Every finding on record at Avera Creighton Care Centre

Licensure Reference Number 175 NAC 12-006.18(B)(D) Based on observation, record review and interview; the facility failed to complete hand hygiene at appropriate intervals to prevent potential infection/cross contamination during the provision of cares for Resident 1, 3, 12, 20, 28 and 36. The total sample size was 12 and the facility census was 37. Findings are:A. Review of the facility policy Hand Hygiene with a revision date of 11/20/25 revealed the facility considered Hand Hygiene to be the primary means of preventing the transmission of infection. -Hand hygiene with either soap and water or Alcohol Based Hand Sanitation (ABHR) was to be completed before touching a resident, before a clean procedure or handling an invasive medical device, after contact with potential for body fluid or contaminated surfaces, after touching a resident or the resident's immediate environment, and after removing gloves. B. Review of the facility policy General Standard Precautions with a revision date of 5/2023 revealed the following: -Standard Precautions synthesized the major features of Universal Precautions (Blood and Body Fluid Precautions) (designed to reduce the risk of transmission of bloodborne pathogens) and Body Substance Isolation (designed to reduce the risk of transmission of pathogens from moist body substances) and applied then to all patients receiving care. This applied to blood, body fluids, non-intact skin, and mucous membranes). -It was the facility policy to use good hand hygiene techniques to prevent the transmission of pathogens and hand washing was recommended whenever hands were visibly soiled and the use of ABHR (alcohol-based hand sanitizer was used when the hands were not visibly soiled or had not come in contact the blood or spore forming pathogens. -Gloves were used as an adjunct to, not a substitute for hand hygiene, and gloves were to be changed between patients and when moving from a contaminated to clean procedure on the same patient. C. Review of Resident 28's Minimum Data Set (MDS) (federally mandated comprehensive assessment used to develop resident care plans) dated 9/24/25 revealed the resident required assistance with toileting cares, dressing cares, transfers from chair and toilet and had disorganized thinking continuously. The resident had a diagnosis of Non-Alzheimer Dementia and Anxiety. Review of Resident 28's Care Plan revealed that the resident was dependent on staff for transfers, dressing, toilet use and personal hygiene and required maximal assistance with bed mobility. During an observation of provision of cares on 12/2/25 at 9:00 AM revealed Nursing Assistant (NA)-G completed the following cares without washing hands: -NA-G had clean gloves on, transferred Resident 28 from wheelchair to the bathroom with use of a mechanical lift, pulled resident pants and incontinent brief down, sat resident on the toilet (did not remove gloves or wash hands). NA-G then rearranged blankets on the bed and touched face and hair with gloved hand, stood resident up with use of mechanical lift, cleaned perineal area and buttocks, pulled up incontinent brief and pants (did not change gloves or wash hands) and then assisted resident to bed. NA-G removed soiled gloves and exited the room (handwashing was not completed.) D. Review of Resident 12's MDS dated [DATE] revealed the resident had an indwelling catheter and an ostomy, used a wheelchair for mobility, required assistance with toileting cares, dressing cares and transfers from bed and chair. Resident 12 had a diagnosis of Paraplegia (paralysis of the lower half of the body) and had limited range of motion to arms and legs bilaterally. Review of Resident 12's Care Plan revealed that the resident was to receive catheter cares (cleaning of the catheter and insertion site) every 8 hours and that resident wore an ostomy appliance and was to be changed on Tuesday and as needed due to leaking. During an observation of provision of cares on 12/2/25 at 9:25 AM revealed NA-G and NA-H completed the following cares without washing hands: -NA-G and NA-H completed foley catheter cares on Resident 12, removed soiled gloves and then applied clean gloves (no handwashing when gloves changed). NA-G and NA-H then completed colostomy cares (removed the colostomy bag and cleaned around the stoma) due to colostomy bag leaking, removed soiled gloves and then applied clean gloves, applied the new ostomy bag and removed the soiled gloves. (No handwashing was identified between glove change) and NA-G did not wash hands after cares were completed and before exiting the room. E. Review of weekly skin measurement documentation for Resident 1 revealed that Resident 1 had a pressure ulcer to right facial cheek and an open area to right side of the coccyx. Pressure ulcer to the right cheek was washed with wound cleanser and covered with a band-aide for protection. Open area to the right side of the coccyx was washed with wound cleanser and covered with a dressing. During an observation of provision of cares on 12/2/25 at 10:05 AM revealed the following: -Registered Nurse (RN)-I applied clean gloves, removed a band-aide from Resident 1's right facial cheek, cleansed the wound with wound cleanser and applied a new band-aide to the area, then removed soiled gloves and applied hand sanitizer to hands. (Did not change gloves or wash hands between soiled wound dressing being removed and a clean wound dressing being applied.) RN-I applied clean gloves, removed an adhesive dressing from Resident 1's right buttock area, cleansed the area with wound cleanser and applied clean dressing to the area. (Did not change gloves or wash hands between soiled wound dressing being removed and a clean wound dressing being applied.) F. An interview on 12/2/25 at 2:55 PM with the Director of Nursing (DON) confirmed the following: -NA-G should have removed dirty gloves and washed hands after Resident 28 was assisted to/from the bathroom and should have washed hands prior to exiting the room after cares were completed. - NA-G and NA-H should have washed their hands after dirty gloves were removed and before clean gloves were applied when catheter and colostomy cares were completed and before exiting the room when Resident 12's cares were completed. -RN-I should have washed hands and changed gloves between the dirty wound dressing removed and the clean wound dressing applied. G. Review of Resident 20's MDS dated [DATE] revealed the resident had mild cognitive impairment; had diagnoses of Right Pelvis Fracture, Dementia and Anxiety; and required assistance with toileting, dressing and transfers. Review of Resident 20's Care Plan, last reviewed 10/28/25 revealed the resident required assistance with dressing, mobility and transfers and was dependent with dressing the lower half of the body and taking off and putting on footwear. On 12/2/25 at 10:30 AM an observation during the provision of cares for Resident 20 revealed NA-E was putting on gloves when this surveyor entered the resident room. NA-E ambulated the resident to the bathroom. At the toilet, NA-E pulled the residents pants and pull-up down and then the resident sat down on the toilet. NA-E removed their gloves and no hand hygiene was observed to be completed. When the resident was finished, NA-E applied clean gloves (no hand hygiene was observed) and performed perineal cares on the resident. NA-E continued to wear the soiled gloves and pulled the resident's pull-up and pants up. NA-E removed their gloves and no hand hygiene was observed. NA-E ambulated the resident to their recliner and NA-E did perform hand hygiene upon exiting the room. H. Review of Resident 36's MDS dated [DATE] revealed the resident had severe cognitive impairment; was dependent with oral hygiene, toileting, dressing and personal hygiene; and had diagnoses of Heart Disease and Dementia. Review of Resident 36's Care Plan initiated 11/11/25 revealed the resident had impaired cognition and required assistance with bed mobility, transfers, dressing, toileting and hygiene. On 12/2/25 at 1:50 PM an observation of provision of cares revealed NA-E entered Resident 36's room and no hand hygiene was observed to be completed. NA-E put on clean gloves. NA-E transferred the resident to the bathroom and NA-E pulled the resident's pull-up and pants down and assisted the resident to sit on the toilet. NA-E removed their gloves, and no hand hygiene was observed to be completed. When the resident was done, NA-E applied a pair of clean gloves without performing hand hygiene and provided perineal cares on the resident. NA-E continued to wear the same pair of soiled gloves and pulled the resident's pull-up and pants up. NA-E, still wearing the same pair of soiled gloves, assisted the resident to ambulate to the wheelchair. NA-E had touched the resident's clothing, the walker and the wheelchair while wearing the same pair of soiled gloves. After the resident sat down, NA-E removed their gloves. No hand hygiene was observed to be completed. The NA-E exited the resident room and no hand hygiene was observed to be completed. I. An interview with the DON on 12/2/25 at 2:45 PM confirmed hand hygiene should be completed after removing gloves and when exiting resident rooms. J. During an observation of toileting/incontinence cares on 12/2/25 at 8:33 AM, NA-E and NE-F entered Resident 3's room and without washing or sanitizing hands put on a clean pair of gloves. Staff transferred the resident into the bathroom with the mechanical sit-to-stand lift. The resident's slacks and disposable incontinent brief were lowered and the resident was observed to be involuntary of feces. Without cleansing the resident's buttocks, the resident was placed onto the toilet. NA-E and NA-F removed soiled gloves but failed to complete hand hygiene before putting on clean gloves. The resident was lifted from the toilet with the mechanical lift and NA-F used multiple pre-moistened cleansing cloths to remove feces from the resident's buttock and the toilet seat. When hygiene cares were completed, NA-F removed soiled gloves but failed to complete hand hygiene before putting on a clean pair of gloves. The resident was assisted out of the bathroom, and into the wheelchair. NA-F adjusted the resident's positioning in the wheelchair, placed foot pedals on the chair, and attached the resident's fall alarm to the resident's clothing before removing gloves and performing hand hygiene. The resident was assisted out of the resident's room to the commons area. During an interview on 12/2/25 at 9:43 AM, NA-E and NA-F confirmed they did not complete hand hygiene when they entered Resident 3's room and before putting on clean gloves. In addition, NA-F confirmed after completing incontinence cares on the resident, NA-E should have performed hand hygiene after removing soiled gloves and before putting on clean gloves.

Licensure Reference Number 175 NAC 12-006.09(E)Based on record review and interview; the facility failed to ensure Resident 2's Post Traumatic Stress Disorder (PTSD-a mental health condition caused by extremely stressful or terrifying events. Symptoms may include flashbacks, nightmares, severe anxiety and uncontrolled thoughts) triggers and interventions to address triggers were identified in the resident care plan. The total sample size was 18 and the facility census was 37. Findings are: Review of Resident 2's Minimum Data Set (MDS- federally mandated assessment used in the development of resident care plans) dated 10/1/25 revealed the resident was admitted [DATE] with diagnoses of anxiety, depression, lung disease, and heart failure. The following was assessed regarding Resident 2:-cognitively intact but had episodes of disorganized thinking. -behaviors which included delusions, resistance with cares and verbal behaviors directed at others. -current medications included an antidepressant, anticonvulsant (used to prevents seizures), and an opioid (used to help manage pain). Review of Resident 2's current Care Plan dated 5/5/25 revealed the resident exhibited verbal behaviors towards the staff and was resistive to cares. The resident was delirious at times and had made comments about being held prisoner at the facility against the resident's will. The resident was impulsive at times. Interventions included the following:-monitor use of Duloxetine (antidepressant medication which can also be used to treat anxiety) 30 milligrams (mg) twice a day.-monitor use of Trazadone (antidepressant medication also used to treat insomnia) 50 mg in the evening. -allow time to verbalize concerns and determine if something was bothering the resident. -help to solve problems as needed. -reorient as needed.-reapproach as needed as will calm self when left alone. Review of a Nursing Progress Note dated 10/1/25 at 9:21 AM revealed the resident was seated in the bathroom. The resident was tearful and indicated a need for help. The resident was stuck and needed help getting up. The resident was tearful and anxious with increased shortness of breath. The resident reported having PTSD and stated the ex-spouse used to lock the resident into the bathroom or a closet. Sometimes being in the bathroom increased the resident's anxiety and the resident would freak out. Review of a Psychiatric Progress Note dated 11/21/25 revealed the resident was seen by the Psychiatric Mental Health Nurse Practitioner (PMHNP) to follow up management of the resident's PTSD, depression, anxiety, insomnia, and nightmare disorder. The resident reported appetite varied, was only sleeping 1-3 hours per night with nightmares most nights, some visual hallucinations, and flashbacks from time to time. A new order was received for Prazosin (medication used to treat high blood pressure and/or to help with PTSD related nightmares) 1 mg at bedtime. To be seen again in 1-2 months. Further review of the resident's current Care Plan revealed no evidence the resident's diagnosis of PTSD was identified with potential triggers and interventions to address the triggers. An interview with the Director of Nursing (DON) on 12/3/25 at 9:53 AM confirmed the resident's current care plan did not list potential triggers for Resident 2's PTSD and no interventions were in place to prevent potential triggers.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(l)Based on observation, record review, and interview; the facility failed to implement assessed interventions to prevent a potential injury from a hot liquid spill for Resident 32. The facility census was 37 and the sample size was 1.Findings are:A. Review of the facility policy Hot Liquids Assessment and Spill Occurrences with a revision date of 11/2025 revealed all residents were to be assessed for risk of injury from consuming hot liquids, including physical capabilities and contributing factors. Residents were to be identified utilizing a Hot Liquid Risk Assessment tool. The assessment was to be completed on admission, annually, with significant changes and with any hot liquid spill. Residents considered at risk or that had a score of 6-9 on the assessment were to wear one lap cover and one apron (one over their lap and one on their chest) and will have an orange name tag on their dining room table. Risk for hot liquids and interventions used were to be included in the residents' care plan. B. Review of Resident 32's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/14/25 revealed the resident was admitted [DATE] with diagnoses of anemia, Alzheimer's disease, and depression. The MDS further revealed the resident had severe cognitive impairment; required setup and clean-up assistance with eating and drinking, and required moderate assistance with personal hygiene.Review of a Hot Liquid Risk screening form completed 6/5/25 revealed a score of 4 which indicated the resident was at low risk for a hot liquid spill. The form indicated the resident was consuming hot liquids, had an intention type tremor (a specific type of tremor that develops as you try to do a purposeful movement), had a diagnosis of dementia with poor decision making abilities and the resident required assistance with eating. The resident was to wear one cover at all times when in the dining room and when consuming hot liquids. Review of a Nursing Progress Note dated 7/7/25 at 3:00 PM revealed the staff were summoned to the dining room and were notified Resident 32 had a hot liquid spill. The resident was attending Bingo and the Activity Director gave the resident a cup of hot water and a snack. The Activity Director failed to place a protective cover on the resident before serving the hot water. The resident had some pinkness to the left side of the resident's neck and down the middle of the resident's chest. No blisters or skin breakdown were observed. Review of a Hot Liquid Risk screening form dated 7/7/25 revealed the resident now scored a 6 indicating the resident's risk for a hot liquid spill had increased. New interventions were developed which included the resident was to wear x2 vinyl clothing protectors in the dining room (one around the neck and one across the resident's lap) and an orange name tag was to be added to the resident's dining room table. Staff were to fill the resident's cup only half full when hot liquids when served. Observations of Resident 32 in the facility dining room revealed the following:-12/2/25 at 7:40 AM, the resident was seated in a wheelchair positioned at the dining room table. The resident was served the breakfast meal which consisted of a bowl of hot cereal, toast with jelly, one strip of bacon and 1/2 of a banana. The resident was observed to have a slight tremor to hands when attempting to eat/drink. In addition, the resident pushed the wheelchair slightly away from the table and had to reach for items as the resident was eating/drinking. Resident 32 was wearing only 1 clothing protector around the resident's neck and did not have the second clothing protector across the resident's lap. -12/2/25 at 12:45 PM the resident was seated in the dining room at the resident's table in a wheelchair. The resident was served a bowl of beef and barley soup. The resident was wearing only one clothing protector which had been placed around the resident's neck. The second clothing protector had not been positioned across the resident's lap. During an interview on 12/2/25 at 12:59 PM the Director of Nursing confirmed the resident did have a hot liquid spill on 7/7/25. The resident had previously been assessed at low risk for a hot liquid spill and had an intervention in place to wear a clothing protector around the resident's neck in the dining room to protect the resident from a potential hot liquid spill. The residents' risk for a hot liquid spill was then reassessed and additional interventions were developed to protect the resident. Resident 32 was always to wear two of the clothing protectors in the dining room. The resident was to wear one around the resident's neck and one was to be placed across the resident's lap.

Licensure Reference Number 175 NAC 12-006.09(H)(vi)Based on record review and interview; the facility to ensure residents received trauma informed care related to diagnosis of Post Traumatic Stress Disorder (PTSD-a mental health condition caused by extremely stressful or terrifying events. Symptoms may include flashbacks, nightmares, severe anxiety and uncontrolled thoughts) and to identify potential triggers as well as resident preferences to prevent and/or mitigate re-traumatization for 1 (Resident 2) of 1 sampled resident. The facility census was 37. Findings include:Review of Resident 2's Minimum Data Set (MDS- federally mandated assessment used in the development of resident care plans) dated 10/1/25 revealed the resident was admitted [DATE] with diagnoses of anxiety, depression, lung disease, and heart failure. The following was assessed regarding Resident 2:-cognitively intact but had episodes of disorganized thinking. -behaviors which included delusions, resistance with cares and verbal behaviors directed at others. -current medications included an antidepressant, anticonvulsant, and an opioid. Review of Resident 2's current Care Plan dated 5/5/25 revealed the resident exhibited verbal behaviors towards the staff and was resistive to cares. The resident was delirious at times and had made comments about being held prisoner at the facility against her will. The resident was impulsive at times. Interventions included the following:-monitor use of Duloxetine (antidepressant medication which can also be used to treat anxiety) 30 milligrams (mg) twice a day.-monitor use of Trazadone (antidepressant medication also used to treat insomnia) 50 mg in the evening. -allow time to verbalize concerns and determine if something was bothering the resident. -help to solve problems as needed. -reorient as needed.-reapproach as needed as will calm self when left alone. Review of Resident 2's Nursing Progress Notes revealed the following:-8/29/25 at 4:09 AM the resident had been crying out for help. The resident was tearful and reported everyone told me yesterday all day that I was dying. -9/22/25 at 1:27 PM the resident made several negative comments about self and called self dumb and/or stupid. -10/1/25 at 9:21 AM the resident was seated in the bathroom. The resident was tearful and indicated a need for help. The resident was stuck and needed help getting up. Remained tearful and anxious with increased shortness of breath. The resident reported having PTSD and stated the ex-spouse used to lock the resident into the bathroom or a closet. Sometimes being in the bathroom increased the resident's anxiety and the resident would freak out. -10/14/25 at 10:10 PM the resident complained of abdominal pain and stated, no one cared for the resident and the resident's spouse wanted to leave the resident in the Nursing Home to die. Review of a Psychiatric Progress Note dated 11/21/25 revealed the resident was seen by the Psychiatric Mental Health Nurse Practitioner (PMHNP) to follow up management of the resident's PTSD, depression, anxiety, insomnia, and nightmare disorder. The resident reported appetite varied, was only sleeping 1-3 hours per night with nightmares most nights, some visual hallucinations, and flashbacks from time to time. A new order was received for Prazosin (medication used to treat high blood pressure and/or to help with PTSD related nightmares) 1 mg at bedtime. To be seen again in 1-2 months. Further review of Resident 2's medical record revealed no evidence the facility had attempted to identify triggers and preferences to eliminate/mitigate triggers related to PTSD. During an interview on 12/3/25 at 9:48 AM, Resident 2 confirmed the resident had a history of PTSD. The resident reported being raped/beaten while in the service and being abused by a previous spouse. The resident's previous spouse would beat the resident and lock in a closet or a bathroom. The resident indicated the facility had not interviewed the resident to determine PTSD triggers and had not asked the resident about potential interventions to address triggers. The resident felt the staff were always in a hurry and did not have time for the resident. An interview with the Director of Nursing (DON) on 12/3/25 at 9:53 AM confirmed the facility had not determined potential triggers for Resident 2's PTSD and no interventions were in place to prevent potential triggers. Interview with the Social Service Director (SSD) on 12/3/25 at 11:27 AM revealed the facility did not have a policy related to Trauma Informed Care. The SSD was not aware if triggers and/or interventions were in place to address Resident 2's PTSD.

Licensure Reference Number 175 NAC 12-006.17 Based on observation, record review, and interview; the facility failed to perform hand hygiene (hand washing using soap and water or an alcohol based hand rub (ABHR) at the required intervals and to utilize the required personal protective equipment (PPE-can include items such as gowns, gloves, masks, goggles and/or face shields) during the provision of room tray meal service to prevent the potential spread of COVID-19. This practice had the potential to affect all facility residents. The total sample size was 17 and the facility census was 34. Findings are: A. Record review of the facility policy Transmission-Based Precautions (Isolation) with a revision date of 10/25/23 revealed residents who had been placed on Airborne Respirator Precautions and Contact Precautions required use of the following PPE before entering the resident's room: -fit tested N95 mask (a respiratory protective device designed to achieve a very close facial fitting and very efficient filtration of airborne particles), -eye protection (face shield or goggles), -gown, and -gloves. B. Record review of the facility policy Standard Precautions, Hand Hygiene with a revision date of 11/21/23 revealed staff were to perform hand hygiene when hands were visibly soiled, between resident contacts, after handling contaminated objects, before applying and removing PPE including gloves, before performing resident care procedures, after handling items potentially contaminated with blood, body fluids, secretions, and excretions and whenever in doubt. The policy further indicated the use of gloves would not replace hand hygiene. If a task required use of gloves, perform hand hygiene prior to putting on gloves and immediately after removing gloves. C. Observation of the noon room-tray meal service on 9/18/24 from 12:29 PM to 12:45 PM revealed the following: -Dietary Aide (DA)-A entered the 100 corridor from the kitchen wearing a surgical mask and propelled a cart which contained 5 room trays and a face shield which was hanging on the side of the cart. -DA-A position the cart outside of room [ROOM NUMBER]. A sign on the room door indicated the residents in the room were on Airborne Respirator Precautions and Contact Precautions. DA-A performed hand hygiene and placed on a disposable gown and gloves. Without removing the surgical mask or putting on an N95 mask and/or eye protection, DA-A entered the resident's room with a room tray. -DA-A exited room [ROOM NUMBER] and removed their gloves and gown and performed hand hygiene. -DA-A still without changing or removing the surgical mask, entered resident room [ROOM NUMBER] who was not on any transmission-based precautions. DA-A exited the room and without completing hand hygiene continued to propel the cart in the corridor. -DA-A positioned the cart outside of room [ROOM NUMBER] which had a sign indicating the residents were on Airborne Respirator Precautions and Contact Precautions. DA-A placed on clean gloves and a gown and without changing the surgical mask or using an N95, put on the face shield which had been hanging from the cart. DA-A entered the room with a room tray. -DA-A left the resident's room, removed the face shield and without cleaning it, placed it back on the food cart with the remaining meal trays. DA-A removed gown and gloves and completed hand hygiene and continued wearing the same surgical mask. -DA-A returned to room [ROOM NUMBER] to provide a second meal tray to the residents in the room. DA-A finally removed the surgical mask and placed it directly on the handrail outside of the resident's room then placed on a clean N95 mask. Without further hand hygiene, DA-A placed on a clean gown and gloves. Without use of the face shield or eye protection, DA-A re-entered room [ROOM NUMBER]. -DA-A exited the resident's room, removed the N95, gown and gloves, completed hand hygiene, removed the surgical mask from the handrail and placed it back on their face before leaving the corridor and returning to the kitchen. Observations of the breakfast meal room tray pass on 9/23/24 at 8:04 AM revealed the following: -DA-B entered the 100-corridor wearing an N95 mask and propelled a food cart which contained a face shield hanging from the cart. -DA-B performed hand hygiene and placed on a gown and gloves and entered room [ROOM NUMBER] without wearing the face shield or eye protection. -DA-A exited the room and removed gloves and gown. DA-A failed to complete hand hygiene before putting on a new gown and gloves as well as the face shield and re-entering room [ROOM NUMBER] with a second room tray. Interview with DA-B on 9/19/24 at 9:30 AM revealed the dietary staff had not received any additional or recent training regarding use of PPE with a COVID-19 outbreak. Interview with the Director of Nursing (DON) on 9/19/24 at 2:57 PM confirmed any staff entering/exiting a room for a resident on Airborne Respirator Precautions and Contact Precautions were to wear an N95 mask, face shield or goggles, a gown, and gloves. Upon exiting a room, staff were to remove eyewear and to clean with a disinfectant wipe, to remove and discard the N95 mask then replace with a new mask and remove gown and gloves. In addition, staff were to complete hand hygiene before putting on and after removing PPE.

Licensure Reference Number 175 NAC 12-006.12(D)(i)(2) Based on observation, record review and interview; the facility failed to account for narcotic medications according to the facility policy. This had the potential to affect Residents 6, 26, 3, 21, 8 and 17. The total sample size was 13 and the facility census was 34. Findings are: Review of the facility policy Long Term Care Controlled Substances with a revision date of 7/24 revealed the following: -all scheduled controlled medications were to be kept in double locked locations on the medication cart with a controlled substance record (form used to document the time a narcotic medication was administered, the number of pills remaining and the staff's initials) to be stored on each cart. -the controlled substance record was to identify a resident's name, room number, their physician, and the medication order including strength and the route used for administration of the medication. Observation of a medication pass on 9/19/24 at 12:05 PM revealed the following: -Registered Nurse (RN)-K administered one tablet of Oxycodone/APAP 7.5/325 (narcotic medication for pain) milligrams (mg) to Resident 17. -RN-K documented the administration of the Oxycodone on the controlled substance record however, the count identified on the record did not match the number of pills remaining in the Oxycodone cassette. -after determining the count was incorrect, RN-K proceeded to document the Oxycodone which had been given that morning at 8:00 AM (4 hours earlier) to ensure the count was now correct. Observation on 9/19/24 at 12:30 PM, revealed Licensed Practical Nurse (LPN)-C administered Tramadol (narcotic medication for pain) 50 mg one half tablet to Resident 6. LPN-C indicated the controlled substance record was not available on the medication cart, and LPN-C further indicated staff would update the controlled substance log later when the medication pass was completed. Review of Resident 6's controlled substance record on 9/19/24 at 12:53 PM revealed a count of 19 Tramadol. Observation of the resident's medication cassette revealed there were only 18 pills remaining. LPN-C verified the count on the resident's controlled substance record should have been 18. Review of the controlled substance records and observations of the medication carts on 9/19/24 at 1:10 PM for the 100 and the 200 hallways revealed the following: -Resident 21's record for Tramadol 50 mg, revealed a count of 2 pills. Observation of the resident's medication cassette for Tramadol 50 mg revealed only 1 pill remained. RN-K verified the count for the Tramadol 50 mg should be 1, and the dose which had been administered at 11:00 AM had not been signed out. -Resident 8's record for Tramadol 100 mg, revealed a count of 16. However, the medication cassette for the resident's Tramadol only contained 15 pills. RN-K verified the count for the Tramadol should have been 15 as the dose administered at 8:33 AM was not signed out. -Resident 3's record for APAP/Codeine (narcotic medication use for pain control) 300-30 mg revealed a count of 31. Observation of the medication cassette for the APAP/codeine revealed only 30 pills remained. RN-K confirmed the count for APAP/Codeine 300-30 mg should have been 30, as the dose administered at 11:17 AM had not been signed out. -Resident 26's record for Tramadol 50 mg revealed a count of 10. Review of the resident's medication cassette for the Tramadol revealed 9 pills remained. LPN-C verified the count for the Tramadol 50 mg should have been 9 but LPN-C had failed to document the last dose of Tramadol the resident had received. -Resident 6's record for Tramadol 50 mg one half tab, revealed a count of 19, LPN-C verified the count for the Tramadol should have been 18 but the dose administered at 12:30 PM had not been signed out. Interview with the Director of Nursing on 9/19/24 at 1:35 PM verified staff were to sign and update the controlled substance record when narcotic medications were administered to ensure the resident's narcotic counts were correct to avoid discrepancies and/or medication errors.

Licensure Reference Number 175 NAC 12-006.11E Based on observation, interview, and record review, the facility failed to ensure hair was restrained with a hair net, proper hand hygiene was followed and that utensils were handled to prevent potential food contamination during the food service. These practices had the potential to affect all residents. The sample size was 13 and the facility census was 41. Findings are: Review of the facility policy Infection Prevention in Food Safety/Sanitation Program for Nutrition Services with a revision date of 7/23 revealed the following: -hair restraints would be worn by all personnel preparing or serving food, -personnel must wash hands with soap and water before handling food and dishes, or after touching face, touching hair or combing hair, -disposable gloves would be worn when handling food with hands to ensure bacteria are not transferred from the food handlers' hands to the food product being served. Gloves are just like hands. Anytime a contaminated surface would be touched, the gloves need to be changed-washing hands after removing the gloves and before putting on a new pair, -food would be served with clean tongs, forks, spoons, spatulas, or other utensils to avoid direct manual contact of food, and -silverware would be stored so people would have contact with handles only. Observation on 8/30/23 at 11:30 AM with Dietary Cook (DC-M) performed hand hygiene and obtained temperatures for the food items for the lunch meal. 3 residents entered the dining room and went to the kitchen window to give their lunch order. DC-M, still wearing the same pair of gloves, obtained a notebook and a pen and wrote down the resident orders. DC-M then place the notebook and pen on the ledge of the steam table. DC-M, continuing to wear the same pair of gloves, obtained a cart and placed trays on the cart for the hospital. DC-M, still wearing the same pair of gloves, opened a bag of buns, pulled out buns and placed them on plates. DC-M turned to a rack holding utensils above the preparation table and obtained a scoop by grabbing the food contact surface of the utensil instead of the handle. DC-M then served loose meat onto the buns with the utensil. Observation on 8/30/23 at 11:50 AM Dietary Aide (DA-N) was observed cooking grilled cheese sandwiches for the lunch meal. DA-N was wearing a hair net, but a large portion of DA-N's bangs were hanging out around DA-N's face. As DA-N was cooking the grilled cheese, DA-N was observed brushing the hair off DA-N's face using a gloved hand several times. When finished cooking, DA-N placed the grilled cheese onto the steam table and removed gloves. No hand hygiene was observed. Observation on 8/30/23 at 11:55 AM DA-N was standing near the preparation table waiting for the cook to start serving the lunch meal. DA-N pulled a phone out of their pocket and was observed scrolling on phone. DA-N was also observed touching their face and brushing hair off their face. No hand hygiene was observed prior to obtaining plates to deliver to the residents. Observation on 8/30/23 at 11:57 AM DC-M performed hand hygiene and put on a clean pair of gloves. DC-M touched the notebook where resident's orders were written down with gloved hands. Wearing the same gloves, DC-M turned to obtain a pair of tongs off the utensil rack above the preparation table and grabbed onto the tongs by the food contact surface of the tongs, not by the handle. DC-M used the tongs to serve grilled cheese. Interview on 8/31/23 at 9:25 AM with the Certified Dietary Manager (CDM) confirmed that staff should wear all their hair in the hair net. Further interview confirmed that the serving scoops and tongs should not be handled by the food contact surface of the tongs, but by the handle and hand hygiene should be completed when touching contaminated surfaces and after the removal of gloves.

Licensure Reference Number 175 NAC 12-006.04A1 Based on record review and interview, the facility failed to ensure 3 nurse aides (NA-F, NA-P, and NA-Q) were certified through the Nebraska board of nursing prior to working with residents. The sample size was 13. The facility census was 41. Findings are: A. Review of the facility's job description for a Certified Nursing Assistant (CNA) revealed nurse aides were required to be certified through the Nebraska board of nursing within 120 days of being hired. B. Review of a hand written document provided by the Director of Nurses (DON), revealed NA-F worked in the facility as a nurse aide on the following dates: -August 2022 (5th, 6th, 8th, 12th, 17th, 23rd, 25th, 26th, 29th, and 31st); -September 2022 (1st, 9th, 10th, 12th, 15th, 22nd, 26th, 28th, and 29th); -October 2022 (4th, 6th, 13th, 14th, 20th, 22nd, 26th, and 27th); -November 2022 (5th, 6th, 15th, and 18th); -December 4, 2022; and -January 2023 (16th, 19th, 20th and 27th) Further review of hand written documents provided by the DON, revealed NA-P and NA-Q worked as nurse aides on the following dates: -NA-P worked in the facility on 2/23/23 and -NA-Q worked in the facility on 4/21/22, 8/4/22, 8/9/22, 8/10/22, 8/25/22, 8/28/22, 9/9/22 and 10/10/22. C. An interview with the DON on 8/31/23 at 1:30 PM confirmed NA-F worked in the facility as a nurse aide on the following dates and did not have the required certification throught the State board of nursing: -August 2022 (5th, 6th, 8th, 12th, 17th, 23rd, 25th, 26th, 29th, and 31st); -September 2022 (1st, 9th, 10th, 12th, 15th, 22nd, 26th, 28th, and 29th); -October 2022 (4th, 6th, 13th, 14th, 20th, 22nd, 26th, and 27th); -November 2022 (5th, 6th, 15th, and 18th); -December 4, 2022; and -January 2023 (16th, 19th, 20th and 27th). The DON also confirmed 2 additional nurse aides (NA-P and NA-Q) had worked in the facility and did not have the required certification through the State board of nursing: -NA-Q worked in the facility on 4/21/22, 8/4/22, 8/9/22, 8/10/22, 8/25/22, 8/28/22, 9/9/22 and 10/10/22; and -NA-P worked in the facility on 2/23/23.

Licensure Reference Number 175 NAC 12-006.04A3b Based on record review and interview; the facility failed to assure background checks were completed through the State Nurse Aide (NA) registry for 2 (NA-S and NA-T) of 5 employees. The sample size was 13. The facility census was 41. Findings are: A. Review of the facility policy Abuse and Neglect with a revised date of 1/2023 revealed the following: -The facility will screen employees and volunteers prior to working with residents. -Screening will include verification of references, certification, license and background checks. -Before new employees are permitted to work with residents, references provided by the employee will be verified as well as appropriate board registrations and certifications regarding the prospective employee's background. -The facility will not employ or otherwise engage an individual who has a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. B. Review of 5 employee files on 8/31/23 revealed the following: -Nursing Assistant (NA)-S was hired on 5/30/23 and NA-T was hired on 8/4/23 and there was no evidence background checks through the State nurse aide registry were completed prior to their hired dates. C. An interview with the administrator on 8/31/23 at 2:45 PM confirmed there was no evidence NA-S and NA-T had background checks completed through the State nurse aide registry prior to their hired dates.

Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to submit investigations to the State agency within 5 working days related to potential misappropriation of money for Resident 9. The sample size was 13. The facility census was 41. Findings are: A. Review of the facility policy Abuse and Neglect with a revised date of 1/2023 revealed the following: -Reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. -The investigation is the process used to try to determine what happened and will begin immediately. -The administrator or designee will make an initial report to the State agency immediately or within 24 hours and a follow up investigation will be submitted within 5 days. B. Review of Resident 9's nursing progress notes revealed the following: -on 5/22/23 at 11:32 AM the resident reported [gender] was missing $10 and an investigation was started; -on 5/25/23 at 5:10 PM the social worker verified the resident's family had given [gender] $10 recently; and -on 5/26/23 at 1:35 PM the resident had $7 in [gender] possession and staff were not able to locate the remainder of the money. C. Review of the facility's investigation reports revealed an investigation was submitted to the state agency on 5/31/23, 6 working days after Resident 9's money was reported missing. An interview with the Director of Nurses (DON) on 8/31/23 at 1:15 PM confirmed the following: -reports of potential misappropriation of personal property should be investigated immediately and a report submitted to the State agency within 5 working days; -Resident 9 reported missing $10 on 5/22/23; and -the investigation was submitted to the State agency on 5/31/23, 6 working days later.

Licensure Reference Number NAC 12-006.17 Based on record review and interview, the facility failed to prevent the potential spread of COVID-19 related to testing symptomatic residents for residents 22 and 30. The sample size was 13 and the facility census was 41. Findings are: A. Review of the facility policy Covid Testing Policy with an origination date of 9/23 revealed the Infection Preventionist (IP) and staff should be aware of any unexplained signs and symptoms of respiratory illness. Nursing staff were to test residents for respiratory illness if the following are present and new: -fever or chills, -cough, -shortness of breath or difficulty breathing, -fatigue, -muscle or body aches, -headache, -new loss of taste or smell, -sore throat, -congestion or running nose, -nausea or vomiting, and -diarrhea. B. Review of Resident 22's Minimum Data Set (MDS- a federally mandated comprehensive assessment used in the development of resident care plans) dated 8/21/23 revealed the following: -had diagnoses of Alzheimer's Disease and dementia, -the resident received extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene and received total assistance with eating, and -the resident was not able to make needs known but could comprehend most conversation. Review of Resident 22's Care Plan revealed the following: -the resident needed extensive to total assistance of 1 with personal hygiene, dressing, and transfers, -the resident was nonverbal and cognitively impaired, and -the resident needed assistance with meals and was on a pureed diet with honey thick liquids. Review of Resident 22's Progress Notes revealed the following: -on 8/23/23 at 6:38 PM the resident was noted to have an ineffective congested cough. The resident was given a nebulizer (an apparatus that produces a fine mist through a mask, used for respiratory treatments) treatment and some improvement in cough was noted, -on 8/28/23 at 4:40 AM the resident had a hacky, ineffective cough. The resident was given a nebulized treatment and the lung sounds were diminished. The resident had a temperature of 98.2 and oxygen saturation was 95% (normal is 90-100), -on 8/28/23 at 11:41 AM the resident's physician saw the resident on rounds and ordered a chest x-ray and a complete blood count (CBC) for a wet cough, -on 8/29/23 at 1:17 PM the resident had a congested, weak, and ineffective cough. A nebulizer treatment was given with minimal improvement. Oxygen saturation was at 93%, and -on 8/31/23 at 1:34 AM the resident had a weak, ineffective cough. A nebulizer treatment was given with good relief. Oxygen saturation was 95%. The resident's lung sounds were decreased. A review of the resident's Covid rapid test history revealed the last time the resident had been tested for Covid was 3/27/23. A review of the Physician Dictation from the physician visit on 8/28/23 revealed the CBC and the chest X-ray were unremarkable (no abnormal findings) and the facility would follow the Covid Protocol for testing. The history of physical illness reported that the resident had somewhat of a wet cough that nursing noticed had gotten worse over the last couple of days. An interview with Medication Aide (MA-A) on 8/31/23 at 9:00 AM revealed the cough was new, the resident had the cough for a few days, but sounded worse. An interview with the Director of Nursing (DON) on 8/31/23 at 10:40 AM confirmed the resident had not been tested for Covid-19 since symptoms started on 8/23/23. Further interview confirmed the facility only tested resident's for Covid-19 when the physician ordered a test to be completed. 42360 C. Review of Resident 30's Progress Notes revealed the following; -on 6/12/23 the resident had a runny nose and was sneezing, the resident's physician was notified and no new orders were given, -on 6/13/23 the resident was noted to have a cough, nasal congestion, and congested lung sounds with wheezing. The physician was notified and ordered a chest x-ray. There was no evidence the facility tested the resident for COVID-19. Review of the Resident 30's COVID-19 testing log dated 6/16/23 (4 days after symptoms first appeared) revealed a negative COVID -19 test. D. During an interview on 8/31/23 at 9:44 AM the Director of Nursing (DON) confirmed that on 6/12/23 and 6/13/23 when Resident 30 presented with respiratory illness symptoms the resident was not tested for COVID-19. In addition, the facility only tests for COVID-19 when the physician orders testing. The facility should notify the physician when a resident presents with respiratory illness to get an order for COVID-19 testing.

Based on interview and record review; the facility failed to review and revise the Facility Assessment as needed to assure the facility had the resources to meet the needs of the residents. The sample size was 18 and the facility census was 36. Findings are: Review of the Facility Assessment received from the facility on 06/02/22 revealed a revision date of 7/10/19. During an interview on 06/02/22 at 1:54 PM, the Interim Director of Nursing (DON) confirmed there was no policy available regarding the Facility Assessment and further confirmed the Facility Assessment should have been updated and/or revised as needed or at least annually.

Licensure Reference Number 175 NAC 12-006.12E1 Based on observation, record review and interview, the facility failed to assure medications were secure. The sample size was 18 and the facility census was 36. Findings are: Review of the facility policy Drug Handling Guidelines dated 3/2021 revealed the following; -the facility established procedures for storing and disposing of drugs and biologicals in accordance with state and local laws, and -all drugs and biologicals would be stored in locked compartments and only authorized personnel responsible for administration of drugs would have access. Observation on 6/7/22 at 8:20 AM of the medication cart revealed the following; Registered Nurse (RN)-P was observed walking away from the medication cart located in the common hallway just outside of the dining room to administer medication. The medication cart remained unlocked, and RN-P proceeded to the opposite side of the dining room and sat next to a resident to administer medication. RN-P remained on the opposite side of the dining room and out of sight of the medication cart for 5 minutes during which time 4 residents walked past the unlocked medication cart. An Interview on 6/7/22 at 10:30 AM with the Director of Nursing (DON) confirmed the medication cart should be locked at all times when not attended.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 (8) Based on interview and record review, the facility failed to submit reports of falls with significant injuries to the State Agency within the required time frame. This affected 1 (Resident 86) out of 4 residents investigated for accidents during the survey process. The facility identified a census of 36. Findings are: Review of the facility Patient/Resident Abuse and Neglect policy with a review date of 4/2022 revealed when there was reason to suspect or believe abuse had occurred or an allegation had been made or conditions were present that could result in abuse, investigating and reporting was to take place as follows: - immediately take steps to protect the individual, - notify the administration, - begin an internal investigation, - immediately report to Adult Protective Services (APS), - conduct an internal investigation, and - submit a completed investigation to the State Agency within 5 working days. Review of Resident 86's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 4/18/22 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The following was assessed regarding Resident 86: -cognition was intact, -no behaviors, -independent with transfers, bed mobility, dressing, toilet use, walking in the resident's room and in the corridors, -continent of bowel and bladder, and -1 fall without injury and 1 fall with injury (except major) since the previous assessment. Review of a Nursing Note dated 3/9/22 at 7:57 PM, revealed the resident was found seated upright on the floor of the resident's room at 5:50 PM. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The note further indicated APS was notified of the resident's fall with injury at 6:40 PM. Review of the facility investigations of potential abuse and neglect from 3/9/22 through 3/17/22 revealed no evidence an investigation was sent to the State Agency within 5 working days of Resident 86's fall with injury on 3/9/22 at 5:50 PM. Review of a Nurse's Note dated 5/22/22 at 9:23 PM revealed the resident was found on the floor next to the recliner in the resident's room at 6:25 PM. The resident had complaints of pain to the resident's left hip. The resident was transferred to the emergency room for an x-ray and found to have a left hip fracture. Review of a Nurse's Note dated 5/22/22 at 7:27 PM revealed APS was notified of the resident's fall with hip fracture at 7:05 PM. Review of facility investigations from 5/22/22 through 5/27/22 revealed no evidence an investigation was sent to the State Agency within 5 working days of the resident's fall with injury on 5/22/22 at 6:25 PM. Interview with the interim Director of Nursing (DON) on 6/7/22 at 9:08 AM confirmed the resident's fall with injury on 3/9/22 at 5:50 PM and the resident's fall on 5/22/22 at 6:25 PM with fractured hip were reported to APS and investigated as potential abuse/neglect however, the results of the investigations were not submitted within the required time frame to the State Agency.

Licensure Reference Number: 175 NAC 12-006.09D7 Based on observations, record reviews and interviews; the facility failed to ensure interventions were developed and/or revised to prevent ongoing falls with resulting injuries for one (Resident 86) of 18 sampled residents. The facility indicated a census of 36. Findings are: Review of Resident 86's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 4/18/22 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The following was assessed regarding Resident 86: -cognition was intact, -no behaviors, -independent with transfers, bed mobility, dressing, toilet use, walking in the resident's room and in the corridors, -continent of bowel and bladder, and -1 fall without injury and 1 fall with injury (except major) since the previous assessment. Review of the resident's current Care Plan with revision date 7/15/21 revealed the resident was at risk for falls related to a history of falls. The following interventions were identified: -to always use walker as designated by physical therapy, -noted to ambulate without the walker and directed to use the walker, -10/22/21 educated regarding safety and use of the walker after a fall, -03/09/22 witnessed fall in the resident's room. Resident struck head and sustained a laceration to the resident's upper, outer right eye. The resident was educated to walk slower and to concentrate on walking, -03/30/22 witnessed fall in the corridor while walking, and -05/22/22 fall in room, laying next to chair. During observations on 6/6/22 at 8:18 AM, 8:58 AM, 10:52 AM and at 2:23 PM the resident was lying in bed in the resident's room. The resident was in a high/low bed and the bed was in the lowered position. In addition, the resident had an alarmed fall mat on the floor to the left side of the resident's bed. The right side of the resident's bed was against the wall. Further review of the care plan revealed no new interventions were developed or current interventions revised after the residents falls on 3/30/22 and 5/22/22. Furthermore, the care plan did not identify the use of a high/low bed or an alarmed floor mat next to the resident's bed. Interview with the interim Director of Nursing (DON) on 6/7/22 at 9:08 AM confirmed Resident 86's care plan was not updated regarding interventions related to the resident's ongoing falls.

Licensure Reference Number: 175 NAC 12-006.09D7 Based on observations, record reviews and interviews; the facility failed to ensure interventions were developed and/or revised to prevent ongoing falls with resulting injuries for one (Resident 86) of 4 sampled residents. The facility indicated a census of 36. Findings are: Review of Resident 86's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 4/18/22 revealed diagnoses of [CONDITION(S)], high blood pressure and dementia. The following was assessed regarding Resident 86: -cognition was intact, -no behaviors, -independent with transfers, bed mobility, dressing, toilet use, walking in the resident's room and in the corridors, -continent of bowel and bladder, and -1 fall without injury and 1 fall with injury (except major) since the previous assessment. Review of the resident's current Care Plan with revision date 7/15/21 revealed the resident was at risk for falls related to a history of falls. The following interventions were identified: -to always use walker as designated by physical therapy, -noted to ambulate without the walker and directed to use the walker, and -10/22/21 educated regarding safety and use of the walker after a fall. Review of a Nursing Note dated 3/9/22 at 7:57 PM, revealed the resident was found seated upright on the floor of the resident's room. The resident sustained a laceration to the upper, outer right eyebrow and voiced complaint of wrist pain. Review of the resident's current Care Plan revealed an intervention dated 3/9/22 to educate the resident regarding safe use of the walker, to walk slower and to concentrate on walking (the same intervention as listed after the resident's fall on 10/22/21). Review of Resident 86's Nursing Notes revealed the following: -3/10/22 at 12:22 PM the resident was seen by the practitioner and a splint was placed on the resident's left wrist for comfort. -3/17/22 at 11:30 AM the resident received a new order for physical therapy due to knee pain and weakness. -3/22/22 at 2:34 PM the resident was started on physical therapy 3/21/22 (12 days after the resident's fall on 3/9/22) to improve safety awareness and decrease risk for falls. -3/30/22 at 5:12 PM the resident was found on the floor across from the public restroom with the walker in front of the resident. The resident was reminded to slow down and to focus on walking. Review of an Incident Report dated 3/30/22 at 5:45 PM revealed an order was received 3/31/22 to obtain blood pressures to check the resident for [CONDITION(S)] (a form of low blood pressure that happens when standing after sitting or lying and can increase risk for falls) for 3 days and then send results to the physician. Review of a Nurse's Note dated 4/6/22 at 1:28 PM revealed Resident 86's blood pressure readings were reviewed by the physician with no new orders. Review of the resident's medical record revealed no additional interventions were identified and/or current fall interventions revised to prevent further falls. Review of Nursing Notes for Resident 86 revealed the following: -5/9/22 at 6:26 PM the resident walked to the Nurse's Station without the walker. -5/22/22 at 9:23 PM the resident was found on the floor next to the recliner in the resident's room at 6:25 PM. The resident had complaints of pain to the resident's left hip. The resident was transferred to the emergency room for an x-ray and found to have a left hip fracture. -5/31/22 at 9:43 PM the resident was readmitted to the Nursing Home. Staff were to reposition the resident every 2 hours. Hospice evaluated the resident with a decision not to place the resident on Hospice at this time. -6/1/22 at 6:33 AM the resident was confused with complaints of pain. Interview on 6/2/22 at 10:18 AM with Nurse Aide (NA)-A revealed the resident was at high risk for falls with a recent hip fracture. NA-A indicated prior to the resident's fall on 5/22/22 at 6:25 PM, interventions were in place for the resident's bed to be in the lowered position and for an alarmed fall mat on the floor next to the resident's bed. NA-A had not worked with the resident since readmitted from the hospital and had not received any report of additional fall interventions to prevent further falls and potential injuries for Resident 86. Review of Nurse's Notes revealed the following: -6/2/22 at 3:21 PM the resident was re-evaluated and then admitted to Hospice due to a decline in status. -6/5/22 at 4:50 AM the resident was confused and calling out for help. The resident was found to have wedged the right side of body between the mattress and the positioning rail and the resident's right foot and leg were between the bed and the wall. -6/5/22 at 6:00 PM the resident was confused and calling out for help and was found slid down in the bed with the resident's head resting against the positioning rail on the right side of the bed. During observations on 6/6/22 at 8:18 AM, 8:58 AM, 10:52 AM and at 2:23 PM the resident was lying in bed in the resident's room. The resident's bed was in the lowered position and the resident had an alarmed fall mat on the floor to the left side of the resident's bed. The right side of the resident's bed was against the wall. Interview with the interim Director of Nursing (DON) on 6/7/22 at 9:08 AM confirmed the following: -Resident 86 had a fall on 3/9/22 at 7:57 PM. The resident was re-educated regarding safe use of the walker. This was the same intervention used for the resident after a fall on 10/22/21. Due to continued complaints of pain to the resident's back and knees after the fall, the resident was started on physical therapy on 3/21/22, 12 days after the resident's fall. -the resident had a subsequent fall on 3/30/22 at 5:12 PM. An intervention was identified with education regarding safe transfers and ambulation as identified after the resident's 2 previous falls. The facility did monitor the resident for potential [CONDITION(S)] with no findings and no additional interventions. -the resident had a fall on 5/22/22 at 9:23 PM and fractured the resident's left hip. No new interventions were developed and/or current interventions revised to prevent further falls.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(9) Based on record review and interview; the facility failed to ensure interventions were in place to protect residents from potential verbal and/or physical abuse for 4 (Residents 1, 2, 3 and 4) of 4 sampled residents. The facility census was 38. Findings are: A. Review of the facility policy titled Patient/Resident Abuse and Neglect (revision date 3/21) revealed all employees were responsible to protect and prevent abuse from occurring. If abuse or neglect was suspected, staff were to immediately [MEDICATION(S)] to ensure the safety of the residents. The following steps were identified: -notify the Charge Nurse who would assess the situation and then notify the Director of Nursing (DON) and the Administrator; -an Incident Report was to be completed which would include the name of the staff member involved related to the alleged abuse, the date of the incident, what occurred and if it was witnessed; -an investigation was to be conducted by the Administrator or the DON; and -any staff suspected of abuse was to be suspended from work until the facility investigation was completed. If the allegation of abuse was substantiated, the employee was to be discharged and the appropriate agency or licensing board notified. B. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 12/27/21 revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The following was identified during the assessment period: -severe cognitive impairment; -required extensive staff assistance with transfers, bed mobility, dressing, personal hygiene and toilet use; -incontinent of bowel and bladder; and -received a scheduled pain medication regimen. Review of Resident 1's current Care Plan (revised 12/22/21) revealed the resident required extensive assistance with activities of daily living which included transfers, bed mobility, dressing, personal hygiene and toilet use. The resident used a mechanical sit-to-stand lift (a mobile lift that allows for patient transfers from a seated position to a standing position. This lift is designed to support only the upper body of the resident and requires the resident to have some weight-bearing capability) for transfers and the resident had increased pain due to arthritis. Review of a facility investigation dated 1/11/22 revealed on 1/2/22 at 11:55 AM, Resident 1 was seated in a wheelchair and Medication Aide (MA)-G was witnessed shaking the resident's chair which caused the resident to scream. The report further revealed the episode was witnessed by Nursing Assistant (NA)-E. NA-E reported MA-G had stated at the time, It is funny to make them scream. Review of facility video footage confirmed MA-G shook Resident 1's wheelchair while the resident was seated in the chair and then kicked at the back wheel of the chair. Review of a facility schedule for the Nursing Department for January 2022 revealed MA-G was scheduled and provided direct resident cares on 1/2/22, 1/5/22 and on 1/6/22. During an interview on 1/24/22 at 10:45 AM, NA-E verified the observation on 1/2/22 of MA-G shaking Resident 1's wheelchair and then kicking at the chair. In addition, MA-G had told NA-E it was fun to make them scream and to piss them off in regards to MA-G's actions with Resident 1's wheelchair. NA-E confirmed the following: -NA-E sent the interim DON a text message on 1/2/22 regarding concerns about MA-G's treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -NA-E did not inform the Charge Nurse on 1/2/22 regarding abuse concerns related to Resident 1 and MA-G; -MA-G remained at work and provided Resident 1 assistance with direct cares on 1/2/22; and -NA-E sent an email to the interim DON on 1/3/22 regarding the potential abuse allegation. During an interview with the interim DON on 1/24/22 at 1:30 PM the following was identified; -received an email from NA-E on 1/3/22 regarding an abuse allegation which had occurred on 1/2/22 involving MA-G and Resident 1; -1/5/22 video footage was reviewed regarding the incident with MA-G and Resident 1 and the abuse allegation was substantiated; -MA-G was placed on suspension on 1/6/22 (4 days after the alleged allegation of abuse was identified) at 12:00 PM; and -no further abuse and/or neglect training had been provided to the staff to protect residents from further potential abuse. C. Review of Resident 4's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The following was assessed regarding Resident 4: -cognitively intact; -required extensive staff assistance with bed mobility, transfers, dressing toilet use and personal hygiene; -frequently incontinent of urine; and -had frequent pain the resident rated at a 7 out of 10 in severity. During an interview on 1/24/22 at 10:45 AM, NA-E reported responding to Resident 4's call light on 1/2/22. Resident 4 had been tearful and indicated MA-G was mean to the resident. The resident stated MA-G had answered the resident's call light earlier and when the resident indicated a need to use the bathroom, MA-G had turned off the resident's call light, told the resident they would have to wait and then exited the resident's room. NA-E assisted the resident to the bathroom and Resident 4 was incontinent of urine. NA-E confirmed the incident was not reported to the Charge Nurse or to the interim DON. During an interview on 1/24/22 at 11:15 AM, Resident 4 confirmed the following: -1/2/22 after the breakfast meal, the resident had returned to the resident's room in a wheelchair. The resident had needed to use the bathroom and had turned on the call light; -MA-G had answered the call light after it had been on for several minutes. MA-G turned off the light, told the resident they would have to wait their turn and then exited Resident 4's room; -after several minutes, Resident 4 turned the call light back on. The call light was answered by a different staff member but by then, the resident was incontinent and in tears; and -Resident 4 had gone out to the Nurse's station in the past and reported MA-G was mean and liked to be the boss but nothing ever got done about it. There was no evidence any investigation was completed regarding Resident 4's concerns regarding treatment by MA-G or that interventions were put into place to prevent the potential for further abuse and/or neglect. D. Review of Resident 2's MDS dated [DATE] revealed the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment revealed the following regarding the resident: -cognition was intact; -required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene; and -incontinent of bladder. Review of Resident 2's nursing progress note dated 12/22/21 at 11:01 AM, revealed the resident's family member expressed concerns related to the cares provided to the resident and wanted to make a formal complaint. The resident also reported an unidentified staff member would not take care of [gender] when the call light was turned on. The staff member would answer the call light, ask what the resident needed, walk away and pass off the care to another staff member. In addition the resident indicated the staff member was not gentle when doing the resident's care. Review of Resident 2's nursing progress note dated 1/14/22 at 9:30 AM, revealed someone from Adult Protective Services was there and spoke with the resident related to a report of a certain staff member being rough with the resident during cares. During an interview with Resident 2 from 9:20 AM to 9:30 AM, the resident indicated having to sometimes wait a long time for staff to respond to the call light and was often incontinent of urine by the time they arrived. In addition, the resident believed a certain staff member (whom the resident did not want to identify by name) was rough when the resident was being transferred in and out of the bed or chair and when being repositioned. The resident stated [gender] told the staff member who was rough I'm not a cow. There was no evidence any investigation was completed regarding Resident 2's concerns regarding treatment by an unidentified staff member or that interventions were put into place to prevent the potential for further abuse and/or neglect. E. Review of Resident 3's MDS dated [DATE], revealed the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment revealed the following regarding the resident: -cognition was intact; -required extensive assistance with bed mobility, dressing, toileting, and personal hygiene and full assistance with transfers; -received oxygen therapy; and -incontinent of bladder. During an interview with Resident 3 on 1/24/22 at 10:45 AM, the resident stated MA-G was rude and liked to aggravate [gender] and would make noises .do crazy dances .wiggled [gender] butt and banged it into the bed. The resident also indicated these behaviors were upsetting and asked MA-G to stop, but [gender] would keep going. The resident reported MA-G to the DON and stated, it got better for a little while but then went back. Review of an undated document related to Resident 3's concerns regarding MA-G's mistreatment toward the resident revealed the following: -The DON received an email from MA-E on 1/3/22 that reported MA-G and another staff member called the resident a 'RAT' to the resident's face and said 'snitches get stitches' and laughed. -The DON interviewed Resident 3 on 1/5/22 (2 days after MA-E reported the concern) and the resident said MA-G frustrated [gender] by singing songs and wiggles [gender] butt. The resident also indicated the behaviors aggravated [gender] and when told to stop, MA-G ignored the resident. -MA-G was placed on suspension at approximately 1200 on 1/6/22 (3 days after MA-E reported the concern). There was no evidence an investigation was completed in a timely manner related to Resident 3's concerns regarding treatment by MA-G or that interventions were put into place to prevent the potential for further abuse and/or neglect.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview; the facility failed to complete an investigation and then to submit the investigation within the required time frame, allegations of potential abuse and/or neglect for 3 (Residents 2, 3 and 4) of 4 sampled residents. The facility census was 38. Findings are: A. Review of the facility policy titled Patient/Resident Abuse and Neglect (revision date 3/21) revealed all employees were responsible to protect and prevent abuse from occurring. If abuse or neglect was suspected, staff were to immediately [MEDICATION(S)] to ensure the safety of the residents. The following steps were identified: -notify the Charge Nurse who would assess the situation and then notify the Director of Nursing (DON) and the Administrator; -an Incident Report was to be completed which would include the name of the staff member involved related to the alleged abuse, the date of the incident, what occurred and if it was witnessed; -an investigation was to be conducted by the Administrator or the DON; and -the completed investigation was to be sent to the State Agency within 5 working days from the allegation. B. Review of Resident 4's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/8/21 revealed the resident was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The following was assessed regarding Resident 4: -cognitively intact; -required extensive staff assistance with bed mobility, transfers, dressing, toilet use and personal hygiene; -frequently incontinent of urine; and -had frequent pain the resident rated at a 7 out of 10 in severity. During an interview on 1/24/22 at 10:45 AM, Nursing Assistant (NA)-E reported responding to Resident 4's call light on 1/2/22. Resident 4 had been tearful and indicated Medication Aide (MA)-G was mean to the resident. The resident stated MA-G had answered the resident's call light earlier and when the resident indicated a need to use the bathroom, MA-G had turned off the resident's call light, told the resident they would have to wait and then exited the resident's room. NA-E assisted the resident to the bathroom and Resident 4 was incontinent of urine. NA-E confirmed the incident was not reported to the Charge Nurse or to the interim DON. During an interview on 1/24/22 at 11:15 AM, Resident 4 confirmed the following: -1/2/22 after the breakfast meal, the resident had returned to the resident's room in a wheelchair. The resident had needed to use the bathroom and had turned on the call light; -MA-G had answered the call light after it had been on for several minutes. MA-G turned off the light, told the resident they would have to wait their turn and then exited Resident 4's room; -after several minutes, Resident 4 turned the call light back on. The call light was answered by a different staff member but by then the resident was incontinent and in tears; and -Resident 4 had gone out to the Nurse's station in the past and reported MA-G was mean and liked to be the boss but nothing ever got done about it. There was no evidence any investigation was completed and reported to the State Agency regarding Resident 4's concerns regarding treatment by MA-G. During an interview on 1/24/22 at 1:30 PM, the interim DON verified no investigation was completed and then sent to the State Agency regarding Resident 4's allegation of potential abuse by MA-G. C. Review of Resident 2's MDS dated [DATE] revealed the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment revealed the following regarding the resident: -cognition was intact; -required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene; and -incontinent of bladder. Review of Resident 2's nursing progress note dated 12/22/21 at 11:01 AM, revealed the resident's family member expressed concerns related to the cares provided to the resident and wanted to make a formal complaint. The resident also reported an unidentified staff member would not take care of [gender] when the call light was turned on. The staff member would answer the call light, ask what the resident needed, walk away and pass off the care to another staff member. In addition the resident indicated the staff member was not gentle when doing the resident's care. Review of Resident 2's nursing progress note dated 1/14/22 at 9:30 AM, revealed someone from Adult Protective Services was there and spoke with the resident related to a report of a certain staff member being rough with the resident during cares. During an interview with Resident 2 on 1/24/22 from 9:20 AM to 9:30 AM, the resident indicated having to sometimes wait a long time for staff to respond to the call light and was incontinent of urine by the time they arrived. In addition, the resident believed a certain staff member (whom the resident did not want to identify by name) was rough when the resident was being transferred in and out of the bed or chair and when being repositioned. The resident stated [gender] told the staff member who was rough I'm not a cow. There was no evidence any investigation was completed and reported to the State Agency regarding Resident 2's concerns regarding treatment by a staff member. During an interview on 1/24/22 at 1:30 PM, the interim DON verified no investigation was completed and then sent to the State Agency regarding Resident 2's allegation of potential abuse by a staff member. D. Review of Resident 3's MDS dated [DATE], revealed the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment revealed the following regarding the resident: -cognition was intact; -required extensive assistance with bed mobility, dressing, toileting, and personal hygiene and full assistance with transfers; -received oxygen therapy; and -incontinent of bladder. During an interview with Resident 3 on 1/24/22 at 10:45 AM, the resident stated MA-G was rude and liked to aggravate [gender] and would make noises .do crazy dances .wiggled [gender] butt and banged it into the bed. The resident also indicated these behaviors were upsetting and asked MA-G to stop, but [gender] would keep going. The resident reported MA-G to the DON and stated, it got better for a little while but then went back. Review of an undated document related to Resident 3's concerns regarding MA-G's mistreatment toward the resident revealed the following: -The DON received an email from MA-E on 1/3/22 that reported MA-G and another staff member called the resident a 'RAT' to the resident's face and said 'snitches get stitches' and laughed. -The DON interviewed Resident 3 on 1/5/22 (2 days after MA-E reported the concern) and the resident said MA-G frustrated [gender] by singing songs and wiggles [gender] butt. The resident also indicated the behaviors aggravated [gender] and when told to stop, MA-G ignored the resident. -MA-G was placed on suspension at approximately 1200 on 1/6/22 (3 days after MA-E reported the concern). There was no evidence any investigation was completed and reported to the State Agency regarding Resident 3's concerns regarding treatment by MA-G. During an interview on 1/24/22 at 1:30 PM, the interim DON verified no investigation was completed and then sent to the State Agency regarding Resident 3's allegation of potential abuse by MA-G.

Licensure Reference Number 175 NAC 12-006.09D7 Based on observation, interview and record review, the facility staff failed to 1) utilize a mechanical lift (a device used to transfer a person from one area to another) in a manner to prevent potential injury for 3 Residents (Resident 2, 5 and 6) and 2) failed to position 1 resident (Resident 2) in a wheel chair in a manner to prevent potential injury. The sample size was 6 and the facility census was 38. Findings are: A. Review of Resident 2's MDS (Minimum Data Set - a federally mandated comprehensive assessment tool used for care planning) dated 12/20/21 revealed the resident was admitted on [DATE] with diagnoses of Cardiovascular Accident (stroke), Depression, and [CONDITION(S)] (inflammation of bone or bone marrow, usually due to infection). The assessment revealed the following regarding the resident: -cognition was intact; -required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene; -range of motion to both lower legs was impaired; and -incontinent of bladder. Review of Resident 2's undated plan of care revealed the resident needed extensive assistance with ADL's (Activities of Daily Living) and staff were to use the full body lift for all transfers. The resident was also at risk for skin breakdown related to incontinence and immobility. Review of a facility incident report dated 10/4/21 revealed the following regarding Resident 2: -at 10:00 AM, MA-A transferred the resident with a mechanical lift; -the resident was lowered into the chair and the leg got scraped on the lift; and -the resident got an abrasion to the leg that measured 0.5 CM (centimeters) by 0.5 CM and required a bandaid. During an interview with Resident 2 on 1/24/22 from 9:20 AM to 9:30 AM, the resident indicated a certain staff member (whom the resident did not want to identify by name) was rough when the resident was being transferred in and out of the bed or chair and when being repositioned. An observation of Resident 2 on 1/24/22 at 11:45 AM, revealed the following: -MA-A and MA-B transferred the resident from the recliner to the wheel chair using a full body mechanical lift; -MA-A then placed the resident's feet on the footrest of the wheel chair and the resident was not wearing shoes; -the resident had difficulty bending the left knee and the left foot slid off the front of the foot rest; -MA-A covered the resident with a blanket, gave the resident the call light, then proceeded to exit the room; and -the resident's left foot remained positioned in front of the foot rest and was pushed against the back of the foot/ankle area. During an interview with MA-A on 1/24/22 at 11:55 AM, MA-A confirmed Resident 2 should have had shoes on and the resident's left foot was not positioned properly on the wheelchair foot rest. In addition, MA-A verified the resident was at risk for skin breakdown and could have developed a pressure sore from the resident's left foot pressing against the front of the foot rest. B. Review of Resident 5's MDS dated [DATE] revealed the resident was admitted on [DATE] with a diagnosis of Alzheimer's Disease and GERD (Gastroesophageal Reflux Disease). The assessment revealed the following regarding the resident: -cognition was severely impaired; -required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene; and -incontinent of bowel and bladder. An observation of Resident 5 on 1/24/21 from 11:05 AM to 11:15 AM revealed the following: -MA-A transferred the resident to the bathroom using the sit/stand mechanical lift; -MA-A completed toileting and hygiene cares with the resident; -MA-A then raised the resident to a standing position in the sit/stand mechanical lift; -Resident 5 held onto the handles with both hands and [gender] elbows were partially bent outward past the sides of the mechanical lift; and -the resident was moved through the doorway of the bathroom and the right elbow bumped the door frame. C. Review of Resident 6's MDS dated [DATE] revealed the resident was admitted on [DATE] with a diagnosis of dementia. The assessment revealed the resident required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene and was incontinent of bladder. An observation of Resident 6 on 1/24/21 from 11:17 AM to 11:27 AM revealed the following: -MA-A transferred the resident from the wheelchair to the bathroom using the sit/stand mechanical lift; -the resident held onto the handles with both hands and the elbows were bent outward slightly past the sides of the mechanical lift; -MA-A positioned the resident over the toilet, removed the clothing and lowered the resident onto the toilet; -the resident's right elbow got stuck on top of the hand rail attached to the wall, while [gender] hands remained gripped onto the mechanical lift handles that were positioned several inches below the hand rail and the resident grimaced; -MA-A commented about the resident's right elbow being stuck on top of the hand rail, then assisted the resident to move [gender] right elbow off the hand rail. D. An interview with MA-A on 1/24/21 at 11:27 AM confirmed MA-A should have positioned Residents 5 and 6 in a manner to prevent potential injury; when Resident 5 bumped [gender] elbow on the door frame and when Resident 6's right elbow got stuck on top of the hand rail when lowered onto the toilet.

Licensure Reference Number 175 NAC 12-006.11E Based on observations and interviews, the facility failed to ensure cookware was maintained in a safe manner to prevent possible foodborne illness. This had the potential to impact all residents of the facility. The facility census was 41. Findings are: An observation on 3/29/21 at 10:50 AM during a follow up tour of the kitchen with the Dietary Manager (DM)-K, revealed frying pans that had a non-stick coating on the inside were peeling and had a rust color on them. During an interview with DM-K on 3/29/21 at 10:50 AM, DM-K confirmed the frying pans had been used to prepare food and the pans should have been removed from service and replaced.