Every finding on record at Brookestone of Papillion

Licensure reference: 175 NAC 12-007.01(A) Based on observation, interview, and record review, the facility failed to ensure handling of food to prevent potential cross contamination and failed to ensure food in snack refrigerators was not expired. This had the potential to affect all 96 residents of the facility. Findings are:A.Observations on 7/7/26 between 12:26 PM-12:31 PM in the satellite kitchen revealed Dietary Aide B wearing gloves to take individual butter and cream cheese packets out of a container in the refrigerator and putting the packets onto a plate to serve to a resident in the dining room. Dietary Aide B then picked up a turkey slice, and an egg roll off the steam table and placed them on a plate for service to residents with Dietary Aide B's hands while wearing the same pair of gloves. Dietary Aide B then handled the plastic bread bags to obtain a English muffin, placed the English muffin in the toaster, removed the English Muffin and buttered the English muffin with Dietary Aide B's hands while wearing the same pair of plastic gloves. In an interview on 7/7/26 between 12:26-12:31 PM, the Dietary Director confirmed that tongs should be used when dishing food. In an interview on 7/9/26 at 9:00 AM, the Administrator reported that the facility does not have policies and procedures regarding safe food handling and uses CMS guidelines. A review of the 2022 United States Food and Drug Administration Food Code revealed the following: - If used single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. B.Observations on 7/9/26 between 9:24-9:40 AM of the Life Enrichment refrigerator revealed the following food was being stored in the refrigerator:-Juicy Juice with expiration date of 5/27/25 and no resident name.-Sweet and Sour sauce with no date.-Olive Garden dressing, 3 bottles, with expiration date of 5/1/26.-Ketchup bottle with no name or date.-Marquerite mix bottle with no name and expiration date of 2/12/26. In an interview on 7/9/26 between 9:24-9:40 AM, the Life Enrichment Coordinator and the Dietary Director confirmed that the items were not dated, labeled or had passed the expiration date. Observations on 7/9/25 between 9:24-9:40 AM revealed a sign on door of refrigerator that stated the following: -Staff: When putting food in this fridge it needs: name of resident, room number, date-Fridge cleaned weekly-If it isn't dated-thrown out-If it's older than a week-thrown out Observations on 7/9/26 between 9:24-9:40 AM also revealed a sign that stated Fridge Checked and Food Discarded if: Food not labeled with date of opening; 3 days past from opening date. The sign included a grid with day and month that refrigerator was checked. The sign was initialed by staff to indicate that the refrigerator had last been checked on 7/4. The sign did not include a year In an interview on 7/9/26 between 9:24-9:40 AM, the Life Enrichment Coordinator reported that the refrigerator included a combination of resident food and food used for staff events. The Life Enrichment Coordinator confirmed that follow up was need on the food being stored in the refrigerator. C.Observations of the snack refrigerator located at the nurses' station between the 300 and 400 hallway on 7/9/26 at 9:53 AM revealed the following outdated food items:-Oikos yogurt container with expiration date of 3/7/26.-Chobani yogurt container with expiration date of 5/3/26.-Noosa yogurt container with expiration date of 7/5/26.-Chobani yogurt container with expiration date of 5/18/26.-Chobani yogurt container with expiration date of 4/26/26.-Activia yogurt 4 pack with expiration date of 6/3/26.-Chobani yogurt with expiration date of 4/4/26.-Raw beverage with expiration date of 9/5/25. In an interview on 7/9/26 at 9:53 AM, the Dietary Director and the Administrator confirmed the expiration dates of food items from the 300-400 hallway nurses' station refrigerator. In an interview on 7/9/26 at 9:53 AM, the Administrator reported the refrigerator is monitored by the nurses and there is no policy related to monitoring of the refrigerator. The Administrator reported that food in the refrigerator had been stocked by the kitchen. D.A review of undated policy titled Visitor Food revealed the following:- Food stored for residents need to be labeled dated and stored safely in designated area per facility policy following the food safety guidelines for personal food.

License Reference Number 175 NAC 12-006.18 Based on observation, records review and interview, the facility failed to ensure that a catheter bag was dated and maintained in a manner to prevent potential cross contamination for resident 68, failed to change and date oxygen tubing for resident 23, failed to complete hand hygiene prior to completing cares, between glove changes during cares and transportation of soiled linens in a barrier through the hallway while providing care for resident 108, failed to ensure scissors were clean prior to dressing change for resident 66, failed to ensure PPE was utilized for resident 13 and 39, and failed to prevent potential cross contamination during wound care for resident 9. The facility identified a census of 96.Findings are:Review of a facility policy dated 4-12-24 revealed the following Policy: It is the policy of VSL ([NAME] Senior Living) to implement EBP (Enhanced Barrier Protection) to help prevent the transmission of multi-drug-resistant Organisms (MDRO). Personal Protective Equipment (PPE) for EBP is only necessary when performing high-contact care activities in resident rooms, therapy gyms, and spa rooms. High contact resident care activities include: Dressing Bathing Transferring Providing hygiene Changing linens Changing briefs or assisting with toileting Device care or use: central lines including PICC lines, urinary catheters, feeding tubes, tracheostomy tubes. Wound care for above mentioned wounds (skin tears are not included in chronic wounds) A. Record review of Resident 9's admission minimum data set (MDS, a federally mandated comprehensive assessment tool used to determine a residents functional capabilities and helps nursing home staff identify health problems) dated 3/18/26 identified the facility admitted the resident on 3/12/26 with the following diagnosis: atrial fibrillation (a sustained heart arrythmia), anemia, hypertension, hemorrhagic (bleeding) disorder, lymphedema (swelling) with a brief interview of mental status (BIMS, screening that aids in detecting cognitive impairment) of 15/15 indicating intact cognition. Record review of Resident 9's Treatment Administration Record (TAR) dated July 2026 revealed and order for Wound Care-Right buttock wound wash area with wound cleanser, apply Santyl (a prescription ointment used to remove dead tissue from wounds) nickel thick to wound, cover with bordered foam dressing, change daily, every day shift. Further review of the TAR revealed an order for wound care-right/left buttock cleanse with wound cleanser-apply combination compound cream **Do not apply combination cream to right buttock open area** every day shift Observation of wound care for Resident 9 on 7/7/26 at 10:25 AM revealed Registered Nurse (RN) A entered the residents room, donned (put on) a gown, performed hand hygiene, donned gloves, removed dressing to right buttock, cleansed wounds on buttocks, removed gloves, performed hand hygiene, donned clean pair of gloves, removed the medicated cream (Santyl) from the manufacturer's box and applied the cream to a clean cotton tipped applicator, placed the medicated cream tube back in the manufacturer's box and sat it on the barrier on the table. RN A applied the cream on the right buttock wound, placed foam bordered dressing to wound. RN A then used the same glove to remove the compound cream from a jar and place around the foam dressing on the right buttock and on the left buttock wound. In an interview with RN A on 7/7/26 at 10:40 AM it was confirmed the gloves were contaminated after handling the Santyl tube and box. B. Review of sign posted on Resident 39's door during the survey dates of 7/6/26 thru 7/9/2026 revealed the following: Stop- Enhanced Barrier Precautions-Stop Everyone must clean their hands, including entering and leaving the room Providers and Staff must also Wear gloves and a gown for the following High Contact Resident Care Activities Dressing Bathing/Showering Transferring Changing Linens Providing Hygiene Changing briefs or assisting with toileting Device care or use: central line, urinary catheter, feeding tube, tracheostomy Wound Care: any skin opening requiring a dressing Do not wear the same gown and gloves for the care of more than one person Record review of Resident 39's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a residents functional capabilities and helps nursing home staff identify health problems) dated 5/28/2026 identified the facility admitted the resident on 11/19/2025 with the following diagnosis: cancer, hypertension, neurogenic bladder (nerve damage that causes overactive or underactive bladder activity- typically causing urine to be retained in the bladder), obstructive uropathy with an indwelling foley catheter, further review of the MDS revealed Resident 39 had a Brief Interview of Mental Status (BIMS, screening that aids in detecting cognitive impairment) of 14/15 indicating intact cognition. Observation of Registered Nurse (RN) A on 7/7/26 at 3:10 PM revealed RN A entered Resident 39's room and did not put on a gown prior to performing foley catheter cares. In an interview with RN A on 7/7/26 at 3:25 PM it was confirmed they had not donned a gown before performing catheter cares and should have. C. Record Review of the facility's undated Hand Hygiene Competency revealed the following: When to wash hands: After touching a resident or handling their belongings After contact with any bodily fluids After handling contaminated items (Linens/garbage/briefs, etc.) Before and after gloving Record Review of the facility's Hand Hygiene policy dated 9/15/2025 revealed the following: An alcohol based hand rub is appropriate for decontaminating the hands; Before direct patient contact, putting on gloves, or inserting an invasive device When moving from a contaminated body site to a clean body site during patient care after contact with a patient or with body fluids, excretions, mucous membranes, nonintact skin, or wound dressings (if hands aren't visibly soiled) after contact with inanimate objects in the patients environment after removing gloves An observation on 07/08/2026 at 7:20 AM revealed Nurse Aide (NA)-E entered Resident 108's room. NA-E put on gloves, did not perform hand hygiene (HH), grabbed non-slip socks and applied to the residents' feet. NA-E assisted the resident to stand, had the resident turn to the toilet, removed brief and discarded the brief in the trash. NA-E removed gloves, performed HH then put new gloves on. NA-E got the resident's cell phone and handed it to the resident. NA-E taped brief around the resident legs, placed gait belt on the resident, assisted the resident to a standing position. NA-E did not complete HH or change gloves. NA-E then obtained a wipe, wiped the resident, folded the wipe, wiped the resident and discarded the wipe. NA-E obtained a new wipe, wiped the resident, folded the wipe, wiped the resident and discarded the wipe. NA-E obtained a new wipe, wiped the resident, folded the wipe, wiped the resident again and discarded the wipe. NA-E did not complete HH or change gloves. NA-E pulled up the resident's brief and pants and assisted the resident back to the wheelchair, assisted resident to sit back in wheelchair, buttoned the resident's pants, then pushed the resident up to the sink. NA-E removed gloves, did not complete HH, put on new gloves, rinsed the resident's partials (dentures) and assisted the resident to put the resident's teeth (dentures) in the resident's mouth. NA-E removed gloves, did not complete HH, assisted the resident to reach the soap to wash their hands. NA-E put a new glove on, did not complete HH, handed the resident soap. NA-E removed the glove, did not complete HH, brushed the resident's hair, obtained the resident's wig and assisted the resident with applying the wig and obtained the resident's glasses. NA-E handed the resident's cell phone and pushed the resident to the breakfast table. NA-E went back to the resident's room put on gloves, did not complete HH, removed trash. NA-E dumped the urine catcher hat in the toilet, flushed the toilet, removed gloves and did not complete HH. NA-E removed trash at bedside and removed the slip sheet from the residents bed. NA-E held the slip sheet against NA-E clothes and tossed it on the floor. NA-E continued to make the resident's bed. NA-E picked up the bags of trash and the slip sheet, held slip sheet against NA-E's body, not in a bag. Took trash and dirty slip sheet to the buckets at the end of the hall. NA-E took dirty dishes to the dish area, went to the other side of the kitchen, applied hair net, did not complete HH, grabbed milk from the refrigerator and poured the resident a glass of milk. NA-E obtained a straw and took the milk to the resident. NA-E did not complete HH, opened the straw and placed the straw in the resident's milk. In an interview on 07/08/2026 at 7:56 AM, NA-E confirmed that HH was not completed when entering resident's room prior to donning gloves and should have. NA-E confirmed no HH after assisting resident off the toilet and inserting partials and should have. NA-E confirmed no HH or glove change prior to completing peri care and should have. NA-E confirmed that the slip sheet against NA-E body and should not have. NA-E confirmed no HH after discarding the soiled linens and trash prior to getting the resident milk and should have. D. Record Review of Resident 68's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 5/29/2026 revealed the facility staff assessed the following about the resident: -admitted to the facility on [DATE] -Brief Interview of Mental Status (BIMS) was scored as a 15. According to the MDS Manual a score of 13-15 indicates a person is cognitively intact. -had diagnosis of Neurogenic bladder, hydronephrosis (swelling of one or both kidneys caused by a backup of urine) with ureteropelvic junction obstruction (blockage where the kidney meets the ureter-the tube draining urine to the bladder), hyperplasia (swelling of an organ or tissue) with lower urinary tract symptoms. Record Review of Resident 68's Order Summary dated 7/6/2026 revealed to change and date bacteriostatic bags (urinary drainage system or bag), every night shift every 4 weeks on Sunday starting 3/30/2025. An observation on 07/06/2026 at 10:53 AM revealed Resident 68 had an overnight catheter bag hanging over the grab bar in the bathroom, over the trash can, not dated or in a barrier bag. An observation on 07/07/2026 at 12:00 PM revealed Resident 68 had an overnight catheter bag hanging over the grab bar in the bathroom not dated or in a barrier bag. In an interview 07/07/2026 at 12:00 PM Register Nurse (RN)-F confirmed that Resident 68 overnight catheter bag was not dated or in a barrier bag and should be. In an interview on 07/07/2026 at 1:13 PM, Administrator confirmed that the administrator could not find a policy that pertains to catheter bag storage and that the facility would follow the urologist order. E. Record Review of Resident 23's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 6/22/2026 revealed the facility staff assessed the following about the resident: -admitted to the facility on [DATE] -Brief Interview of Mental Status (BIMS) was scored as a 15. According to the MDS Manual a score of 13-15 indicates a person is cognitively intact. -had diagnosis of pneumonia, asthma, chronic obstructive pulmonary disease or chronic lung disease, and respiratory failure Record Review of Resident 23's Order Summary dated 7/6/2026 revealed that resident had an order for oxygen via nasal cannula continuously every shift. Record Review of Resident 23's Order Summary dated 7/6/2026 did not reveal an order to change oxygen tubing. An observation on 07/06/2026 at 1:39 PM revealed that Resident 23's oxygen tubing is not dated. An observation on 07/07/2026 at 11:23 AM revealed that Resident 23's oxygen tubing is not dated. In an interview on 07/07/2026 at 11:47 AM, License Practical Nurse (LPN)-G confirmed that oxygen tubing was not dated and should have been. In an interview on 07/07/2026 at 1:12 PM, Administrator confirmed that the administrator could not find a policy that pertains to oxygen and they would follow the provider order. F. A review of Resident 13's admission Record revealed Resident 13 was admitted to the facility on [DATE] with a diagnosis of unspecified severe protein-calorie malnutrition. Observations on 7/6/26 at 8:27 AM revealed Resident 13's room door had sign that indicated Resident 13 was on enhanced barrier precautions. Observations on 7/7/26 at 6:39 AM revealed Resident 13's tube feeding alarm sounding. Registered Nurse D entered room without donning a gown and attempted to clear the warning. Registered Nurse D disconnected the water flush, added water to the bag, primed the water flush disconnected the tube feeding, checked for placement of tube and residual, and reconnected the tube feeding. In an interview on 7/7/26 at 9:33 AM, Registered Nurse D confirmed Registered Nurse D had not worn a gown when providing cares to Resident 13 at 6:39 AM. A review of undated Enhanced Barrier Precaution sign on Resident 13's door revealed a gown is to be worn when providing care to a feeding tube. G. Record review of a facility document entitled Clean Dressing Competency dated active 2026 revealed the following information related to dressing changes : - Open dressing supplies onto a clean field, including several clean gloves. If scissors are used, they are to be cleaned with alcohol wipe before and after use. Record review of Resident 66's Medicare 5-day MDS dated [DATE] revealed that Resident 66 was admitted to the facility on [DATE] with a diagnosis of perforation of the intestine (nontraumatic). The MDS revealed that Resident 66 had a BIMS score of 12 which indicated moderate cognitive impairment, required substantial to maximum assistance with activities of daily living and had a surgical wound. Record review of Resident 66's Physician Order dated 6/26/2026 revealed the following order: - Abdominal wound: Wet to dry Dressing twice daily. D/C treatment when resolved. every day and evening shift for Abdominal wound Observation on 07/07/2026 between 9:15 AM and 9:40 AM revealed RN-H entered Resident 66's room and gathered supplies for the treatment to a surgical wound to the abdomen. After the cleansing of the abdominal wound, RN-H removed the soiled gloves, took a scissors from the pocket on [gender] uniform and proceeded to cut the package to the clean dressing open and cut the dressing to fit over the wound. With clean gloves in place, RN-H folded the dressing, wet the dressing with normal saline and placed the dressing over the wound. RN-H removed the gloves, took a pen from [gender] pocket, dated and initialed a boardered dressing. RN-H applied hand sanitizer, donned clean gloves and placed the bordered dressing over the wet dressing to cover the surgical wound. Interview on 07/07/2026 at 9:41 AM with RN-H confirmed that the RN had not cleansed the scissors with an alcohol wipe prior to or after it's use and that the pocket would be considered dirty. Interview on 07/07/2026 at 10:42 AM with the Director of Nursing confirmed that the scissors should have been cleaned with an alcohol wipe prior to and after use during a dressing change for Resident 66.

License Reference Number 175 NAC St 71 -6022(2)Based on record review and interview the facility failed to provide written notice 30 days prior to discharge for 1 (resident 101) of 1 sample resident, facility staff failed to convey information in writing to the resident and family representative of reason for transfer for 2 (Resident 102 and 53) of 2 sample residents, failed to provide a bed hold policy including payment for 3 (Residents 13, 102 and 53) of 3 sample resident and failed to convey reason and status of resident to the receiving facility for 1 (Resident 102) of 1 sample resident. The facility staff identified a census of 96. Findings are: Record review of the facility admission Packet revealed: III. Termination, transfer, and Discharge B. Involuntary Transfer- The facility may terminate this Agreement and your right to stay at the Facility and transfer or discharge you if: 1. The transfer or discharge is necessary to meet your welfare, and your needs cannot be met at the Facility; 2. Your health has improved sufficiently so that you no longer need the services provided by the Facility; 3. The safety or health of individuals in the facility is or otherwise would be in danger; 4. For charges who are financially able to pay or to have paid on your behalf under the applicable Medicare or Medicaid programs charges for your care and stay at the facility; and 5. The facility ceases to operate. The Facility will notify you and any responsible person (or if none, a family member or legal representative if known to the Facility) at least thirty (30) days in advance of transfer or discharge. However, in any case described in subparagraph 1-2 or 3 above, or if you have not resided in the Facility for at least 30 days, the Facility will give you only such notice before transfers or discharge as is practicable under the circumstances. Written notice of such discharge shall specify the reason for the proposed transfer or discharge, the effective date of the proposed transfer or discharge, and the location to which you will be transferred to or discharge. The written notice shall also notify you of your right to appeal the transfer or discharge decision and provide you with the names and phone numbers of agencies available to furnish you with legal or other assistance. A copy of the notice will also be sent to the representative of the office of the State Long-Term Care Ombudsman. Record Review of the facility's undated Notice of Bed hold policy revealed the following: When a resident requires hospitalization or therapeutic leave, we advise the resident and the family of our bed hold policy in writing. We give this notice in advance when we have notice of the leave. When possible, we provide this notice to the family within 24 hours of an emergency transfer. We notify the residents by including this notice with other papers that accompany the resident to the hospital in an emergency. Record Review of the facility's undated Guidelines for Transfer of Resident to Emergency Department revealed the following: Assess resident condition and vital signs Check code status and rehospitalization wish of resident Intervene for residents' safety and comfort (O2, pain medication, etc.) Call family and PCP to report resident VS and condition Obtain order from PCP for ED assessment Notify family of condition, reason for transfer and inform them of bed hold policy (Provide physical copy if they are present) May send to ED per resident or family request without order, or if situation is emergent and cannot wait for an order. Call nurse leadership on call and inform them of transfer out if resident is unstable call 911 for transport If resident is stable may arrange transport Complete e-interact transfer for and print to send. Provide resident with a copy of the bed hold policy paperwork for hospital to be sent with emergency personal 2 copies of admission record (face sheet), 1 for squad, 1 for hospital 2 copies of code status sheet, 1 for squad, 1 for hospital; e-interact transfer form (UDA) order summary Bed hold policy Call ED of receiving hospital and give report Post transfer documentation Progress note for transfer should include: Notification of PCP and family with names Name of hospital Condition of resident/reason for transfer Full set of vital signs Any interventions prior to transfer What documents were sent to the hospital Including bed hold, resident transfer record, face sheet, code status, order summary Call in of report and name of ED nurse receiving report Complete bed hold evaluation UDA A. Record review of the Electronic Medical Record revealed Resident 101 was admitted to the facility on [DATE] with a diagnosis of hemiplegia and hemiparesis following cerebral infarction, type II diabetes mellitus with diabetic polyneuropathy, morbid obesity due to excess calories, cerebral aneurysm, non-ruptured, anemia unspecified, other mixed anxiety disorder. Record review of a progress note dated 7/16/25 at 5:16 PM revealed a Certified Nursing Aide (C.N.A.) reported to Resident 101 had stated 'I am going to kill my roommate', the C.N.A. told the resident that was not ok to say things like that and the resident stated Then I'll just kill myself! I'm going to write a note to management and tell them this is what happens when you don't do anything. The administrator was notified. Adult Protective Services and the police were notified by the administrator. Record review of the Investigation report written on 7/21/25 revealed the C.N.A.'s who witnessed the incident reported Resident 101 had commented (gender) had a horrible day because (gender) roommate was rude to the nurse that day. The C.N.A. apologized for (gender) having a bad day and the resident claimed they wanted to kill (gender). The C.N.A. told the resident they cannot say things like that, and (gender) proceeded to say they would just kill themselves then. Further review of the investigation form revealed the police interviewed Resident 101 and the roommate and determined Resident 101 was not an immediate threat to the roommate. 1:1 supervision continued throughout the remainder of the 7/1625 and into 7/17/25. At that time nursing leadership reviewed the situation and the determination of the police and removed the 1:1 monitoring. Resident 101 was moved to another room where (gender) will not have a roommate, and a 30-day discharge notice was issued to Resident 101due to statements of threatening to kill their roommate/being a danger to others and the facility not having a private room that can be provided to (gender). Record review of Resident 101's progress notes revealed the facilities former administrator notified Resident 101's Guardian on 7/16/25 at 7:38 PM verbally of the possibility of a 30-day discharge due to an incident on the same day with Resident 101's roommate. Record review of a progress note written by the former administrator on 7/17/25 at 3:35 PM revealed Resident 101 and the Guardian were told the facility would be looking for other placement for Resident 101. Record review of an undated facility form titled Nursing Facility Transfer or Discharge Notice revealed Resident 101 was being Transferred /discharged on 8/6/25. Further review of the form revealed the reason for transfer or discharge was for -The safety of the individuals in the facility is endangered due to the clinical behavior status of the resident. Record review of a progress note written by the former administrator on 8/4/25 at 2:24 PM revealed the Discharge notice was sent via certified mail to the son/guardian and ombudsman and the letter was given to Resident 101. Record review of a progress note on 8/6/25 at 1:49 PM revealed Resident 101 was discharged to another facility at approximately 10:18 AM- 44 hours after the letter was sent to the guardian and 20 days after the guardian was verbally told of the involuntary discharge. In an interview with the former administrator on 7/9/26 at 8:04 AM it was revealed that the former administrator informed the son of the 30-day notice verbally on 7/17/25, but did not inform him of the right to appeal if they did not agree with the decision. B. Record review of Resident 53's electronic health record did not reveal a social service discharge, user defined assessment (UDA) was completed, notifying the resident and resident representative of reason for transfer on 5/7/2026 for Resident 53. Record review of Resident 102's electronic health record did not reveal a social service discharge, user defined assessment (UDA) was completed, notifying the resident and resident representative of reason for transfer on 12/27/2025 for Resident 102. In an interview on 07/09/2026 at 7:27 AM, Administrator confirmed that the facility did not have a transfer policy. In an interview on 07/09/2026 at 7:33 AM, Administrator confirmed that the discharge process was not being completed correctly. In an interview on 07/09/2026 at 12:14 PM, Administrator confirmed that there was no social service discharge, user defined assessment (UDA) for Resident 53 on 5/7/2026 or for Resident 102 on 12/27/2025. C. Record review of Resident 53 electronic health record did not reveal that a bed hold policy including charges was conveyed to the resident and/or resident representative at the time of transfer for Resident 53 on 5/7/2026. Record review of Resident 102 electronic health record did not reveal that a bed hold policy including charges was conveyed to the resident and/or resident representative at the time of transfer for Resident 102 on 12/27/2025. In an interview on 07/07/2026 at 11:49 AM, Administrator confirmed there was no bed hold or transfer form seen in Resident 53's electronic health record for the transfer on 5/7/2026. In an interview on 07/09/2026 at 7:27 AM, Administrator confirmed that the facility did not have a transfer policy. In an interview on 07/09/2026 at 7:33 AM, Administrator confirmed that the discharge process was not being completed correctly. In an interview on 07/09/2026 at 12:14 PM, Administrator confirmed there was no bed hold or transfer form found in Resident 102's electronic health record for the transfer on 12/27/2025. D. Record review of Resident 102's electronic health record did not reveal that information regarding the residents' status and reason for transfer was conveyed to the receiving facility for Resident 102's transfer on 12/27/2025. In an interview on 07/09/2026 at 7:27 AM, Administrator confirmed that the facility did not have a transfer policy. In an interview on 07/09/2026 at 7:33 AM, Administrator confirmed that the discharge process was not being completed correctly. In an interview on 07/09/2026 at 7:38 AM, Director of Nursing (DON) confirmed that there was no evidence that information regarding the residents' status and reason for transfer was conveyed to the receiving facility for Resident 102's transfer on 12/27/2025. E. A review of Resident 13's admission Record revealed Resident 13 was admitted to the facility on [DATE] with a diagnosis of unspecified severe protein-calorie malnutrition. A review of Resident 13's eInteract Transfer Form dated 6/10/26 revealed Resident 13 was transferred to the hospital for abdominal pain on 6/9/26. The eInteract Transfer Form did not include any documentation regarding the bed hold policy. A review of Resident 13's Progress Note dated 6/9/26 revealed Resident 13 requested to go to the hospital with complaints of abdominal pain. Resident 13's daughter was aware of transfer. The notes did not include any information about the bed hold policy being provided to Resident 13 or Resident 13's family. A review of Resident 13's eInteract Transfer Form dated 6/17/26 revealed Resident 13 was transferred to the hospital for gastrostomy tube malfunction [a medical device inserted through the abdomen to deliver nutrition, fluid and medications directly into the stomach] on 6/15/26. The eInteract Transfer Form did not include any documentation regarding the bed hold policy. A review of Resident 13's Progress Notes dated 6/15/26 revealed nurse practitioner was notified of malfunctioning gastrostomy tube lumen with order received to send to emergency department with Resident 13's daughter being notified. The notes did not include any information about the bed hold policy being provided to Resident 13 or Resident 13's family. In an interview on 7/8/26 at 1:50 PM, Social Worker C reported that Social Worker C will contact resident's representative regarding bed hold when made aware of transfer and leaves a copy of the Social Services Discharge Plan with bed hold information in the resident's room or mails to the representative. Social Worker C confirmed that Social Worker C had not completed the Discharge Plan form for Resident 13's hospital transfers on 6/15/26 and 6/9/26. In an interview on 7/9/26 at 7:28 AM, the Administrator confirmed there was issues with notification of bed hold.

License Reference Number 175 NAC 12-006.09 (I) Based on record review and interviews, the facility failed to implement interventions to prevent injury for 1 (Resident 102) of 1 sample resident. The facility staff identified a census of 96. Findings are:Record Review of the facility's undated Fall Prevention/Management Standard document revealed the following: Implement interventions based on individual needs identified to include comprehensive review of resident risk factors (e.g, diagnosis, ADL status, cognition, mobility impairments, fall history. Record Review of Resident 102's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 12/30/2025 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE]-Brief Interview of Mental Status (BIMS) was scored as a 10. According to the MDS Manual a score of 8-12 indicates a person has moderate cognitive impairment.-Resident was partial/moderate assistance from staff with sit to lying and lying to sitting.-Resident was substantial/maximum assistance from staff with oral hygiene, toilet hygiene, upper and lower body dressing, putting on and taking off footwear, personal hygiene, sitting to stand, chair to bed transfer and toilet transfer. -Walking had not been attempted.-had diagnosis of non-Alzheimer's dementia, Parkinson's, other lack of coordination and essential tremor Record Review of the facility's unwitnessed fall documentation dated 12/16/2025 revealed that Resident 102 fell attempting to walk to the bathroom without residents' walker. Intervention was for staff to check on resident at 6:00 AM daily to ask if the resident needs to use the restroom. Resident was alert and oriented times 3. Record Review of the facility's unwitnessed fall documentation dated 12/18/2025 revealed that Resident 102 fell while ambulating to the bathroom without assistance and that the resident was getting ready for a bath. Resident had a golf ball size raised area on the residents posterior right head resident was complaining of pain in resident's back and head. On-call provider notified and ordered the resident be sent to the ED (Emergency Department). No intervention noted on the form. Resident last BIMS was 14. Indicating cognitively intact. The resident often self-transfer despite staff reminding the resident to ask for assistance due to safety needs. Resident continues to exercise right to self-transfer, goal at this time is to prevent major injury resulting from a fall. The resident is alert and oriented times 2. Record Review of the facility's unwitnessed fall documentation dated 12/23/2025 revealed that Resident 102 was found on the floor in front of the recliner facing the bathroom. The resident was unable to tell staff what happened. The resident was educated to utilize (gender) call light and ask for staff assistance, signage posted in has been placed in the residents' room, the resident has been referred to physical and occupation therapy as needed. Medications reviewed, bowel and bladder diary reviewed, staff to round per standards. Goal is to prevent any major injury. The resident is alert and oriented times 2. Record Review of the facility's unwitnessed fall documentation dated 12/27/2025 revealed that resident was found lying on the floor next to the recliner on the residents left side with a blanket under the residents' head. Resident said the resident bent down on one knee to pick up a shoe and lost balance and went on the residents' side. No intervention noted in the report. The resident is alert and oriented times 2. In an interview on 7/8/2026 at 9:19 AM, Assistant Director of Nursing (ADON) confirmed that every fall incident report should have an immediate intervention all falls do not have an immediate intervention. In an interview on 7/8/2026 at 9:20 AM, ADON confirmed that the intervention on 12/18/2025 and 12/23/205 should not have been the same intervention and was.

Licensure reference Number 12-006.05Based on record review and interview the facility failed to ensure evidence was in place to support discharge due to being a danger to other residents for 1 (Resident 101) of 1 sampled resident. The facility identified a census of 96.Findings are:Record review of the Electronic Medical Record (EMR) of Resident 101 revealed the resident was admitted to the facility on [DATE] with a diagnosis of hemiplegia (paralysis of one entire side) and hemiparesis (weakness or inability to move on one entire side of the body) following cerebral infarction (stroke), type II diabetes mellitus with diabetic polyneuropathy (disease of the peripheral nerves typically causing numbness and tingling), morbid obesity due to excess calories, cerebral aneurysm, non-ruptured, anemia unspecified, other mixed anxiety disorder.Record review of a Progress Note dated 7/16/25 at 5:16 PM revealed a Certified Nursing Aide (C.N.A.) reported that Resident 101 had stated 'I am going to kill my roommate', the C.N.A. told the resident that it was not ok to say things like that and the resident stated Then I'll just kill myself! I'm going to write a note to management and tell them this is what happens when you don't do anything. The administrator was notified. Adult Protective Services and the police were notified by the administrator.Record review of Resident 101's Progress Notes revealed that the facility's former administrator notified Resident 101's guardian on 7/16/25 verbally of the possibility of a 30-day discharge due to an incident on the same day with the roommate. The guardian was also notified that the resident would have a 1:1 sitter (a person designated to watch a resident continuously) overnight to ensure the safety of Resident 101 and the roommate. Record review of the Investigation Report written on 7/21/25 revealed the C.N.A.'s who witnessed the incident reported that Resident 101 had commented (gender) had a horrible day because (gender) roommate was rude to the nurse that day. The C.N.A. apologized for (gender) having a bad day and Resident 101 claimed (gender) wanted to kill (gender) [roommate]. The C.N.A. told Resident 101 [gender] cannot say things like that, and Resident 101 proceeded to say [gender] would just kill [gender] then. Further review of the investigation form revealed that the police interviewed Resident 101 and the roommate and determined Resident 101 was not an immediate threat to the roommate. 1:1 supervision continued throughout the remainder of 7/16/25 and into 7/17/25. At that time nursing leadership reviewed the situation and the determination of the police and removed the 1:1 monitoring. Resident 101 was moved to another room where [gender] will not have a roommate, and a 30-day discharge notice was issued to Resident 101 due to statements of threatening to kill the roommate/being a danger to others and the facility not having a private room that can be provided to [gender]. Record review of an undated facility form titled Nursing Facility Transfer or Discharge Notice revealed Resident 101 was being transferred /discharged on 8/6/25. Further review of the document revealed the reason for transfer or discharge was The safety of the individuals in the facility is endangered due to the clinical behavior status of the resident.In an interview with the former administrator on 7/9/26 at 8:04 AM it was revealed that Resident 101 was placed with a 1:1 sitter the night of 7/16/25 and then was placed in a private room on 7/17/25. The former administrator revealed that Resident 101 was able to move about the building freely in (gender) wheelchair to go to the dining room and activities from the day after the incident on 7/17/25 until discharge on [DATE] - a period of 20 days. It was revealed that the facility did frequent checks on the resident with no explanation to how often frequent was and a confirmation there was no documentation of the checks being done.Record review of the progress notes from 7/16/25 to 8/6/25 revealed no other incidents of Resident 101 making statements of wanting to harm self or others.Record review of a Physician Visit/Communication Form completed by a former social worker dated 8/4/2025 revealed orders to discharge Resident 101 on 8/6/26 on current medications and treatments. The communication did not include the reason for the discharge or provide documentation of evidence the resident was a danger to (themselves) or other residents.Record review of the EMR from 7/16/25 to 8/6/25 revealed no documentation by a physician that Resident 101 was a danger to self or others.Record review of a progress note on 8/6/25 at 1:49 PM revealed Resident 101 was discharged to another facility at approximately 10:18 AM. The facility was given the opportunity to provide additional information prior to exit on 7/9/26 and none was provided.

License Reference Number 175 NAC 12-006.05(B) Based on record review and interviews the facility staff failed to ensure that Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) was completed for 1 (Resident 62) of 3 sampled residents. The facility staff identified a census of 96. Findings are:Record Review of Resident 62's Skilled Nursing Facility Advanced Beneficiary Notice of Non- coverage (SNFABN) signed by Resident 62's Power of Attorney (POA) on 4/15/2026. Resident 62 remained in the facility. The occupational therapy box was marked which indicated that the resident had received the care, but Medicare may not pay for the services. There was no option selected to determine if the POA or Resident 62 wanted to continue with the cares listed. In an interview on 07/08/2026 at 2:10 PM Social Service Coordinator (SSC) confirmed that there was not a document with a checked selection to continue care. In an interview on 07/08/2026 at 2:14 PM SSC confirmed that one of the boxes should be checked. In an interview on 07/08/2026 at 2:22 PM Administrator (Admin) confirmed that the facility does not have a policy for SNFABN and that the forms are self-explanatory.

Licensure Reference Number 175 NAC 12.006.09(H)(iii)(2) Based on observation, interview, and record review; the facility failed to follow practitioner's orders for wound care for 2 (Residents 2 and 3) of 4 residents sampled. The facility census was 92. The findings are: A. Record review of Resident 2's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 10-05-2024 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) score of 15. According to the MDS Manual a score of 13 to 15 indicate a person is cognitively intact. -had abdominal hernia surgery, -had a surgical wound, -was receiving surgical wound treatments. Record review of Resident 2's Electronic Health Record (EHR) revealed an order for a wet to dry dressing (a wound dressing that is applied wet and allowed to dry before removal) to abdominal wound daily. An observation of wound care was conducted on 11-19-2024 at 12:15 PM of the facility Wound Nurse (WN) performing a wet to dry dressing change for Resident 2. WN lifted Resident 2's shirt to reveal a transparent dressing covering a gauze dressing dated 11-18-2024. WN removed the transparent dressing and then removed the gauze dressing that was inside the wound bed. The gauze dressing was a dull yellow color. During the wound care observation on 11-19-2024 at 12:15 PM an interview was conducted with the WN, which revealed the gauze removed from the wound bed was moist and not dry. An interview with WN on 11-19-2024 at 12:45 PM confirmed the practitioner's orders were for a wet to dry dressing to the abdomen. Furthermore, WN confirmed the transparent dressing did not allow the gauze to dry, therefore was not a wet to dry dressing. B. Record review of Resident 3's MDS dated [DATE] revealed the facility staff assessed the following about the resident: -BIMS score of 15 indicating a person is cognitively intact, -required maximal assistance with personal hygiene, bed mobility, and lower body dressing, -required total assistance with transfers, -had a fracture, -had a surgical wound. Record review of Resident 3's Medication Administration Record (MAR) printed on 11-19-2024 revealed an order for treatment to the left pelvis as follows: Left pelvis: cleanse with facility cleanser, pat dry, apply xeroform to slough area (cut to fit size of area), cover with an Abdominal (ABD) dressing and secure with paper tape. Change daily and as needed for surgical site. Record review of an evaluation of the wound conducted by a Nurse Practitioner dated 10-29-2024 revealed an order for the left pelvis as follows: -Wash with facility wound cleanser, pat dry. -Paint periwound (skin around the wound) with skin prep and allow to dry. -Cover with ABD and or gauze pads for drainage and secure with tape. -Change daily and as needed. Record review of the facility policy Non-Pressure Skin Conditions revealed once a non-pressure skin change has been identified ongoing monitoring, treatment, and a documentation plan will be initiated. The treatment plan related to non-pressure skin changes will be specific for each individual resident as directed by the practitioner and documented on the resident's treatment sheet. An interview with Nurse Supervisor (NS) on 11-19-2024 at 3:00 PM confirmed the step in the wound treatment, Paint periwound with skin prep and allow to dry was not on the MAR and staff wound not have known to do it. The NS further confirmed the omission was a transcription error.

Licensure Reference Number 175 NAC 12.006.09(I) Based on observation, interview, and record review, the facility staff failed to ensure interventions were implemented to prevent hot liquid burns for 2 (Residents 1 and 2) of 3 sampled residents that had been identified as at risk for injury from hot liquids to prevent potential accidents. The facility census was 89. Findings are: A record review of the facility's Hot Liquid Management Guidelines dated 03/2016 revealed hot liquids could increase a resident's risk of injury if hot liquids are not maintained within point of service temperature. Coffee, tea, and hot chocolate are commonly served at 160-180 degrees Fahrenheit (F). This temperature can cause instantaneous burns. A 3rd degree burn can happen at 155 degrees F in 1 second. Identify a resident at high risk and reduce temperature, communicate as needed, use adaptive equipment/clothing as necessary, and update the care plan. Residents with hot liquids should not be left unsupervised. A record review of the facility's Hot Liquid Risk Management training assigned to the facility staff following Resident 1's hot liquid accident on 08/11/2024 revealed coffee, hot tea, hot cocoa, soup, gravy and sauces and liquid with vegetables are liquids that create a burn risk. Skin contact time for a 3rd degree burn to occur in 1 second if the hot liquid temperature was 156 degrees F, 2 seconds if the hot liquid temperature was 149 degrees F, 5 seconds if the hot liquid temperature was 140 degrees F, and 15 seconds if the hot liquid temperature was 133 degrees F. A record review of the facility's Enrollments & (and) Completions with multiple dates revealed 1 of 13 dietary staff and 14 of 107 nursing staff had completed the Hot Liquid Risk Management training. It did not reveal that Culinary Assistant (CA)-A or CA-B completed the education. A. A record review of Resident 1's Clinical Census dated 09/04/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 1's Medical Diagnosis dated 09/04/2024 revealed the resident had diagnoses of Transient Cerebral Ischemic Attack (a medical emergency that occurred when blood flow to the brain was interrupted), Syncope and Collapse (passed out), Other Lack Of Coordination, Muscle Weakness, History Of Falling, and Dysphagia (trouble swallowing). A record review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment used to develop a resident's care plan) dated 06/27/2024 revealed the resident had a Brief Interview for Mental Status (BIMS, a score of a residents cognitive abilities) of 15 of 15 that indicated the resident was cognitively aware. The resident needed set up assistance for eating and oral hygiene (teeth brushing), needed substantial/maximal assistance for toileting, dressing, footwear, and personal hygiene (body cleaning), and was dependent on staff for bathing. A record review of Resident 1's Care Plan with an admitted [DATE] revealed the resident was at risk for potential impaired nutritional status and had interventions of: hot liquids risk, cool before serving, accidental hot liquids spill if resident awake for meals place towel on lap and if the resident is asleep do not leave hot liquids on tray, lids to coffee cups as needed to avoid hot liquid spills. A record review of Resident 1's Hot Liquids Risk assessment dated [DATE] revealed the resident was at risk for injury from hot liquids, and interventions were to see the Care Plan. Therapy, Dietary, licensed nurses, and direct care staff had been updated on the resident's risk status. A record review of Resident 1's Incident Investigation/Interdisciplinary Team Review Meeting dated 08/11/2024 revealed the resident had been burned from spilled soup and interventions put in place to prevent future incidents was to use lids and education. A record review of Resident 1's Breakfast-Day 11 diet sheet dated 09/04/2024 revealed the resident was to get coffee and had a note of cool hot liquids. In an observation on 09/04/2024 at 7:10 AM revealed Resident 1 was seated in a wheelchair in the resident's room with an uncovered cup of coffee in front of the resident. In an observation on 09/04/2024 at 9:04 AM revealed CA-A poured steaming hot coffee from an insulated carafe (container), delivered it on a food tray uncovered to Resident 1, placed the tray on the overbed table in front of the resident, and left the room. In an observation on 09/04/2024 at 9:06 AM , using a thermometer revealed the temperature of the coffee in the carafe that was served to Resident 1 was 163 degrees F. In an interview on 09/04/2024 at 7:10 AM, Resident 1 confirmed the resident is served hot coffee in an uncovered cup and the staff does not place a towel over the lap when eating or drinking hot liquids. In an interview on 09/04/2024 at 9:55 AM, Resident 1 confirmed the resident is served steaming hot coffee all the time and had to add creamer and wait for it to cool before drinking it. In an interview on 09/04/2024 at 9:13 AM, CA-A confirmed that when the Resident 1's diet ticket said cool hot liquids, that meant the staff was to put ice in the cup of coffee. CA-A confirmed that was not done for Resident 1 prior to being served, but then said CA-A put ice in the pot this morning. CA-A confirmed CA-A did not know what the safe temperature was to prevent scalding (burn). In an interview on 09/04/2024 at 9:17 AM, the facility's Administrator confirmed the coffee temperature of 163 degrees F was too hot to prevent scalding and should not have been served to at risk residents. B. A record review of Resident 2's Clinical Census dated 09/04/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 2's Medical Diagnosis dated 09/04/2024 revealed the resident had diagnoses of Cerebral Infarction Due To Unspecified Occlusion or Stenosis (stroke), Unspecified Dementia (confusion), Memory Deficit following Cerebral Infarction, Other Lack Of Coordination, Weakness, and Dysphagia (trouble swallowing). A record review of Resident 2's MDS dated [DATE] revealed the resident had BIMS of 9 of 15 which indicated the resident was moderately cognitively impaired. The resident independent for eating, need partial/moderate assistance with oral hygiene and upper body dressing, needed substantial/maximal assistance for lower body dressing and footwear, and was dependent on staff for toileting. A record review of Resident 2's Care Plan with an admitted [DATE] revealed the resident was at risk for potential impaired nutritional status and had interventions of set up assist with meals in room or dining room per choice and hot liquids risk, cool before serving. A record review of Resident 2's Hot Liquids Risk assessment dated [DATE] revealed the resident was at risk for injury from hot liquids, and interventions were to see the Care Plan. Therapy, Dietary, licensed nurses, and direct care staff had been updated on the resident's risk status. A record review of Resident 2's Breakfast-Day 11 diet sheet dated 09/04/2024 revealed the resident was to get coffee and had a note of cool hot liquids. In an observation on 09/04/2024 at 9:02 AM revealed CA-B poured steaming hot coffee from an insulated carafe (container), delivered it uncovered to Resident 2, placed it on the overbed table in front of the resident, and left the room. In an observation on 09/04/2024 at 9:06 AM, using a thermometer revealed the temperature of the coffee in the carafe served to Resident 2 was 163 degrees F. In an interview on 09/04/2024 at 12:35 PM, Resident 2 confirmed the coffee is normally delivered really hot. The resident confirmed the resident had to wait to drink it and hold the cup correctly. The resident confirmed the coffee is not delivered with a lid and only a napkin is placed on the resident's lap when eating or drinking hot liquids. In an interview on 09/04/2024 at 9:15 AM, CA-B confirmed that when the Resident 2's diet ticket said cool hot liquids, that meant the staff was to put ice cubes in the cup of coffee. CA-B confirmed CA-B did not place ice cubes in Resident 2's coffee before CA-B delivered the coffee to Resident 2. CA-A confirmed CA-A did not know what the safe temperature was to prevent scalding (burn). In an interview on 09/04/2024 at 9:17 AM, the facility's Administrator confirmed the coffee temperature of 163 degrees F was too hot to prevent scalding and should not have been served to at risk residents.

Licensure Reference Number 175 NAC 12-007.01A Based on observations, record reviews and interviews; the facility kitchen staff failed to monitor water sanitation level used for cleaning food preparation surfaces and failed to ensure food temperatures were maintained to prevent the potential for food borne illness. This practice had the potential to effect 84 of 84 residents who ate food from the kitchen. The facility staff identified a census of 84. Findings are: A. Record review of the facility policy Sanitizing Food Contact Surfaces dated 8/2020 revealed the following information: -Instructions for tabletops, and arms of dining room chairs: -Sanitize same surfaces using Smart Power Sink and Surface Cleaner Sanitizer. Use spray bottle or bucket method using a microfiber cloth. -Notes Section: -Check ppm (parts per million) of the sanitizer using approved test strips and change the sanitizer bucket frequently (a minimum of every 2 hours or more frequently) and when it falls below the ppm requirements. Observation on 10-31-2023 at 11:35 AM revealed a bucket with fluid was setting on the food preparation table. During the observation Prep Cook B was not able to test the ppm of the solution used for cleaning as testing strips were not available. Further observation revealed the Dietary Manager (DM) left the kitchen area and returned to the kitchen approximately 5 minutes later with a test strip that unrolled for use. Prep Cook B removed a portion of the test strip and placed in into the buck of fluid used for cleaning revealing there was no indications the fluid use for cleaning food contact surfaces would sanitize. On 10-31-2023 at 11:35 AM an interview was conducted with Prep Cook B. During the interview Prep cook B reported the testing of the sanitation bucket should be done ever 2 hours and that has not been implemented. Prep Cook B confirmed the bucket of fluid on the preparation table was used for cleaning the equipment including food contact surfaces. Prep Cook B reported the test strip used to test the bucket of fluid use for cleaning was outdated and confirmed the fluid tested in the sanitation bucket used for cleaning would not have sanitized. B. Record review of an undated facility menu revealed the lunch meal to be served on 10-31-2023 was as follows: -Chef's soup of the day. -Breaded Pork Chop/Loin with Onions. -Parslied Butter Pasta. -Green Beans. Further review of the undated facility menu revealed the alternate option for the lunch meal to be served on 10-31-2023 was as follows: -Turkey and Stuffing Casserole. -Sweet Roasted Brussels Sprouts. -Brownie. In addition sliced ham and diced potato's was prepared as a alternate option. Observation on 11-01-2023 at 12:15 PM with the DM revealed a test tray of food that included sliced ham, carrots and potato's was placed on a tray cart along with food for residents on the 200 and 300 halls who were eating lunch in their rooms. Further observations revealed the last resident room tray was delivered at 12:25 PM. During the observation the DM using the facility thermometer revealed the following temperatures of the test tray of food: -The sliced ham was 124.0 degrees. -Carrots was 121.5 degrees. -Diced Potato's was 123.6 degrees. On 11-01-2023 at 12:25 PM during the observation of room trays meal delivery an interview was conducted with the DM. The DM confirmed the food on the test tray was cold and should have been maintained at 135 degrees. The DM reported ham was warm, not hot, the carrots were mushy and the diced potato's were chewy.

Licensure Reference Number 175 NAC 12.006.05(4). Based on interview and record review, the facility failed to provide bathing according to the resident preferences for 3 residents (Resident #6, #30, and #73) of 3 sampled residents. The facility staff identified a census of 84. Findings are: Record Review of undated facility admission packet included a document titled Resident Rights last revised on 5/19 stated: Your Right: to have your needs and preferences met and your right: to choose activities and schedules. A. Record Review of Resident #6's Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 2/22/23 revealed an admitted to the facility of 2/10/23 and a Brief Interview for Mental Status (BIMS- a test used to get a snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 15 which indiciated the resident was cognitively intact. Record Review of an undated Life Story document (a document used by the facility to guide the personalization of the care and services provided to the resident) revealed that Resident #6 preferred to have a bath 3 times a week. A record review of Resident #6's Care Plan revised on 8/10/23 revealed the resident was currently scheduled for bathing 2 times a week and the resident expressed a desire for a third bath. A record review of the Task Care within Resident #6's Electronic Medical Record (EHR) for October 1st through October 30th 2023 revealed Resident #6 received a bath on 3 out of 12 times resident #6 should have received a bath. An interview with Resident #6 on 10/31/23 at 9:25 AM revealed Resident #6 was scheduled to have a bath on 10/30/23 and didn't get one. An interview with Assistant Director of Nursing (ADON) on 11/02/23 at 11:51 AM revealed the facility staff could not locate any documentation to support why the resident didn't get baths as desired and confirmed that baths were not offered as desired by the resident. B. Record Review of Resident #30's MDS dated [DATE] revealed a reentry date of 11/11/22 and a BIMS score of 15 which indiciated the resident was cognitively intact. A record review of Resident #30's undated Life Story document revealed the resident would like a bath or shower 2-3 times per week. Record review of the Task Care within Resident #30's EHR for October 2023 revealed the resident received a whirlpool bath 9 out of 12 times Resident #30 should have had a bath. Record review of Resident #30's Care Plan revised on 5/31/23 revealed the resident's bathing preference is 3 times a week and to offer 3 baths a week and as needed. Interview on 10/31/23 at 9:35 AM with Resident #30 revealed they would prefer more baths and would like them on Monday, Wednesday, and Friday. Resident #30 reported not receiving a bath on 10/30/23. An interview on 11/02/23 at 11:51 AM with the ADON revealed baths were not offered as desired by Resident #30. C. Record Review of Resident #73's MDS dated [DATE] revealed a BIMS score of 15 which indiciated the resident was cognitively intact. Record Review of Resident #73's undated Life Story document revealed the resident preferred a sponge bath 2 times a week. Record review of Task Care in EHR revealed documentation that Resident #73 received a whirlpool on 10/6/23, 10/12/23, 10/16/23, 10/23/23 and 10/26/23 or 5 out of 8 times Resident #73 should have received a bath. An interview with Resident #73 on 10/30/23 at 10:49 AM revealed Resident #73 would like 2 baths a week. Resident #73 further reported they recieved 1 bath a week. An interview with the ADON on 11/02/23 at 8:58 AM confirmed Resident #73 did not have any bathing preferences listed on her care plan. An interview with ADON on 11/02/23 at 11:51 AM confirmed Resident #73 did not receive the baths as desired.

Licensure Reference Number 175 NAC 12-006.11A Based on observation, record review and interview; the facility kitchen staff failed to follow the recipes when making pureed foods. The facility staff identified 3 residents in the building received puree foods. The facility staff identified a census of 84. Findings are: Record review of an undated facility menu revealed the lunch meal to be served on 10-31-2023 was as follows: -Chef's soup of the day. -Breaded Pork Chop/Loin with Onions. -Parslied Butter Pasta. -Green Beans. Further review of the undated facility menu revealed the alternate option for the lunch meal to be served on 10-31-2023 was as follows: -Turkey and Stuffing Casserole. -Sweet Roasted Brussels Sprouts. -Brownie. Record review of an undated recipe for pureed green bean revealed the following information: -To make 3 serving, staff were to use 1 and 1/2 cups of green beans and add liquid as needed until the desired consistency was achieved. According to the recipe, staff were to use a #12 scoop for each portion size. Record review of an undated recipe for pureed turkey and stuffing casserole revealed the following: -To make 3 servings, staff were to use 3 cups of the turkey and stuffing casserole, 3/4 cup of water and 3/4 teaspoon of chicken base. The recipe instructed staff to combine the chicken base with the water to make chicken broth. Staff were to remove the portions of the turkey and stuffing casserole needed, place the casserole into the blender. Staff were to gradually add the chicken broth until the desired consistency was achieved. Record review of an undated recipe for breaded pork chop with onions revealed the following: -To make 3 servings staff were to place the required number of servings into a processor and blend until smooth. Hot broth could be used until the desired consistency was achieved. According to the recipe, a 3-ounce pork chop was 1 serving. Record review of a Diet Spread Sheet ( a sheet that instructs what portion size or dip( commonly know as scoop. The scoop size determines the amount of food item to be given) to be used for each food item for the residents. Observation on 10-31-2023 at 11:04 of the preparation of the pureed foods for the lunch meal and meal service revealed Cook C obtained a black scoop and took 2 scoops of green beans that had been placed on the steam table. Cook C added 2 scoops of broth to the green beans and blended the mixture into a smooth consistency. Cook C without measuring the portion size poured the pureed beans into 2 plastic cups. Cook C using scoop removed 2 and 1/2 scoops of the turkey and stuffing casserole and placed it into a mixer. Cook C added 3 unmeasured scoops of broth to the casserole and blended until the casserole was smooth. Cook C without measuring the portion size placed the pureed casserole into 3 plastic cups. Cook C placed 1 piece of pork loin into a deep fat fryer and removed it after cooking. Cook C took the 1 piece of cooked pork loin and placed it into a blender. Cook C added 2 and 1/2 scoops of broth and blended the pork loin. Cook C then added an additional scoop of the broth in order to achieve a smooth consistency. Cook C added a thickening agent as the pureed pork loin was a little runny and achieved a smooth consistency. Cook C without measuring the portion size of the pureed pork loin, poured the pureed pork loin into 3 plastic cups. Further observation of the food service revealed Cook C served the pureed meals to the facility residents. On 10-31-2023 at 12:15 PM an interview was conducted with Cook C. During the interview Cook C reported there were 3 residents in the building on pureed diets. Cook C confirmed the portion sizes were not measured when making and serving the pureed meals.

Licensure Reference Number 175 NAC 12-006.17B Based on observations, record review and interview; the facility staff failed to disinfect a mechanical lift after each use on the 400 hall and failed to maintain a catheter drainage bag in a manner to prevent to potential of cross contamination for 1 (Resident 30) of 1 resident. The facility staff identified a census of 84. Findings are: A. Record Review of the facility Medical Device Disinfection Competency dated 12-2019 revealed the following information: -Procedure Steps: -1. To be completed following each use of a medical device, also when in contact with blood or body fluid or when visible soiling is evident. -2. Medical devices include stethoscopes, lifts, kiosks, keyboards and vital signs (VS) equipment. Record Review of Infection Control Assessment and Promotion Program (ICAP) Zones, Personal Protective Equipment (PPE) and Testing revised on 9-29-2022 revealed [NAME] Zone (facility in outbreak status) everyone should wear a mask in communal areas of the facility. An observation on 10/31/23 at 8:00 AM revealed a sign was posted instructing the 400 Hall was in a [NAME] Zone. An observation on 11/01/23 at 7:25 AM of Nursing Assistant (NA)-D entering room [ROOM NUMBER] with a sit to stand mechanical lift. An observation on 11/01/23 at 7:35 AM revealed NA-D exited room [ROOM NUMBER] with the sit to stand mechanical lift, placing the lift in the hallway next to room [ROOM NUMBER] without disinfecting the lift. On 11/01/23 at 7:45 AM an interview was conducted with NA-D which revealed the sit/stand mechanical lift is to be sanitized after each use. NA-D confirmed it was not sanitized after exiting room [ROOM NUMBER]. B. Record Review of Foley Catheter Care Competency sheet dated 7-2009 revealed that staff are to check drainage tubing and bag to ensure proper positioning and drainage. Record Review of Resident 30's care plan revised on 5/31/23 revealed Resident 30 had a indwelling catheter (tube placed into the bladder to drain urine) and was to receive catheter care every shift with proper technique and to use a catheter bag cover at all times. Record Review of Resident 30's active orders dated 10-31-2023 revealed an order for Ciprofloxacin (an antibiotic) 250 miligrams (mg) two times a day related to urinary tract infection. An observation on 10/30/23 at 9:26 AM revealed the catheter drainage bag for Resident 30 was uncovered hanging on a trash can and with the drain tubing laying on floor. An observation on 10/31/23 at 9:25 AM revealed Resident 30's catheter drainage bag was hanging on a trash can, uncovered and touching the floor. A interview on 10-31-2023 at 10:25 AM was conducted with NA-F. During the interview NA-F reported assisting Resident 30 and was aware the catheter drainage bag was hanging on the trash can without a cover. NA-F confirmed Resident 30's catheter drainage bag should not have been hanging on the trash can on touching the floor. An interview with the Director of Nursing (DON) on 10/31/23 at 10:35 AM confirmed that catheter bags should not be hung on a trash can or touch the floor.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on record review and interview; the facility staff failed to follow up on pharmacy recommendations for 2 (Resident 27 and 64) and failed to have indications for continued use of an antibiotic medication for 1 (Resident 64) of 6 sampled residents. The facility staff identified a census of 79. Findings are: A. Record review of a Note To Attending Physician/Prescriber (NTAPP) dated 3-04-2022 for Resident 27 revealed the facility Pharmacist identified [MEDICATION(S)] (medication used in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the NTAPP dated 3-04-2022, the facility Pharmacist recommended another medication and if the practitioner did not want to change the medication the pharmacist requested a rational be documented on Resident 27's NTAPP dated 3-04-2022. Further review of the NTAPP dated 3-04-2022 revealed the practitioner documented disagree and did not provide the requested rational. B. Record review of Resident 27's NTAPP dated 10-05-2022 revealed the facility pharmacist identified Omeprazole (medication used to treat acid re-flux, heartburn, and indigestion). According to Resident 27's NTAPP dated 10-05-2022 the use of Omeprazole should not be used longer the 8 weeks and made a recommendation for a alternate medication for Resident 27 to use. Further review of Resident 27's NTAPP dated 10-05-2022 revealed the pharmacist request risk/benefits of the continued use of Omeprazole be documented on Resident 27's NTAPP dated 10-05-2022. Further review of Resident 27's NTAPP dated 10-05-2022 revealed the practitioner documented disagree and did not provide the documentation of the risk/benefits of the medication. Record review of Resident 27's Order Summary Report dated 11-07-2022 revealed Resident 27 has been on [MEDICATION(S)] sine 2-02-2022 and the Omeprazole sine 1-11-2022. ON 11-07-2022 at 2:25 PM an interview was conducted with the Director of Nursing (DON). During the interview review of the NTAPP dated 3-04-2022 and the NTAPP dated 10-05-2022 was completed. The DON confirmed Resident 27's practitioner did not provide the rational for the use of the [MEDICATION(S)] and did not provide the risk/benefits for the continued use of the Omeprazole. C. Record review of Resident 64's NTAPP dated 7-6-2022 revealed the facility pharmacist identified Resident 64 was on [MEDICATION(S)] (used to treat overactive bladder). According to Resident 64's NTAPP dated 7-06-2022, the use of [MEDICATION(S)] in addition to another medication has been associated with clinically significant elevations in blood pressure and reported Resident 64's systolic (top number of a blood pressure) was frequently running above 150 millimeters of mercury. Resident 6+4's NTAPP dated 7-06-2022 from the facility pharmacist requested the practitioner make a determination on the use of the medications. The practitioner marked disagree without an indication of the medication being evaluated. D. Record review of Resident 64's NTAPP dated 10-05-2022 revealed the facility pharmacist identified a need for a dose reduction attempt for the use of [MEDICATION(S)] (an antidepressant medication). According to Resident 64's NTAPP dated 10-05-2022 if the dose reduction was contra-indicated and the pharmacist requested the practitioner to document the contra-indications on Resident 64's NTAPP form dated 10-05-2022. Further review of Resident 64's NTAPP dated 10-05-2022 revealed the practitioner documented disagree and did not document why the dose reduction of Resident 64's [MEDICATION(S)] was contra-indicated. On 11-08-2022 at 8:45 AM a interview was conducted with the DON. During the interview review of Resident 64's NTAPP dated 7-06-2022 and 10-05-2022 were completed. The DON confirmed Resident 64's NTAPP's were not completed. E. Record review of Resident 64's Order Summary Report dated 11-07-2022 revealed Resident 64 has been on [MEDICATION(S)] (antibiotic medication) 250 milligrams prophylactly since 7-19-2022. Review of Resident 64's medical records that included Progress Notes, Practitioners Orders and Medication Administration Records revealed there was not an evaluation of the need for Resident 64 to remain on [MEDICATION(S)]. According to medlineplus.gov/drug info.com revealed [MEDICATION(S)] is usually taken for 7 to 14 days. On 11-07-2022 at 3:40 PM an interview with Registered Nurse (RN) A . During the interview RN A confirmed there was not an evaluation and rational of the need for Resident 64 to remain on the [MEDICATION(S)] . Record review of the facility Policy for [CONDITION(S)]/Psychoactive Medication Management dated 1-2017 revealed the following information: -The facility will utilize appropriate resources to assist in managing psychoactive /[CONDITION(S)] medications that are prescribe for the resident. -Page 13. -The attending physician must document in the residents record that the identified irregularity has been reviewed and what, if any action, has been taken to address it. If there is to be no change in medication, the attending physician will document his or her rational in the residents's medical record.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on observation, interview and record review; the facility failed to identify and notify the physician of a change in condition related to worsening [CONDITION(S)] and weight gain for Resident 68. The sample size was 18. The facility identified a census of 84. FINDINGS ARE: An observation on 08/16/21 at 02:17 PM revealed Resident 68 had been resting in the recliner with legs elevated. The observation revealed bilateral lower extremities to have [CONDITION(S)] (swelling caused due to excess fluid accumulation in the body tissues). A record review of the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the weights for Resident 68 revealed a 5 lb weight gain since admission on 7/14/21. The record review of the recorded weights for Resident 68 since admitted until present date are listed as follows: 8/10/2021 16:35 118.5 Lbs Bath (Manual) 8/6/2021 19:46 120.0 Lbs Bath (Manual) 8/3/2021 18:53 118.5 Lbs Bath (Manual) 7/27/2021 19:57 119.5 Lbs Bath (Manual) 7/24/2021 18:30 118.0 Lbs Bath (Manual) 7/17/2021 10:32 114.0 Lbs Sitting (Manual) 7/16/2021 15:18 113.0 Lbs Sitting (Manual) 7/15/2021 12:05 112.0 Lbs Sitting (Manual) 7/14/2021 12:02 113.5 Lbs Bath (Manual) The record review revealed the 8/6/21 weight of 120.0 lbs. had been an increase of 6.5 lbs. in 3 weeks since admission with no noted physician notification. A record review of the assessment titled Daily Skilled Documentation - V 3 for Resident 68 revealed no lower extremity [CONDITION(S)] upon admission on 7/14/21. A record review of the notes sent to the physician revealed that on 7/23/21 a fax had been sent to the physician requesting TED hose (compression stockings used to promote the return of blood from legs and feet) due to [CONDITION(S)]. The record review revealed that the fax sent to the physician did not contain information regarding an amount of [CONDITION(S)], weights, or respiratory status for Resident 68. After review of the daily skilled assessments titled Daily Skilled Documentation - V 3 for Resident 68 dated 7/23/21 through 8/15/21 revealed [CONDITION(S)] documentation as follows; 7/23/21 noted Resident 68 to have shortness of breath but no [CONDITION(S)] present 7/24/21 noted Resident 68 to have [CONDITION(S)] present but did not indicate how much 7/30/21 noted non pitting [CONDITION(S)] present 8/1/21 [CONDITION(S)] noted at 1+ 8/4/21 [CONDITION(S)] noted at 1+ 8/11/21 no [CONDITION(S)] indicated 8/13/21 [CONDITION(S)] indicated but not amount 8/14/21 [CONDITION(S)] 4+ pitting indicated 8/15/21 [CONDITION(S)] 4+ pitting indicated A record review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The record review revealed the fax sent to the physician did not contain information regarding any [CONDITION(S)] or weight gain. An observation of skin care on 08/18/21 at 09:00 AM for Resident 68 with RN-A (Registered Nurse) revealed that Resident 68 had voiced leg pain during the assessment. The observation revealed white TED hose hanging in bathroom and Resident 68 had been wearing black socks. An interview with RN-A on 08/18/21 at 09:00 AM revealed that Resident 68 had mushy heels with continued gross [CONDITION(S)] present to bilateral lower extremities. During the interview conducted with RN-A, the black stockings which Resident 68 had been wearing were also compression stockings. A record review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the orders list for Resident 68 revealed the following order had been obtained on 8/18/21; Notify MD / APRN of weight gain of 3+ pounds in a day or 5+ pounds in a week. DX: Heart Failure every day shift for [CONDITION(S)] An interview with the facility DON (Director of Nursing) on 08/18/21 at 03:30 PM after review of the weight gain and [CONDITION(S)] documented for Resident 68, revealed the DON would review the Record for further information to provide to the surveyor. An interview conducted on 8/23/21 at 12:00 PM during status with the DON revealed the DON had presented dates of nearly daily physician notifications regarding the health status for Resident 68. During the interview, it had been questioned if the frequent physician contact had been specifically related to the [CONDITION(S)] and weight gain for Resident 68, the DON confirmed it had not been related to the [CONDITION(S)] and weight gain but other health concerns.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.16 Based on observation, interview and record review; the facility failed to ensure complete documentation of behavior monitoring for Resident 79 related to the identified target behaviors. The sample size was 18. The facility identified a census of 84. FINDINGS ARE: A record review of the demographic information for Resident 79 revealed an admitted [DATE]. The record review revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) for Resident 79 revealed a BIMS ( Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 5. An interview on 08/18/21 at 11:25 AM with the facility DON (Director of Nursing) confirmed Resident 79 had not been followed by the therapy group that came to the facility due to Resident 79 not having the mental capability to follow the recommendations or use of coping skills. The interview with the DON held on 08/18/21 revealed Resident 79 was not followed by any psychiatrist and that the primary care physician for Resident 79 had been addressing orders or concerns related to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the documents titled BEHAVIOR/INTERVENTION MONTHLY FLOW RECORD and dated May 2021, June 2021, July 2021 and August 2021 revealed multiple blank days with no charting, and contained mostly 0's related behaviors displayed. The record review of the Behavior monthly flow sheets dated May 2021, June 2021, July 2021 and August 2021 for Resident 79 revealed a target behavior of sad/negative comments and refusing meds. During the record review when the behavior flow sheets had been compared to the MAR (Medication Administration Record) for the correlating month/year, the section related to refusing meds did not correlate to the refusals documented on the MAR's. An interview with the DON and facility Administrator on 08/18/21 at 01:04 PM after review of the Behavior monthly flow sheets confirmed the documents had numerous blank days which had not been documented. The interview revealed that the staff attempt to educate at the time of refusal despite Resident 79 having a BIMS of 5 but did confirm that Resident 79 would not recall education provided. During the interview, the Administrator voiced that the section listing a behavior of refusing meds only pertained to the 2 antidepressant medications ordered and not the refusal of all medications. A review of the behavior flow sheet for June 2021 revealed medication refusals on 14 occasions. The review revealed this behavior to be marked out for 6/1/21 through 6/4/21. A review of the behavior flow sheet for June 2021 revealed sad/negative comments 0 occasions and left blank on 8 occasions. A review of the behavior flow sheet for July 2021 revealed medication refusals on 15 occasions. A review of the behavior flow sheet for July 2021 revealed sad/negative comments 0 occasions and left blank on 10 occasions. A review of the behavior flow sheet for August 2021 8/1-8/16/21, revealed medication refusals on 6 occasions. A review of the behavior flow sheet for August 2021 revealed sad/negative comments 0 occasions and left blank on 10 occasions. A record review of the MAR date June 2021 revealed medication refusals on 13 occasions at 0800 and 8 occasions at 2000 A record review of the MAR date July 2021 revealed medication refusals on 4 occasions at 0800 and 12 occasions at 2000 A record review of the MAR date [DATE]-17 2021 revealed medication refusals on 1 occasion at 0800 and 6 occasions at 2000 A record review of the Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) for Resident 79 revealed the following problem statement; Uses psychoactive medications related to: Depression Target Behavior: Sad/Negative Statement Level I PASRR with no recommendations Date Initiated: 05/24/2021 Created on: 05/24/2021

Licensure Reference Number 175 NAC 12-006.11 E Based on observation and interview, the facility failed to ensure cleanliness of the kitchen related to personal belongings in the food prep area, debride on floors of walk in refrigerators, food not labeled or dated, and dirty air vents and failed to ensure hair and beard restraints were worn in a manner to contain all hair to prevent the potential for foodborne illness. This had the potential to affect 99 of the 100 residents that ate food prepared in the facility kitchen. The facility census was 100. Findings are: [NAME] Observation on 08/21/19 at 8:09 AM to 8:40 AM of the initial tour of the kitchen revealed the following: -Dietary Assistant (DA) D, with facial hair and no beard net going into the kitchen -DA D's hair was also not tucked into the hair net. -The Assistant Director of Nursing (ADON) retrieved a Mountain Dew Bottle with fluid in the bottle, from the refrigerator by the Dietary Supervisor Office. -In the walk-in refrigerator the ADON picked up a piece of lettuce, and a crumpled paper. -Debris which appeared to be dust and grime on the floor of the walk-in refrigerator. -The prep area contained personal items on a table including a cell phone plugged in, a container with a straw sticking out of the top. -In the prep area the flour bin was open. -In the dry storage area muffins were in a pan and were not covered or dated. -There was debris on the floor which appeared to be food particles, brown grey dust and grime. Interview on 8-22-19 at 8:24 AM with the Dietary Supervisor revealed the floors did not get swept or mopped 8/21/19. B. Observation on 8-21-19 at 11:30 AM revealed DA F had facial hair with no beard net and hair not completely contained by the hair net. Interview on 8-21-19 at 11:30 AM RN B confirmed that DA F should not have hair uncovered and beard nets should be worn with facial hair present. Observation of dietary staff on 8-22-19 between 8:00 and 8:30 AM revealed that staff continued to have hair appearing out of hair nets. RN B confirmed that hair was out of the hairnets. C. Observation on 08/26/19 at 10:00 AM revealed the kitchen air ventilation covers to be covered with brown colored debris. Interview on 8/26/19 at 10:00 AM RN B stated that the vents should be cleaned. Interview on 8/26/19 at 12:00 PM with the Dietary Supervisor revealed maintenance is responsible for cleaning the air ventilation covers. Interview with the maintenance supervisor on 8/26/19 at 12:14 PM revealed that no one is assigned to clean the air ventilation covers in the kitchen. Interview on 08/26/19 at 12:29 PM with RN B reveals RN B is unable to locate the kitchen cleaning policy, however the Nebraska Food Code Manual should be followed. Interview on 08/26/19 at 2:38 PM with RN B reveals there is no cleaning policy for the kitchen.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A (1) Based on observation, interview and record review; the facility failed to maintain doors in a manner to prevent gouges on 8 of 90 rooms, missing paint on walls on 4 of 7 hallways. The facility census was 100. Findings are: [NAME] Observations on 08/26/19 between 7:47 AM to 8:07 AM during an environmental tour completed with Registered Nurse (RN) B. The environmental tour revealed marred doors on the following resident rooms 409, 411, 410, 408, 501, 506, 505, 507. Interview on 08/26/19 at 7:53 AM revealed that RN B confirmed the resident room doors were marred. B. Observation on 08/26/19 during the environmental tour revealed paint missing on hallway walls in the 700 hall, 600 hall, 200 hall, and 300 hall. Record review of the current facility floor plan provided by the facility on entrance revealed seven total hallways. Interview during environmental tour revealed RN B confirmed the hallway walls should be repainted.

Licensure Reference Number 175 NAC 12-006.09D7 Based on record review and interviews, the facility failed to evaluate and put interventions in place to prevent the potential for self-harm for 1 resident, Resident 86 when resident voiced [MEDICAL CONDITION]. The facility census was 100. Findings are: [NAME] Interview with Resident 86 on 8/22/19 at 9:48 AM revealed Resident 86 was going to commit suicide. Registered Nurse (RN) B was informed of Resident 86's statement and RN B revealed Resident 86 does this all the time. Record Review of Progress note dated 7-10-19 on 4:40 PM reveals Social Services Staff (SS) was walking past Resident 86's room and resident was sitting at (gender) counter slicing tomatoes. Resident 86 smiled and made an exaggerated motion from about 12 inches away from Resident 86's neck and then chuckled. Resident 86 has made comments in the past of self-harm, SS told the resident that Resident 86 would likely not be allowed to keep the knife in the room if Resident 86 continued to joke in this manner. Record Review of the Psychiatrist note dated 7-16-19 reveals that resident threatened to harm self with knife yesterday. Record Review of a document entitled PHQ-9 (Patient Health Questionnaire) dated 7-26-19 reveals resident scored a 15 out of 27 on this test indicating moderate depression. Record review of a document dated 7-27-19 and titled Physician 60 day visit reveals Resident 86 did indicate self-harm to several nurses. Record review of Social Service notes revealed on 8-2-19 at 1:18 PM Resident 86 has made statements of being better off dead. The resident is currently taking psychoactive medication. Resident takes [MEDICATION NAME] 10mg (an anti-depressant). Record review of Resident 86's electronic medical record revealed no documentation of the knife being removed from Resident 86's room. B. Record review of Progress Notes dated 8-21-19 at 11:16 PM revealed that Resident 86 was visibly upset when RN passed bedtime medications. Initially Resident 86 stated Resident 86 will not take medications as Resident 86 is going to kill (gender)self by refusing but did agree to take the medications. RN left the room and went down the hallway to administer medications to another resident. No further conversation. Record review on 08/22/19 at 2:43 PM of document titled Suicidal Ideation/ Intervention Guidelines reveals the following: - All [MEDICAL CONDITION]/self-harm should be taken seriously and require immediate intervention and follow-up. -The Administrator, DON and Social Services shall be notified immediately of any residents with potential self-harm. - A resident assessment will be completed including mood state, verbal statements, and resident's risk of suicide. -Resident's environment will be checked for potential safety concerns and remove any items that could be a hazard to the resident. -The attending Physician will be notified. An interview on 8/27/19 at 2:00 PM with the Administrator revealed that the facility did not initiate the Suicidal Prevention Guidelines in response to previous self-harm statements by Resident 86.

Licensure Reference Number 175 NAC 12-006.18B1 Based on observation, record review and interview; the facility failed to ensure the correct size sling was used when transferring 1 resident (Resident 86) of one resident reviewed for mechanical lift transfers. The facility census was 100. Findings are: Interview on 08/22/19 at 9:48 AM with Resident 86 revealed the mechanical lift sling (a belt used for resident safety) is too small and causes discomfort. Observation on 8/22/19 at 2:25 PM of a sit to stand lift in the hall by Resident 86's room revealed the sling on the lift was a size large. Interview on 08/22/19 at 2:25 PM with nursing assistant (NA) A revealed that NA A transferred Resident 86 to the bathroom using the sit to stand lift (a mechanical lift used to assist resident to a standing position) and the sling was a size large. Record review of the facility document titled Lift assessment dated [DATE] revealed Resident 86 requires a size extra-large sling. Interview with Registered Nurse (RN) B on 8-22-19 at 2:30 PM revealed the sling was a large sling and should have been an extra-large. RN B was not aware of the facility having any other size of mechanical lift sling.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.-09C1b Based observation, record review, and interview; the facility failed to revise a care plan with current transfer status for 1 (Resident 3) of 3 sampled residents. The facility staff identified a census of 101. The findings are: Record review of the CCP (Comprehensive Care Plan) dated 9/12/18 revealed that Resident 3 was noted to be at risk for a decline due to muscle weakness and difficulty with ambulating. The goal was to transfer safely with 1-2 staff assist daily. Interventions for transfers included 1-2 staff assist with Front wheel walker. Record Review of the Lift and Transfer Review dated 3/1/19 revealed the resident could ambulate safely with assistance and perform greater than 50% of lift/transfer with staff assist to stand and pivot. Observation on 3/19/19 at 11:00 AM of a transfer for Resident 3 revealed staff utilized an EZ stand lift ( a piece of equipment used to transfer a resident from a sitting position to a standing position) to transfer Resident 3 from the bed to the recliner. Observation on 3/19/19 at 1:20 PM of a transfer for Resident 3 from the recliner to the wheelchair revealed the use of an EZ stand lift. Interview conducted on 3/19/19 at 2:25 PM confirmed that the CCP did not include the use of an EZ stand lift for transfers.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and interview; the facility staff failed to implement assessed interventions to prevent falls for 1 resident (Resident 1). The facility staff identified a census of 92. Findings are: Record review of a undated Resident Admission Record sheet revealed Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 1's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated signed as completed on 1-27-2015 revealed the facility staff assessed the following about Resident 1: -BIMS ( Brief Interview for Mental Status) score of 9. According to the MDS Manuel, a score of 8 to 12 indicate moderately impaired cognition. -Required extensive assistance with bed mobility, transfers, walking in room, dressing, toilet use and personal hygiene. -Frequently incontinent of bowel and bladder. -Falls during the assessment reference date. Record review of a Fall Risk Assessment (FRA) sheet completed on 8-15-2014 revealed Resident 1 was assessed with [REDACTED]. Record review of Resident 1's FRA dated 10-31-2014 revealed Resident 1 was assessed with [REDACTED]. Record review of Resident 1's FRA dated 1-21-2015 revealed Resident 1 was assessed with [REDACTED]. Record review of Resident 1's Comprehensive Care Plan (CCP) dated 9-19-2014 revealed Resident 1 was .at risk for falls related to impaired mobility and weakness as well as poor safety awareness. The goal identified for Resident 1 was to remain free from fall related injury. Approaches identified on Resident 1's CCP were to not leave unattended in bathroom. (Start date of this approach was 3-09-2015), Manuel recliner given at this time, continue current fall interventions, request a med review, sensor pad alarm when in bed and in recliner, remain with resident while in bathroom (start dated of this approach was 9-23-2014). Record review of a Accidents sheet dated 3-24-2015 revealed Resident 1 was assisted onto the toilet on 3-18-2015 at 10:30 AM. According to the information on the Accident sheet, Resident 1 spontaneously fell to the side and onto the floor with a resulting laceration to the left temple area. Resident 1 was transferred to the hospital for an evaluation and treatment. An interview was conducted on 4-07-2015 at 11:59 AM with Nursing Assistant (NA) A and Director of Nursing (DON). During the interview NA A reported assisting Resident 1 onto the toilet. NA A stated I left the bathroom door open and made the bed. NA A reported not seeing Resident 1 fall from the toilet, however heard Resident 1 fall. When asked if Resident 1 could be left alone in the bathroom, NA A reported the Care Guide ( a sheet of paper that has basic information on how to take care of the resident). indicated B.R. NA A reported B.R. meant bed room. During the interview, Resident 1's CCP was reviewed with NA A. NA A confirmed Resident 1's CCP directed that Resident 1 not be left alone in the bathroom. When asked if Resident 1 was left alone in the bathroom, NA A stated yes. An interview on 4-07-2015 at 11:59 AM with the DON revealed the Care Guide is basic information on how to take of a resident that might also indicate family instructions. According to the DON, the Resident Care Guide is not part of the residents record. Record review of a Computerized Tomography (CT) imaging report dated 3-18-2015 revealed the CT impression was that Resident 1 had a small amount of Subarchnoid (section of the brain) hemorrhage (bleeding) along the Cerebellar Vermis (area between 2 hemisphere of the brain). An interview was conducted on 4-7-2015 at 1:15 PM with the DON and facility Administrator. During the interview the DON reported that the facility nurses had been inserviced of ensuring care plans were followed, however, not all of the nursing assistants had been inserviced on following the resident plan of care. The facility did not provide a copy of the Resident Care Guide that was in use for Resident 1 or were there any further information provided prior to the exit from the facility.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observation, record review and interview; the facility staff failed to ensure assessed interventions were in place to prevent falls for 2 residents (Resident 1 and 4). The facility staff identified a census of 94. Findings are: A. Record review of an undated Resident Admission Record revealed Resident 1 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 1's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated and signed as completed on 7-16-2014 revealed the facility staff assessed the following about Resident 1: -BIM's (Brief Interview for Mental Status) revealed Resident 1 scored an 11. According to the MDS Manuel, a score of 8 to 12 indicated moderately impaired cognition. -Required supervision walking in the room. -Required Limited assistance with transfers, bed mobility, and personal hygiene. -Required extensive assistance with Locomotion on and off the unit, Dressing, and toilet use. -Always incontinent of bladder. Record review of a History and Physical sheet dated 3-31-2014 revealed Resident 1 had fallen at Resident 1's prior residence resulting in a laceration to the right eyebrow, and a Right Humerus Fracture. Record review of Resident 1's Comprehensive Care Plan (CCP) dated 4-14-2014 revealed the facility staff had identified Resident 1 "...is impulsive and has poor safety awareness, (Resident 1) does not use the call light for assistance with transfers. Fall precautions include alarms." Further review of Resident 1's CCP dated 4-14-2014 revealed the facility staff had identified Resident 1 was at risk for falls due to weakness and loss of mobility related to the Right Humerus fracture. The goal identified for Resident 1 was Resident 1 fall related injuries would be minimized with interventions. The interventions listed on Resident 1's CCP included the following: -When restless bring Resident 1 to nursing station. -Assist with transfers, mobility to extent required to complete task. -Bed and Chair alarm for safety. Toilet at regular intervals. -Non-skid footwear. Record review of Resident 1's Progress Note (PN) dated 8-12-2014 revealed Resident 1 was found laying on the right side under the bathroom sink. "Appears to have hit head on counter." According to the PN dated 8-12-2014, Resident 1 was sent to the hospital for an evaluation. Further Resident 1's PN dated 8-12-2014 revealed there was not any evidence identified in the PN that Resident 1's personal alarm was sounding with the fall. Record review of a Physician Orders/ Progress Notes (POPN) dated 8-13-2014 revealed Resident 1 was diagnosed with [REDACTED]. Record review of a Safety Events-Falls (SEF) sheet for Resident 1 dated 8-12-2014 revealed there was not a witness to the fall. The SEF sheet contained a section that was identified as "Interventions-Immediate measures taken" revealed a bed and chair alarms were applied and first aid provided. The SEF also contained information that Resident 1 had fallen in the past 30 days and and had a fracture in the last 180 days. An interview with the facility Director of Nursing (DON) was conducted on 10-02-2014 at 8:15 AM. When asked what "interventions-immediate measures taken" meant on the Safety Event - Falls sheet, the DON stated "something you do right now." A follow up interview was conducted with the DON on 10-02-2014 at 8:45 AM. When asked if the alarm had been sounding when Resident 1 had fallen on 8-12-2014, the DON reported they were not able to determine if the alarm had been sounding or not. An interview was conducted on 10-02-2014 at 10:15 AM with Registered Nurse (RN) A. During the interview when asked if the personal alarm had been sounding when Resident 1 had fallen, RN A stated " I don't think the alarm was sounding, but I can't be sure." B. Record review of an undated Resident Admission Record revealed Resident 4 was admitted to the facility on [DATE] and re-admitted on [DATE]. Record review of Resident 4's CCP dated 8-30-2014 revealed Resident 4 was at risk for falls related to weakness and loss of mobility. The goal identified on the CCP for Resident 4 was Resident 4 would be free from fall related injury. Review of the approaches used to meet this goal revealed a updated entry dated 9-29-2014 that identified Resident 4 was to have a "Touch Pad Call Light" system, alarms while in bed and chair, bed in a low position and staff were to place Resident 4 at the nurses desk when awake and restless. Observation on 10-01-2014 at 9:00 AM revealed Resident 4 was out of the room. Observation of Resident 4's room revealed there was not a touch pad call light in Resident 4's room. Observation on 10-01-2014 at 10:00 AM revealed Resident 4 was sleeping in the recliner and had a piston push call light system for use. Observations on 10-01-2014 at 11:00 AM revealed Resident 4 was awake seated in a recliner and had a piston type of call light system in the room. An interview was conducted with RN B on 10-01-2014 at 3:55 PM. During the interview when asked what type of call light system Resident 4 used, RN B stated "plunger/button type." Review of Resident 4's CCP was conducted with RN B. RN B confirmed Resident 4 was to have a touch pad call light system in the room. A interview was conducted on 10-02-2014 at 7:45 AM with the DON. During the interview, the DON confirmed Resident 4 did not have the correct call light system. When as to why Resident 4 required the touch pad call system, the DON stated "it's a safety device since it was so sensitive that it will activate when the resident moves."