/intact cognition, 8-12 moderately impaired cognition, 0-7 severely impaired cognition).On 4/7/25 Resident 1 scored 8 out of 15 possible points.On 6/26/25 Resident 1 scored 10 out of 15 points.On 7/26/25 Resident 1 scored 8 out of 15 points.On 8/21/25 Resident 1 scored 7 out of 15 points.On 9/16/25 Resident 1 scored 7 out of 15 points.On 10/23/25 Resident 1 scored 8 out of 15 points.On 1/7/26 Resident 1 scored 0 out of 15 points.On 2/2/26 Resident 1 scored 0 out of 15 points.A record review of Resident 1's nursing progress notes from 1/6/26 at 2:33 PM revealed that Resident 1 did not have a current POA (power of attorney) on file at the facility.A record review of Resident 1's care plan revealed the following goals and interventions:Behavior management, staff should reorient resident to person, place, time and situation, date initiated 03/19/2024.The resident has impaired cognitive function or impaired thought processes related to difficulty making decisions and BIMS score less than 13, date initiated 12/08/2023, revision on 10/24/2025.Give simple directions using simple words and short sentences, date initiated 12/08/2023.Resident dependent on staff for cognitive stimulation, activity attendance, and social interaction related to cognitive impairment and was at risk for isolation, date initiated 03/29/2024, revision on 10/24/2025.Resident unable to effectively communicate the presence of pain and is dependent upon staff to monitor and identify signs and symptoms of pain and to provide the appropriate interventions, date initiated 05/01/2025, revision on 01/06/2026.Determine whether resident can make their own medical decisions as necessary, date initiated 03/13/2024.An interview on 3/3/25 at 2:44 PM with the Social Services Designee (SSD) revealed Resident 1 has had a BIMS score below 11 since they were admitted in 2023. The interview also revealed the facility had attempted to get Resident 1 to appoint a POA but Resident 1 did not want to do that, and there was not any documentation of that communication taking place. The interview revealed the facility was contacted by the hospital on a recent admission regarding whether the resident had a POA and they had to explain to the hospital staff the resident did not have a POA or any documents stating who assists the resident in decision making while cognitively impaired.An interview with the Administrator on 3/3/26 at 3:07 PM confirmed the resident does not have a representative in place.An interview on 3/5/26 at 11:23 AM SSD confirmed there was no documentation with Resident 1's medical providers discussing Resident 1's decision-making capacity, decreased BIMS scores, or cognitive decline.

Licensure Reference Number 175 NAC 12-006.09(I)Based on record review and interviews, the facility failed to accurately assess a resident for elopement, failed to provide interventions to prevent elopements, and failed to implement interventions to prevent further elopement for 1 resident (Resident 1) of 3 sampled residents. The facility census was 41.Findings are:The facility was notified on [DATE] at 3:45 PM of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification.Review of a facility policy titled Elopement and Wandering Residents dated 2025 revealed the facility would ensure that residents who are at risk for elopement receive adequate supervision to prevent accidents. An Elopement occurs when a resident leaves the premises or a safe area without authorization and or any necessary supervision to do so. The facility would establish and utilize a systematic approach in monitoring and managing residents at risk for elopement including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness, and modifying interventions when necessary.Review of a facility policy titled Incidents and Accidents dated 2025 revealed it is the policy of the facility to report, investigate, and review any accidents or incidents that occur or allegedly occur. The policy stated the incident/accident of elopement required an incident or accident report to be completed within 24 hours of the incident which was to include immediate and follow up interventions.A review of an Admission record revealed that the facility admitted Resident 1 on [DATE] with diagnoses of Parkinson's Disease which is a progressive neurological disorder that affects movement, balance, and coordination, a history of traumatic brain injury which is a disruption in the normal function of the brain caused by an external force, such as a blow, bump, jolt, or penetrating injury to the head, and schizo-affective disorder which is a mental health condition that combines symptoms of schizophrenia and a mood disorder such as depression or bipolar disorder. The comprehensive Minimum Data Set (MDS), a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems dated [DATE] revealed Resident 1 had a Brief Interview for Mental Status (BIMS), which is a brief screen that aids in detecting cognitive impairment score of 15 indicating the resident was cognitively intact. In the resident's interview for activity preferences the resident expressed that it was very important to them to be able to go outside. The resident required supervision or touching assistance with mobility using a walker or a wheelchair for an assistive device.Review of Resident 1's Care Plan revealed the resident was at risk of injury, ineffective coping, and self-care deficit related to disorganized thinking, behavioral disturbances and reduced insight and judgment. The resident had a focus of the resident being able to independently make activity choices dated [DATE] with interventions listed as the resident liked to go outside unattended and unassisted to enjoy the fresh air dated [DATE]. A Focus of Falls due to the resident having an actual fall dated [DATE] with interventions listed of the resident would have stand by assistance while using their walker or wheelchair dated [DATE]. The focus of the resident desiring to go outside unaccompanied dated [DATE] had interventions listed that the resident would sign out when exiting the facility, for staff to educate the resident on the importance of telling them where the resident wished to go, and staff would safely assist the resident through the doors and to the resident's desired location all dated [DATE]. A review of Resident 1's admission Assessment dated [DATE] revealed that the resident was assessed to not be at risk for elopement due to not being able to leave/exit the facility independently. The assessment revealed that the resident required extensive assistance with a wheelchair for mobility.A review of Resident1's Progress Notes revealed documentation of an admission summary completed [DATE] at 2:00 PM stating that Resident 1 walked independently with a walker and used a wheelchair for distances and was able to self-propel the wheelchair.A review of Resident 1's Progress Notes revealed documentation that on [DATE] at 9:39 AM Resident 1 exited the facility out of the front door without their assistive device. Documentation stated that the resident was educated to sign out when leaving the facility.A review of Resident 1's Electronic Medical Health Record revealed that Resident 1 was not re-assessed for their risk of elopement after the incident that occurred on [DATE].A review of Resident 1's Progress Notes revealed documentation that on [DATE] at 3:59 AM the facility received a telephone call from a police officer informing the facility that Resident 1 was sitting in the road in front of the building and had been there a while. The resident was assisted into their wheelchair and then back into the facility by staff. The resident did not have their assistive device of walker or wheelchair in use. The resident did not sign out or notify facility staff that they were exiting the facility.A review of Resident 1's Electronic Medical Health Record revealed an Elopement Assessment was completed on [DATE] indicating the resident was at risk for elopement.A review of Resident 1's Care Plan on [DATE] at 1:20 PM revealed no new or changes in interventions or focuses due to Resident 1 exiting the building twice without staff knowledge or assistance to assist in the prevention of the incident occurring again.A review of a facility supplied document titled Incidents by Incident Type on [DATE] at 11:50 AM revealed an incident of Elopement occurring on [DATE] for Resident 1. The document revealed no incident of Elopement for Resident 1 on [DATE].In an interview completed on [DATE] at 2:10 PM with the facility Director of Nursing (DON), the DON confirmed that Resident 1's admission assessment indicating the resident was unable to leave the facility independently was not an accurate assessment of Resident 1. The DON confirmed that this error resulted in the resident's elopement risk being incorrectly addressed on admission. The DON stated knowledge on admission of Resident 1 that the resident wished to and previously was able to independently exit the resident's prior living situation at will and was aware when admitting the resident to the facility it would be a change for the resident to have to sign out and notify staff when exiting the facility. The DON stated Resident 1 was educated on this on admission to the facility. The DON confirmed that Resident 1 exited the facility without signing out or staff having knowledge on [DATE]. The DON confirmed that this met the facility's definition of Elopement, and an incident or accident report was not completed as directed to be done in the facility policy. The DON confirmed that Resident 1 had an elopement from the facility on [DATE] and an immediate intervention of placing the resident on 15-minute checks for 72 hours was implemented. The DON confirmed that no additional interventions were placed after this intervention expired to prevent the resident from eloping from the facility again.The facility took the following actions to address the citation and prevent any additional residents from experiencing an adverse outcome on [DATE].- Once Administrator was made aware, the elopement was reported to DHHS on 9-23-25. Residents directly involved in this deficient practice had their care plan reviewed and updated by the DON and updated to reflect current wandering and elopement risk. New interventions for Resident 1 are as follows:- All entryway doors will remain locked at all times- Resident to be seen by Primary Care Physician on 9-24-25 for current plan of care and health status.- Medical Director notified of elopement- Resident to be seen by Psychiatric physician on 9-26-25 for recent behaviors and auditory hallucinations.- 9-23-25 elopement risk assessment completed again for Resident 1 - Resident 1 has an appointment for [DATE] with physician at GPH Psychiatric Services due to recent behaviors and auditory hallucinations.- Elopement assessment was done on [DATE] and Resident 1 is now at risk for Elopement. Attempted a wander guard and Resident 1 refused so facility doors will be secured at all times. - Elopement risk assessment for the whole facility will be completed by end of day 9-23-25.- Elopement Training was completed for all The Leadership Team Members including the Elopement Policy, Resident Abuse prevention and Timely Reporting, and Abuse Policy reviewed 9-23-25. - Each Department Head completed 9-23-25 Elopement Training including the Elopement Policy, Resident Abuse prevention and Timely Reporting, and Abuse Policy reviewed with each staff member before they work again beginning on 9-23-35. Any staff on leave will receive education on their next scheduled workday. - Education was provided on 9-23-25 to staff currently working in the facility that the doors will be locked all the time. Facility will continue to educate all staff on each shift until all staff have been educated. Audit will be conducted by Maintenance/Nursing that doors are locked every shift for a minimum of three months or until the pattern of compliance is maintained.- The Elopement Binder was updated by DON/ADON(Assistant Director of Nursing) using elopement risks assessment completed 9-23-25. The assessments completed on 9-23-25 were placed in the Elopement Binder by DON/ADON.- Social Services will audit starting 9-23-25 the elopement binder 2 x weekly through morning standup to ensure accuracy of the binder, to include all residents that are admitted , readmitted , or had a change of condition and deemed to be at risk for elopement. This will be done for a minimum of three months or until the pattern of compliance is maintained.- Elopement care plans were reviewed and updated to ensure they reflect audit findings by MDS/Social Services. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 9-23-25)- Elopement and wandering residents' policy was reviewed.- The DON or designee will audit new admissions for elopement risk and ensure care plans are completed, and appropriate interventions are in place.- The DON or designee will audit that Elopement Risk Assessment are completed upon Admission, Re-admission, Quarterly, Change of Condition, or as needed.- New hires will receive education on wandering, elopement, and resident safety by the DON, Director of Social Services, or designee(s). - All licensed nurses will be educated and trained on accurate completion of elopement risk assessment. Audit will be done by DON/ADON for a minimum of three months or until the pattern of compliance is maintained for accuracy beginning on 9-23-25 until all staff have been educated.- All staff will be educated on Independent Out on Pass Policy starting on 9-23-25 until all staff have been educated. This policy defines who can go out on pass without an escort or responsible party. A competency assessment progress note will be documented by clinical staff to determine the resident's ability to leave the facility safely. The residents will be educated on the sign out/sign in process. Approval is based on the resident's ability to make sound decisions regarding their safety, manage their medications, if applicable, and physically navigate their surroundings without significant fall risk. It will be care planned and noted on special instructions on PCC if the resident is assessed to be safe to go out on pass independently.- Performance Improvement Project (PIP) was implemented and presented to all Department Heads on 9-23-25. The incident was reviewed, and all audit findings were discussed. All findings will be discussed at the monthly QAA meeting for a minimum of three months or until the pattern of compliance is maintained for accuracy.At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the immediacy of the IJ violation at 6:50 PM on [DATE]. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to D Level.

Licensure Reference Number 175 NAC 12-006.04Based on record review and interview, the facility failed to complete competencies to ensure proficiency for 8 of 9 sampled staff which had the potential to affect all of the residents residing in the facility. The facility census was 41.Findings are:In an interview completed on 09/23/2024 at 12:50 PM with Medication Aide A(MA-A), MA-A stated that a competency had not been completed on the services they provide to residents in the last year.Record review of MA-A facility supplied documents revealed a date of hire of 10/20/2023. There were no competencies for MA-A supplied in the documents.Record review of Medication Aide B (MA-B) facility supplied documents revealed a date of hire of 06/09/2025. There were no competencies for MA-B supplied in the documents.Record review of Nurse Aide D (NA-D) facility supplied documents revealed a date of hire of 06/24/2025. There were no competencies for NA-D supplied in the documents.Record review of Nurse Aide E (NA-E) facility supplied documents revealed a date of hire of 01/05/2025. There were no competencies for NA-E supplied in the documents.Record review of Registered Nurse F (RN-F) facility supplied documents revealed a date of hire of 01/02/2025. There were no competencies for RN-F supplied in the documents.Record review of Licensed Practical Nurse G (LPN-G) facility supplied documents revealed a date of hire of 07/28/2025. There were no competencies for LPN-G supplied in the documents.Record review of Registered Nurse H (RN-H) facility supplied documents revealed a date of hire of 03/12/2025. There were no competencies for RN-H supplied in the documents.Record review of Licensed Practical Nurse I (LPN-I) facility supplied documents revealed a date of hire of 07/28/2025. There were no competencies for LPN-I supplied in the documents.In an interview completed on 09/24/2025 at 1:15 PM with the Director of Nursing (DON), the DON confirmed that MA-A, MA-B, NA-D, NA-E, RN-F, LPN-G, RN-H, and LPN-I had not completed competencies ensuring proficiency of skills and services the individuals were providing to residents who reside in the facility. The DON confirmed that staff should complete competencies on hire and annually there after on these skills and services and this was not completed.

Licensure Reference Number 175 NAC 12-006.02(H)Based on record review and interviews, the facility failed to investigate and report to the regulatory agencies possible incident of abuse and or neglect for 1 residents (Resident 1) of 3 sampled residents. The facility census was 41.Findings are:Review of a facility policy titled Abuse, Neglect and Exploitation and dated 2025 revealed the definition of an Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or other but has not been investigated and if verified could be indication of noncompliance with the Federal requirements related to mistreatment, neglect, or abuse, including injuries of unknown source. An immediate investigation is warranted of alleged abuse and or neglect. Reporting of all alleged violations to the administrator, state agency, adult protective services and all other required agencies immediately but not later then 2 hours after allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury or not later then 24 hours if the events that cause and allegation do not involve abuse and do not result in serious bodily injury. Review of a facility policy titled Incidents and Accidents dated 2025 revealed it is the policy of the facility to report, investigate, and review any accidents or incidents that occur or allegedly occur. The policy stated the incident/accident of elopement required an incident or accident report to be completed within 24 hours of the incident which was to include immediate and follow up interventions.A review of an Admission record revealed that the facility admitted Resident 1 on 09/05/2025 with diagnoses of Parkinson's Disease which is a progressive neurological disorder that affects movement, balance, and coordination, a history of traumatic brain injury which is a disruption in the normal function of the brain caused by and external force, such as a blow, bump, jolt, or penetrating injury to the head, and schizo-affective disorder which is a mental health condition that combines symptoms of schizophrenia and a mood disorder such as depression or bipolar disorder. The comprehensive Minimum Data Set (MDS), a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems dated 09/11/2025 revealed Resident 1 had a Brief Interview for Mental Status (BIMS), which is a brief screener that aids in detecting cognitive impairment score of 15 indicating the resident was cognitively intact. In the residents' interview for activity preferences the resident expressed that it was very important to them to be able to go outside. The resident required supervision or touching assistance with mobility using a walker or a wheelchair for an assistive device.Review of Resident 1's Care Plan revealed the resident was at risk of injury, ineffective coping, and self-care deficit related to disorganized thinking, behavioral disturbances and reduced insight and judgment. The resident had a focus of the resident being able to independently make activity choices dated 09/08/2025 with and interventions listed as the resident liked to go outside unattended and unassisted to enjoy the fresh air dated 09/18/2025. A Focus of Falls due to the resident having an actual fall dated 09/08/2025 with interventions listed of the resident would have stand by assistance while using their walker or wheelchair dated 09/11/2025. The focus of the resident desiring to go outside unaccompanied dated 09/19/2025 had interventions listed that the resident would sign out when exiting the facility, for staff to educate the resident on the importance of telling them where they wished to go, and staff would safely assist the resident through the doors and to their desired location all dated 09/19/2025. A review of Resident 1's Progress Notes revealed documentation that on 09/18/2025 at 9:39 AM Resident 1 exited the facility out of the front door without their assistive device. Documentation stated that the resident was educated to sign out when leaving the facility.A review of Resident 1's Progress Notes revealed documentation that on 09/20/2025 at 3:59 AM the facility received a telephone call from a police officer informing the facility that Resident 1 was sitting in the road in front of the building and had been there a while. The resident was assisted into their wheelchair and then back into the facility by staff. The resident did not have their assistive device of walker or wheelchair in use. The resident did not sign out or notify facility staff that they were exiting the facility.A review of a facility supplied document titled Incidents by Incident Type on 09/23/2025 at 11:50 AM revealed and incident of Elopement occurring on 09/20/2025 for Resident 1. The document revealed no incident of Elopement for Resident 1 on 09/18/2025.In an interview completed on 09/23/2025 at 2:10 PM with the facility Director of Nursing (DON), the DON confirmed that an incident report and investigation was not completed for elopement when Resident 1 exited the facility on 09/18/2025 with out signing out or staff knowledge. The DON confirmed that this incident met the definition of elopement and should have been completed. The DON confirmed that the facility Administrator, Adult Protective Services, and the state regulatory agency were not notified of Resident 1's Elopement incidents on 09/18/2025 and 09/20/2025. The DON confirmed that the facility policy was not followed for these incidents.

Licensure Reference Number 175 NAC 12-006.09(H) Based on record reviews and interviews, the facility failed to assess non-verbal indications of pain, and implement, monitor and revise interventions to manage pain for 1 (Resident 3) of 3 sampled residents. The facility identified a census of 45. Findings are: A record review of a facility policy, Pain Management with a date of 4/1/2024, revealed the following: -To help a resident attain or maintain their highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain, the facility will. -Recognize when the resident is experiencing pain or activities where the resident may experience pain. -Assess resident for pain upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (e.g. change in behavior, new pain, or an exacerbation of pain). -Manage or prevent pain, consistent with the resident's comprehensive assessment (Minimum Data Set) and care plan (a document outlining a person's healthcare or personal care needs, their medical history, expected outcomes, and the care and support they will receive), current professional standards of practice, and the resident's goals and preferences. -Staff will observe for nonverbal indicators of pain which may indicate the presence of pain, such as increased or recurring restlessness, facial expressions, behaviors (such as resisting care, distressed pacing, irritability), difficulty eating or loss of appetite, weight loss, or negative vocalization (such as groaning, crying, whimpering, screaming). -An assessment of pain should include: -A history of pain and its treatment [including pharmacological (treatments involving medications) and non-pharmacological (treatments to involving medications)] -Key characteristics of the pain (duration, frequency, location, timing, pattern (constant or intermittent), radiation of pain, descriptors (stabbing, aching), what exacerbates the pain, what reduces the pain, the impact of pain on quality of life, current medication regimen, and the resident's goal for pain management. -Based upon assessment of the pain, the facility, in collaboration with the physician and the resident or their representative, will develop, implement, monitor and revise the resident's interventions to prevent or manage each resident's pain beginning at admission. -Staff will reassess the effectiveness of the resident's pain management at established intervals. If the re-assessment findings indicate the resident's pain is not adequately controlled, staff will notify the physician to consider a revision of the resident's pain regimen and will update the resident's care plan with other interventions. A record review of an admission Record indicated the facility admitted Resident 3 on 1/22/2021. Resident 3 had diagnoses of cognitive communication deficit (difficulties in communication skills), dementia (a usually progressive condition marked by the development of multiple cognitive deficits such as memory impairment, aphasia, and the inability to plan and initiate complex behavior), transient ischemic attack (TIA, a mini stroke), and a history of a hip joint replacement. A record review of Resident 3's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) with an Assessment Reference Date (ARD) of 3/5/2025 revealed Resident 3 had a Brief Interview for Mental Status (BIMS, a brief screening that aids in detecting cognitive impairment) score of 9/15, which indicated Resident 3 had moderate cognitive impairment. The MDS also revealed Resident 3 had received a PRN (as needed) medication and non-pharmacological interventions for pain in the last 5 days. A pain assessment was conducted with Resident 3 and revealed Resident 3 had moderate pain over the last 5 days but was unable to answer how often the pain occurred and whether the pain had interfered with their sleep, therapy activities, or day-to-day activities. It also revealed Resident 3 had displayed indications of pain or possible of non-verbal sounds, vocal complaints of pain, facial expressions, and protective body movement or postures daily within the past 5 days of the assessment. Resident 3 received an opioid (narcotic pain medication) within the last 7 days of the assessment. Additionally, the MDS revealed Resident 3 had displayed physical and verbal behaviors towards other 1-3 days and had not exhibited any behaviors of rejection of care within the last 7 days of the assessment. A record review of Resident 3's Care Plan revealed a focus area for pain which was last revised on 3/26/2025. The focus area revealed Resident 3 was at risk for pain due to poor dentition (teeth conditions) and a recent hip surgery. Resident 3's goals for pain were to not have moderate or severe pain through the next review date and pain to be relieved within a timely manner of receiving pain medications or treatment. Resident 3's interventions for pain were as follows: -Administer pain medications and treatments as ordered by the physician and when requested. -Monitor for side effects of pain medication. -Attempt non-pharmacological pain interventions of massage, repositioning, peaceful environment, aroma therapy music, etc. -Evaluate the effectiveness of treatment or medication in a timely manner after administration. Record and report to the physician any pain that is not at or below the resident's acceptable level of pain. -Report to the nurse any changes of sleep, weight loss, withdrawal from activities or relationships, decrease in physical activity or changes in mood/emotions. An additional record review of Resident 3's Care Plan revealed the following: -As of 3/26/2025, Resident 3 was at risk for a decline in their Activities of Daily Living (ADLs) and at risk for falls due to their pain. -As of 4/18/2024, Resident 3 was at risk of skin breakdown on their feet due to their diabetes with a goal that Resident 3 will experience no foot pain over the next 3 months. -As of 3/26/2025, Resident 3 had a pressure ulcer and was at risk for pain with a goal for Resident 3's pain to be at or below their acceptable level of pain and have no non-verbal indicators of pain throughout the next review date. An intervention to repositioning Resident 3 and administer pain medication as needed for discomfort or pain and prior to dressing changes had been implemented. A record review of Resident 3's Order Summary Report with an active orders' date of 4/8/2025 revealed the following orders: -Assess for pain, document using the numerical scale if verbal or PAINAD (Pain Assessment in Advanced Dementia, a scale used to assess pain in people with advanced dementia or who are unable to communicate their pain verbally) if nonverbal, and document any non-pharmacological interventions implemented. This order had a start date of 11/5/2024. -Apply Polar Ice Machine as needed for pain management with a start date of 3/1/2025. -Tylenol (Acetaminophen) 325 milligrams (mg) with instructions to give two tablets by mouth every six hours as needed for moderate pain with a start date of 1/22/2021. -Tramadol (a pain medication) 50 mg with instructions to give one tablet every eight hours as needed for pain management with a start date of 3/1/2025. -Ativan (a sedative medication) 0.5 mg with instruction to give every six hours as needed for anxiety with a start date of 3/20/2025. -Seroquel (an antipsychotic medication used to manage psychosis and its symptoms, such as delusions, hallucinations, and disorganized thinking) 12.5 mg with direction to give by mouth three times a day for dementia with behavioral disturbances. -Zoloft (an antidepressant) 50 mg with instructions to give 50 mg by mouth one time a day for anxiety with a start date of 4/2/2025. A record review of Resident 3's Progress Notes and Medication Administration Record (MAR) / Treatment Administration Record (TAR) from 3/1/2025 revealed the following: -Progress Notes revealed Resident 3 had returned to the facility after a hospitalization for a left hip fracture and surgical repair. -The MAR/TAR revealed the order to assess pain, document the rating, and document any non-pharmacological interventions had been documented on dayshift as Resident 3 having a pain level of 9 and no evidence non-pharmacological interventions had been implemented. -There was no evidence non-pharmacological interventions had been implemented for Resident 9's pain in the Progress Notes. A record review of Resident 3's Progress Notes from 3/5/2025 revealed Resident 3 had moderate pain after the administration of prescribed pain medication. There was no evidence further interventions had been implemented. A record review of Resident 3's Progress Notes and MAR/TAR from 3/6/2025 revealed the following: -The MAR/TAR revealed the order to assess pain, document the rating, and document any non-pharmacological interventions had been documented on dayshift as Resident 3 having a pain level of 6/10 and no non-pharmacological interventions had been implemented. -The MAR revealed the order for Tylenol 325 mg had been administered at 9:03 AM for a pain level of 6/10. The documented follow-up revealed it had been ineffective. -The MAR revealed the order for Tramadol 50 mg had been administered at 5:52 PM for a pain level of 5/10. The documented follow up revealed it had been ineffective. -The Progress Notes revealed no evidence non-pharmacological interventions had been implemented during dayshift for Resident 3's pain. -The Progress Notes also revealed Resident 3's physician had been contacted for additional pain medication but there was no evidence a new order had been received. A record review of Resident 3's Progress Notes from 3/7/2025 revealed a response from Resident 3's physician had been received but there was no evidence a new order had been obtained for Resident 3's pain. A record review of Resident 3's Progress Notes and MAR/TAR from 3/8/2025 revealed the following: -A Progress Note from 9:28 AM revealed Resident 3 had moderate pain after the administration of prescribed pain medication. -The MAR revealed Resident 3 had an available PRN Tylenol that could have been administered for Resident 3's residual moderate pain but had not been administered. A record review of Resident 3's Progress Notes and MAR/TAR from 3/9/2025 revealed the following: -A Progress Note from 2:12 PM revealed Resident 3 had moderate pain after the administration of prescribed pain medications. -A Progress Note from 5:29 PM revealed Resident 3 had been administered PRN Tramadol due to exhibiting pain gestures to their left hip. -A Progress Note from 10:16 PM revealed the PRN Tramadol had been effective, with a residual pain rating of 5/10, but Resident 3 continued to flinch with pain during repositioning. There was no evidence additional interventions had been implemented. -The MAR revealed Resident 3 had an available PRN Tylenol that could have been administered for Resident 3's residual moderate pain but had not been administered. A record review of Resident 3's Progress Notes and MAR/TAR from 3/10/2025 revealed the following: -A Progress Note from 3:25 AM revealed Resident 3 had moderate pain after the administration of prescribed pain medication. There was no evidence that additional interventions had been implemented following this. -A Progress Note from 3:10 PM revealed Resident 3 had been evaluated by a healthcare practitioner and had no new orders. There was no evidence that pain management concerns had been discussed with the healthcare practitioner by staff. -The MAR revealed Resident 3 had an available PRN Tylenol that could have been administered for Resident 3's residual moderate pain but had not been administered. A record review of Resident 3's Healthcare Practitioner's documentation from their visit on 3/10/2025 revealed Resident 3 had denied pain to the Healthcare Practitioner. There was no evidence that the staff had brought forth concerns of pain management with the Healthcare Practitioner. A record review of Resident 3's Progress Notes and MAR/TAR from 3/11/2025 revealed the following: -A Progress Note from 4:06 AM revealed Resident 3 had moderate pain after the administration of prescribed pain medications. -A Progress Note from 7:41 AM revealed a PRN Tramadol follow up that had been documented as effective but Resident 3 had a residual follow up pain rating of 5/10. -The MAR revealed Resident 3 had an available PRN Tylenol that could have been administered for Resident 3's residual moderate pain but had not been administered. A record review of Resident 3's Progress Notes and MAR/TAR from 3/13/2025 revealed the following: -A Progress Note from 7:41 AM revealed a PRN Tramadol follow up that had been documented as effective but Resident 3 had a residual follow up pain rating of 6/10. -The MAR revealed Resident 3 had an available PRN Tylenol that could have been administered for Resident 3's residual pain but had not been administered. A record review of Resident 3's Progress Notes from 3/14/2025 at 8:59 AM revealed PRN Tramadol for Resident 3 had been ineffective with a residual pain level rating of 5/10. A record review of Resident 3's Progress Notes and MAR/TAR from 3/17/2025 revealed the following: -A Progress Note from 1:54 AM revealed Resident 3 had moderate pain after the administration of prescribed pain medications. -A Progress Note from 1:38 PM revealed Resident 3 had mild pain after the administration of prescribed pain medications. -The MAR revealed Resident 3 had an available PRN Tylenol that could have been administered for Resident 3's residual pain but had not been administered. A record review of Resident 3's medical record revealed no evidence additional attempts to address Resident 3's pain management with their physician between 3/6/2025 and 3/17/2025 had been made. A record review of Resident 3's Progress Notes and MAR/TAR from 3/18/2025 revealed the following: -A Progress Note from 8:35 AM revealed a PRN Tramadol follow up that had been documented as effective but Resident 3 had a residual follow up pain rating of 5/10. There was no evidence of additional interventions for Resident 3's residual pain. -A Progress Note from 11:17 AM revealed staff had sent a fax to Resident 3's physician requesting alternative pain medication for increased pain. The physician responded that the resident pain was managed by Resident 3's orthopedic physician. Staff had refaxed the request to Resident 3's orthopedic physician. -The MAR/TAR revealed the order to assess pain, document the rating, and document any non-pharmacological interventions had been documented on dayshift as Resident 3 having a pain level of 5/10 and no non-pharmacological interventions had been implemented. -The MAR revealed Resident 3 had an available PRN Tylenol that could have been administered for Resident 3's residual pain but had not been administered. A record review of Resident 3's medical record revealed no evidence the facility had received a response from their request for a pain medication alternative for Resident 3 from their orthopedic physician or additional attempts had been made to obtain the alternative. A record review of Resident 3's Progress Notes and MAR/TAR from 3/20/2025 revealed the following: -A Progress Note from 10:26 AM revealed a PRN Tramadol follow up that had been documented as ineffective with a residual pain rating of 7/10. There was no evidence of additional interventions for Resident 3's residual pain. -A Progress Note from 5:52 PM revealed Resident 3 had been grabbing other residents and scratching and grabbing at the Nurse Aides (NA). Resident 3 had also hit the NA twice when the NA had put a pillow between their legs. -A Progress Note from 7:01 PM revealed PRN Tylenol had been administered to Resident 3. -A Progress Note from 7:38 PM revealed Resident 3 had been combative and refused cares. The nurse had attempted to talk with Resident 3 and Resident 3 had yelled to go away. The physician had been contacted and an order for Ativan (a sedative medication) had been obtained for every six hours as needed. There was no evidence that the staff had addressed Resident 3's pain with the physician at this time. -A Progress Note from 7:46 PM revealed a PRN Tramadol and PRN Tylenol follow up had been documented as ineffective with a residual pain rating of 10/10. There was no evidence of additional interventions for Resident 3's residual pain. -The MAR/TAR revealed the order to assess pain, document the rating, and document any non-pharmacological interventions had been documented for day and night shift that Resident 3 had no pain, and no non-pharmacological interventions had been implemented. -The MAR revealed Resident 3's PRN Tylenol had only been administered once, at 7:01PM, but could have been administered every six hours as needed but was not. -There was no evidence Resident 3's physician had been notified regarding Resident 3's pain. A record review of Resident 3's Progress Notes and MAR/TAR from 3/21/2025 revealed the following: -The MAR revealed Resident 3 had been administered PRN Tramadol and PRN Ativan. -A Progress Note from 9:10 AM revealed a PRN Tramadol follow up had been documented as effective with a residual pain rating of 7/10. -A Progress Note from 3:10 PM revealed a nurse from Resident 3's physician's office had called for an update regarding Resident 3's behaviors. The nurse informed regarding the PRN Ativan order that had been obtained due to Resident 3's increase in agitation and combativeness. An order for Seroquel had been received. There was no evidence the facility had addressed concerns of Resident 3's pain and ineffective results with the physician's nurse at this time. -A Progress Note from 4:56 PM revealed Resident 3 had moderate pain after the administration of prescribed pain medications. A record review of Resident 3's Progress Notes from 3/22/2025 at 1:07 PM revealed Resident 3 had grabbed another resident and had been redirected. There was no evidence Resident 3 had been assessed for pain. A record review of Resident 3's Progress Notes and MAR/TAR from 3/24/2025 revealed the following: -A Progress Note from 3:30 PM revealed Resident 3 had moderate pain after the administration of prescribed pain medications. -The MAR revealed Resident 3 Resident 3 had available PRN Tramadol and PRN Tylenol that could have been administered for Resident 3's pain but had not been administered. A record review of Resident 3's Progress Notes and MAR/TAR from 3/26/2025 revealed the following: -A Progress Note from 10:37 AM revealed Resident 3 had been screaming and began to have a panic attack when staff had attempted to apply a pillow boot to their left foot to assist with their pressure sore. -A Progress Note from 11:55 AM revealed Resident 3 had been restless, anxious, and yelling out despite multiple attempts to redirect, food, snack, toileting, and music had been offered. PRN pain medications and anxiety medications had been administered with little effectiveness and continued to have moderate pain after the administration of prescribed pain medication. -A Progress Note from 12:51 PM revealed a Physician's Assistant had been in the facility completing rounds and had evaluated Resident 3. There was no evidence staff had addressed Resident 3's pain with the Physician's Assistant during the rounds. -The MAR revealed Resident 3 had been administered PRN Tramadol at 11:01 AM for pain of 5/10 and PRN Ativan. A record review of Resident 3's Progress Notes and MAR/TAR from 3/27/2025 revealed the following: -A Progress Note from 1:26 PM revealed Resident 3 had been having verbal outbursts and facial grimacing after working with therapy. PRN Pain medication had been administered. -A Progress Note from 4:12 PM revealed Resident 3 had severe pain after the administration of prescribed pain medication. -The MAR revealed Resident 3's PRN Tramadol was last administered at 7:16 AM and could have been administered at 4:12 PM for Resident 3's severe pain but had not been administered. -The MAR revealed Resident 3 had an available PRN Tylenol that could have been administered for Resident 3's residual severe pain but had not been administered. -There was no evidence that Resident 3's physician had been notified of Resident 3's severe pain continuance after the administration of prescribed pain medications. A record review of Resident 3's Progress Notes and MAR/TAR from 3/30/2025 revealed the following: -A Progress Note from 3:16 PM revealed Resident 3 had moderate pain after the administration of prescribed pain medication. -The MAR revealed Resident 3 had an available PRN Tylenol that could have been administered for Resident 3's residual moderate pain but had not been administered. -A Progress Note from 10:54 PM revealed Resident 3 had been noted to fake cry and yell at the staff. Resident 3 had demanded staff take them back to their room and be laid down in bed immediately follow supper meal. There was no evidence Resident 3 had been assessed for pain. A record review of Resident 3's Progress Notes and MAR/TAR from 4/1/2025 revealed the following: -A Progress Note revealed new orders to increase Resident 3's Seroquel to 12.5 mg from twice a day to three times a day and add Zoloft 50 mg daily. -A Progress Note at 7:33 PM revealed a PRN Tramadol follow up had been documented as effective but Resident 3 had a residual pain level of 5/10. There was no evidence of additional interventions. -The MAR/TAR revealed the order to assess pain, document the rating, and document any non-pharmacological interventions had been documented for day shift that Resident 3 had a 5/10 pain and no non-pharmacological interventions had been implemented. -The MAR revealed Resident 3 had an available PRN Tylenol that could have been administered for Resident 3's residual severe pain but had not been administered. A record review of Resident 3's Progress Notes and MAR/TAR from 4/3/2025 revealed the following: -A Progress Note from 11:13 PM revealed Resident complains of pain. There was no evidence of interventions for Resident 3's pain. -The MAR revealed Resident 3 had an available PRN Tylenol and PRN Tramadol could have been administered for Resident 3's pain but had not been administered. -The MAR/TAR revealed the order to assess pain, document the rating, and document any non-pharmacological interventions had been documented for night that Resident 3 had a 0/10 pain, and no non-pharmacological interventions had been implemented. A record review of Resident 3's Progress Notes and MAR/TAR from 4/4/2025 revealed the following: -A Progress Note from 4:16 PM revealed Resident 3 had moderate pain after the administration of prescribed pain medication. -The MAR revealed Resident 3 had an available PRN Tylenol could have been administered for Resident 3's residual moderate pain but had not been administered. A record review of Resident 3's Progress Notes and MAR/TAR from 4/6/2025 revealed the following: -A Progress Note from 7:14 AM revealed Resident 3 had been exhibiting behaviors. -A Progress Note from 8:59 AM revealed Resident 3's PRN Tramadol follow up had been documented as effective but had a residual pain level of 6/10. A record review of Resident 3's medical record revealed no evidence the facility had attempted to contact Resident 3's physician again after 3/18/2025 about Resident 3's pain medication regimen as of 4/9/2025. An interview on 4/9/25 at 10:50 AM with NA-B revealed Resident 3's pain appeared to be severe, especially 2-3 weeks ago, stating that Resident 3 could barely be moved or touched due to their pain. NA-B revealed they would assist Resident 3 with laying down, repositioning, and medication, but those interventions only seemed to help some. An interview on 4/9/25 at 10:55 AM with Registered Nurse (RN)-A revealed moderate pain is considered to be rated at a 4-6/10 and severe pain rated at a 7-10/10. RN-B revealed if a resident's PRN medication is not available to be administered, non-pharmacological interventions should be implemented and documented. If the resident rated their pain or was found to have indications of pain at a moderate level at the PRN follow-up, RN-B would not consider the PRN medication to have been effective and additional interventions should be implemented and documented. If these do not resolve the pain, the physician should be called at that time. If the resident rated their pain or was found to have indications of pain at a severe level at the PRN follow-up, RN-B would not consider the PRN medication to have been effective and the physician should be called at that time for additional orders. Additionally, RN-B revealed Resident 3 has frequent pain and frequently sits in the hall and yells. An interview on 4/9/2025 at 11:30 with the Director of Nursing (DON) revealed verbal residents are assessed for pain by the nurse asking assessment questions, such as a description of the pain, location, what makes it worse, what makes it better, and level of severity. If the resident is non-verbal, the nurse would assess the resident visually for non-verbal indications of pain, such as restlessness, agitation, tearfulness, frowning, wincing or other behaviors and utilize the PAINAD scale. Residents are assessed at least once a shift and as needed. If a resident is experiencing pain, but it is too early to administer another PRN or one is not available, non-pharmacological interventions should be utilized and documented. The interview also revealed the following: -Resident 3's physician was faxed on 3/18/2025 for concerns regarding pain management, but the facility did not receive a response. There was no evidence staff had attempted to contact the physician again or was brought to the rounding providers attention to address regarding concerns of pain management effectiveness. The DON revealed they would have expected staff to follow up a day or two after if there was no response by telephone. - Confirmed on 3/1/2025 and 3/5/2025 there was no evidence of non-pharmacological interventions for Resident 9's pain had been implemented and should have been. - Confirmed on 3/6/2025 PRN Tramadol and Tylenol had been documented as ineffective and there was no evidence non-pharmacological interventions had been implemented and should have been. - Confirmed on 3/8/2025, Resident 3 had PRN Tylenol available and should have been administered it for their moderate pain. - Confirmed on 3/9/2025, Resident 3 had PRN Tylenol available and should have been administered it for their moderate pain. Additionally, Resident 3's PRN Tramadol would not have been considered effective due to Resident 3 still displaying non-verbal indications of pain. - Confirmed on 3/10/2025, Resident 3 had PRN Tylenol available and should have been administered it for their moderate pain. - Confirmed on 3/11/2025, Resident 3 had PRN Tylenol available and should have been administered it for their residual pain following their PRN Tramadol. - Confirmed on 3/13/2025 Resident 3 had PRN Tylenol available and should have been administered it for their residual pain following their PRN Tramadol. - The DON also confirmed that staff should have reached out to the Resident 3's physician prior to 3/13/2025 to address Resident 3's pain medication regimen being ineffective. - Confirmed on 3/17/2025, Resident 3's PRN Tramadol pain follow up was documented as 7/10, which would have not been considered as effective due to continuance of severe pain. Resident 3 had PRN Tylenol available and should have been administered it for their residual pain following their PRN Tramadol. - Confirmed on 3/18/2025, Resident 3's had PRN Tylenol available that should have been administered and/or non-pharmacological interventions been attempted. - Confirmed on 3/20/2025, Resident 3's PRN Tramadol and PRN Tylenol had been documented as ineffective and there had been no evidence additional interventions had been implemented. - Confirmed on 3/21/2025, Resident 3's follow-up PRN Tramadol w this would not have been considered effective due to continuance of severe pain. Resident 3 had PRN Tylenol available and should have been administered it for their severe pain. - Confirmed on 3/24/2025, Resident 3 had PRN Tylenol available that should have been administered for Resident 3's moderate pain. - Confirmed on 3/26/2025 there was no evidence the staff had addressed Resident 3's ineffective pain management with the rounding physician. - Confirmed on 3/27/2025, Resident 3 had PRN Tylenol available that should have been administered for Resident 3's severe pain. - Confirmed on 3/30/2025, Resident 3 had PRN Tylenol available and should have been administered it. Additionally, Resident 3 should have been assessed for pain due to their behaviors. - Confirmed on 4/3/2025, there was no evidence of pharmacological or non-pharmacological interventions and should have been implemented for Resident 3's pain. - Confirmed on 4/1/2025, there had been no evidence of non-pharmacological or other interventions implemented and should have been. Resident 3 had PRN Tylenol available and should have been administered it. - Confirmed on 4/3/2025, Resident 3 had been decumulated as having complaints of pain, but there was no evidence of interventions for Resident 3's pain and PRN Tylenol and PRN Tramadol had been available and should have been administered. - Confirmed on 4/4/2025, Resident 3 had PRN Tylenol available and should have been administered it for their residual moderate pain. - Confirmed on 4/6/2025 Resident 3's PRN Tramadol would not have been considered as effective. Additionally, confirmed Resident 3's behaviors could have been related to pain and should have been assessed. - Confirmed Resident 3's pain management regimen had not been effective and should have been addressed with the physician. - The DON also confirmed Resident 3 had an increase in behaviors during this time and had the potential to be related to their uncontrolled pain.

Licensure Reference 175 NAC 12-006.09(E) Based on record review and interview, the facility failed to develop and implement a comprehensive care plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) regarding pain for 1 (Resident 1) of 3 sampled residents. The facility identified a census of 45. Findings are: A record review of a facility policy, Comprehensive Care Plans with a date of 4/1/2024, revealed the facility would develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified on the resident's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems). Additionally, the policy revealed all Care Assessment Areas (CAAs) triggered by the MDS will be considered when developing the plan of care. A record review of an admission Record indicated the facility admitted Resident 1 on 2/25/2025. Resident 1 had diagnoses of a history of stroke with paralysis to their right side, chronic pain syndrome, a history of opioid (narcotic pain medication) abuse, anxiety, and depression. A record review of Resident 1's admission MDS with an Assessment Reference Date of 2/28/2025 revealed Resident 1 had received scheduled pain medication, PRN (as needed) medication, and non-pharmacological interventions for pain within the last 5 days. A Pain Assessment Interview was conducted with Resident 1 and revealed Resident 1 had occasional pain within the last 5 days that occasionally interfered with their sleep, rarely affected their therapy sessions, and frequently limited their day-to-day activities. Resident 1 had rated their pain at a 8/10. The CAA Summary revealed the Pain Care Area had been triggered. A record review of Resident 1's Care Plan revealed no focus care area for pain as of 4/8/2025. An interview on 4/9/225 at 10:55 AM with Registered Nurse (RN) - A revealed RN-A would utilize a resident's care plan to know what interventions are effective for resident's pain. An interview on 4/6/2025 at 12:30 PM with the Director of Nursing (DON) confirmed Resident 1's CCP did not include a focus area of pain until today (4/9/2025) and should have due to their diagnoses and ongoing pain since their admission.

Licensure Reference Number 175 NAC 12--006.04(F)(i)(5) Based on record reviews and interview, the facility failed to notify the physician of ongoing pain for 1 (Resident 3) of 3 sampled residents. The facility identified a census of 45. Findings are: A record review of an undated facility policy, Notification of Changes, revealed the facility must inform the resident's physician when there are circumstances that require a need to alter treatment or require a new treatment. A record review of a facility policy, Pain Management with a date of 4/1/2024, revealed if assessment findings of a resident's pain indicate the resident's pain is not adequately controlled, staff will notify the physician to consider a revision of the resident's pain regimen. A record review of an admission Record indicated the facility admitted Resident 3 on 1/22/2021. Resident 3 had diagnoses of cognitive communication deficit (difficulties in communication skills), dementia (a usually progressive condition marked by the development of multiple cognitive deficits such as memory impairment, aphasia, and the inability to plan and initiate complex behavior), transient ischemic attack (TIA, a mini stroke), and a history of a hip joint replacement. A record review of Resident 3's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) with an Assessment Reference Date (ARD) of 3/5/2025 revealed Resident 3 had a Brief Interview for Mental Status (BIMS, a brief screening that aids in detecting cognitive impairment) score of 9/15, which indicated Resident 3 had moderate cognitive impairment. The MDS also revealed Resident 3 had received a PRN (as needed) medication and non-pharmacological interventions for pain in the last 5 days. A pain assessment was conducted with Resident 3 and revealed Resident 3 had moderate pain over the last 5 days but was unable to answer how often the pain occurred and whether the pain had interfered with their sleep, therapy activities, or day-to-day activities. It also revealed Resident 3 had displayed indications of pain or possible of non-verbal sounds, vocal complaints of pain, facial expressions, and protective body movement or postures daily within the past 5 days of the assessment. A record review of Resident 3's Care Plan revealed a focus area for pain which was last revised date on 3/26/2025. The focus area revealed Resident 3 was at risk for pain due to poor dentition (teeth conditions) and a recent hip surgery. Resident 3's goals for pain were to not have moderate or severe pain through the next review date and pain to be relieved within a timely manner of receiving pain medications or treatment. An intervention to evaluate the effectiveness of treatment and record/report to the physician any pain that is not at or below the resident's acceptable level of pain had been implemented. A record review of Resident 3's Order Summary Report with an active orders date of 4/8/2025 revealed the following orders: - Tylenol (Acetaminophen) 325 milligrams (mg) with instructions to give two tablets by mouth every six hours as needed for moderate pain with a start date of 1/22/2021. - Tramadol (a pain medication) 50 mg with instructions to give one tablet every eight hours as needed for pain management with a start date of 3/1/2025. A record review of Resident 3's Progress Notes from 3/8/2025-4/6/2025 revealed the following: - On 3/8/2025, Resident 3 had been documented as having moderate pain after the administration of prescribed pain medications. - On 3/9/2025, Resident 3 had been documented as having moderate pain after the administration of prescribed pain medications. Additionally, Resident 3 had been documented as continuing to display non-verbal indications of pain following their administration of PRN (as needed) Tramadol. - On 3/10/2025, Resident 3 had been documented as having moderate pain after the administration of prescribed pain medications. - On 3/11/2025, Resident 3 had been documented as having moderate pain after the administration of prescribed pain medications. - On 3/13/2025, Resident 3 had a residual pain of 6/10 following the administration of their PRN Tramadol. - On 3/14/2025, Resident 3's PRN tramadol had been documented as ineffective with a residual pain level of 5/10. - On 3/17/2025, Resident 3 had been documented as having moderate pain after the administration of prescribed pain medications. - On 3/20/205, PRN Tramadol had been documented as ineffective with a residual pain rating of 7/10. A physician had been notified of Resident 3's behavior, but there was no evidence that pain management had been discussed with the physician at this time. Later, Resident 3's PRN Tramadol and PRN Tylenol had been documented as ineffective with a residual pain rating of 10/10. - On 3/21/2025, Resident 3 had a residual pain of 7/10 following the administration of their PRN Tramadol. Additionally, Resident 3 had been document as having moderate pain after the administration of prescribed pain medications. - On 3/24/2025, Resident 3 had been documented as having moderate pain after the administration of prescribed pain medications. - On 3/26/2025, Resident 3 had been documented as having moderate pain after the administration of prescribed pain medications. A Physician's Assistant had been in the facility and had evaluated Resident 3. There was no evidence staff had notified the Physician's Assistant of Resident 3's pain. - On 3/27/2025, Resident 3 had been documented as having severe pain after the administration of prescribed pain medications. - On 3/30/2025, Resident 3 had been documented as having moderate pain after the administration of prescribed pain medications. - On 4/4/2025, Resident 3 had been documented as having moderate pain after the administration of prescribed pain medications. - On 4/6/2025, Resident 3 had a residual pain of 6/10 following the administration of their PRN Tramadol A record review of Resident 3's medical record revealed no evidence the facility had notified the physician of Resident 3's pain between 3/6/2025-3/18/2025 or after 3/18/2025. An interview on 4/9/25 at 10:55 AM with Registered Nurse (RN)-A revealed moderate pain is considered to be rated at a 4-6/10 and severe pain rated at a 7-10/10. RN-B revealed if a resident rated their pain or was found to have indications of pain at a moderate level after a PRN had been administered, RN-B would not consider the PRN medication to have been effective and additional interventions should be implemented and documented. If these do not resolve the pain, the physician should be called at that time. If the resident rated their pain or was found to have indications of pain at a severe level at the PRN follow-up, RN-B would not consider the PRN medication to have been effective and the physician should be called at that time for additional orders. An interview on 4/9/2025 at 11:30 with the Director of Nursing (DON) confirmed Resident 3's physician should have been notified prior to 3/18/2025 and again after 3/20/2025 of their ineffective pain management regimen.

Licensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview, the facility failed to assess and evaluate underlying causes of behavior to prevent the unnecessary use of a psychotropic (medications that affect the mind, emotions, or behavior, often used to treat mental health disorders) medication for 1 (Resident 3) of 1 sampled resident. The facility identified a census of 45. Findings are: A record review of an undated facility policy Use of Psychotropic Medications revealed the following: -Psychotropic medication should only be used to treat the resident's medical symptoms -Underlying medical conditions should be identified and ruled out prior to initiating a psychotropic medication -Non-pharmacological interventions must be attempted to minimize the need for psychotropic medications. A record review of a facility policy, Pain Management with a date of 4/1/2024, revealed staff will observe nonverbal indicators of pain which may indicate the presence of pain, such as increased or recurring restlessness, facial expressions, behaviors (such as resisting care, distressed pacing, irritability), difficulty eating or loss of appetite, weight loss, or negative vocalization (such as groaning, crying, whimpering, screaming). A record review of an admission Record indicated the facility admitted Resident 3 on 1/22/2021. Resident 3 had diagnoses of cognitive communication deficit (difficulties in communication skills), dementia (a usually progressive condition marked by the development of multiple cognitive deficits such as memory impairment, aphasia, and the inability to plan and initiate complex behavior), transient ischemic attack (TIA, a mini stroke), and a history of a hip joint replacement. A record review of Resident 3's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) with an Assessment Reference Date (ARD) of 3/5/2025 revealed Resident 3 had a Brief Interview for Mental Status (BIMS, a brief screening that aids in detecting cognitive impairment) score of 9/15, which indicated Resident 3 had moderate cognitive impairment. The MDS also revealed Resident 3 had received a PRN (as needed) medication and non-pharmacological interventions for pain in the last 5 days. A pain assessment was conducted with Resident 3 and revealed Resident 3 had moderate pain over the last 5 days but was unable to answer how often the pain occurred and whether the pain had interfered with their sleep, therapy activities, or day-to-day activities. It also revealed Resident 3 had displayed indications of pain or possible of non-verbal sounds, vocal complaints of pain, facial expressions, and protective body movement or postures daily within the past 5 days of the assessment. Resident 3 received an opioid (narcotic pain medication) within the last 7 days of the assessment. Additionally, the MDS revealed Resident 3 had displayed physical and verbal behaviors towards other 1-3 days and had not exhibited any behaviors of rejection of care within the last 7 days of the assessment. A record review of Resident 3's Order Summary Report with an active orders date of 4/8/2025 revealed the following orders: -Ativan (a sedative medication) 0.5 mg with instruction to give every six hours as needed (PRN) for anxiety with a start date of 3/20/2025. -Seroquel (an antipsychotic medication used to manage psychosis and its symptoms, such as delusions, hallucinations, and disorganized thinking) 12.5 mg with direction to give by mouth three times a day for dementia with behavioral disturbances with a start date of 4/2/2025. -Zoloft (an antidepressant) 50 mg with instructions to give 50 mg by mouth one time a day for anxiety with a start date of 4/2/2025. A record review of Resident 3's Progress Notes from 3/20/2025 revealed: -At 10:26 AM, staff had re-evaluated effectiveness of Resident 3's PRN Tramadol. Resident had a follow-up pain rated at a 7/10. There was no evidence of additional interventions to address Resident 3's pain. -At 5:52 PM, Resident 3 had hit the Nurse Aide (NA) twice when the NA had attempted to place a pillow between the resident's legs. There was no evidence of non-pharmacological interventions attempted. -At 7:01 PM, Resident 3 had been administered PRN Tylenol and PRN Tramadol for pain. -At 7:38 PM, Resident 3 had been combative and resistive with cares. Resident 3 yelled at staff to go away. The on-call provider had been contacted and an order for PRN Ativan was obtained. There was no evidence staff had notified the on-call provider of Resident 3's pain. -At 7:46 PM, Resident 3 had rated their pain at a 10/10 following the administration of their PRN Tramadol and PRN Tylenol. Staff documented the medications as ineffective for Resident 3's pain. There was no evidence of additional pain interventions completed. A record review of Resident 3's Progress Notes from 3/21/2025 revealed: -At 9:10 AM, Resident 3 had rated their pain a 7/10 after the administration of their PRN Tramadol. -At 3:09 PM, the nurse from Resident 3's physician requested an update regarding Resident 3's behaviors. This nurse had been informed about the PRN Ativan order received due to increased agitation and combativeness. An order to restart Resident 3's Seroquel had been obtained. There was no evidence staff had notified the physician's nurse of Resident 3's ongoing pain. A record review of Resident 3's Progress Notes from 3/23/2025 revealed Resident 3 had reported minimal pain and had been displaying behaviors of yelling and crying. There was no evidence that interventions had been attempted for the behaviors. A record review of Resident 3's Progress Notes from 3/26/2025 revealed Resident 3 had been restless and anxious. PRN pain and anxiety medication were administered with little effectiveness. A record review of Resident 3's Progress Notes from 3/27/2025 revealed Resident 3 had been displaying verbal outburst and facial grimacing. PRN pain medication had been administered and was effective. A record review of Resident 3's Progress Notes from 3/27/2025 revealed Resident 3 had been fake crying, yelling, and demanding to be laid down in their bed. There was no evidence of interventions that had been attempted for these behaviors. A record review of Resident 3's Progress Notes from 4/6/2025 revealed: -At 8:59 AM, Resident 3 had rated their pain at 6/10 following the administration of their PRN Tramadol. -At 11:12 AM and 9:35 PM, Resident 3 had been attempting to remove the pillow between their legs. An interview on 4/9/25 at 10:50 AM with NA-B revealed Resident 3's pain appeared to be severe, especially 2-3 weeks ago, stating that Resident 3 could barely be moved or touched due to their pain. NA-B revealed they would assist Resident 3 with laying down, repositioning, and medication, but those interventions only seemed to help some. An interview on 4/9/2025 at 11:30 with the Director of Nursing (DON) confirmed Resident 3 had an increase in behaviors during this time and had the potential to be related to their uncontrolled pain. The DON revealed it would have been expected of staff to assess Resident 3 when having behaviors, implement non-pharmacological interventions, notify the physician of ongoing pain, and confirmed no evidence these had been done.

Licensure Reference Number 175 NAC 12.006.11(E) Based on observations, interview, and record review, the facility failed to store, label, cover, and use or discard food and drink items to prevent the potential for foodborne illness. This had the potential to affect all 39 residents that resided at the facility and consumed foods from the kitchen. Findings are: A record review of 2017 Nebraska Food Code, under section 3-501.17 revealed food held for more than 24 hours should be clearly marked to indicate the date by which food should be consumed or discarded. An observation on 12/16/24 at 10:57 AM during the initial kitchen tour revealed the following refrigerated items: -2 unlabeled, undated bulk bags of salad mix of lettuce, purple cabbage, carrots, and one of the bags contained lettuce which had turned brown. -One 1-gallon ziploc bag with lettuce, unlabeled. -1 unlabeled gallon-sized bag of bulk shredded carrots, mushy with liquid in bag. -1 opened 1-gallon size bottle of [NAME] Lynch salad dressing, labeled with an opened-on date of 11-2. -1 opened 1-gallon Golden Italian dressing labeled open 10-7. -1 squirt bottle labeled Ranch 11-27, with an uncovered spout. -1 partially used 1-gallon Kikkoman brand soy sauce, opened and not dated. -Two 46-ounce boxes of grape juice, opened and not dated. -One 46-ounce box of thickened orange juice Sysco Imperial brand, opened and not dated. -One 46-ounce bottle of Thick and Easy nectar thickened orange juice, opened and not dated. -One 16-ounce bottle of Diet Coke that was half empty and not labeled with a date or name. A record review of The FoodKeeper, an online resource developed by the United States Department of Agriculture Food Safety and Inspection Service with Cornell University and the Food Marketing Institute, revealed creamy salad dressings should be consumed within 3-4 weeks if refrigerated after opening. Review of an undated facility policy titled, Food Safety Requirements, revealed safe refrigerated storage practices included needed to be labeled and dated and covered in tight containers. An interview on 12/16/24 at 11:30AM with Dietary Manager (DM) confirmed the DM did not locate a date on the 2 bulk bags of salad mix. The interview confirmed that all items listed above should have been labeled with an open date, and that they should have been discarded if not labeled as required. The interview also confirmed the salad dressings should be discarded withing 30-60 days of being opened. DS confirmed the Diet Coke likely belonged to an employee and should not have been stored in a residents' food refrigerator.

Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on observation, record review, and interview, the facility failed to identify and update the comprehensive care plan with interventions after a fall for one (Resident 39) of one sampled resident. The facility identified a census of 39. Findings Are: A record review on 12/16/24 of Resident 39's Minimum Data Set (MDS, a federally mandated process that helps to standardize assessments, improve the accuracy of care, and facilitate care management) dated 11/18/24 reveals in Section GG: Resident 39 was independent with eating. They required set up assistance with oral hygiene. They were total dependence with transfers and toileting. They required moderate assistance with upper body dressing and maximum assistance with lower body dressing. A record review on 12/16/24 of Resident 39's diagnosis revealed diagnoses of: -Amyotrophic lateral Sclerosis (a terminal, progressive, and fatal neurological disorder that affects the nerve cells in the brain and spinal cord) -Unspecified Osteoarthritis (a condition that causes the breakdown of cartilage in the joints, leading to pain and stiffness.) -Hereditary and idiopathic neuropathy (damage to the nerves passed on genetically from parent to child and nerve damage that has no apparent cause) -Muscle Wasting and Atrophy (the loss or thinning of muscle tissue), not elsewhere classified -Muscle Weakness, Generalized A record review of Resident 39's Progress Note dated 11/26/24 revealed that Resident 39 fell while being transferred from the toilet to the wheelchair. Note stated Resident 39 pushed themselves back with their feet and fell on their bottom on the floor. Resident 39 did not hit [gender] head. No redness, bruises, or alterations to skin. Resident 39 denied pain. Resident 39 helped back into chair by nurse and NA using gait belt. A record review of Resident 39's Care Plan dated 12/2/24 revealed Resident 39 is dependent for transfers requiring two staff for assistance and a Hoyer lift (an assistive device that lifts the body into the air with use of a sling in order to transfer between surfaces). The Care Plan further revealed Resident 39 required partial to moderate assistance from one staff member, gait belt, and walker for ambulation. The care plan stated the Resident had the potential for falls related to medication side effects, gait/balance problems, and weakness. The care plan did not contain evidence of Resident 39 having a fall on 11/26/24 and had no evidence of any new interventions being put into place following the fall. An interview with Resident 39 on 12/16/24 at 11:49 AM revealed that Resident 39 had a fall in their bathroom in which they stated I told them I was going to fall. They just told me no, you're not. But I did fall. I could feel my legs giving out. Resident 39 stated that prior to fall they were able to utilize their walker and wheelchair for transfers, but that after the fall the facility had been using the Hoyer lift to transfer them. An interview with the Director of Nursing (DON) on 12/18/24 at 2:47 PM revealed that facility processes after a fall involve updating the care plan with the date of fall, any injuries, and interventions. The DON confirmed that the current care plan was not updated with the fall that occurred on 11/26/24 and that interventions were not placed in the Falls section of the care plan.

Licensure Reference Number 175 NAC 12-006.09(B) Based on record review and interview, the Minimum Data Set (MDS, a federally mandated assessment used for Care Planning purpose) was not coded correctly for pressure ulcer of 1 (Resident 34) out of 10 sampled residents' pressure sores. The facility census was 39. Findings are: A record review of the Admission Record with the printed date of December 18th, 2024 revealed that Resident 24 was admitted to the facility on [DATE] with the diagnoses of: Type 2 Diabetes Mellitus with Hyperglycemia (a condition where someone with type 2 diabetes has elevated blood sugar levels, also known as high blood sugar or hyperglycemia), Pressure Ulcer to Left Heel, unstageable (Unstageable pressure ulcers are a type of bed sore that occurs when prolonged pressure on an area of the skin cuts off blood flow and oxygen to the tissue). A record review of Resident 24's Care Plan dated 12/12/24 revealed a focus, goal and intervention for Pressure Ulcers. A record review of Resident 24's quarterly MDS dated [DATE] revealed documentation in section M that the resident had 0 unstageable pressure ulcers that were present upon admission/entry or reentry. A record review of the Weekly Wound assessment dated [DATE] for Resident 24 revealed pressure ulcers to their to right buttock, left buttock and left heel. An interview on 12/16/24 at 2:30 PM with the MDS/Care Plan Coordinator confirmed that the MDS section M for Resident 24 Unstageable E2 was marked no and it should of been marked yes and in section B1 number of Stage 2 pressure ulcers was marked 1 and should of been marked 2 Stage 2 pressure ulcer for Resident 24.

Licensure Reference 175 NAC 12-006.09(F)(i) Based on record reviews and interview, the facility failed to develop baseline care plans (a document that outlines a resident's healthcare needs and safety concerns when they are first admitted to a nursing home) within 48 hours of admission as required for 2 (Residents 9 and 96) of 2 sampled residents. The facility identified a census of 39. Findings are: A record review of an undated facility policy, Baseline Care Plan revealed baseline care plans will be developed within 48 hours of a resident's admission. A. A record review of an Admission Record revealed the facility admitted Resident 9 on 6/14/2024 with diagnoses of: depression, repeated falls, difficulty swallowing, and Chronic Obstructive Pulmonary Disease (a common lung disease that causes breathing problems and restricted airflow). A record review of Resident 9's AS - Baseline Careplan - V 1 revealed a signed date of 6/17/2024, which was more than 48 hours after Resident 9's admission. B. A record review of an Admission Record revealed the facility admitted Resident 96 on 4/19/2024 with diagnoses of atrial flutter (a common heart rhythm abnormality that causes the upper chambers of the heart to beat rapidly and irregularly,) acute and chronic respiratory failure, difficulty in walking, depression, high blood pressure, and a history of falls. A record review of Resident 96's AS - Baseline Careplan - V 1 revealed a signed date of 4/30/2024, which was more than 48 hours after Resident 96's admission. An interview on 12/18/2024 at 4:04 PM with the Director of Nursing (DON) confirmed baseline care plans should be completed within 48 hours of admission and confirmed Resident 9 and 96's baseline care plans were not completed within 48 hours of their respective admission.

Licensure Reference 175 NAC 12-006.09(E)(iii) Based on record reviews and interview, the facility failed to develop a comprehensive care plan (CCP, a document that outlines a resident's needs and the services that are to be provided to meet these needs) regarding activities of daily living (ADLs) for 1 (Resident 97) of 12 sampled residents. The facility identified a census of 39. Findings are: A record review of a facility policy, Comprehensive Care Plans with a date of 4/1/2024 indicated the CCP would, at a minimum, include the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psycho-social well-being and resident specific interventions that reflect the resident's needs and preferences. A record review of an Admission Record revealed the facility admitted Resident 97 on 11/13/2024 with diagnoses of Chronic Respiratory Failure (a long-term condition that prevents the body from exchanging oxygen and carbon dioxide properly,) Chronic Obstructive Pulmonary Disease (a common lung disease that causes breathing problems and restricted airflow,) heart failure, and diabetes. A record review of Resident 97's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) with an Assessment Reference Date of 11/26/2024 indicated Resident 97 was independent with eating; required set up for oral hygiene, required substantial assistance for toileting, bathing, and personal hygiene; and required total assistance for lower body dressing. Resident 97 also required moderate assistance for all transfers. A record review of Resident 97's undated Care Plan revealed a section for ADLs. The intervention initiated on 12/16/2024 indicated therapy to screen, evaluate, and treat as needed. Further record review of Resident 97's Care Plan revealed no evidence of interventions to address Resident 97's need for assistance with oral hygiene, toileting, bathing, personal hygiene, dressing, or transfers. An interview on 12/19/2024 at 9:00 AM with the Director of Nursing (DON) confirmed Resident 97's care plan was not comprehensive and would expect it to include specific interventions with information regarding the amount of assistance Resident 97 required for all ADLs.