Every finding on record at Colonial Manor of Randolph

Licensure Reference Number: 175 NAC 12-006.09H Based on record review and interview: the facility failed to administer medications for Resident 1 as ordered by the Primary Care Practitioner (PCP). The sample size was 4 and the facility census was 39.Findings are: A. Review of the facility policy Physician Orders, Pharmacy/Nursing Services with a revision date of 1/18 revealed it was the policy of this facility that medications and treatments were to be administered only upon the written order of a person who was licensed and authorized to prescribe medications. The following procedure was identified:-no drugs or biologicals were to be administered except upon the order of a person lawfully authorized to prescribe for and treat human illness.-all drug and biological orders were to be written, dated and signed by the person lawfully authorized to give such an order. -medications, treatments and procedures are to be administered per physician order. B. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/19/26 revealed the resident was admitted [DATE] with diagnoses of chronic kidney disease, heart failure, high blood pressure, diabetes, Parkinson's disease, depression and anxiety. The following was assessed regarding Resident 1:-cognitively intact.-required substantial assistance with dressing, personal hygiene, bed mobility and transfers. -received insulin injections and a diuretic 7 out of 7 days of the assessment period. Review of Resident1's physician orders revealed an order dated 9/17/25 for sliding scale insulin (method for managing blood sugar, where insulin doses are determined immediately before meals based on current blood glucose levels. It uses a predetermined, tiered chart where higher glucose readings dictate a larger dose of fast-acting insulin) which indicated the resident was to receive the following doses of Humulin insulin based on blood sugar readings: blood sugars between 151 and 200=2 units; blood sugars between 201-250=4 units; blood sugars between 251 and 300=6 units; blood sugars between 301-350=8 units; blood sugars between 351-400=10 units and blood sugars greater than 400 the resident was to receive 12 units of insulin. Review of the resident's medical record revealed the following:-10/5/25 at 5:00 PM the resident's blood sugar was 561. Review of the resident's medical record revealed no evidence any insulin was administered and if it was administered what dose was given. -10/6/25 at 11:00 AM the resident's blood sugar was 461. Review of the resident's medical record revealed no evidence the resident was given 12 units of insulin as indicated by the physician order. -10/10/25 at 7:00 AM the resident's blood sugar was 499 and at 11:00 AM the resident's blood sugar remained 499 with no evidence any insulin was administered and if it was administered what dose was given. Interview with the Director of Nursing (DON) and the Registered Nurse Consultant on 4/14/26 at 11:45 AM confirmed there was no evidence Resident 1 received the ordered sliding scale insulin on 10/5/25 at 5:00 PM, on 10/6/25 at 11:00 AM and on 10/10/25 at 7:00 AM and at 11:00 AM.

Licensure Reference Number 175 NAC 12.006.11EBased on observation, record review and interview; the facility failed to store and prepare food in a manner to prevent the potential for food borne illness. This practice had the potential to affect all residents who were served snacks and meals from the kitchen. The facility identified census was 40. Findings are:A. Review of the undated facility policy Food Safety Requirements revealed the following:-It was the policy of the facility that food would be stored, prepared, distributed and served in accordance with professional standards for food service safety. Food service safety referred to the handling, preparing, and storing of food in ways that prevent foodborne illness. -Foods that required refrigeration should be refrigerated immediately upon receipt. Foods should be labeled, dated and monitored so it is used by its use-by date. B. Observation conducted during the initial kitchen tour on 12/8/25 at 8:20 AM revealed the following prepared undated food items in the refrigerator:-2 bags of bologna meat which were undated and-7 sandwiches of salami/cheese in the snack container were undated. An interview with the Dietary Manager on 12/08/25 at 8:30 AM confirmed that all food items were to be labeled and dated when opened or prepared and disposed of 3 days after the open date.

Licensure Reference Number 175NAC 12-006.19(A) Based on observation, and interview; the facility failed to maintain the cleanliness and condition of walls, floors, doors, and bathrooms in 3 (North 1, 2, and 12) of 28 occupied rooms. This had the potential to affect 6 residents who resided in those rooms. The total sample size was 18 and the facility census was 40. Findings are: Observations on 12/10/25 at 8:24 AM with the Administrator revealed the following environmental issues:Bathroom of resident room North 1:-wall between the stool and the handwashing sink with a hole which was approximately 3 centimeters (cm) by 6 cm with exposed piping visible. Bathroom of resident room North 2: -scrapped area with a hole to the bathroom door. -concrete floor with missing linoleum in the bathroom underneath the handwashing sink. 2 uncovered bedpans and a package of disposable urinary incontinence products were stored directly on the concrete.-the wall covering around the handwashing sink had been removed with exposed dry wall. Bathroom of resident room North 12:-dark brown stains to the top and the inside of the stool, and the stool riser. -pervasive smell of feces to the resident's room and bathroom. During an interview with the Administrator on 12/10/25 at 8:44 AM, the Administrator confirmed areas to resident rooms North 1, 2 and 12 needed to be repaired and/or cleaned. Interview with the Maintenance Supervisor on 12/10/25 at 8:45 AM revealed the staff were to complete work orders on any areas which required repair/fixing and currently no works orders have been completed regarding the concerns in the North corridor resident rooms [ROOM NUMBERS].

Licensure Reference Number 175 NAC 12-006.04(A)(iii)(2) Based on record review and interview; the facility failed to ensure background checks were completed through the State Nurse Aide (NA) registry for 2 (NA-Q and NA-R) of 5 employees. The total sample size was 18. The facility census was 40. Findings are: Review of the facility policy Freedom from Abuse, Neglect, Exploitation and Misappropriation with a revised date of 10/2022 revealed it was the policy of the facility to protect residents from abuse, neglect, exploitation, and misappropriation of resident property. The facility sought to protect its residents from being subjected to incidents of crime and to ensure that any such incidents were reported in a timely manner to the State Agency and local law enforcement. Further review revealed, the facility would conduct background checks and not knowingly employ or otherwise engage any individual who:-had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law.-had a negative finding in the State Nurse Aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property.-a disciplinary action was in effect against his or her professional license by a state licensure body because of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. Record review of 5 employee files revealed the following:-Dietary Aide (DA)-Q was hired on 10/27/25 and there was no evidence the facility had completed a background check through the State Nurse Aide Registry prior to the staff's hire date. -DA-R was hired on 10/1/25 and there was no evidence that a background check was completed through the State Nurse Aide Registry prior to the staff's hire date. During an interview on 12/10/25 at 1:04 PM, the facility Administrator confirmed the facility failed to check the Nurse Aide Registry upon employment for DA-Q and DA-R to ensure no negative findings and that the residents were protected from potential abuse.

Licensure Reference Number 175 NAC 12-006.05 Based on record review and interview; the facility failed to provide evidence that a bed hold notice was provided to Resident 1 related to a hospitalization. The sample size was 2 and the facility census was 40. Findings are: Review of the facility policy Bed Hold dated 12/2023 revealed the facility was to inform the resident or the resident representative in writing of the right to exercise the bed hold provision upon admission and provide a second notice prior to transfer to a general acute care hospital or before the resident goes on therapeutic leave. In the event of an emergency transfer, the second notice would be provided within 24 hours. A copy of the notification would be part of the resident's health record at the time of the transfer. Each notice would include the following:-the duration of the State bed-hold policy and/or the facility policy that the resident bed would be held for the duration of days, during which time the resident would be permitted to return to the facility, -the amount required to be paid by the resident or the payor source to hold the bed for the duration of the bed-hold period,-that insurance may or may not cover the costs and the resident may be responsible for uncovered costs, and-this information would be provided to the resident and/or their representative in a language they could understand. If the bed hold option was exercised, the resident or their representative would notify the facility within 24 hours after being informed of the right to have the bed hold. If the resident's hospitalization or therapeutic leave exceeded the bed-hold period, the resident may return to their previous room, if available, or immediately upon the first availability of a bed in a semi-private room, if the resident required the services provided by the facility, and was eligible for Medicare skilled nursing services, or Medicaid nursing services. Review of Resident 1's Minimum Data Set's (MDS-a federally mandated assessment tool used in care planning) revealed the resident had a discharge assessment with anticipated return dated 10/3/25 and an entry assessment dated [DATE]. Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact; required staff assistance with toileting, dressing, and mobility; and had diagnoses of Debility, High Blood Pressure, Pneumonia, Bladder Infection, and Diabetes. Review of Resident 1's Medical Record including Progress Notes for October 2025, Care Plan, and scanned in documents revealed no evidence a bed hold was offered and/or completed. Interview on 12/9/25 at 10:15 AM with Licensed Practical Nurse (LPN)-H revealed Resident 1 had a hospitalization in early October 2025 and was admitted with Covid-19 (a respiratory infection) and a bladder infection. The resident was in the hospital for a couple of days and returned to the facility. Interview with the Social Services Director on 12/10/25 at 9:30 AM confirmed the facility did not have evidence Resident 1 or the resident representative was offered a bed hold when the resident was transferred to the hospital.

Licensure Reference Number 175 NAC 12-006.09BBased on record review and interview; the facility failed to accurately code Resident 8's assessment related to Pre-admission Screening and Resident Review (PASRR) status. The sample size was 1 and the facility census was 40. Findings are: Review of the facility policy Preadmission Screening last revised 4/2021 revealed the following: -the facility would not admit any new residents with a mental illness until unless the State Mental Health Authority had determined, based on an independent physical and mental evaluation performed by a person or entity other than the State Mental Health Authority prior to admission,-because of the physical and mental condition of the individual, the individual required the level of services provided by a nursing facility, -if the individual required such level of services, whether the individual required specialized services for mental retardation,-a PASRR would be completed on every resident upon admission and as needed per the Resident Assessment Instrument (RAI- a guide on how to use the Minimum Data Set (MDS) to create individualized care plans) instructions,-Based upon the assessment, the facility would ensure proper referral to appropriate State agencies for the provision of specialized services to residents with MI/MR,-Social Services would contact the appropriate State Agency for referral of specialized care and services the resident may require, and-Care Plans would be updated to reflect any specialized services needed. Review of Resident 8's MDS dated [DATE] revealed the resident was admitted [DATE]; had moderate cognitive impairment; limitation in upper and lower extremities for range of motion; was dependent on staff for toileting, dressing, personal hygiene, and mobility; diagnoses included Cancer, High Blood Pressure, paralysis affecting one side of the body, Seizures, Anxiety, Depression and Psychotic Disorder. Review of Resident 8's Comprehensive MDS dated [DATE] revealed the resident did not have a PASRR Level II Determination. Review of Resident 8's Care Plan, undated revealed the resident had impaired cognitive function related to a Traumatic Brain Injury; had mood disturbance related to depression, anxiety, and behaviors such as resistive with cares and required assistance with toileting, mobility, dressing, and hygiene. Review of Resident 8's PASRR Level II Determination dated 5/2/23 revealed the resident was found to have an Intellectual Disability or a related condition. Further review revealed the resident required and was appropriate for nursing facility services. Interview on 12/10/25 at 11:55 AM with the Director of Nursing confirmed the residents PASRR dated 5/2/23 stated Resident 8 had an intellectual Disability. Further interview confirmed the Comprehensive MDS assessment dated [DATE] was not coded accurately to reflect Resident 8's Level II PASRR Determination.

Licensure Reference Number 175 NAC 12-006Based on record review and interview; the facility staff failed to ensure the accuracy of the posted nursing staff hours (the total number of staff and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses (RN), Licensed Practical Nurses (LPN) Certified Medication Aide (CMA) and Certified Nurse Aides (CNA). The total sample size was 18 and the facility census was 40.Findings are:A. Review of the staff posting for 12/08/25 revealed the following:-From 6 AM to 2 PM there were 2 RN's, 2 LPN's and 6 CNA's or CMA's. The nursing schedule revealed that there were 2 LPN's and 6 CNA's that took care of the residents.-From 2 PM to 10 PM there were 2 LPN's and 5 CNA's/CMAs. The nursing schedule revealed that there were 2 LPN's and 5 CNA/CMA's that took care of the residents.-From 10 PM to 6 AM there was 1 LPN and 2 CNA/CMAs. The nursing schedule revealed that there were 1 LPN and 2 CNA/CMA's that took care of the residents. Review of the staff posting for 12/09/25 revealed the following:-From 6 AM to 2 PM there were 3 RN's, 3 LPN's and 5 CNA's/CMAs. The nursing schedule revealed that there were 2 LPN's and 5 CNA's that took care of the residents.-From 2 PM to 10 PM there were 1 RN, 1 LPN and 7 CNA's/CMAs. The nursing schedule revealed that there were 1 RN, 1 LPN and 7 CNA/CMA's that took care of the residents.-From 10 PM to 6 AM there was 1 RN and 2 CNA/CMAs. The nursing schedule revealed that there was 1 RN and 2 CNA/CMA's that took care of the residents. An interview on 12/09/25 at 3:15 PM with the Director of Nursing (DON) and the Administrator confirmed the following regarding the staff posting of hours:-Professional Nursing hours (RN and LPN) posted were the hours of all the RN's and LPN's working that day in the facility, this was not completed correctly and -hours that staff worked in the Assisted Living Facility (ALF) were not removed from the posted nursing staff hours and should have been.

Licensure Reference number 175 NAC 12-006.04D2 Based on record review and interview; the facility failed to ensure the Dietary Manager (DM) held the required certification credentials for the position or employed a full time dietician. In addition, the facility failed to ensure staff had received training and/or were competent to serve as a cook at the facility. This had the potential to affect all residents that resided in the facility and who ate food from the kitchen. The facility census was 44.Findings are: A. Review of the facility Job Description for the DM revealed the following regarding the essential duties and responsibilities for the position of a DM: -plans, develops, organizes, implements, evaluates and directs the Dietary Department, its programs and activities.-receives frequently scheduled consultations from a qualified dietician/nutritional professional.-develops and maintains written dietary policies and procedures.-interviews residents or family members as necessary to obtain diet history, visit residents periodically to evaluate the quality of meals served, likes and dislikes.-ensures the menus are maintained and filed in accordance with established policies and procedures. -ensures dietary staff are properly orientated and trained.The following qualifications were identified for the position:-must possess at a minimum, a high school diploma.-must have as a minimum, 2 years of experience in a supervisory capacity in a hospital, skilled nursing care facility or other medically related facility.-must have training in cost control, food management and diet therapy. If the DM is not a qualified Dietician or Nutrition Professional, the individual must:-be a Certified DM, Certified Food Service Manager or has a similar national certification from a national certifying body for food service management and safety; or-have an Associate Degree or higher in food service management or in hospitality, if the course study from an accredited institution includes food service or restaurant management; and-meets state requirements for food service managers or dietary managers in states that have such established requirements. B. Review of the facility Job Description for a Dietary [NAME] revealed the cook was to prepare food in accordance with current applicable federal, state and local standards, guidelines and regulations, with established policies and procedures and as may be directed by the Dietary Supervisor, Administrator and Dietician to ensure that quality food service was always provided. The following essential duties were identified:-ensure that menus are maintained and filed in accordance with established policies and procedures.-assist in establishing food service production line to assure that meals are prepared on time.-prepare meals in accordance with planned menus. -prepare and serve meals that are palatable and appetizing in appearance. -prepare and serve substitute foods to residents who refuse foods served. -follow established Infection Control and Universal Precautions policies. C. Interview with Dietary [NAME] (DC)-L on 10/1/25 at 9:35 AM revealed the facility Operations Manager (OM) was currently fulfilling the role of DM as the previous DM had quit a month ago and a new DM had not been hired. In addition, DC-L revealed the facility had been very short staffed in the dietary department and the OM had also been working as a cook to fill in shifts as needed. D. Review of the facility Month at a Glance noon meal menu for 10/1/25 revealed the noon meal was listed as breaded chicken patty on a bun, mini baker potatoes, cream gravy, country trio vegetables, bread with margarine and flamingo cake. Observation of the noon meal service on 10/1/25 from 11:45 AM to 1:27 PM revealed the residents were served Salisbury steak, au gratin potatoes, country trio vegetables, white gravy, and a cookie. An interview with DC-L on 10/1/25 at 12:09 PM revealed the facility was not following the preapproved/planned menus as the OP was ordering the food for the kitchen and had failed to order enough food for the designated menus. DC-L had replaced items on the menu with food that was available in the facility freezers and storeroom.E. Review of the facility Dietary schedule for 9/1/25 to 9/30/25 revealed the following:-9/5/25 the OM served as the evening cook.-9/6/25 the OM served as the day shift cook.-9/7/25 the OM served as the day shift and the evening shift cook.-9/13/25 the OM served as the day shift cook. F. An interview on 10/2/25 at 9:30 AM with the facility OM confirmed the following:-currently worked in the capacity of the interim DM. The previous DM had left last month, and the facility had been unable to hire another DM.-the OM had not had any training related to the DM position or as a cook and had not consulted with the Registered Dietician regarding menu changes.-the facility has struggled with the staffing in the kitchen and the Interdisciplinary Team (IDT) was helping with the Dietary Aide position and had training regarding safe dishwasher temperatures and the completion of the dishwasher temperature logs.

Licensure Reference: 175 NAC 12-006.11A1 Based on observation, interview, and record review, the facility failed to follow planned menus for all residents who consumed food from the facility kitchen. The facility had a total census of 44 residents.Findings are:Review of the facility Month at a Glance noon meal menu for 10/1/25 revealed the noon meal was listed as breaded chicken patty on a bun, mini baker potatoes, cream gravy, country trio vegetables, bread with margarine and flamingo cake. Observation of the noon meal service on 10/1/25 from 11:45 AM to 1:27 PM revealed the residents were served Salisbury steak, au gratin potatoes, country trio vegetables, white gravy, and a cookie. An interview with Dietary [NAME] (DC)-L on 10/1/25 at 12:09 PM revealed the facility was not following the preapproved/planned menus as the Operations Manager (OM) was ordering the food for the kitchen and had failed to order enough food for the designated menus. DC-L had replaced items on the menu with food that was available in the facility freezers and storeroom.An interview on 10/2/25 at 9:30 AM with the facility OM confirmed the following-currently worked in the capacity of the interim Dietary Manager (DM). The previous DM had left last month, and the facility had been unable to hire another DM. -the OM had not had any training related to the DM position or as a cook and had not consulted with the Registered Dietician regarding menu changes.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11D Based on observations, record review and interviews; the facility failed to ensure that hot foods were served at a palatable temperature for facility residents. This had the potential to affect all 24 residents in the facility that ate food served out of the kitchen. The facility census was 44. Findings are: A. Review of the facility policy Food Temperatures (undated) revealed it was the policy of this facility to take and record food temperatures for each meal to ensure food was served at the proper temperature. The following guidelines were to be followed:-food temperatures were to be recorded on all items prepared in the dietary department.-hot food items were to be maintained at 135 degrees Fahrenheit (F) or higher.-food that was cooked and then cooled was to be reheated so that all parts of the food reached an internal temperature of 165 degrees (F). B. Review of a Food Temperature Log from 8/31/25 to 9/6/25 revealed no evidence food temperatures were obtained and/or recorded for the breakfast, noon, and the evening meals from 8/31/25 to 9/6/25. Review of Food Temperature Log form 9/7/25 to 9/13/25 revealed the following:-breakfast meal no temperatures were documented on 9/7, 9/10, 9/11, 9/12 and on 9/13.-noon meal no temperatures were documented on 9/7, 9/9, 9/10, 9/11, 9/12 and on 9/13.-evening meal no temperatures were documented on 9/8, 9/9, 9/10 and on 9/13. Review of a Food Temperature Log from 9/14/25 to 9/20/25 revealed the following:-breakfast meal no food temperatures were documented on 9/14, 9/15 and on 9/20.-noon meal no temperatures were documented on 9/14, 9/15, and on 9/20.-evening meal no food temperatures were documented on 9/14, 9/15, 9/16, and on 9/18. Review of a Food Temperature Log from 9/21/25 to 9/27/25 revealed the following:-breakfast meal no food temperatures were documented on 9/21 and on 9/26.-noon meal no temperatures were documented on 9/21 and on 9/26.-evening meal no food temperatures were documented on 9/21, 9/22, and on 9/27. Review of a Food Temperature Log from 9/28/25 to 10/1/25 revealed the following:-breakfast meal no temperatures were documented on 9/29.-noon meal no temperatures were obtained on 9/29.-evening meal no food temperatures were obtained on 9/29 and on 9/30. C. During the service of the noon meal on 10/1/25 from 11:45 AM to 1:27 PM the following was observed:-12:28 PM Dietary [NAME] (DC)-L removed a hot dog stored on a plate from the kitchen refrigerator. DC-L put the plated hot dog into the microwave for 55 seconds and then placed the hot dog into a bun with ketchup. The hot dog was sent out of the kitchen without checking the temperature of the item to ensure palatability before serving.-12:41 PM DC-L placed soup into a bowl from a container which had been stored in the refrigerator. The soup was then placed into the microwave for 1 minute. Without obtaining a temperature of the food item to ensure palatability, the bowl of soup was served out of the kitchen. -12:43 PM DC-L removed another hot dog from the refrigerator, which was already stored on a plate, heated in the microwave for 50 seconds and then placed into a bun with mustard/ketchup. DC-L failed to obtain a temperature of the food item before it was served to the resident. During an interview on 10/1/25 at 12:55 PM, DC-L confirmed the failure to obtain the temperature of the hot dogs and soup served at the noon meal. DC-L further confirmed all food items were to have a temperature obtained and then recorded prior to serving. If a food item had been pre-cooked and then refrigerated, the food should have a reheated temperature of 165 degrees (F) to ensure palatability. In addition, DC-L identified the staff had failed to obtain and/or document food temperatures at meals at times throughout the month of September due to staffing concerns.

Licensure Reference Number 175 NAC 12-006.04(D) Based on record review and interview; the facility failed to ensure timely call light response times for residents 4, 1, and 2. The facility census was 44 and the sample size was 4. Findings are:A. Review of the facility policy Resident Call Light Policy last reviewed 9/2025 revealed the following: -the purpose was to ensure all residents had timely access to assistance by maintaining functional, accessible, and responsive call light system in accordance with federal and state regulations, -call lights would be installed at each resident's bedside, in bathrooms, bathing areas, and in commons areas, -call lights would be within reach of the residents, -staff were to respond to call lights as timely as possible when activated, and -staff were to report and malfunctioning call lights immediately to the maintenance supervisor. B. Review of Resident 4's Care Plan, last revised 8/28/25 revealed the resident was cognitively intact; diagnoses included: Pressure Ulcers, Diabetes, Quadriplegia (paralysis or severe weakness in all four limbs); and Contracture of Muscle (a permanent tightening of muscles that limits range of motion and can cause deformity); and the resident was dependent on staff for toileting, transfers, mobility, and dressing. Review of the facility form Incident List with call light response times revealed the following call light time frames: -9/2/25 from 7:14 PM to 8:35 AM (1 hr, 20 min, 50 sec), -9/9/25 from 4:25 PM to 4:40 PM (14 min, 36 sec), -9/11/25 from 10:16 PM to 10:30 PM (13 min, 51 sec), -9/12/25 from 9:20 AM to 9:37 AM (16 min, 7 sec), -9/12/25 from 6:06 PM to 6:17 (11 min, 12 sec), -9/12/25 from 9:25 PM to 9:40 PM (15 min, 44 sec), -9/12/25 from 10:31 PM to 10:42 PM (11 min, 43 sec), -9/14/25 from 10:24 PM to 10:39 PM (14 min, 57 sec), -9/15/25 from 2:34 PM to 3:14 PM (40 min, 10 sec), -9/15/25 from 3:31 PM to 3:48 PM (17 min, 5 sec), -9/16/25 from 4:02 AM to 4:28 AM (21 min, 1 sec), -9/16/25 from 3:28 PM to 3:44 PM (16 min, 4 sec), -9/25/25 from 6:14 PM to 6:27 PM (13 min, 18 sec), -9/26/25 from 6:16 PM to 6:48 PM (32 min, 42 sec) -9/27/25 from 8:17 PM to 8:32 PM (15 min, 2 sec), -9/28/25 from 7:50 AM to 8:08 AM (17 min, 59 sec), -9/28/25 from 11:02 PM to 11:34 PM (32 min, 17 sec), and -9/30/25 from 8:02 AM to 8:15 AM (13 min, 0 sec). Interview on 10/1/25 at 1:45 PM with Resident 4 revealed call lights are not always answered timely, sometimes they wait an hour. Further interview revealed wait times were worse in the evenings. C. Review of Resident 1's current Care Plan dated 2/28/25 revealed the resident had an activity of daily living deficit related to diagnosis of heart failure. The following interventions were identified:-encourage use of the call light.-resident dependent with bathing and bathing transfers.-assist with toileting transfers and hygiene as needed due to bladder incontinence. During an interview on 10/2/25 at 11:00 AM, Resident 1 indicated the facility did not have enough staff, especially on the evening shift. Resident 1 reported it took up to 30 minutes at times for the staff to respond to the resident's call light. Review of Resident 1's call light response times from 9/1/25 to 9/30/25 revealed the following: -9/26/25 the call light was on from 11:11 AM to 11:41 AM (30 minutes, 31 seconds). -9/26/25 the call light was on from 6:23 PM to 6:53 PM (30 minutes, 7 seconds). D. Review of Resident 2's undated, current Care Plan revealed the resident required assistance with cares related to diagnosis of Spina Bifida (a neural tube birth defect where the spinal cord does not close completely during pregnancy) and paraplegia (a medical condition characterized by the partial or complete loss of motor and sensory function in the lower half of the body, including both legs). The following interventions were identified: -the resident can transfer self independently from the bed to the wheelchair with set-up assistance from the staff. -does not use the toilet or the bedpan. The resident is unable to sense when needing to use the bathroom. Staff check and change every 2 hours. -dependent with toileting hygiene. -encourage use of call light to seek staff assistance. -setup assist and cues with personal hygiene. -dependent on staff for dressing and undressing. Review of a Grievance Resolution Form dated 8/27/25 at 12:10 PM revealed Resident 2 had a concern related to call light response times. The resident indicated on 8/23/25 the resident placed on the call light at 6:58 PM to have the resident's room tray picked up. The resident indicated the call light was not answered until 7:54 PM (56 minutes later). The resident indicated the call light was left on for longer periods of time when certain staff members were working. Further review of the form revealed no evidence that an investigation was completed or a corrective action developed to address the residents' concern. An interview with the resident on 10/1/25 at 10:40 AM confirmed the following: -normally receives a room tray for breakfast and the evening meal. -does not feel enough staff available as has waited up to an hour at times for the staff to respond to the call light, especially on the evening shift. -has filled out a grievance form related to call lights but did not see any changes as a result. Review of Resident 2's call light response times from 9/1/25 to 9/230/25. -9/1/25 the call light was on from 10:00 AM to 10:31 AM (31 min, 6 sec). -9/1/25 the call light was on from 1:41 PM to 1:58 PM (17 min, 43 sec). -9/1/25 the call light was on from 5:29 PM to 5:52 PM (23 min, 3 sec). -9/1/25 the call light was on from 7:37 PM to 8:00 PM (22min, 33 sec). -9/3/25 the call light was on from 1:52 PM to 2:10 PM (17 min, 24 sec). -9/3/25 the call light was on from 5:21 PM to 6:01 PM (40 min, 32 sec). -9/4/25 the call light was on from 10:12 AM to 10:23 AM (11 min, 9 sec). -9/4/25 the call light was on from 10:23 PM to 10:47 PM (23 min, 55 sec). -9/5/25 the call light was on from 10:58 AM to 11:26 AM (27 min, 59 sec). -9/7/25 the call light was on from 7:22 PM to 8:11 PM (48 min, 45 sec). -9/10/25 the call light was on from 8:02 PM to 8:22 PM (20 min, 38 sec). -9/11/25 the call light was on from 2:48 PM to 3:04 PM (16 min, 17 sec). -9/11/25 the call light was on from 10:15 PM to 10:31 PM (16 min, 5 sec). -9/12/25 the call light was on from 10:00 AM to 10:13 AM (13 min, 3 sec). -9/12/25 the call light was on from 1:57 PM to 2:14 PM (17 min, 13 sec). -9/12/25 the call light was on from 7:43 PM to 8:09 PM (25 min, 54 sec), -9/14/25 the call light was on from 12:26 PM to 12:37 PM (11 min, 15 sec). -9/24/25 the call light was on from 7:51 PM to 8:35 PM (43 min, 52 sec). -9/25/25 the call light was on from 7:55 PM to 8:15 PM (20 min, 11 sec). -9/26/25 the call light was on from 9:25 AM to 10:00 AM (34 min, 47 sec). -9/26/25 the call light was on from 10:17 AM to 10:31 AM (13 min, 44 sec). -9/26/25 the call light was on from 6:03 PM to 6:50 PM (47 min, 3 sec). -9/27/25 the call light was on from 11:00 AM to 11:10 AM (10 min, 45 sec). -9/27/25 the call light was on from 11:24 PM to 11:43 PM (19 min, 8 sec). -9/28/25 the call light was on from 7:50 PM to 8:06 PM (16 min, 3 sec). -9/29/25 the call light was on from 10:07 AM to 10:19 AM (12 min, 38 sec). -9/29/25 the call light was on from 5:17 PM to 5:47 PM (29 min, 58 sec). -9/29/25 the call light was on from 7:34 PM to 7:49 PM (15 min, 6 sec), and -9/30/25 the call light was on from 8:13 PM to 8:30 PM (16 min, 39 sec). Interview on 10/2/25 at 2:50 PM with the Administrator confirmed call lights were to be answered within 10 minutes, and further interview confirmed the call lights on the Incident List were not answered within the expected time frame.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(H)Based on record review and interview; the facility failed to report an allegation of potential staff to resident abuse to the State Agency for 1 (Resident 2) of 4 sampled residents. The facility census was 44. Findings are:A. Review of the facility policy Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment with a reviewed date of 12/2023 revealed it was the policy of the facility that each resident had the right to be free from abuse, neglect, misappropriation of property, exploitation, and mistreatment. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility would:-ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin and misappropriation of resident property were reported immediately but not later than 2 hours after the allegation was made if the events that cause the allegation involved abuse or resulted in serious bodily injury and not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury.-ensure all alleged allegations were reported to the Administrator of the facility, the State Agency, and Adult Protective Services (APS). B. During an interview on 10/1/25 at 10:40 AM, Resident 2 identified feeling threatened by the Operations Manager (OM) of the facility. The resident reported being told if the resident did not take steps to resolve an outstanding bill, the facility would give the resident a 30 day notice. The facility would assist Resident 2 with trying to find an alternate facility, but if no one would accept the resident, then the OM would drop the resident with the resident's medications at a homeless shelter. The resident indicated telling the Social Service Director (SSD) about feeling threatened by the OM. Review of facility investigations from 10/3/24 to 10/1/25 revealed no evidence Resident 2's allegation of verbal abuse was reported to the State Agency. An interview with the SSD on 10/2/25 at 9:10 AM confirmed on 8/10/25 at 2:22 PM, the resident notified the SSD the resident had felt threatened by the OM and did not want to be placed at a Homeless Shelter. The SSD indicated feeling the resident was verbally abused. The SSD, however, failed to report this allegation of potential abuse to the State Agency and failed to notify anyone else at the facility about this allegation. During an interview on 10/2/25 at 11:00 AM, the OM confirmed telling Resident 2 if the resident's bill was not resolved, the facility would issue the resident a 30 day notice. The OM further confirmed if the resident could not find placement with another facility, the OM's plan was to take the resident to a homeless shelter with the resident's medications.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(H)Based on record review and interview; the facility failed to investigate an allegation of potential staff to resident abuse and to submit the results of the investigation to the State Agency within the required timeframe for 1 (Resident 2) of 4 sampled residents. The facility census was 44. Findings are:A. Review of the facility policy Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment with a reviewed date of 12/2023 revealed it was the policy of the facility that each resident had the right to be free from abuse, neglect, misappropriation of property, exploitation, and mistreatment. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility would:-ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin and misappropriation of resident property were reported immediately but not later than 2 hours after the allegation was made if the events that cause the allegation involved abuse or resulted in serious bodily injury and not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury. -ensure all alleged allegations were reported to the Administrator of the facility, the State Agency, and Adult Protective Services (APS).-ensure that the results of all investigations were reported within 5 working days of the incident to the Administrator and the State Survey Agency. B. During an interview on 10/1/25 at 10:40 AM, Resident 2 identified feeling threatened by the Operations Manager of the facility. The resident reported being told if the resident did not take steps to resolve an outstanding bill, the facility would give the resident a 30 day notice. The facility would assist Resident 2 with trying to find an alternate facility, but if no one would accept the resident, then the OM would drop the resident with the resident's medications at a homeless shelter. The resident indicated telling the Social Service Director (SSD) about feeling threatened by the OM.Review of facility investigations from 10/3/24 to 10/1/25 revealed no evidence Resident 2's allegation of verbal abuse was reported to the State Agency. An interview with the SSD on 10/2/25 at 9:10 AM confirmed on 8/10/25 at 2:22 PM, the resident notified the SSD the resident had felt threatened by the OM and did not want to be placed at a Homeless Shelter. The SSD indicated feeling the resident was verbally abused. The SSD, however, failed to notify the facility Administrator and to initiate an investigation of the resident's abuse allegation. During an interview on 10/2/25 at 11:00 AM, the OM confirmed telling Resident 2 if the resident's bill was not resolved, the facility would issue the resident a 30 day notice. The OM further confirmed if the resident could not find placement with another facility, the OM's plan was to take the resident to a homeless shelter with the resident's medications. During an interview on 10/2/25 at 12:48 PM the facility Administrator confirmed no investigation was completed and/or submitted to the State Agency regarding Resident 2's allegation of verbal abuse as the Administrator was unaware of the allegation.

Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, record review, and interview; the facility failed to store foods to prevent the potential for food borne illness and assure food safety as staff and/or resident food items were stored in a resident refrigerator without a label and date; This had the potential to affect all residents that ate from the facility kitchen. The facility census was 38. Findings Are: Review of the Nebraska Food Code based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service and sanitation practices revealed the following: -2-401.11(A) an employee shall eat, drink . in designated areas where the contamination of exposed food; clean equipment, utensils, and linens; unwrapped single-service and single-use articles; or other items needing protection cannot result. -3-201.11(C) Packaged Food shall be labeled as specified by law, including 21 CFR 101 Food labeling, 9 CFR 317 Labeling, Marking Devices, and Containers and 9 CFR 381 Subpart Labeling and Containers. -3-501.17 of the Food Code, refrigerated, ready to eat, time/temperature control for safety food prepared and held in a food establishment for more than twenty-four hours shall be clearly marked to indicate the date of preparation. Observation conducted during the initial kitchen tour on 9/30/24 at 10:34 AM with Dietary Aide (DA)-G, revealed the following items in the resident refrigerator which were stored without a label and/or a date and without identification as to which resident the items belonged to: -A juice-like drink in a 24-ounce clear plastic container. -2 containers with tomatoes. -A sandwich in plastic wrap. -A container with peppers, onions, chicken legs and squash. During an interview on 10/2/24 at 3:00 PM, the facility Operations Manager confirmed items stored in the kitchen refrigerators should be labeled and dated.

Licensure Reference Number 175 NAC 12-006.05(B) Based on record review and interview, the facility failed to provide Resident 36 and/or the resident's representative, bed hold information when the resident was transferred to the hospital. The sample size was 1 and the facility census was 38. Findings are: A. A record review of the facility's Bed Hold policy (revision date of 12/23) revealed the facility was to provide written information to the resident and/or the resident representative regarding the right to exercise the bed hold provision of 15 days at admission and then provide an additional notice before transferring to a general acute care hospital or before the resident went on a therapeutic leave. In the event of an emergency transfer, the additional notice was to be provided within 24 hours. The written information to be given to the resident and/or representative included the following: -The duration of the state bed-hold, if any, during which the resident was permitted to return and resume residence in the facility. -The reserve bed payment policy in the state plan if any. -The facility policy regarding bed-hold periods to include permitting residents to return to the next available bed. -Conditions upon which the resident would be able return to the facility. B. A record review of Resident 36's nursing progress notes revealed the following: -9/10/2024 at 3:39 AM the resident reported to the direct care staff that something was wrong and wanted the nurse. Upon assessment, the resident had an irregular respiratory rate and pulse with complaints of difficulty breathing. The resident requested to be evaluated in the emergency room . -9/10/2024 at 7:15 AM the facility received notification the resident was admitted to the hospital. -9/12/24 at 1:45 PM the facility received notification the resident was to be discharged from the hospital and was to return to the facility. A record review of Resident 36's medical record from 9/10/24 to 9/12/24 revealed no evidence the resident or the resident's representative were notified of the facility bed hold policy. During an interview on 10/02/24 at 10:19 AM, the Administrator confirmed the facility had no documented evidence that Resident 36 or their representative were provided with the required bed hold information when discharged to the hospital from 9/10/24 to 9/12/24.

Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on interview and record review; the facility failed to ensure Resident 30's Care Plan was revised to address suicidal ideation and failed to include mood and behavior interventions in the Care Plan for Resident 35. The sample size was 15 and the facility census was 38. Findings are: A. Review of the facility's undated Care Plan policy revealed that care plans were modified between care conferences and when appropriate to the resident's current needs, problems, and goals. This included: -A significant change in the resident's condition, -a change of planned interventions, -new goals were established, -new diagnosis, medication, or abnormal labs, and -revisions that involved the care of other disciplines were done through consultative and collaborative efforts and documented. B. Review of Resident 30's Minimum Data Set (MDS, federally mandated comprehensive assessment tool used to develop resident care plans) dated 9/6/24 revealed the resident had intact cognitive functioning, had complex medical conditions including hemiplegia (partial or complete paralysis on one side of the body), diabetes, hypertension, and vascular (blood circulation) disease. The resident was mildly depressed, always felt socially isolated and had chronic pain. In addition, the resident was dependent for bathing, toileting hygiene, and bed mobility, and received substantial assistance with dressing. A record review of Resident 30's Care Plan with a revision date of 7/14/24 revealed the resident had chronic pain and used antidepressant medication. There was no indication the Care Plan addressed the resident's comments of self-harm or include interventions related to the residents comments of self-harm. A record review of Resident 30's progress notes revealed the following: -On 9/21/24 at 9:48 PM The resident had requested arsenic or cyanide to get this over with. In addition, the resident requested a knife and stated, All I need is a butter knife through my skull. The nurse implemented 15-to-30-minute checks and notified the Director of Nursing (DON). The DON directed the staff to use plastic silverware and notify the physician. During an interview on 10/03/24 at 9:21 AM the DON confirmed that Resident 30's Care Plan did not address the Resident's suicidal ideation, or the interventions put in place for the resident's safety (15-to-30 minute checks and plastic silverware). 45739 C. A record review of Resident 35's MDS dated [DATE] revealed the resident was cognitively intact, had diagnoses of depression, spine narrowing, heart disease and stroke, and the mood assessment indicated the resident had felt down, depressed or hopeless nearly every day; had trouble falling or staying asleep, or was sleeping too much nearly every day; felt tired or had little energy nearly every day; felt bad about themselves or that they were a failure or let their family down nearly every day; had thoughts that they were better off dead, or of hurting themselves in some way nearly every day, the resident had pain almost constantly rated 9 out of 10, had limited range of motion, and was dependent with toileting, lower body dressing and required maximal assistance with upper body dressing, and hygiene. A record review of Resident 35's Care Plan last revised 9/3/24 revealed the resident required assistance with hygiene, dressing, transfers, and toileting; had a history of a stroke; had depression with interventions to encourage to express feelings, monitor/document/report signs or symptoms of depression and provide the resident gaming time. There was no documentation to show the facility addressed the resident had thoughts they were better off dead, or of hurting themselves. A record review of the facility facsimile form Physician Fax regarding Resident 35 dated 5/21/24 revealed the resident was interviewed and revealed they had no plan of hurting themselves. The facility had interventions to increase staff 1:1 to four times per week, encourage the resident to go outside daily for 15-20 minutes, and continue to encourage the resident to go to the dining room for meals. Interview on 10/3/24 at 11:20 AM with the DON confirmed Resident 35's Care Plan did not address Resident 35's thoughts that they were better off dead or of hurting themselves. Further interview confirmed the interventions indicated on the fax were not implemented onto the Care Plan.

Licensure Reference Number 175 NAC 12-006.09(H) Based on observations, record review and interview; the facility staff failed to identify and/or monitor bruising and to evaluate causal factors related to the bruise for 1 (Resident 17) of 1 sampled resident. The facility identified a census of 38. Findings are: A record review of Resident 17's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 9/19/24 revealed the resident was admitted on [DATE] with diagnoses of stroke, hemiplegia (weakness or partial paralysis of 1 side of the body) and anemia. The facility staff assessed the following about the resident: -Severe cognitive impairment. -Substantial to maximal assistance required with bathing/showering, dressing, personal hygiene, bed mobility and transfers. -Always incontinent of bladder and frequently involuntary of bowel. A record review of Resident 17's current Care Plan (undated) revealed the resident was at risk for impairment to the resident's skin. Interventions included: -Monitor/document/report to the physician any changes in skin status, appearance, color, wound healing, signs of infection and wound size. -Weekly head to toe skin assessment. -Notify the Charge Nurse immediately of any new areas of skin breakdown; redness, bruising, blisters, and any discoloration noted with the resident's bath or with cares. -Encourage to turn and reposition and provide assist, as necessary. Observations of Resident 17 on 9/30/24 at 2:51 PM, and on 10/1/24 at 6:45 AM revealed the resident had a large bruise to the top of the resident's left hand. The bruise was yellow/green in appearance and completely covered the dorsal aspect of the resident's left hand. A record review of Weekly Skin Evaluations conducted on 9/24/24 at 8:27 PM and on 9/30/24 at 11:30 PM revealed documentation which indicated Resident 17 had no new skin issues noted. During an interview on 10/1/24 at 7:00 PM, Nurse Aide (NA)-B confirmed the bruising to the top of the resident's left hand was at least 1 week old. NA-B stated they had reported the bruise to the Charge Nurse a week ago when NA-B gave the resident a bath. NA-B was uncertain as to how the bruising had occurred. A record review of Resident 17's medical record which included Treatment Administration Records (TAR), Nursing Progress Notes, and Weekly Skin Evaluations revealed the bruising to the resident's left hand had not been identified and was not being monitored to ensure healing. In addition, there was no evidence the staff had evaluated causal factors to determine how the bruising had occurred. During an interview on 10/1/24 at 10:20 AM, Registered Nurse (RN)- I confirmed staff were to complete weekly skin evaluations on each resident to identify any new areas of skin breakdown and then were to continue to monitor/assess the areas weekly until resolved. RN-I indicated no knowledge regarding the bruising to Resident 17's left hand.

Licensure Reference Number 175 NAC 12-006.09 Based on interview and record review; the facility failed to ensure Resident 18's antianxiety medication had a duration for use/stop-date. The sample size was 5 and the facility census was 38. Findings are: Review of the facility's Psychotropic Medication policy with a revision date of 12/2023 revealed the following: -The facility ensured residents who had not used psychotropic (drug that affects how the brain works and causes changes in mood, awareness, thoughts, feeling, or behavior) drugs were not given those drugs, unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record, -Residents who used psychotropic drugs received gradual dose reductions and or behavioral interventions unless clinically contraindicated, -Psychotropic medications were not administered for the purpose of discipline or convenience and only administered when required to treat the resident's medical symptoms after nonpharmacological interventions had been attempted and failed, and -as needed (PRN) orders for psychotropic medications were limited to 14 days, and in order for psychotropic medication orders to be extended beyond 14 days, the provider documented the rationale and duration for the order. Review of Resident 18's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) dated 9/6/24 revealed the resident had severe cognitive impairment, had diagnoses of cancer, seizures, anxiety, depression, and a psychotic disorder; and was dependent in oral hygiene, toileting, dressing, and transfers. Review of Resident 18's Care Plan last revised 9/20/24 revealed the resident was at risk for seizures, was receiving hospice services, had severe cognitive impairment, required assistance with transfers, toileting, bed mobility, and dressing, and had anxiety with behaviors. Review of Resident 18's Medication Administration Records (MAR) for August and September 2024 revealed an order for Lorazepam (antianxiety medication) Concentrate every 6 hours PRN (as needed) for anxiety, shortness of breath, restlessness, or seizure activity. This order was started on 8/14/24 with no documented stop date or duration. Review of the facility form Medical Doctor (MD)/Nursing Communications dated 8/14/24 revealed an order for Lorazepam liquid for seizure activity every 6 hours PRN with no stop date or duration documented. Interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 10/3/24 at 9:50 AM confirmed as needed Lorazepam should have a stop date documented. Further interview with the DON on 10/3/24 at 11:20 AM confirmed Resident 18's as needed Lorazepam did not have a stop date documented.

Licensure Reference Number 175 NAC 12-006.10(D) Based on observations record review and interviews; the facility failed to ensure a medication error rate of less than 5%. Observations of 31 medications revealed 2 errors resulting in an error rate of 6.45%. The errors effected 2 (Resident 25 and 21) of 3 residents. The facility census was 38. Findings are: A. Review of the facility policy Administering Medications with a review date of 5/21 revealed the following: -Medications must be administered in accordance with the orders, including any required times. -Medications must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). -The individual administering the medication must check the label 3 times to verify the right resident, right medication, right dosage, right time, and right route before giving the medication. B. Review of the undated manufacturer's instructions for administration of an insulin pen revealed the following procedure should be completed: -To avoid air being injected and ensure the proper dose is administered, turn the dose selector to select 2 units. -Hold the insulin pen with the needle pointing up. Tap the cartridge gently with finger a few times to make any air bubbles collect at the top. -Keep the needle pointing upwards, press the push-button all the way in until the dose selector returns to zero. A drop of insulin should appear at the needle tip. If not, change the needle and repeat. Ensure the dose selector is set at zero after air is expelled. -Turn the dose selector to the number of units you need to inject and insert the needle into the skin. -Inject the dose by pressing the push button all the way in until the dose selector returns to zero. C. Review of Resident 25's physician orders revealed an order dated 8/7/25 for Insulin Glargine (medication used to treat diabetes) 15 units subcutaneously (applied under the skin) twice a day. Observation on 10/1/24 at 9:38 AM of Licensed Practical Nurse (LPN)-A preparing to administer Resident 25's Insulin Glargine 15 units subcutaneously per an insulin pen: -LPN-A held the pen sideways, then turned the dose selector to 15 units. -LPN-A injected the insulin into the resident's skin until the dose selector returned to zero. Interview with LPN-A on 10/1/24 at 10:00 AM confirmed the LPN failed to prepare the Glargine Insulin pen by expelling 2 units of potential air bubbles prior to selecting the ordered dose of insulin to prevent a medication error. D. Review of Resident 21's physician orders revealed an order dated 3/3/23 for Pantoprazole (medication used to treat heartburn and acid reflux) 20 milligrams daily. Review of Resident 21's medication label for Pantoprazole 20 milligrams revealed the medication was to be administered daily. In addition, the medication label indicated it was to be given 30 to 60 minutes before the meal. Observation of Registered Nurse (RN)-I preparing medications for Resident 21 on 10/2/24 at 8:01 AM, revealed RN-I administered Resident 21's Pantoprazole 20 milligrams. The resident was seated at the dining room table and was served their breakfast meal at 8:10 AM (9 minutes after the resident's Pantoprazole was administered). During an interview on 10/3/24 at 8:42 AM, RN-I confirmed Resident 21's Pantoprazole 20 mg was to be given 30-60 minutes before the resident was served their meal and had not been administered as ordered by the physician.

Licensure Reference Number NAC 175 12-006.18 Based on observation and interview; the facility failed to wear Personal Protective Equipment (PPE) as required to prevent the potential spread of infection, failed to store Resident 30's urinal to prevent the potential for cross contamination, failed to store oxygen equipment for Resident 34 to prevent the potential for cross contamination, and failed to change gloves and wash hands at the required intervals during the provision of incontinence cares for Resident 23. The total sample size was 17 and the facility census was 38. Findings are: A. Review of the facility policy Infection Control, last revised 10/22 revealed the following: -The elements of infection prevention and control program consisted of oversight, surveillance, data analysis, outbreak management, and prevention of infection, -The goals were to to decrease the risk of infections, identify and correct problems related to infection control, ensure compliance, and monitor personnel health and safety, -Under the infection control program, the facility would decide what measures would be applied in individual circumstances, and -The facility staff would conduct themselves and provide care in a way that would minimize the spread of infections. B. The following observations were made: -On 9/30/24 at 10:15 AM upon entering the facility a sign out front that read the staff were to be wearing masks and eye protection, -On 10/2/24 at 7:30 AM Registered Nurse (RN)-H was talking to a visitor in the facility and their mask was below their nose, -On 10/2/24 at 9:22 AM RN-H was observed pushing a resident in a wheelchair, RN-H stopped to talk to the resident and their mask was below their nose, -On 10/2/24 at 2:10 PM RN-H came out of a resident's room with their mask below their nose and their eye protection on top of their head, -On 10/3/34 at 8:10 AM RN-H was walking through the dining room (residents were eating breakfast) and their mask was below their nose, and -On 10/3/24 at 8:50 AM RN-H was in the dining room assisting a resident to eat their breakfast and the RN's mask was below their nose. An interview on 10/3/24 at 9:30 AM with the Infection Preventionist confirmed masks were to be worn covering the nose and the mouth. An interview on 10/3/24 at 9:35 AM with the Director of Nursing (DON) confirmed RN-H was not wearing their mask correctly. 51391 C. Review of the facility policy Respiratory Equipment Cleaning & Storage with a revision date of 2/2019 revealed the following: -It was the policy of the facility to maintain respiratory therapy equipment in a clean and sanitary manner and to use tubing, masks, and cannulas (the nasal cannula end of the tubing fits into your nose and is the most common delivery accessory) for residents receiving therapy. -When licensed staff removed treatment, the tubing would be covered or stored in a bag. D. Review of the facility's Hand Hygiene Infection Control Policy with a revision date 10/2022 revealed the following: -It was the policy of the facility to provide the necessary supplies, education, and oversight to ensure healthcare workers performed hand hygiene based on accepted standards. -All personnel followed the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors. -Use of an Alcohol-Based Hand Rub (ABHR), containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: -before moving from a contaminated body site to a clean body site during resident care, -after contact with a resident's intact skin, -after contact with blood or bodily fluids, and -after removing gloves. E. The following observations of Resident 34's oxygen equipment from 9/30/24 through 10/2/24 revealed the following: -On 9/30/24 at 3:36 PM the oxygen tubing and nasal cannula (a device that delivers extra oxygen through a tube and into the nose) laid on the floor with no date on the tubing and no storage bag on the concentrator (takes air from your surroundings, extracts oxygen and filters the oxygen into purified oxygen for breathing). -On 10/1/24 at 7:55 AM the oxygen tubing and nasal cannula laid on the floor with no date on the tubing and no storage bag on the concentrator. -On 10/2/24 at 7:36 AM the oxygen tubing was hung over the side of the oxygen concentrator, and the oxygen cannula touched the floor. During an interview on 10/1/24 at 7:55 AM, Certified Nursing Assistant (CNA)-L confirmed Resident 34 wore oxygen at night, took the oxygen tubing off in the morning, staff shut the oxygen concentrator off and put the tubing in a white bag. CNA-L confirmed that there was no white bag on the side of the concentrator. An interview on 10/1/24 at 9:16 AM with Licensed Practical Nurse (LPN)-J confirmed that Resident 34 wore oxygen at night, took the oxygen tubing off, handed the tubing to staff or laid it on the resident lap, staff shut oxygen concentrator off and put the tubing in a white mesh bag. An interview on 10/2/24 at 7:36 AM with Resident 34 confirmed taking the oxygen tubing off and I either hand it to the staff or lay it on my lap. An interview on 10/2/24 at 10:30 AM with the DON, confirmed that the oxygen tubing with the nasal cannula should be stored in a bag on the side of the concentrator when not in use. F. During an observation of care for Resident 23 on 10/2/24 at 7:52 AM, CNA-B put gloves on, assisted the resident with sitting up on the edge of bed, dressing and hygiene. CNA-B transferred the resident with a mechanical stand-up lift, removed an incontinent brief (was wet), completed perineal cares (washing the genital and rectal areas of the body), put on a clean brief, pulled up the resident pants, transferred resident into wheelchair and then removed the gloves that had been worn throughout all cares provided. CNA-B made the resident's bed, straightened up the room and took out the trash and dirty linens. All tasks were completed without the benefit of hand hygiene. An interview on 10/2/24 at 2:45 PM with the DON confirmed that hand hygiene should be completed when staff enter a resident room, after gloves are removed from hands, when going from a dirty to a clean task, and before exiting the resident room. 42360 G. Review of Resident 30's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to develop resident care plans) dated 9/6/24 revealed the resident had intact cognitive functioning, had complex medical conditions including hemiplegia (partial or complete paralysis on one side of the body), diabetes, and hypertension and vascular (blood circulation) disease. The resident was mildly depressed, always felt socially isolated and had chronic pain. In addition, the resident was dependent for bathing, toileting hygiene, and bed mobility, and received substantial assistance with dressing. Review of Resident 30's Care Plan with a revision date of 7/14/24 revealed the resident was dependent on staff for cares, had a history of a stroke with hemiplegia (partial or complete paralysis on one side of the body), required the assistance of 1-2 staff to turn side to side in bed, was dependent for transfers using a mechanical lift, was dependent for dressing, and dependent for toileting hygiene. During observations of Resident 30 from 9/30/24 through 10/3/24 the following was identified: -On 9/30/24 at 1:35 PM the resident was lying in bed, and a tray of food was present on the overbed table. There were also several cans of chips on another overbed table next to the resident. There was also a urinal with a small amount of urine in it sitting on the overbed table near the snacks. -On 9/30/24 at 3:25 PM the resident was lying in bed and there was an empty urinal on overbed table next to the resident's snacks. -On 10/1/24 at 6:50 AM the resident was lying in bed and a urinal was on the overbed table next to snacks. -On 10/1/24 at 9:10 AM the resident was sitting up in the bed talking on the telephone and a urinal was sitting on the bedside table beside a food tray. -On 10/2/24 at 7:01 AM the resident was lying in bed and a urinal was sitting on the overbed table next to a water pitcher and box of crackers. -On 10/3/24 at 7:45 AM the resident was lying in bed and the urinal was on the overbed table next to the water pitcher. During an interview on 10/2/24 at 10:30 AM RN-R confirmed that allowing Resident 30's urinal to be stored/kept on the overbed table next to the residents' water pitcher, food or snacks was not in line with the facility infection control practices.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on record review and interview; the facility failed to develop interventions to prevent a fall with injury for Resident 6 and to identify causal factors and then revise and/or develop new interventions to prevent ongoing falls for Resident 3. The sample size was 5 and the facility census was 31. Findings are: A. Review of the facility policy Fall Risk Assessment (revision date 5/07) revealed it was the policy of the facility to identify the resident at risk for falls and to initiate a preventative plan of care to reduce fall occurrence. Further review revealed any resident identified at high risk was to have a prevention protocol initiated and documented on the care plan and was to be referred to the rehabilitation team for further evaluation. B. Review of the facility policy Falls (revision date 5/07) revealed the facility was to evaluate the resident's extent of injury after a fall and attempt to prevent complications. The staff were to initiate neurological checks (assessment completed every 15 minutes for hour, every 30 minutes for 2 hours, every hour for 4 hours, every 4 hours for 16 hours and every 8 hours for 48 hours which determines the resident's level of consciousness, pupil response, motor functions, pain response and vital signs) if the fall was unwitnessed or the resident struck their head. Staff were to determine the cause of the fall and then update the care plan with appropriate interventions to prevent further falls. C. Review of Resident 6's Nursing Progress Notes revealed the resident was admitted on [DATE] at 12:15 PM. The resident was admitted from a rehabilitation hospital after previous falls with a traumatic brain injury and multiple traumas. Review of a Baseline Care Plan dated 10/5/20 revealed the following regarding Resident 6: -confused; -wore glasses with a patch due to double vision; -required 1 staff assist with transfers, dressing, personal hygiene, bed mobility and ambulation; and -at risk for falls with an intervention for a call light. Review of a Fall Risk assessment dated [DATE] revealed the resident was at high risk for falls due to current mental status, history of falls, poor vision, need for assistance with cares and current medications. Review of Resident 6's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 10/7/20 revealed diagnoses of traumatic brain dysfunction, visual disturbances, fractures to T5-T6 vertebra, unsteadiness on feet, anxiety, impulsiveness, restlessness and agitation. The assessment indicated the resident's balance was unsteady and the resident required staff assistance to stabilize. The resident did not have a condition or chronic disease that could result in a life expectancy of less than 6 months. Review of a Nursing Progress Not dated 10/6/20 at 3:39 AM revealed the resident was quick to stand up and unsteady when staff assisted with cares. Review of Nursing Progress Notes dated 10/7/20 revealed the following: -4:32 AM the resident has taken self to the bathroom and has not called for assistance; and -4:49 AM the resident was confused at times, was getting up independently and did not use the call light to make needs known. Review of a Nursing Progress Note dated 10/8/20 at 1:05 AM revealed the resident was found on the floor of the resident's room. On interview the resident did not know what had happened or what the resident was doing. The resident had abrasions to the right knee, the right outer ankle and on top of the 2nd right toe. Neurological checks were initiated. Review of Resident 6's Neurological Assessment Flowsheet dated 10/8/20 revealed the resident was assessed at 1:05 AM, at 1:20 AM and at 1:35 AM. Further review revealed at 1:50 AM, at 2:20 AM, at 2:50 AM at 3:20 AM, at 3:50 AM, at 4:50 AM and at 5:50 AM when the resident was to be reassessed, staff failed to complete an assessment as the resident was either asleep or was resting. When the resident was finally assessed at 6:50 AM (5 hours after the resident was to be assessed) the resident was complaining of back pain at a 9 out of 10. Review of Nursing Progress Notes dated 10/8/20 revealed the following: -9:30 AM, the Charge Nurse was called to the resident's room as the resident's oxygen saturation level was in the upper 70's to lower 80's. Oxygen was initiated at 2 liters per nasal cannula and when asked if having difficulty breathing the resident responded it just hurts when I take a deep breath. The physician was notified by facsimile (fax) of the resident's change of condition; -1:20 PM the resident was unable to follow simple commands and was striking out at staff. The staff was unable to obtain vital signs as the resident was continually moving. The resident's physician was called regarding the resident's decline in status. The physician was to call the facility back; -1:55 PM the resident was attempting to get out of the recliner and staff attempted to reposition. The resident was combative and striking out at staff; -2:00 PM a call was received from the resident's physician with a new order to transfer the resident to the emergency room ; -2:10 PM the resident was unresponsive and staff assisted into the resident's bed; and -2:15 PM the resident had no respirations or pulse. During interview on 1/6/21 at 9:30 AM, the Director of Nursing (DON) and the Administrator verified the following: -the resident was assessed as a high risk for falls with admission; -the resident's Base Line Care Plan identified a risk for falls with only an intervention for a call light; -staff failed to complete neurological assessments per facility policy after the resident's fall on 10/8/20; and -no further interventions were developed and/or implemented to prevent the resident's fall with injury on 10/8/20. D. Review of Resident 3's Electronic Medical Record revealed the following diagnoses; Parkison's Disease, Hypertension (elevated blood pressure), Diabetes, and Muscle Weakness. Review of Resident 3's MDS dated [DATE] revealed Resident 3 had significant cognitive impairment and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene cares. Review of Resident 3's Fall Risk Assessments dated 8/28/20 and 12/27/20 revealed the resident was a high risk for falls. Review of Resident 3's current undated care plan revealed the resident was at risk for falls related to balance problems with the following interventions in place; -be sure call light is within reach and encourage to use it (initiated 7/5/20); -occupational, physical, speech-language therapy evaluation and treatment per physician's order (initiated 7/5/20); -put up sign in room to remind the resident to use call light before trying to get up (initiated 7/6/20); -dycem (non-skid material) in recliner (initiated 7/15/20); -resident is receiving Physical, Occupational, and Speech-Language Therapy to continue strengthening, transfers, safety and cognition (initiated 7/21/20); -utilize a pressure alarm instead of tabs alarm on the resident (initiated 7/26/20); -put gripper socks on when resident is up in the recliner in the evening (initiated 9/6/20); -ensure resident's combs are on the bedside table next to resident (initiated 9/7/20); -keep resident's walker within reach (initiated 11/3/20); -toilet the resident after supper then bring to the nurses station for activity (initiated 9/30/20); and -use a weighted blanket as needed. Review of Resident 3's Progress Notes revealed the following: -9/10/20 at 3:15 A.M. a staff member heard a thud from Resident 3's room and found the resident sitting on the floor with feet facing toward the door; back facing toward the sink and the resident was leaning on the left hand. There was no documentation related to causal factors and no new interventions were noted; -9/18/20 at 5:55 P.M. Resident 3 was observed sitting on the floor in the doorway to the bathroom. The resident stated, I was going to the bathroom. No new interventions were noted; -9/24/20 at 3:25 P.M. Resident 3 was observed positioned on her buttocks sitting on the floor in front of the recliner. There was no documentation related to causal factors and no new interventions were noted; -9/29/2020 at 6:40 P.M. Resident 3's TABs alarm (a device attached to a person that sounds using an alarm to alert others when a person attempts to self-transfer) was going off. A staff member responded and observed the resident sitting on the floor in the room. The Resident stated, I was getting my water pitcher. The resident had obtained a small laceration to the back of the head. No new interventions were noted; and on -9/29/20 at 7:25 P.M. Resident 3 was found sitting on the floor in front of the recliner with legs tucked up to buttocks and leaning on left arm. The resident reported getting up to make a phone call and then fell . No injuries were noted and the resident was assisted back into the recliner. The staff member left the room briefly and when the staff member returned, the resident was sitting on the bed and had self-transferred from the recliner to the bed. No new interventions were noted. E. An interview with the administrator on 1/7/21 at 3:20 P.M. confirmed Resident 3 should have had new interventions developed/implemented and causal factors were not identified consistently. The administrator also added the facility was now using a new form to address these areas, but the form had not been developed until recently.