Every finding on record at Crowell Memorial Home

Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview and record review the facility failed to implement interventions identified on the care plan to prevent falls for 3 (Resident 1, 2 and 4) of 4 residents sampled. The facility census was 77. Findings are:Record review of the facility's undated policy titled Fall Prevention Program revealed the following:-each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. -the facility uses a standardized risk assessment for determining a resident's fall risk.-the risk assessment categorizes residents according to low, moderate or high risk.-for program purposes the facility utilizes High Risk protocols and Low/Moderate risk protocols. -upon admission the nurse will complete a fall risk assessment to determine the resident's level of risk.-the nurse will indicate the resident's fall risk and initiate interventions on the resident's care plan, in accordance with the resident level of risk. -the nurse will refer to the facility's High Risk or Low/Moderate Risk protocols when determining primary interventions. -Low/Moderate Risk Protocols: implement universal environmental interventions that decrease the risk of the resident falling, implement routine rounding schedule, monitor for changes in the resident's cognition, gait or balance, encourage resident's to use non slip footwear when ambulating, ensure eye glasses are in use if applicable, monitor vital signs in accordance with facility policy and complete a fall risk assessment every 90 days and as needed when the resident's condition changes. -High Risk Protocols: implement interventions from the Low/Moderate Risk Protocols, provide interventions that address unique risk factors measured by the risk assessment tool such as medications, cognitive status, psychological or functional status.-each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care.-interventions will be monitored for effectiveness and the care plan will be revised as needed. A.Record review of Resident 2's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 12-29-2025 revealed the facility staff assessed the following about the resident:-was rarely able to make self-understood.-was always incontinent of bowel and bladder.-required extensive assistance with toilet transfers-required total assistance with lower body dressing, personal hygiene, bed mobility and transfers from bed to chair.-had a fall with major injury-had a closed fracture of the pelvis. Record review of Resident 2's Comprehensive Care Plan (CCP) under the Category Activities of Daily Living (ADL) dated 09-15-2022 revealed Resident 2 required limited to extensive assistance with ADLs and required a Hoyer (a mechanical lift that utilizes a sling to the lift a person) for transfers at all times. Record review of Resident 2's Progress Notes (PN) dated 12-19-2025 at 9:47 PM revealed Resident 2 had fallen while being transferred from the toilet to the wheelchair, had complained of left knee pain and had been transferred to the emergency room. Record review of Resident 2's Incident and Investigation Form dated 12-19-2025 revealed the root cause of the fall was the Nursing Assistant (NA) transferred Resident 2 without a gait belt. Record review of Resident 2's CCP revealed the only method of transfer for Resident 2 was a Hoyer lift. Record review of Resident 2's PN dated 12-19-2025 revealed Resident 2 had returned to the facility at 10:45 PM and had a new order to change the band-aid to the left shin daily. Record review of Resident 2's PN dated 12-20-2025 revealed Resident 2 had complained of left hip pain and the facility staff noted the left leg was rotated inward and was shorter than the right leg. Resident 2 had been transferred to the hospital and was being admitted for a possible pelvic fracture. Record review of Resident 2's Emergency Department Course dated 12-20-2025 revealed Resident 2 had a second visit to the emergency room in 24 hours for a fall sustained on 12-19-25 while being assisted to the bathroom by the nursing home staff. The final impression was closed fracture of the left inferior pubic ramus (left side of the pelvis). Record review of Resident 2's After Visit Summary (AVS) dated 12-23-2025 revealed the primary diagnosis was a closed fracture of the pelvis. Record review of Resident 2's PN dated 12-23-2025 revealed Resident 2 had returned to the facility. An interview conducted with the Director of Nursing on 02-18-2026 at 1:30 PM confirmed Resident 2 had not been transferred properly and Resident 2 sustained a pelvic fracture. B. Record review of Resident 1's MDS dated [DATE] revealed the facility staff assessed the following about the resident:-was rarely able to make self-understood-required extensive assistance with eating-required total assistance with transfers, toileting, hygiene, dressing, bed mobility and bathing-was always incontinent of bowel and bladder Record review of Resident 1's CCP printed on 02-11-2026 revealed Resident 1 was at risk for falls related to medications increasing the risk for falls, ADL and mobility deficits, weakness, incontinence, decreased safety awareness and/or cognitive deficits. Resident 1's Fall Risk Score was 15. The goal identified Resident 1 would not sustain a serious injury should a fall occur through the review date of 03-06-2026. Approaches identified for the staff to utilize were:-place Resident 1 in bed for a nap after lunch dated 12-16-2025,-place Resident 1 in bed for a nap dated 12-17-2025,-Fall assessment upon admission, quarterly, annually and PRN (as needed) dated 12-05-2025,-Pharmacy to monitor medications increasing the risk for falls monthly and as needed dated 12-05-2025,-While Resident 1 is in [gender] w/c tilt the w/c back so she isn't sitting upright dated 12-05-2025,-Place in lounge for observation as Resident 1 desires dated 12-05-2025,-Resident 1 to be taken out of the dining area after eating dated 12-05-2025,-Assist with toileting prior to bedtime dated 12-05-2025,-Bolster mattress placed dated 12-05-2025,-Fall mat next to bed dated 12-05-2025,-Place body pillow next to Resident 1 on right side dated 12-05-2025,-Keep call light and frequently used items (i.e. Kleenex, water pitcher) within reach. dated 12-05-2025,-Assist with toileting and transfers as needed dated 12-05-2025. An observation conducted on 02-18-2026 at 1:00 PM revealed Resident 1 was lying in bed and the fall mat was leaning against the wall at the foot of the bed and the absence of a fall alarm. An interview conducted with Nursing Assistant (NA) C on 02-18-2026 at 1:05 PM confirmed that the fall mat was not next to the bed and the fall alarm had not been moved from the wheelchair to the bed and both should have been in place. C. Record review of Resident 4's MDS dated [DATE] revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored as a 15. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact.-required limited assistance with toileting, transfers, bathing and dressing.-required extensive assistance when going from sitting to standing.-required total assistance with shower transfers. -was occasionally incontinent of bladder.-required oxygen. Record review of Resident 4's CCP printed on 02-11-2026 revealed Resident 4 was at risk for falls related to: medications increasing the risk for falls, ADL and mobility deficits, weakness, and occasional incontinence of bowel or bladder. Resident 4's fall risk score was 13. On 02-09-2026 Resident 4's legs gave out and was lowered to the floor while ambulating to the bathroom with walker. The goal was Resident 4 would not sustain a serious injury if a fall occurs through the review date. The approaches listed were:- Approach start date: 02/09/2026 Transfer with gait belt to wheelchair, propel resident to bathroom, assist on toilet.-Approach start date 06-20-2025 -Fall assessment upon admission, quarterly, annually and PRN.-Pharmacy to monitor medications increasing the risk for falls monthly and PRN -(Resident name) will participate in restorative program when offered.-Assist with toileting and transfers as needed.-Keep call light and frequently used items (i.e. Kleenex, water pitcher, phone, etc.) within reach.-Larger recliner placed -Keep blue Dycem (a non-slip material used to provide grip and stability) between seat of wheelchair and gel cushion to prevent gel cushion from slipping off of w/c seat. An observation on 02-18-2026 at 6:45 AM revealed Resident 4's the absence of blue Dycem between the seat of the wheelchair and the gel cushion. An observation on 02-18-2026 at 8:50 AM of NA- A assisting Resident 4 to the bathroom which revealed Resident 4 was ambulated to the bathroom with a walker and a gait belt. An observation on 02-18-2026 at 8:55 AM with NA- A revealed the absence of blue Dycem in between the wheelchair seat and the gel cushion. An interview conducted with NA-A at 8:55 AM confirmed the absence of the blue Dycem in the wheelchair and revealed NA -A was not aware Resident 4 was to be taken to the bathroom by wheelchair. An interview conducted with the Director of Nursing on 02-18-2026 at 3:00 PM confirmed Resident 4 should not have been ambulated to the bathroom.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview, the facility failed to report a significant injury to the state agency in appropriate time frames for 1(Resident 2) of 4 residents sampled. The facility census was 77. The findings are:Record review of the facility's policy dated 09-23-2022 titled Abuse, Neglect and Exploitation revealed it is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Under section Identification of Abuse, Neglect and Exploitation:-the facility will have procedures to assist staff in identifying the different types of abuse.-possible indicators of abuse include but are not limited to: --Resident, staff or family report abuse,--Physical marks such as bruises --Physical injury of a resident of unknown source--Resident reports theft of property--Verbal abuse of a resident is observed--Physical abuse of a resident is observed--Psychological abuse of a resident is observed--Failure to provide care such as comfort, safety, feeding, bathing, dressing, turning and positioning. --Evidence of photographs or videos of a resident that are demeaning or humiliating in nature. --Sudden or unexplained changes in behaviors and or activities such as fear of a person or place or feelings of guilt or shame.Under section Reporting/Response of the policy revealed the facility will have procedures for reporting of all alleged violations to the Administrator (ADM), state agency, adult protective services and to all other required agencies within specified time frames: immediately, but no later than 2 hours after the allegation is made, if the events caused the allegation involve abuse or result in serious bodily injury and no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Record review of Resident 2's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 12-29-2025 revealed the facility staff assessed the following about the resident:-was rarely able to make self-understood.-was always incontinent of bowel and bladder.-required extensive assistance with toilet transfers-required total assistance with lower body dressing, personal hygiene, bed mobility and transfers from bed to chair.-had a fall with major injury-had a closed fracture of the pelvis. Record review of Resident 2's Progress Notes (PN) dated 12-19-2025 at 9:47 PM revealed Resident 2 had fallen while being transferred from the toilet to the wheelchair, had complained of left knee pain and had been transferred to the emergency room.Record review of Resident 2's PN dated 12-20-2025 revealed Resident 2's had complained of left hip pain and the facility staff noted the left leg was rotated inward and was shorter than the right leg. Resident 2 had been transferred to the hospital and had been admitted for a possible pelvic fracture. Record review of Resident 2's Emergency Department Course dated 12-20-2025 revealed Resident 2 had a second visit to the emergency room in 24 hours for a fall sustained on 12-19-25 while being assisted to the bathroom by the nursing home staff. The final impression was closed fracture of the left inferior pubic ramus (left side of the pelvis).Record review of Resident 2's After Visit Summary (AVS) dated 12-23-2025 revealed the primary diagnosis was a closed fracture of the pelvis.An interview conducted with the Director of Nursing (DON) on 02-18-2026 confirmed Resident 2's fall with pelvic fracture had not been reported to the State Agency (SA).An interview with the Administrator on 02-18-2026 at 2:50 PM confirmed the diagnosis on Resident 2's After Visit Summary (AVS) dated 12-23-25 was a closed fracture of the left inferior pubic ramus (pelvic bone fracture). An interview conducted with the DON and the ADM on 02-18-2026 at 3:15 PM revealed Resident 2's pelvic fracture was not reported to the state agency because the facility felt it was not a new injury.

Licensure Reference Number 175 NAC 12-006.09(I)Based on record review and interview; the facility staff failed to implement assessed interventions to prevent falls for 1 (Resident 4) of 3 sampled residents. The facility staff identified a census of 66. Findings are:Record review of Resident 4's Face Sheet dated 9/15/2025 revealed Resident 4 had the diagnoses of Parkinson's disease, Spinal stenosis (narrowing of the spaces between spinal bones) of the Lumbar area, Radiculopathy ( a pinched or pressed nerve) in the spine of the lumbar area, hypertension, muscle weakness and Depression.Record review of Resident 4's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 7/24/2025 revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS, method to evaluate cognitive status) was a 10. According to the MDS Manual, a score of 8 to 12 indicates moderately impaired cognition.-Required partial to moderate assistance with eating, oral hygiene, upper body dressing, personal hygiene, sitting to standing position, and toilet transfers. -Used chair and bed alarms daily.Record review of Resident 4's Comprehensive Care Plan (CCP) dated 7/10-2024 revealed Resident 4 was at risk for falls. The goal identified on Resident 4's CCP was Resident 4 would be free of falls through the next review date. Interventions listed were to assess for pain, encourage Resident 4 to reside in the lounge area, attend activities and encourage socialization, Keep snacks at bed time and to use a pd (movement of pressure detection) alarm in Resident 4's wheelchair or bed due to Resident 4's non-compliance with calling for assistance.Record review of a Incident & Investigation sheet dated 9/10-2025 revealed Resident 4 was found on the floor. Further review of the Incident & Investigation sheet dated 9/10-2025 revealed the call light within reach was identified as the intervention in place at the time of Resident 4 being found on the floor. The wheelchair, bed/chair alarm was not identified as being in use at the time of Resident 4 being found on the floor. According to the Incident & investigation sheet dated 9-10-2025 the post fall follow up intervention was the use of the sit stand alarm to the bed would be implemented. On 9-25-2025 at 12:34 PM an interview was conducted with Registered Nurse (RN) A. During the interview RN A reported Resident 4 did have falls and that a alarm pad was in use for the resident. RN A reported when Resident 4 was found on the floor on 9-10-2025 an alarm should have been in place. On 9-25-2025 at 2:45 PM an interview was conducted with the Director of Nursing. During the interview the DON reported Resident 4 did have falls and the pd alarm should have been in place according to resident 4's care plan.

Licensure reference: 175 NAC 12-006.09(H)(iv)(5)Based on record review and interview, the facility failed to ensure monitoring of bowel function for 1 [Resident 3] of 3 sampled residents. The facility had a total census of 63 residents.Findings are:A. A review of the facility Bowel Program dated 12/10 revealed the following procedure:- 1. The charge nurse is to monitor the BM [bowel movement] sheet and or caretracker every shift.- 2. On day 1 with no bowel movement, give 4 oz. of Prune juice to resident. Do not give to diabetics or no Concentrated (NCS) diets.- 3. On day 2, with no bowel movement, give prune juice and oral laxative (MOM [Milk of Magnesia], Sorbitol, Cascara, etc.) per MD [Medical Doctor] orders.- 4. On day 3 with no bowel movement, give prune juice and suppository (Dulcolax or Bisadocyl) per MD Orders. - 5. If no BM, notify the resident's physician for possible new orders.- 6. [NAME] meds given on MAR every shift.- 7. Monthly, complete the Bowel Assessment on every resident. B. A review of Resident 3's Face Sheet revealed Resident 3 admitted to the facility on [DATE] with diagnoses of Parkinson's disease and constipation. A review of Resident 3's Care Plan revealed a problem dated 7/10/24 of bowel incontinence with a diagnosis of constipation and a history of fecal impaction with an approach of ensure adequate bowel elimination with approach of administering medications promoting bowel movements. A review of Resident 3's Progress Note dated 7/14/25 revealed Resident 3 was readmitted to the facility on [DATE] at 4:10 PM. A review of Resident 3's bowel monitoring revealed the following documentation between 7/15/25 and 7/25/25:-no bowel movement record from 7/17/25 to 7/21/25, 4 days-no bowel movement recorded from 7/21/25-7/25/25, 4 days A review of Resident 3's Progress Notes dated 7/25/25 revealed Resident 3 was admitted to the hospital on [DATE]. A review of 24-hour vital sheets, a record used to determine interventions are to be implemented, between 7/15/25 and 7/25/25 revealed Resident 3 was only identified as being with a bowel movement on 2 days as follows:-for 1 day on 7/20/24 -for 2 days on 7/21/25 A review of Resident 3's 7/2025 MAR [Medication Administration Record] revealed an order for Miralax [laxative] 17 gms daily as needed for constipation. A review of Resident 3's 7/2025 MAR revealed Resident 3 was not administered Miralax during the month of 7/2025. In an interview on 8/6/25 at 2:12 PM, Registered Nurse A reported that the night charge nurse is to check the bowel movement book and make a list of residents that need follow up for bowel movements. Registered Nurse A reported the facility policy is after 1 day with no bowel movement the resident is to receive prune juice, day 2 with no bowel movement the resident is to receive milk of magnesia, and the third day with no bowel movement the resident is to receive a suppository. In an interview on 8/7/25 at 9:39 AM, Registered Nurse B reported that bowel movements were recorded in the bowel movement book and on the 24-hour report is a list of residents who have not had a bowel movement in 1, 2, or 3 days. Registered Nurse B confirmed that after 1 day with no bowel movement the resident is to receive prune juice, after the second day with no bowel movement the resident is to have milk of magnesia, and after the third day to resident is to have a suppository. Registered Nurse B reported the medication aides are given the 24-hour vital sheet in the morning and are responsible for giving the prune juice after 1 day with no bowel movement and the milk of magnesia after 2 days with no bowel movement. Registered Nurse B confirmed that a physician order is required for the bowel protocol. In an interview on 8/7/25 at 9 AM, Medication Aide C reported that the daily report sheet identified who had not had a bowel movement in 3 days and those residents are to be given bowel medication. Medication Aide C reported that the resident is given whatever medication the resident has an order for. In an interview on 8/7/25 at 9:15 AM, Medication Aide D reported that Medication Aide D would check the bowel monitoring book. Medication Aide D reported if a resident had not had a bowel movement in 3 days, Medication Aide D would give whatever medication was on the medication administration record to give. In an interview on 9/7/25 at 10:40 AM, the Dietary Manager E reported that occasionally a nurse will request a glass of prune juice for a resident. The Dietary Manager E reported that dietary staff doesn't get a list of residents that are to be served prune juice and was not aware of the facility bowel protocol. In an interview on 8/7/25 at 9:52 AM, the DON [Director of Nursing] confirmed the bowel monitoring tracking was not consistently filled out for Resident 3 during the month of 7/2025. The DON confirmed that based on the documentation that is available in the bowel monitoring book, Resident 3 should have been given something for Resident 3's bowels. The DON reported the nurse is to notify the physician if a resident has not had a bowel movement in 2 days and get an order for milk of magnesia. The DON reported if the resident has not had a bowel movement in 3 days, the nurse would get an order for a suppository. The DON reported it the nurse's job to assess the resident. Nursing staff are to inform the dietary staff of who needs prune juice and the medication aide of who to give oral medication to. It is the nurse's job to administer the suppository.

Licensure Reference Number 175 NAC 12-006.05(G) Based on record reviews and interviews, the facility failed to provide a rationale for not conducting a Gradual Dose Reduction (GDR, Stepwise tapering of a dose to determine whether or not symptoms, conditions, or risks can be managed by a lower dose or whether or not the dose or medication can be discontinued) for 1 (Resident 2) of 3 residents sampled. The facility census was 62. Findings are: Record review of Resident 2's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 5/11/2025 revealed Resident 2 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 13/15. The MDS manual identified a score of 13 as cognitively intact. Record review of Resident 2's medication order summary revealed Risperidone solution 1 milligram per milliliter (mg/mL) was ordered and the amount to be administered was 0.5 mL to be taken 3 times per day for bipolar disorder. A pharmacy review of the medication was conducted by a pharmacist on 11/26/2024 with a recommendation to gradually reduce the amount to be administered to 0.25 mL in the morning and 0.5 mL in the afternoon and evening. The primary physician disagreed with the recommendation for a dose reduction and did not provide a rationale for disagreement. An interview with the Director of Nursing (DON) on 06/12/25 at 9:16 AM confirmed there was no rationale provided by the doctor regarding not conducting the GDR of risperidone for Resident 2. Record review of Consonus Pharmacy's policy on Medication Regimen Review dated August 2024 revealed: H. Recommendations are acted upon and documented by the facility staff and or the prescriber. 1) a physician accepts and acts upon suggestion or rejects and provides an explanation for disagreement. 2) If there is potential for serious harm and the attending physician does not concur, or the attending physician refuses to document an explanation for disagreeing, the director of nursing contacts the medical director.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview, the facility failed to report an allegation of misappropriation within the required timeframe to Adult Protective Services [APS] and the Department of Health and Human Services [DHHS] for 1 (Resident 39) of 5 facility investigations reviewed. The facility census was 61. Findings are: Record review of facility policies and procedures entitled Abuse, Neglect and Exploitation and dated 9/23/22 revealed the following information: The definition of an alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has yet to be investigated and , if verified, could be an indication of noncompliance with the federal requirements related to mistreatment, exploitation, neglect or abuse, including injuries of unknown source and misappropriation of resident property. Reporting and response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the admin, state agency, adult protective services and to all other required agencies within the specified timeframe's a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse or do not result in serious bodily injury. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation within 5 working days of the incident, as required by state agencies. Record review of Resident 39's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) revealed an admission date of 10/5/22 with diagnoses that included unspecified psychosis not due to a substance or known physiological condition, major depressive disorder, recurrent, severe with psychotic symptoms, personality disorder, unspecified(History of), Anxiety disorder, unspecified, adjustment disorder with mixed anxiety and depressed mood, type 2 diabetes mellitus without complications, Schizophrenia, unspecified, age-related osteoporosis without current pathological fracture, stress incontinence, unsteadiness on feet, and unspecified abnormalities of gait and mobility. The MDS identified that Resident 39 had a BIMS (Brief interview Mental Status, a brief screener that aids in detecting cognitive impairment) score of 13/15. The MDS Manual identified that a score of 13-15 indicated intact cognition. The MDS identified that Resident 39 had a mood score of 10 (moderate depression is a score of 10-14 according to the MDS manual), had exhibited no behaviors and required partial to moderate assist with activities of daily living. Record review of complaint intake information received by APS on 5/23/25 revealed a report was called into Adult Protective Services [APS] on 5/23/25 by an anonymous reporter. The APS report indicated that the person that called the report into APS revealed that Resident 39 identified that a nurse aide [NA-B] at the facility told Resident 39 that they owed the NA 5 dollars. The resident did not give the NA-B five dollars and Resident 39 told NA-A to leave [gender] alone. The APS report revealed that NA-B allegedly told Resident 39 see if I do anything for you anymore. The reporter said that Resident 39 was now fearful of the NA and stated that Resident 39 had reported this incident to a nurse and had also left a voice mail for the Director of Nursing [DON]. Interview on 06/10/25 at 01:18 PM with the DON confirmed knowledge of the incident and that the DON had talked to Resident 39 and NA-B on 05/23/25 and instructed the NA to no longer go into Resident 39's room. The DON stated that NA-B had been joking and didn't mean anything by it. The DON stated I did not think it was abuse and did not need to be reported as the resident didn't want to file a grievance. The DON confirmed that the incident had not been reported to APS or DHHS.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview, the facility failed to thoroughly investigate an allegation of misappropriation for 1 (Resident 39) of 5 facility investigations reviewed. The facility census was 61. Findings are: Record review of facility policies and procedures entitled Abuse, Neglect and Exploitation and dated 9/23/22 revealed the following information: The definition of an alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has yet to be investigated and , if verified, could be an indication of noncompliance with the federal requirements related to mistreatment, exploitation, neglect or abuse, including injuries of unknown source and misappropriation of resident property. Investigation of abuse, neglect and exploitation: a. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation. 3. Investigating different types of alleged violations 4. Identifying and Interviewing all involved people, including the alleged victim, alleged perpetrator, witnesses or others who might have knowledge of the allegations 5. Focusing the investigation on determining if abuse, neglect or exploitation and or mistreatment occurred, the extent and cause 6. Providing complete and thorough documentation of the investigation. Record review of Resident 39's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) revealed an admission date of 10/5/22 with diagnoses that included unspecified psychosis not due to a substance or known physiological condition, major depressive disorder, recurrent, severe with psychotic symptoms, personality disorder, unspecified(History of), Anxiety disorder, unspecified, adjustment disorder with mixed anxiety and depressed mood, type 2 diabetes mellitus without complications, Schizophrenia, unspecified, age-related osteoporosis without current pathological fracture, stress incontinence, unsteadiness on feet, and unspecified abnormalities of gait and mobility. The MDS identified that Resident 39 had a BIMS (Brief interview Mental Status, a brief screener that aids in detecting cognitive impairment) score of 13/15. The MDS Manual identified that a score of 13-15 indicated intact cognition. The MDS identified that Resident 39 had a mood score of 10 (moderate depression is a score of 10-14 according to the MDS manual), had exhibited no behaviors and required partial to moderate assist with activities of daily living. Record review of complaint intake information received by APS on 5/23/25 revealed a report was called into Adult Protective Services [APS] on 5/23/25 by an anonymous reporter. The APS report indicated that the person that called the report into APS revealed that Resident 39 identified that a nurse aide [NA-B] at the facility told Resident 39 that they owed the NA five dollars. The resident did not give NA-B five dollars and Resident 39 told NA-A to leave [gender] alone. The APS report revealed that NA-B allegedly told Resident 39 see if I do anything for you anymore. The reporter said that Resident 39 was now fearful of the NA and stated that Resident 39 had reported this incident to a nurse and had also left a voice mail for the Director of Nursing [DON]. Interview on 06/10/25 at 1:18 PM with the DON confirmed knowledge of the incident and that the DON had talked to Resident 39 and NA-B on 05/23/25 and instructed the NA to no longer go into Resident 39's room. The DON stated that NA-B had been joking and didn't mean anything by it. The DON stated I did not think it was abuse and did not need to be reported as the resident didn't want to file a grievance. The DON confirmed that a thorough written investigation had not been completed into the incident with Resident 39 and NA-B.

Licensure Reference Number 175 NAC 12-006.09(H)(v) Based on record reviews and interviews, the facility failed to provide services as care planned to help prevent further decrease in range of motion for 2 (Residents 40 and 8) out of 2 residents sampled. The facility census was 61. Findings are: A. Record review of Resident 40's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 04/25/2025, revealed Resident 40 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) blank score. The MDS manual identified a score of blank as resident was unable to complete the interview. Record review of Resident 40's diagnoses revealed muscle wasting and atrophy, contracture of left hand and anoxic brain damage. Record review of Resident 40's restorative care plan dated 05/12/2025 revealed staff should be performing bed mobility and passive range of motion (PROM, range of motion that is performed by the staff moving the resident's body parts) exercises with the resident at least 2-3 times per week. Record review of Resident 40's Restorative Nursing Program Flow Sheet dated June 2025 revealed Resident received these exercises on 06/09/2025 and 06/10/2025. On 06/12/2025 at 9:18 AM the Director of Nursing (DON) confirmed there were only two days marked for restorative care for the month of June. B. Record review of Resident 8's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 05/02/2025 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15/15. The MDS manual identified a score of 15 as cognitively intact. Record review of Resident 8's diagnoses revealed a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the right dominate side. Record review of Resident 8's restorative care plan dated 5/12/2025 revealed staff should be performing bed mobility and PROM exercises with the resident at least 2-3 times per week. Record review of Resident 8's Restorative Nursing Program Flow Sheet dated June 2025 revealed Resident received these exercises on 06/09/2025 and 06/10/2025. On 06/12/2025 at 9:18 AM the Director of Nursing (DON) confirmed there were only two days marked for restorative care for the month of June for Resident 8. The DON also confirmed that the facility did not have a restorative care policy.

Licensure Reference Number 175 NAC 12-006.18(B) & 12-006.09(H)(vi)(3)(g) Based on observation, record review and interview; the facility failed to date oxygen tubing for 1 (Resident 11) of 1 sampled resident. The facility also failed to utilize Personal Protective Equipment (PPE, includes clothing, gloves, face shields, goggles, facemask's, respirators, and other equipment to protect front-line workers from injury, infection, or illness) for Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) for 1 (Resident 51) of 5 sampled residents and failed to perform hand hygiene prior to donning gloves during the provision of medication administration for 1 (Resident 39) of 1 sampled resident. The facility census was 61. Findings are: A. Record review of Resident 11's Face Sheet printed 06/11/2025 revealed the facility admitted the resident on 5/20/2025. Further review of the Face Sheet revealed that Resident 11 had diagnoses which included dyspnea (difficulty breathing), congestive heart failure, obstructive sleep apnea, and acute and chronic respiratory failure. Record review of Resident 11's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 06/02/2025 revealed the resident had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14/15. According to the MDS Manual, a score of 14 indicated that the resident was cognitively intact. Further review of the MDS revealed that Resident 11 received oxygen while a resident at the facility. Record review of Resident 11's Orders printed 6/11/2025 revealed an order for oxygen at four liters per nasal canula as needed for dyspnea. An observation on 06/09/2025 at 1:18 PM revealed Resident 11's oxygen tubing connected to the concentrator in the resident room. The tubing was not marked with a date it was placed. An observation on 06/10/2025 at 9:35 AM revealed Resident 11's oxygen tubing connected to the concentrator in the resident room. The tubing was not marked with a date it was placed. An observation on 06/11/2025 at 11:40 AM revealed Resident 11 in the hallway going to lunch with oxygen nasal cannula in place. The nasal cannula was not dated. An interview on 06/11/2025 at 11:40 AM with Registered Nurse (RN)-A confirmed that the tubing attached to the portable oxygen tank was undated. RN-A returned to Resident 11's room and further confirmed that the oxygen tubing attached to the concentrator was undated and should have been dated. RN-A revealed that oxygen tubing was to be changed weekly on the night shift. An interview on 06/11/2025 at 12:10 PM with the Director of Nursing (DON) confirmed that oxygen tubing is to be changed weekly. An interview on 06/12/2025 at 8:18 AM with the DON further confirmed that there was no method for tracking the change of respiratory supplies. B. Record review of a policy entitled Enhanced Barrier Precautions dated 2019 revealed the following information: Definitions: Enhanced barrier Precautions refer to the use of gowns and gloves for certain residents during specific high contact resident care activities that have been found to increase the risk for transmission of multi drug-resistant organisms. 1 c: Clear signage will be posted on the door or wall outside of the residents room indicating the type of precautions, required personal protective equipment (PPE) and the high contact resident care activities that require the use of gowns and gloves. 2 b: An order for enhanced barrier precautions will be obtained for residents with any of the following: indwelling medical devices (feeding tube) etc. High-contact resident care activities include: transferring, providing hygiene and changing briefs or assisting with toileting, device care including feeding tube. Residents on EBP will have a station for PPE donning and hand hygiene directly outside the door. If staff entering the residents room will be doing any of the following, they should follow posted instructions prior to entering: High-contact resident care activities include: transferring, providing hygiene and changing briefs or assisting with toileting, device care including feeding tube. Record review of Resident 51's quarterly MDS dated [DATE] revealed an admission date of 3/13/24 and diagnoses that included Parkinson, gastrostomy, anxiety and bipolar disorder. The MDS identified that resident 51 had a BIMS score of 15/15. The MDS manual identified that a score of 13-15 indicated intact cognition. The MDS identified that resident 51 exhibited, no behaviors and required assistance from staff for all activities of daily living needs including toileting and transfers. Record review of Resident 51's Comprehensive Care Plan (a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) dated revised 6/10/25 revealed that Resident 51 had a Gastrostomy Tube (a surgically placed tube that provides direct access to the stomach for feeding and hydration) present and staff were to follow EBP. Observation on 06/09/25 at 9:15 AM revealed a sign was present on the outside of the door that identified Resident 51 was in Enhanced Barrier Precautions. The sign identified that providers and staff must: Wear gloves and a gown for the following high contact activities: transferring, providing hygiene, changing briefs, assisting with toileting. Observation on 06/09/25 at 9:15 AM revealed a Hospice Nurse Aide (NA-E) present in Resident 51's room. With no gown in place, NA-E entered the restroom in Resident 51's room and assisted with completing toileting hygiene for Resident 51. Observation on 06/11/25 between 9:50 AM and 10:00 AM revealed Hospice NA-E brought the sit stand lift into Resident 51's room and provided transferring assistance and then took Resident 51 into the bathroom to toilet. NA-E did not donn a gown before entering Resident 51's room. Interview on 06/11/25 at 10:05 AM with Hospice NA-E confirmed that toileting, a brief change and transfer assistance had been provided to Resident 51. NA-E confirmed that a gown was not donned prior to entering the room or used during the provision of personal hygiene cares, toileting or transfer assistance and should have been according to the EBP sign outside the door. Interview on 06/11/25 at 10:21 AM with the facility Wound Nurse confirmed that the Hospice NA did not follow EBP precautions and did not donn a gown when toileting assistance, personal hygiene and transfer assistance was provided to Resident 51. C. Record review of an undated facility policy entitled Hand Hygiene revealed: -6. Additional Considerations: -a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning (applying) gloves, and immediately after removing gloves. An observation on 06/11/2025 at 7:15 AM with Nurse Consultant (NC)-D revealed Medication Aide (MA)-C prepared Resident 39's medications to be administered. When completed, MA-C collected Resident 39's medications, opened the medication cart and returned the medications, closed the drawer, and locked the medication cart. Without the benefit of hand hygiene, MA-C donned gloves and proceeded to administer eye drops in both of Resident 39's eyes. In an interview on 06/11/2025 at 7:30 AM MA-C confirmed that [gender] did not perform hand hygiene prior to donning gloves and should have.

Licensure Reference Number 175 NAC 12-006.05(G) Based on observation, interview, and record review, the facility staff failed to ensure individualize use of restraints to include identification of medical symptoms for use, duration of use, evaluation of less restrictive alternatives, review of risk and benefits, and re-evaluation of need for a restraint in accordance with facility policy for restraint use for 3 [Residents 1, 2, and 5] of 3 sampled residents. The facility had a total census of 63 residents. Findings are: A. A review of undated facility policy titled Restraint Free Environment revealed the following: -Physical Restraint: refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include, but are not limited to: .Placing a resident in an enclosed framed wheeled walker, in which the resident cannot open the front gate, or if the device has been altered to prevent the resident from exiting the device. A review of undated facility policy titled Restraint Free Environment under Compliance Guidelines revealed the following: -1. The resident has the right to be treated with respect and dignity, including the right to be free from any physical or chemical restraint imposed for the purpose of discipline or staff convenience, and not required to treat the resident's medical symptoms. -2. Physical restraints may be used in emergency care situations for brief periods to permit medically necessary treatment that has been ordered by a practitioner, unless the resident has previously made a valid refusal of the treatment in question. Falls do not constitute self-injurious behavior or a medical symptoms that warrants the use of a physical restraints. -3. Behavioral interventions should be used and exhausted prior to the application of a physical restraint or administration of medications that could be perceived as a chemical restraint. -4. A physician's order alone is not sufficient to warrant the use of a physical restraint or a medication that could be construed as a chemical restraint. The facility is responsible for the appropriateness of the determination to use a physical restraint. -5. Before a resident is physically restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints, and determine: a. How the use of restraints would treat the medical symptoms(s). b. The length of time the restraint is anticipated to be used to treat the medical symptom(s), who may apply the restraint, and the time and frequency that the restraint will be released. c. The type of direct monitoring and supervision that will be provided during use of the restraint. d. How the resident will request staff assistance and how his/her needs will be met while the restraint is in place. e. How to assist the resident in attaining or maintaining his or her highest practicable level of physical and psychosocial well-being. -6. Medical symptoms warranting the use of restraints should be documented in the resident's medical record. The resident's record needs to include documentation that less restrictive alternatives were attempted to treat the medical symptom but were in effective, ongoing re-evaluation of the need for the restraint, and the effectiveness of the restraint in treating the medical symptoms. The care plan should be updated accordingly to include the development and implementation of interventions, to address any risks related to the use of the restraint. -7. If a medication was initially administered for a medical symptom and continues to be administered in the absence of such symptom, the facility should re-evaluate the need for such medication to ensure that it does not sedate the resident or make it easier for the staff to care for the resident, causing it to be deemed a chemical restraint. -8. The resident/resident's representative may request the use of a physical restraint; however, the facility is responsible for evaluating the appropriateness of the request. The facility shall explain to the resident/resident's representative, the potential risks and benefits of using a restraint, not using a restraint, and alternative to restraint use. Potential negative outcomes should also be explained including, but not limited to: a. Decline in physical functioning b. Decreased muscle condition c. Contractures d. Increased risk for infection e. Pressure ulcers/injuries f. Delirium g. Agitation h. Incontinence i. Accidents such as falls, strangulation, or entrapment j. Loss of autonomy and dignity k. Withdrawal or reduced social contact. B. A review of Resident 1's Face sheet revealed Resident 1 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of Resident 1's quarterly MDS [Minimum Data Set; a comprehensive assessment used in care planning] dated 3/28/25 revealed the following -Resident 1 had a BIMS [Brief Interview for Mental Status] score of 4. A review of the MDS manual revealed a score of 0-7 indicates severe cognitive impairment -Resident 1 required supervision or touching assistance for walking -Resident 1 used a bed alarm, chair alarm, and wander/elopement alarm daily -Resident 1 was not identified as utilizing a restraint A review of Resident 1's Care plan revealed a problem dated 9/14/23 of falls with the following interventions: -Ensure Resident 1's pad alarm in in place when in recliner in 2 North lunge area with recliner reclined back dated 4/14/25 -Educate staff to know Resident 1's where about's at all times, assign a staff member to monitor Resident 1 and if staff member leaves another staff member is to be assigned to monitor the resident dated 4/13/25 -After Resident 1 is up and dressed Resident 1 will be taken to the 2 N lounge area dated 1/9/25. -Resident 1 utilizes a bed alarm dated 1/9/25 -Resident 1 chair pad alarm is to be under Resident 1 in Merry walker [an enclosed framed wheeled walker] dated 1/9/25 -Fall assessment upon admission, quarterly, annually and as needed dated 1/9/25 -Gait belt changed to latching style belt dated 1/9/25 -Keep call light and frequently used items within reach dated 1/9/25 -Make sure bed alarm is not under pillow dated 1/9/25 -Offer routine/as needed toileting dated 1/9/25 -Resident 1's pad alarm to be on Resident 1's wheelchair at all times. Wheelchair is only used for transporting Resident 1. Resident 1 is not to rest in Resident 1's wheelchair dated 1/9/25 -Pharmacy to monitor Resident 1's medications increasing risk for falls monthly and as needed dated 1/9/25 -Resident 1 to transfer using walker and gait belt with staff present at all times dated 1/9/25 -Resident 1 not to be transferred to wheelchair and left alone. Resident 1 to be transferred to Merry walker with chair pad alarm on and functioning properly dated 1/9/25 A review of Resident 1's Care Plan revealed a problem dated 9/14/23 related to activities of daily living functional with the following intervention related to use of Merry Walker: -Utilize Merry [NAME] for ambulation. Remove from Merry [NAME] every 2 hours: toilet, position in recliner/bed for at least 15 minutes. Observations on 4/16/25 at 7:41 AM revealed Resident 1 up in wheelchair in hallway near nurses' station with pad alarm in place on wheelchair. Resident 1 was observed to have 2 dark purple eyes. A review of undated facility investigation for Resident 1 revealed on 4/12/25 at 1:10 AM Medication Aide A heard stairwell alarm sounding by assisted living room [ROOM NUMBER]. Medication Aide A saw a Merry [NAME] lying on its side on second landing and Resident 1 lying on left side on first landing. Conclusion from facility investigation revealed that Resident 1 was in Merry [NAME] and went through the fire doors on 2 North sounding the door alarm. Resident continued down the hallway went through the stairway door by room [ROOM NUMBER] and fell down the stairs. Resident 1 was transferred to the hospital and returned to the facility on 4/14/25 with no injury. A review of Resident 1's physician's orders revealed an order dated 1/2/24 for physical therapy to evaluate Resident 1 for a Merry Walker. A review of Resident 1's Progress Note dated 4/13/25 at 4:33 AM revealed Resident 1 had multiple bruises all over including black and blue right eye, bruising to forehead, pain to right knee and head. A review of Physical Therapy (PT) Progress Note dated 1/4/24 revealed Resident 1 was evaluated for safety and appropriateness to utilize a Merry Walker. Resident 1's Progress Note identified Resident 1 could safely complete sit to stand transfers without tipping laterally but may need increased practice to shift weight forward with the walker rolling backwards. According to the PT Progress Note dated 1/4/2024 care givers were to monitor for Resident 1 possible fidgeting with latch in an attempt to exit the walker unsupervised. Physical Therapy recommendation included Resident 1 remain in the Merry [NAME] for a bursts of time when active and mobile but return to other sitting surface for meals or when resting for greatest skin integrity. A review of Resident 1 medical record didn't reveal any additional information related to the use of Merry Walker. In an interview on 4/17/25 at 9:05 AM, Nurse Aide D reported Resident 1 is up in Merry [NAME] other than during meals. Nurse Aide D reported Resident 1 is placed in recliner when sleepy. Nurse Aide D reported being unaware of timeframe for Resident 1 to be in the Merry [NAME] but is gotten out after breakfast and before lunch for toileting. Nurse Aide D reported Resident 1 can't get out of the Merry [NAME] by themselves. In an interview on 4/17/25 at 9:11 AM, LPN E [Licensed Practical Nurse] reported Resident 1 is placed in Merry [NAME] when Resident 1 wants to go and used so that Resident 1 can get around independently. LPN E reported Resident 1 is to be out every 2 hours, for meals, and when tired. LPN E reported that LPN E has never seen Resident 1 get out of the Merry [NAME] by themselves. In an interview on 4/17/25 at 9:49 AM, PT F [Physical Therapist] reported getting orders for a physical therapy evaluation for use of a Merry Walker. PT F reported the focus of the evaluation is to determine if the use of the Merry [NAME] is safe and not a restraint. PT F reported focusing evaluation on safety of the memory walker and was not aware of the definition of a restraint in federal regulations. PT F reported Resident 1 was utilizing the Merry [NAME] due to delirium and restlessness and should be used for 2 hours but may be extended if restlessness continues. PT F reported the PT F has not reevaluated Resident 1's use of the Merry [NAME] since 1/4/24 and it is up to nursing to discontinue the Merry [NAME] if no longer safe. In interviews 4/17/25 at 9:30 AM and 11:32 AM, Registered Nurse I confirmed that Registered Nurse I was not coding use of Merry [NAME] as a restraint on the MDS. In further interviews, Registered Nurse I reported that use of Merry [NAME] needed to documented as a restraint on the MDS and put on the care plan. In interviews on 4/17/25 at 10:26 AM and 11:28 AM, the DON [Director of Nursing] confirmed Resident 1 can't get out of the Merry [NAME] by themselves and no risk benefit statement was signed by Resident 1's responsible party had been completed. If the guideline is that they have to be able to open the Merry Walker, it would be considered a restraint. The DON would consider it more of a restraint if the resident could not walk by themselves. C. A review of Resident 2's Face Sheet revealed Resident 2 was admitted to the facility on [DATE] with diagnoses of dementia, muscle weakness, and at admission intertrochanteric fracture of right femur [hip fracture]. A review of Resident 2's quarterly MDS dated [DATE] revealed the following: -Resident 2 had a BIMS [Brief Interview for Mental Status] score of 2. A review of the MDS manual revealed a score of 0-7 indicates severe cognitive impairment -Resident 2 required partial/moderate assistance for walking -Resident 2 used a bed alarm, chair alarm, and wander/elopement alarm daily -Resident 2 was not identified as utilizing a restraint A review of Resident 2's Care Plan revealed a problem of falls dated 6/11/23 with the following interventions related to use of Merry Walker: -Provide Resident 1 with safety device/appliance: utilize Merry Walker -When Resident 2 utilizes recliner in lounge, ensure current plan of care safeguards are in place such as alarm, check on every 15-30 minutes to see if Resident is ready to change position, go to bathroom or use Merry Walker. A review of Physical Therapy Progress Note dated 9/29/22 revealed Resident 2 did not have finger strength or cognitive level to unhook a latch but did not attempt to get out of Merry [NAME] without asking for assistance. A review of Resident 2 medical record didn't reveal any additional information related to use of Merry Walker. Observations on 4/16/25 at 2:58 PM and 3:49 PM revealed Resident 2 up in Merry Walker. Observations on 4/17/25 at 11:26 AM revealed Resident 2 up in Merry Walker. Medication Aide G requested Resident 2 open up latch on Merry [NAME] revealing Resident 2 did not attempt to open latch and stated I don't think I will. In an interview on 4/17/25 at 9:16 AM, Medication Aide G reported that Resident 2 is placed in Merry [NAME] when Resident 2 gets up in the morning. Resident 2 gets out every 2 hours and lays down when tired or placed in recliner. Medication Aide G reported that Resident 2 uses Merry [NAME] for ambulation and Medication Aide G has never seen Resident 2 try to get out of it. In an interview on 4/17/25 at 9:20 AM, Nurse Aide C reported that Resident 2 sleeps late and will get up between 11:20-12 PM and be put in Merry Walker. Nurse Aide C reported Resident 2 is fed in Merry [NAME] and may still be in Merry [NAME] when Nurse Aide C leaves shift at 1:30 PM. In interviews 4/17/25 at 9:30 AM and 11:32 AM, Registered Nurse I confirmed that Registered Nurse I was not coding use of Merry [NAME] as a restraint on the MDS. In further interviews, Registered Nurse I reported that use of Merry [NAME] needed to documented as a restraint on the MDS and put on the care plan. In interviews on 4/17/25 at 10:06 AM and 11:14 AM, PT F reported Resident 2 utilized Merry [NAME] for symptoms of restlessness and delirium. PT F reported Resident 2 could be in the Merry [NAME] for 2 hours but if continued to be restless that could be extended. PT F reported Resident 2 was evaluated for use of Merry [NAME] while on a skilled stay and that there was not a specific order for an evaluation for use of a Merry Walker. PT F confirmed that Resident 2 has not been reevaluated for use of Merry [NAME] as Resident 2 is now on hospice. In interviews on 4/17/25 at 10:26 AM and 11:28 AM, the DON [Director of Nursing] confirmed Resident 2 can't get out of the Merry [NAME] by self and no risk benefit statement signed by Resident 2's responsible party had been completed. If the guideline is that they have to be able to open the Merry Walker, it would be considered a restraint. The DON would consider it more of a restraint if the resident could not walk by themselves. D. A review of Resident 5's Care Plan revealed Resident 5 was admitted on [DATE] and had diagnoses of Alzheimer's disease and an admission diagnosis of encounter for fracture of medial malleolus of right tibia with routine healing. A review of Resident 5's Care Plan revealed a problem of falls dated 9/5/24 with intervention of therapy to screen and evaluate for use of Merry [NAME] dated 4/17/25. A review of Resident 5's Progress Notes revealed the following: -4/16/25 at 11:20 AM Resident 5 found lying on the floor on back in front of nurses' desk. Full range of motion done with no noted injuries. Resident 5 rubbing right side and back. Resident 5 leaves the facility with the squad for transfer to emergency room. -4/16/25 at 1:30 PM Resident 5 returned to facility with no fracture. Resident 5 was placed in a Merry Walker. -4/17/25 at 2:29 AM Resident 5 up as desired in Merry Walker. A review of Resident 5's medical record didn't reveal any additional information related to use of Merry Walker. Observations on 4/17/25 at 8:36 AM revealed Resident 5 up in Merry Walker. Observations on 4/17/25 at 11:25 AM revealed Resident 5 up in Merry Walker. Nurse Aide H requested Resident 5 open the latch on the Merry Walker. Resident 5 did not respond to the command. In an interview on 4/17/25 at 9:19 AM, Nurse Aide C reported being directed by DON to put Resident 5 in Merry [NAME] today. In an interview on 4/17/25 at 10:10 AM, PT F reported starting an evaluation of Resident 5's use of Merry [NAME] yesterday but had not yet completed it. PT F reported Resident 5 was not in a restless state at the time of the evaluation and needed to be in a restless state to complete the evaluation. PT F report having an order from Resident 5's physician to evaluate for use of a Merry Walker. In interviews on 4/17/25 at 10:26 AM and 11:28 AM, the DON [Director of Nursing] confirmed Resident 5 can't get out of the Merry [NAME] by self and no risk benefit statement signed by Resident 5's responsible party had been completed. The DON confirmed directing staff to place Resident 5 in a Merry [NAME] as Resident 5 is unsteady and unsafe to ambulate by self. E. In an interview on 4/17/25 at 10:26 AM, the DON reported the following procedure for use of a Merry Walker: an order is gotten from the physician to screen the resident for use of a Merry Walker, the physical therapist makes a recommendation, and the Merry walker is implemented. The DON reported the only physician order is for the screen for use of a Merry Walker. The DON confirmed the decision to discontinue use of the Merry [NAME] would be made by the DON. F. Facility was encouraged to provide any additional information relevant to this tag at exit with no additional information being provided at time of report completion.

Licensure Reference Number NAC 12-006.09(D) Based on record review and interview, the facility failed to accurately code MDS [Minimum Data Set; a comprehensive assessment used in care planning] related to use of restraint for 2 [Residents 1 and 2] of 3 sampled residents utilizing a Merry Walker. The facility had a total census of 63 residents. Findings are: A. A review of Resident 1's Face sheet revealed Resident 1 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of Resident 1's quarterly MDS [Minimum Data Set; a comprehensive assessment used in care planning] dated 3/28/25 revealed the following -Resident 1 had a BIMS [Brief Interview for Mental Status] score of 4. A review of the MDS manual revealed a score of 0-7 indicates severe cognitive impairment -Resident 1 required supervision or touching assistance for walking -Resident 1 used a bed alarm, chair alarm, and wander/elopement alarm daily -Resident 1 was not identified as utilizing a restraint A review of Resident 2's Care Plan revealed a problem of falls dated 6/11/23 with the following interventions related to use of Merry Walker: -Provide Resident 1 with safety device/appliance: utilize Merry Walker -When Resident 2 utilizes recliner in lounge, ensure current plan of care safeguards are in place such as alarm, check on every 15-30 minutes to see if Resident is ready to change position, go to bathroom or use Merry Walker. A review of Resident 1's physician's orders revealed an order dated 1/2/24 for physical therapy to evaluate Resident 1 for a Merry Walker. In an interview on 4/17/25 at 9:05 AM, Nurse Aide D reported Resident 1 is up in Merry [NAME] other than during meals. Nurse Aide D reported Resident 1 is placed in recliner when sleepy. Nurse Aide D reported being unaware of timeframe for being in Merry [NAME] but is gotten out after breakfast and before lunch for toileting. Nurse Aide D reported Resident 1 can't get out of the Merry [NAME] by self. In an interview on 4/17/25 at 9:11 AM, LPN E [Licensed Practical Nurse] reported Resident 1 is placed in Merry [NAME] when Resident 1 wants to go and used so that Resident 1 can get around independently. LPN E reported Resident 1 is to be out every 2 hours, for meals, and when tired. LPN E reported that LPN E has never seen Resident 1 get of the Merry [NAME] by self. In interviews 4/17/25 at 9:30 AM and 11:32 AM, Registered Nurse I confirmed that Registered Nurse I was not coding use of Merry [NAME] as a restraint on the MDS. Registered Nurse I reported that use of Merry [NAME] needed to documented as a restraint on the MDS and put on the care plan. B. A review of Resident 2's Face Sheet revealed Resident 2 was admitted to the facility on [DATE] with diagnoses of dementia, muscle weakness, and on admission intertrochanteric fracture of right femur [hip fracture]. A review of Resident 2's quarterly MDS dated [DATE] revealed the following: -Resident 2 had a BIMS [Brief Interview for Mental Status] score of 2. A review of the MDS manual revealed a score of 0-7 indicates severe cognitive impairment -Resident 2 required partial/moderate assistance for walking -Resident 2 used a bed alarm, chair alarm, and wander/elopement alarm daily -Resident 2 was not identified as utilizing a restraint A review of Resident 2's Care Plan revealed a problem of falls dated 6/11/23 with the following interventions related to use of Merry Walker: -Provide Resident 1 with safety device/appliance: utilize Merry Walker -When Resident 2 utilizes recliner in lounge, ensure current plan of care safeguards are in place such as alarm, check on every 15-30 minutes to see if Resident is ready to change position, go to bathroom or use Merry Walker. Observations on 4/16/25 at 2:58 PM and 3:49 PM revealed Resident 2 up in Merry Walker. Observations on 4/17/25 at 11:26 AM revealed Resident 2 up in Merry Walker. Medication Aide G requested Resident 2 open up latch on Merry [NAME] revealing Resident 2 did not attempt to open latch and stated I don't think I will. In an interview on 4/17/25 at 9:16 AM, Medication Aide G Resident 2 gets is placed in Merry [NAME] when Resident 2 wakes up. Medication Aide G reported Resident 2 gets out every 2 hours and lays down when tired or placed in recliner. Medication Aide G reported Resident 2 uses the Merry [NAME] for ambulation has never seen Resident 2 try to get out of it. In an interview on 4/17/25 at 9:20 AM, Nurse Aide C reported Resident 2 sleeps late and will get up between 11:20-12 PM and be put in Merry Walker. Nurse Aide C reported Resident 2 is fed in Merry [NAME] and may still be in Merry [NAME] when Nurse Aide C leaves shift at 1:30 PM. C. In interviews 4/17/25 at 9:30 AM and 11:32 AM, Registered Nurse I confirmed that Registered Nurse I was not coding use of Merry [NAME] as a restraint on the MDS. Registered Nurse I reported that use of Merry [NAME] needed to documented as a restraint on the MDS and put on the care plan.

Licensure Reference Number 175 NAC 006.09(I) Based on observation, interview, and record review, the facility failed to ensure supervision to protect residents from elopement for 3 [Residents 1, 4, and 6] of 3 sampled residents at risk for elopement. The facility had a total census of 63 residents. Findings are: A. A review of Resident 1's Face sheet revealed Resident 1 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of Resident 1's quarterly MDS [Minimum Data Set; a comprehensive assessment used in care planning] dated 3/28/25 revealed the following -Resident 1 had a BIMS [Brief Interview for Mental Status] score of 4. A review of the MDS manual revealed a score of 0-7 indicates severe cognitive impairment -Resident 1 required supervision or touching assistance for walking -Resident 1 used a bed alarm, chair alarm, and wander/elopement alarm daily A review of Resident 1's Care plan revealed a problem dated 9/14/23 of falls with the following interventions: -Ensure Resident 1's pad alarm in in place when in recliner in 2 North lunge area with recliner reclined back dated 4/14/25 -Educate staff to know Resident 1's where about's at all times, assign a staff member to monitor Resident 1 and if staff member leaves, staff member must let the manager know and some one will be assigned to monitor Resident 1 dated 4/13/25 -After Resident 1 is up and dressed Resident 1 will be taken to the 2 N lounge area dated 1/9/25. -Resident 1 utilizes a bed alarm dated 1/9/25 -Resident 1 chair pad alarm is to be under Resident 1 in Merry walker [an enclosed framed wheeled walker] dated 1/9/25 -Fall assessment upon admission, quarterly, annually and as needed dated 1/9/25 -Gait belt changed to latching style belt dated 1/9/25 -Keep call light and frequently used items within reach dated 1/9/25 -Make sure bed alarm is not under pillow dated 1/9/25 -Offer routine/as needed toileting dated 1/9/25 -Resident 1's pad alarm to be on Resident 1's wheelchair at all times. Wheelchair is only used for transporting Resident 1. Resident 1 is not to rest in Resident 1's wheelchair dated 1/9/25 -Pharmacy to monitor Resident 1's medications increasing risk for falls monthly and as needed dated 1/9/25 -Resident 1 to transfer using walker and gait belt with staff present at all times dated 1/9/25 -Resident 1 not to be transferred to wheelchair and left alone. Resident 1 to be transferred to Merry walker with chair pad alarm on and functioning properly dated 1/9/25 A review of Resident 1's Care Plan revealed a problem dated 9/14/23 of wandering with the following interventions: -Approach Resident 1 from the front. Walk in step with Resident 1 first before redirecting dated 1/9/25 -Assure Resident 1 has proper fitting and appropriate foot attire dated 1/9/25 -Avoid over-stimulation dated 1/9/25 -Convey an attitude of acceptance toward Resident 1 dated 1/9/25 -Equip Resident 1 with a device that alarms when Resident 1 wanders. Check for proper functioning of device every shift dated 1/9/25 -If Resident 1 looks for family/significant other reassure that other know where to find him/her dated 1/9/25 -Label Resident 1 belongings and environment to promote recognition dated 1/9/25 -Maintain a calm environment and approach to Resident 1 dated 1/9/25 -Removed Resident 1 from other resident's rooms an unsafe situations dated 1/9/25 -When Resident 1 begins to wander, provide comfort measures for basic needs dated 1/9/25 Observations on 4/16/25 at 7:41 AM revealed Resident 1 up in wheelchair in hallway near nurses' station with a pad alarm in place on wheelchair and had 2 dark purple eyes. Observations on 4/16/25 at 11:39 AM revealed Wanderguard [an alarm system in which a bracelet worn by a resident trips an audible alarm when passing a unit installed in the wall] bracelet on Resident 1's right wrist. A review of undated facility investigation for Resident 1 revealed on 4/12/25 at 1:10 AM Medication Aide A heard stairwell alarm sounding by assisted living room [ROOM NUMBER]. Medication Aide A saw Merry walker lying on its side on second landing and Resident 1 lying on left side on first landing. Conclusion from facility investigation revealed Resident 1 was in Merry [NAME] and went through the fire doors on 2 North sounding the door alarm. Resident continued down the hallway went through the stairway door by room [ROOM NUMBER] and fell down the stairs. Resident 1 was transferred to the hospital and returned to the facility on 4/14/25 with no injury. The facility investigation revealed that the Wanderguard alarm and the Fire Door alarm were both going off. Registered Nurse B reported hearing the door alarm but did not get up and check to see who was going through the door. The following interventions were implemented in response to the incident: -Education was immediately provided to staff on 4/12 to ensure staff knew the whereabouts of Resident 1 at all times and to report to the manager when leaving to ensure a staff member would monitor and ensure another staff member was designated. -30-minute checks being done on Resident 1 -An in-service was scheduled for 5/1/25 regarding responding to all alarms and monitoring of wandering residents as well as documentation. -Registered Nurse B was placed on suspension during the investigation and employment would be terminated. In an interview on 4/16/25 at 8:20 AM, the Administrator reported Registered Nurse B had been in the TV area near the second floor nurses station and had heard the alarm go off from the double doors which enter into the assisted living area. Registered Nurse B had called out asking who was going through the double doors but did not check to see who had gone through the doors when no one replied to Registered Nurse B's question. The Administrator reported that Resident 1 went down the empty assisted living hallway, opened the door to the stairway and fell down two flights of stairs. According to the Administrator, Resident 1 had been in the Merry [NAME] at the time and the Merry [NAME] was found on the first landing and Resident 1 on the lower landing. A review of Resident 1's Progress Note dated 4/13/25 at 4:33 AM revealed Resident 1 had multiple bruises all over including black and blue right eye, bruising to forehead, pain to right knee and head. Observations on 4/16/25 at 8:25 AM revealed the double doors between the nurses' station and the elevator on the second floor north unit was equipped with a doorbell alarm that sounds each time the door is opened. The hallway on the other side of the double doors is licensed as assist living and has no residents residing on it. The hallway in the assisted living leads to the main entrance of the facility. On 4/16/25 between 11:25-11:39 AM, Maintenance Director activated stairway alarm near room [ROOM NUMBER]/260. The Administrator confirmed that stairway door alarm near room [ROOM NUMBER]/260 could not be heard from second floor nurses station located on other side of the double doors. On 4/17/25 at 1:03 PM, Maintenance Director activated Wanderguard alarm on wall near room [ROOM NUMBER] in the assisted living section of second floor. The Administrator confirmed the Wanderguard alarm could not be heard past the nurses' station located by the TV area on second floor. A review of Intervention Education dated 4/12/25 revealed staff were educated to be aware of Resident 1's location at all times. Signature paper for education also stated Wanderguard alarm box to be placed outside of 2 North double doors going to assisted living. In an interview on 4/16/25 at 3:35 PM, the Administrator reported that the notation on the education about placing a Wanderguard Alarm by second floor double doors had been identified by the staff providing the education and was not currently being implemented but could be considered. B. A review of Resident 6's Face Sheet revealed Resident 6 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of Face Sheet revealed Resident 6 resided on the first floor of the facility. A review of Resident 6's quarterly MDS dated [DATE] revealed the following -Resident 6 had a BIMS score of 7. A review of the MDS manual revealed a score of 0-7 indicates severe cognitive impairment -Resident 6 required supervision or touching assistance for walking -Resident 6 used wander/elopement alarm daily A review of Resident 6's Care Plan revealed intervention dated 4/3/25 to monitor for any episodes of wandering, document in progress notes, complete an updated wandering assessment and place wander guard indicated. Observations on 4/17/25 at 12:35 PM revealed Resident 6 had a wander guard bracelet on walker and left wrist. A review of Resident 6's Progress Notes did not reveal any documentation of wandering behaviors between 1/1/25 to 4/16/25. C. A review of Resident 4's Face Sheet revealed Resident 4 was admitted to the facility on [DATE] and resided on the first floor of the facility. Further review of Resident 4's Face Sheet revealed a diagnosis of dementia. A review of Resident 4's quarterly MDS dated [DATE] revealed the following: -Resident 4 had a BIMS score of 3. A review of the MDS manual revealed a score of 0-7 indicates severe cognitive impairment -Resident 4 required supervision or touching assistance for wheeling manual wheelchair -Resident 4 used bed alarm, motion sensor alarm and wander/elopement alarm daily A review of Resident 4's Care Plan revealed a problem dated 10/14/22 of Resident 4 exhibiting wandering behaviors with interventions for checking alarms on exit doors and utilizing motion detector. The use of a Wanderguard bracelet was not listed on Resident 4's Care Plan. Observations on 4/16/25 at 4 PM revealed a Wanderguard bracelet in place on Resident 4's wrist. A review of Resident 4's Progress Notes dated 3/23/25 revealed Resident 4 trying to go through doors to the long term care unit on the other side. In an interview on 4/17/25 at 9:22 AM, Nurse Aide C reported Resident 4 only wanders around the side of the building that Resident 4 lives on and doesn't go to the other side of the floor. D. Observations on 4/16/25 between 11:25 AM-12:08 PM revealed the Wanderguard did not alarm near rooms [ROOM NUMBERS] [opposite ends of the hallway on the first floor] when tested by Maintenance Director. Observations revealed the Wanderguard near 161 was near a stairway door that was also alarmed. Further observations revealed double doors near room [ROOM NUMBER] was equipped with a doorbell and opened to a landing area with 3 doors. One door in the landing opened to a stairway and is equipped with a Wanderguard alarm. The second door was open and led to the administrative offices and a third set of doors exited to the outside. There is a doorbell on the door exited outside of the facility. A review of Wanderguard Door Monitoring for months 1/25-3/25 revealed the following: -Wanderguard wall unit near administrative offices was not working during checks completed 1/1/25, 2/4/25, and 3/17/25 with a note on each month that a white alarm had been installed and Wanderguard company called. -Wanderguard wall unit on first North [NAME] Hall North was not working during checks on 2/4/25 and 3/17/25 with note that white alarm was installed and Wanderguard company called. In an interview on 4/16/25 between 11:25 AM and 12:08 PM, the Administrator reported that the doorbell was added to the door by room [ROOM NUMBER] as the Wanderguard was not working. In an interview on 4/16/25 between 11:25 AM and 12:08 PM, Maintenance Director reported the new Wanderguard units needed to be installed as replacement parts can no longer be obtained for the current units. In an interview on 4/16/25 at 2:29 PM, Maintenance Director reported the Wanderguard on one end of the first floor hallway was not working since January and the other end since March. Doorbell alarms were placed in January by the Administrative offices due to the Wanderguard alarm not working. A review of In-service education dated 1/9/25 and 3/19/25 revealed staff education that first North Wanderguard units were not working. On 4/16/25 at 4:25 PM, the door near room [ROOM NUMBER] was opened by the Administrator causing the doorbell to sound. At 4:28 PM the exit door to the outside from the first floor landing by the administrative office was opened causing the doorbell to sound. Observations on 4/16/25 at 4:31 PM revealed no staff member had come to check the reason for the doorbell sounding and no staff were observed in the hallway. In an interview on 4/16/25 between 4:25-4:31 PM, the Administrator acknowledged no staff member had come to check the door. The Administrator reported new Wandergard units had been ordered to replace the current Wanderguard units. Observations on 4/17/25 at 7:17 AM revealed motion detector alarms had been installed on the doors near room [ROOM NUMBER] that opened into the area by the administrative offices.

Licensure reference Number 175 NAC 12-006.11E Nebraska Food Code 4-601.11(C) Based on observation, interview, and record review; the facility staff failed to ensure dietary staff wore beard restraints that fully enclosed all hair on the face during 2 meal service observations, failed to ensure scoops were stored separate from the flour and sugar, failed to ensure that the surface of plates stored in a plate warmer were not exposed to potential contaminants and failed to maintain the cleanliness and condition of floors, ventilation covers and ceiling tiles, the interior of conventional ovens and convection ovens, the exterior of the stove, stove back splash, convection ovens, shelf above the stove, floors in the walk in cooler, fans in the walk in cooler, pan storage units, electric slicer, and the large commercial mixer in the facility kitchen. These practices had the potential to cause food borne illness. This had the potential to affect 60 residents that resided in the facility and ate foods prepared in the facility kitchen. The facility census was 60. Findings are: A. Record review of an undated facility Policy entitled Dietary: Infection Control revealed the following information: - c. Hair restraints are required and should cover all hair. B. Record review of an undated facility policy entitled Food safety - Dietary revealed the following information: - 1. Good sanitary food handling practices with sanitary conditions maintained in the storage, preparation and serving of foods will be carried out at all times. - 6. Hair must be restrained. C. Observation during the initial kitchen tour on 04/10/24 between 7:45 AM and 8:00 AM, with the Dietary Manager [DM] in the facility kitchen, revealed the following hair restraint, storage and sanitation concerns: - The DM wore a beard restraint but it did not cover a full mustache. The beard was positioned below the mouth and did not fully enclose all the facial hair. - Inside the reach in refrigerator, a container of sour cream and cottage cheese were not labeled or dated when they had been opened. - A exhaust fan in the walk in refrigerator was heavily coated with a gray fuzzy substance that resembled dust. - There were several areas of burnt on food particles, grease and spatters on the backslash of the stove, side and top of a convection oven, on the interior of the conventional oven and on the interior of 2 convection ovens. D. Observations during meal services on 4/10/24 between 8:00 AM and 9:05 AM and between 12:05 PM and 1:00 PM revealed the following: - The DM served the food to the residents from the steam table. The DM wore a beard restraint but it did not cover a full mustache. The beard was positioned below the mouth and did not fully enclose all the facial hair. - Dietary Aide [DA] E passed trays to the residents. DA E had on an N 95 mask that did not fully cover all facial hair. E. Interview on 04/10/24 at 01:50 PM with the facility Registered Dietician [RD] confirmed that the Dietary Managers beard net did not fully enclose the mustache and confirmed that DA E's mask did not fully contain all facial hair. The RD confirmed that the beard restraint should fully enclose all hair on the face. F. Observation on 04/11/24 between 09:00 AM and 9:45 AM with RD and the DM revealed the following storage and sanitation concerns in the facility kitchen and the service area of the dining room: - Four containers of cereal in the service area in the main dining room were not labeled or dated when opened. - There was no covers for the hot dish storage unit in the service area in the main dining room. The loaded dishes were face up with the surface of the plates exposed to potential contaminants. - There were 2 packages of crispy onions in the dry storage area that were open but not labeled or dated. - The floors in the dry storage area had several food particles present and a buildup of wax and dirt along the edges of the walls, corners and under the storage carts. - The floors in the kitchen preparation area and the dish machine area had several food particles present and a buildup of wax, dust and dirt along the edges of the walls, corners and under the counters and machines. - A pan storage 3 shelf unit, near the 3 compartment sink, had a buildup up of a fuzzy grey substance and rust in several areas where the plastic coated surface had worn away. - In the walk in refrigerator, there was no date or label indicating when a bag of carrots had been opened. - The blade on the commercial electric slicer had several areas of nicks and breaks on the blade. - The large commercial mixer guard and back splash had dried on spatters of food present. - The large flour and the sugar bins had scoops laying on top of the product inside the bins which could cause contamination of the product from contact with the handle of the scoop. - A 4 shelve pan storage unit in the food preparation area unit had a buildup up of a fuzzy grey substance that resembled dust and rust in several areas where the plastic coated surface had worn away. - Two ventilation exhaust fans in the walk in refrigerator were heavily coated with gray fuzzy substance that resembled dust. - There were several areas of burnt on food particles, grease and spatters on the flat griddle, stove, back splash of the stove, side and top of 2 convection ovens, interior of 2 conventional ovens and the interior of 4 convection ovens - Three ceiling ventilation covers and the surrounding ceiling panels, all located directly above the center of the kitchen food preparation areas, had a heavy build up of a fuzzy dark grey substance that resembled dust and rust was present in several areas where the plastic coated surface had worn away. G. Interview with the RD on 04/11/24 at 9:45 AM confirmed the identifed areas of concern and that the issues need to be addressed and corrected. The RD confirmed that food contamination potentially could occur due to the sanitation issues identified. H. Interview with the RD on 04/11/24 at 10:05 AM confirmed that all residents ate foods prepared in the facility kitchen.

Licensure Reference Number 175 NAC 12-006.18 Based on observation, and interview, the facility failed to maintain the cleanliness and condition of walls, floors, fixtures, ceilings, and baseboards in 24 (rooms: 102, 105, 106, 113, 116, 122, 123, 125, 131, 132, 134, 144, 146, 158, 159, 162, 203, 205, 212, 215, 225, 233, 236, and 238) of 59 occupied resident rooms and the 2nd floor north hallway nurses station of the facility. The facility census was 60. Findings are: Observation on 04/15/24 between 8:05 AM and 09:30 AM, during the environment tour with the facility Maintenance Director [MD] and the Administrator, revealed the following concerns with the facility environment: - There were several scrapes on the walls by beds in resident rooms 106, 113, 223 and 236. - There were several scrapes on the wall under the window in room [ROOM NUMBER]. - There were several scrapes on the wall behind the recliner in room [ROOM NUMBER]. - There were several scrapes on the walls in the bathroom by the toilet in room [ROOM NUMBER]. - There were several scrapes on the wall in the bathroom by the toilet paper holder in room [ROOM NUMBER]. - There were several scrapes on the wall beside the bathroom door in room [ROOM NUMBER]. - There were several scrapes on the wall beside the window ledge in room [ROOM NUMBER]. - There was a large crack in the wall that extended from floor to ceiling by the bed in room [ROOM NUMBER]. - The top of the toilet tank was broken and cracked in rooms 102, 131 and 158. - The caulking was cracked and broken at the juncture of the wall to the sink in resident bathrooms in rooms 131, 132, 134, 146, 212, 225 and 238. - There were water stains and plaster peeling away on the bathroom ceilings in rooms [ROOM NUMBERS]. - There were brown stains and dirt buildup surrounding the base of the toilets in resident bathrooms in rooms 113, 122, 123, 125, 131, 134, 225 and 233. - There was a large pink colored stain on the floor under the floating toilet in resident bathroom in room [ROOM NUMBER]. - There was a large yellow stain on the floor at the entrance to the bathroom in room [ROOM NUMBER]. - The linoleum was cracked on the floor in front of the sink in the bathroom in room [ROOM NUMBER]. - The light bulbs were burned out in the bathrooms in rooms 125, 134 and 162. - The cable TV outlet cover was cracked and broken in room [ROOM NUMBER]. - The baseboard was loose and pulled away from the wall in room [ROOM NUMBER] by the door to the room and in the bathroom beside the door in room [ROOM NUMBER]. - There was a heavy buildup of dirt, wax and dust particles along the edges of the bathroom walls and corners in rooms 122, 125, 131, 203, 205, 212 and 233. - There were several dead bugs present inside the light fixtures in rooms [ROOM NUMBERS]. - There were several scrapes along the bottom of the wall underneath the window of the 2 North nurses station. Interview on 04/15/24 at 09:30 AM with the MD confirmed that those areas that had been identified during the environmental tour needed to be cleaned and/or repaired. The MD confirmed that there were no work orders for the areas identified and that the concerns had not been identified prior to the environmental tour of the facility.

Licensure Reference Number 175 NAC 12-006.10D Based on observation, record review and interview the facility failed to maintain a medication error rate of less than 5% which affected 1(Resident 44) of 3 sampled residents. There were 26 opportunities and 2 errors observed resulting in a 7.69% medication error rate. Facility Census was 60. Findings are: Record Review of Resident 44's active orders listing printed on 04-16-2024 revealed an order for aspirin 81 milligram (mg) delayed release tablet, take one tablet by mouth daily. Do not crush. The listing also revealed an order for DOK (generic name Docusate Sodium, a stool softener) 100 mg tablet take by mouth twice daily. An observation on 04-16-2024 at 7:30 AM of Medication Assistant (MA) D preparing medications for Resident 44, revealed MA-D took the Aspirin 81 mg medication card out and popped the pill into a clear medication cup. MA D also took the DOK 100 mg card out and popped the pill into the same clear medication cup. MA D poured the medications into a clear pouch and then placed the pouch in the pill crusher and crushed the medication. MA D removed the pouch, poured the crushed medications into a clear medication cup and mixed the medications with pudding. MA D then took the cup to Resident 44 and administered the medications. Record review on 04-16-2024 at 7:35 AM of the label on the Medication Card for Aspirin revealed: Aspirin 81 mg delayed release 1 tablet by mouth daily. Take with food and do not crush. Record review on 04-16-2024 at 7:37 AM of the label on the Medication Card for DOK revealed: DOK 100 mg tablet take by mouth twice daily. Do not crush. An interview with MA D on 04-16-2024 at 7:40 AM confirmed that the Aspirin 81 MG tablet and the DOK 100 mg tablet were both crushed. An interview with the Assistant Director of Nursing (ADON) on 04-16-2024 at 10:27 AM confirmed crushing a medication with do not crush instructions was a medication error. Record review of the facility policy titled Medication Administration dated 04-09-2024 revealed a policy statement: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Under the section Policy Explanation and Compliance Guidelines #14 Administer medication as ordered in accordance with manufacturer specifications. -Provide appropriate amount of food and fluid. -Shake well to mix suspensions. -Crush medications as ordered. Do not crush medications with do not crush instructions.

Licensure Reference Number 175 NAC 12-006.17B Based on observation, interview, and record review the facility failed to handle linens and a catheter drainage bag in a manner to prevent the potential for cross contamination for 1(Resident 44) of 3 sampled residents. The facility census was 60. Findings are: A. Record review of Resident 44's Comprehensive Care Plan (CCP, Care that is planned and coordinated around the resident's physical, mental and cognitive health needs) with a review date of 04-02-2024 revealed Resident 44 had a diagnosis of Chronic Kidney Disease Stage 3 (CKD3, mild to moderate loss of kidney function) and had a hospitalization in March of 2024 for an Acute Kidney Injury (AKI, is the sudden loss of kidney function) and returned to the facility with an indwelling catheter (a tube inserted into the bladder to drain urine). The approaches listed on the CCP to care for the indwelling catheter are: -Be sure catheter tubing does not become kinked or placed under the legs to promote adequate drainage. -Do not allow any part of the drainage system to touch the floor. -Monitor for changes in urinary output and/or infections: such as foul odor, blood in the urine, decreased output, or sediment in the urine. -Obtain order and change catheter per physician instructions. -Follow up after hospitalization with nephrology and urology. -Labs per physician order. -Provide catheter care with 2 staff each shift. An observation on 04-16-2024 at 6:55 AM with Nursing Assistant (NA) B and NA C providing catheter care for Resident 44. NA C donned a gown and gloves and entered Resident 44's room. NA C went to the bathroom and obtained a stack of dry wipes (a disposable linen washcloth) and placed them into the sink basin and turned on the water. After wipes were moistened, NA C took the wipes out of the sink basin and placed them on top of the handrail on the right side of Resident 44's bed. After exposing the insertion site of the catheter, NA C took a wipe off the stack on the handrail and wiped around the top of the catheter insertion site. NA C threw away the wipe and obtained another wipe off of the stack on the handrail and wiped around the bottom of the insertion site, then discarded wipe into the trash. Then NA C took another wipe off the stack on the handrail and wrapped the wipe around the catheter tubing and wiped the tubing from insertion site down. An interview on 04-16-2024 at 7:10 AM with NA C confirmed that the wipes were placed in the sink basin and the basin of the sink is considered contaminated. NA C also confirmed that the wipes were placed on the handrail and should not have been. An interview with the Assistant Director of Nursing (ADON) on 04-16-2024 at 11:20 AM confirmed that placing wipes in the sink basin or on the handrail could cause cross contamination. B. An observation on 04-16-2024 at 6:35 AM revealed Resident 44 was lying in bed and the indwelling catheter bag was hanging on the bed frame without a cover, touching the floor mat that was located on the left side of Resident 44's bed. An interview on 04-16-2024 at 6:40 AM with NA B, who had entered Resident 44's room confirmed that the indwelling catheter bag was uncovered and was touching the mat that was on the floor. An interview on 04-16-2024 at 6:45 AM with the facility Infection Preventionist (IP)-A in Resident 44's room confirmed that the indwelling catheter bag should been covered and not have contact with the mat on the floor. Record review of the undated facility policy titled Catheter Care revealed the objective of catheter care is to maintain patency, prevent infection by performing catheter care at least one time per shift, and monitoring of catheter function. Step 11 indicates to make sure catheter tubing is hanging properly below the resident's bladder level. Check the drainage bag for leaks. Observe for urine flow; report any abnormalities to the area charge nurse. Have the drainage bag off the floor. An interview conducted on 04-16-2024 at 11:21 AM with the ADON confirmed the catheter drainage touching the mat on the floor could cause cross contamination. Record Review of the facility policy Infection Prevention and Control Program dated 02-20-2020 revealed a policy statement as follows; This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Under policy explanation and compliance guidelines #11 Linens: -laundry and direct care staff shall handle, store, process and transport linens to prevent the spread of infection. -Clean linen shall be separated from soiled linen at all times. -Clean linen shall be delivered to resident care units on covered linen carts with covers down. -Linen shall be stored on all resident care units on covered carts, shelves, in bins, drawers or linen closets. -Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. -Environmental services staff shall not handle soiled linen unless it is properly bagged.

Licensure Reference Number 175 NAC 12-006.04A3b Based on record review and interview the facility failed to conduct adult and child protective service (APS and CPS) registry checks upon hire for 1 (Nursing Assistant, NA G) of 5 sampled new employee files. Record Review of NA G's employee file revealed NA G was hired on 03-04-2024. Further review of NA G's employee file revealed results from registry checks with APS and CPS were not observed in the file. An interview conducted with the Administrator (Admin) on 4-16-2024 at 2:20 PM revealing APS and CPS registry checks are completed on hire and employees should not be allowed to work until the results are back. An interview conducted on 4-16-2024 at 2:40 PM with the Administrative Assistant confirmed APS and CPS registry checks were not completed for NA G. Record Review of the facility policy Background Investigations dated June 2015 revealed a policy statement of personal reference checks, driving record investigations, background investigations are conducted on all personnel employed with this facility. Listed under policy interpretation and implementation under #1 indicated in keeping with the Omnibus Budget Reconciliation Act of 1987 the Administrative Assistant will conduct any applicable background investigation(s) on each individual newly employed with this facility and on any current employee if such background investigation(s) is/are appropriate in light of the position for which the individual has applied. Listed under #4 when conducting background investigations, the facility may consult an or all of the following agencies, depending upon the position for which the employee was hired: -Local, state and/or federal law enforcement agencies; -Adult and Child abuse registries; -Professional licensing boards; -Nebraska state registry for nursing aides; -Consumer reporting agencies; and -other agencies as deemed appropriate in determining employment eligibility.

Based on interview and record review, the facility failed to ensure residents were free from significant medication error for 1 (Resident 3) of 3 sampled residents. The facility had a total census of 59 residents. Findings are: Record review of Resident 3's undated Face Sheet revealed, the resident was admitted to the facility with a diagnosis of chronic kidney disease and unspecified dementia. A review of Medication Error Report dated 11/27/23 revealed, Resident 3's Lasix 80 mg one time per day was held on 11/21/23, 11/22/23, and 11/23/23. According to Medication Error Report, Resident 3 was taken to emergency room for assessment on 11/26/23. A review of Resident 3's 11/2023 MAR (Medication Administration Record) revealed, order for Lasix (a diuretic that may cause dehydration and electrolyte imbalance) 80 mg (milligrams) with start date of 10/24/23. Resident 3's Lasix 80 mg once per day was not administered on 11/21/23, 11/22/23, 11/23/23 and 11/25/23 as medication was unavailable according to 11/2023 MAR. Lasix 80 mg once per day was documented as being administered on 11/24/23. A review of Resident 3's 11/2023 MAR revealed, order for potassium chloride (a mineral used as medication to treat and prevent low blood potassium) tablet extended release 10 meq (milliequivalent) to be administered 3 times per day with start date of 7/24/23. Resident 3's potassium chloride extended release 10 meq was administered 3 times per day on 11/21/23, 11/22/23, 11/23/23 and 11/25/23. A review of Progress Note dated 11/25/23 at 10:37 PM revealed, Resident 3 complaint of dizziness and shortness of breath. Progress Note stated that Resident 3 was sitting on side of bed spitting up a lot of phlem and complaining of nausea. A review of Progress Note dated 11/26/23 at 10:27 AM revealed, Resident 3 was complaining of being light headed, having a headache, tired and having diarrhea for 3-4 days. Resident 3 was taken to emergency room by family. A review of Progress Note dated 11/26/23 at 3:28 PM revealed, Resident 3 was admitted to the hospital for a few days for high potassium and an increase in fluid. A review of Progress note dated 11/29/23 revealed, Resident 3 returned to the facility with no change in medications and order to eat less potassium rich foods. A review of Resident 3's hospital discharge instructions for admission on 11/26/23 revealed, Resident 3 was diagnosed with hyperkalemia which means Resident 3 had a high level of potassium. Discharge instructions stated that a high level of potassium can cause serious problems including abnormal heart rhythms and even heart attack. In an interview on 12/14/23 at 3:08 PM, the Director of Nursing reported that Resident 3's Lasix was on reorder and did not come in. Resident 3's physician was not notified that it was not available. According to the Director of Nursing, the medication aide should have reported to the nurse and the nurse should have called the physician. The Director of Nursing confirmed, that Resident 3 was hospitalized for hyperkalemia. The Director of Nursing reported the medication aide was counseled regarding the medication error and education was provided to staff. In an interview on 12/14/23 at 4:06 PM, the Assistant Director of Nursing reported doing monthly audits related to timeless of medication administration. The Assistant Director of Nursing reported education was provided to staff on 12/5/23. A review of Inservice Training Report dated 12/5/23 revealed, the following education was provided to licensed nurses and medications: -We just had a resident hospitalized for hyperkalemia because they didn't receive their Lasix for four days and potassium built up in the system. Don't assume because a reorder sticker is removed that a medication was reordered. Many times it hasn't been. -What do we do when med is not in the med cart? We look in the overflow bins first. If not there, MA's (medication aide) tell a licensed nurse so they can call the pharmacy and then document that the med is unavailable, which nurse you notified and that the pharmacy was called by the nurse. Always, Always call the pharmacy. In a follow-up interviews on 12/14/23 at 3:29 PM and 4:29 PM, the Director of Nursing confirmed, a Performance Improvement Project had not been started for missing medications. The Director of Nursing reported the facility does not have a policy and procedure on missing medications only what is in the training.

Licensure reference: 175 NAC 12-006.09D1c Based on interview and record review, the facility failed to ensure baths were being offered in accordance with resident preferences for 2 (Residents 1, and 2) of 3 sampled residents. The facility had a census of 59 residents. Findings are: A. A review of undated Resident Face Sheet revealed, Resident 2 was admitted to the facility on [DATE] with a diagnosis of bipolar disorder (a disorder with extreme mood swings) and difficulty in walking. A review of Resident 2's Care Plan revealed the following: -Resident 2 preferred 2 baths per week dated 11/2/23 -Resident 2 utilizes limited to total assist with ADL's (activities of daily living) with level of assist varying with review/revised date of 11/6/23. -Resident 2 utilizes a sit-stand lift with assist of 2 staff for transfers with review/revise date of 11/6/23. -Resident 2's Brief Interview for Mental Status completed 11/1/23 identified Resident 2 as having a score of 15 indicative of cognitive intactness. In an interview on 12/14/23 between 11:01-11:12 AM, Resident 2 reported getting a bath every 1-2 weeks. Resident 2 reported that Resident 2 received bed baths due to having legs wrapped at the lymphedema [swelling in an arm or leg caused by a blockage in due to blockage in the lymphatic system] clinic. A review of bathing record for Resident 2 revealed, 3 documented baths between 11/1/23-12/14/23 on 11/21/23, 11/28/23, and 12/6/23. A review of Resident 2's TAR (Treatment Administration Record) for 11/2023 revealed, an order with start date of 10/21/23 to give bath every Monday, Wednesday, and Friday per physician with baths to be given between 2-4 PM per Resident 2's preference. Baths were documented as given to Resident 2 on 11/3/23, 11/22/23 and 11/29/23. The following explanations were documented on the TAR for Resident 2 not receiving a bath: -11/1/23 drug/item unavailable -11/6/23 no bath staff -11/8/23 no bath aide -11/13/23 drug/item unavailable -11/15/23 drug/item unavailable -11/17/23 short -11/20/23 no bath given -11/24/23 no bath aide -11/27/23 drug/item unavailable A review of Resident 2's TAR for 12/2023 revealed, an order with start date of 10/21/23 to give bath every Monday, Wednesday, and Friday per physician with baths to give between 2-4 PM per resident's request. No baths were documented as given between 12/1/23-12/14/23. The following explanations were documented on the TAR for Resident 2 not receiving a bath: -12/1/23 refused -12/4/23 refused -12/6/23 drug/item unavailable -12/8/23 refused -12/11/23 refused -12/13/23 drug/item unavailable In an interview on 12/14/23 at 3:54 PM, Medication Aide A reported that it takes 1.5-2 hours to give Resident 2 a bath and Resident 2 refuses frequently. In an interview on 12/14/23 at 4:28 PM, the Director of Nursing reported Resident 2 is only to have bed bath at this time. The Director of Nursing reported just becoming aware of bath issue today. B. A review of Resident 1's undated Face Sheet revealed, Resident 1 was admitted on [DATE] with diagnoses of post-traumatic stress disorder and Bipolar I. A review of Resident 1's care plan revealed the following: -Give Resident verbal reminders not to ambulate/transfer without assistance dated 12/1/23. -Continue to encourage resident to call staff for assistance with cares to keep from sitting on floor from chair and etc dated 12/1/23. -Resident 1's preferences for baths was not identified in care plan. A review of 11/25/23 quarterly MDS (Minimum Data Set; a comprehensive assessment used for care planning) revealed, a score of 14 on the Brief Interview for Mental Status indicating cognitive intactness. In an interview on 12/14/23 at 10:38 AM, Resident 1 reported getting a bath every 1 to 2 months and doesn't know when baths are scheduled. A review of undated bath schedule revealed, Resident 1 is scheduled for baths on Tuesday and Fridays. A review of Resident 1's bathing record for 11/1/23 to 12/14/23 revealed, Resident 1 had a bath documented on 11/9/23. Bath refusals were documented on 11/6/23, 11/16/23, 11/29/23 and 12/1/23. In an interview on 12/14/23 at 1:55 PM, Bath Aide B reported that Resident 1 refuses baths much of the time. In an interview on 12/14/23 at 2:52 PM, the Director of Nursing reported Resident 1 is scheduled for baths twice per week and frequently refuses. The Director of Nursing acknowledge that staff are not documenting Resident 1's bath refusals. In a further interview on 12/14/23 at 3:49 PM, the Director of Nursing confirmed the bath schedule is based on resident preferences.

Licensure Reference Number NAC 12-006.09D Based on interview and record review the facility failed to; identify, assess, and obtain treatment for head injury for 1 resident (Resident 1) of 4 residents reviewed. The facility staff identified a census of 62. Findings are: A. Record review of the facility Policy and Procedure for Accidents and Incidents dated 9-2022 revealed the following information: -Protocol: -1. The facility strives to ensure that residents/patients, visitors, and/or volunteers will not experience undue discomfort and/or have their health and safety placed in jeopardy due to an unusual occurrence (accident/incident). -2. The facility defines an accident/incident as an event, occurrence, or happening that may produce actual or potential undesirable outcome. -3. The event may be an accident or a situation that could result in an accident/incident may include, but not limited to falls, suspected falls, elopement and injuries of unknown origin. -Procedure: -5. Obtain and record vital signs including neurological checks (a testing method to evaluate for potential head injury), as applicable for a minimum of 72 hours on the resident/patient. B. Record review of Resident 1's Care Plan (CP) dated 5/17/2023 reveal diagnoses of Unspecified dementia, (a group of thinking and social symptoms that interferes with daily functioning), Unspecified Atrial Fibrillation, (an irregular heart beat that causes poor blood flow), Pseudobulbar affect, (Inappropriate involuntary laughing and crying due to a nervous system disorder), Long term (current) use of anticoagulants. (commonly known as a blood thinner), History of falling and had presence of prosthetic (artificial) heart valve. A record review of Resident 1's Progress Note (PN) dated 5/18/2023 with a time identified as 1:00 AM revealed Resident 1 was very agitated, crying, pacing, exit seeking. Further review of Resident 1's PN dated 5/18/2023 revealed Resident 1 crossed their legs and fell to the floor hitting the back of their head and getting a rug burn on right elbow. According to Resident 1's PN dated 5-18-2023 with a time notes as 1:00 AM revealed the resident reported having a head ache. Record review of Resident 1's medical record that included PN's, Practitioners Orders, faxes and Resident 1's Care Plan revealed there was not a indication that the facility had implemented and completed neurological evaluation for Resident 1. On 7-26-2023 at 1:15 PM PM an interview with Licensed Practical Nurse (LPN) A. During the interview LPN A reported neurological checks are to be completed if a resident fell , is unwitnessed and is not a reliable reporter. A record review of the Incident and Investigation (II) note dated 5/18/2023 at 10:15 AM revealed staff heard Resident 1 yelling help and found Resident 1 on floor with head against bathroom door and lying partially on right side. According to the II dated 5-18-2023 Resident 1 Has bump (goose egg) on right side of head, unknown if happened night before, right pink elbow and did not answer if Resident 1 had hit (gender) head. Record review of Resident 1's medical record that included PN's, Practitioners Orders, faxes and Resident 1's Care Plan revealed there was not a indication that the facility had implemented and completed neurological evaluation for Resident 1. On 7-26-2023 at 3:13 PM an interview was conducted with LPN A. During the interview LPN reported not initiating neurological checks for Resident 1 for the fall on 5-18-2023 at 10:15 AM. Record review of Resident 1's PN dated 5-20-2023 revealed Certified Medication Assistant (CMA) E had noticed Resident 1 was walking in the hall with an odd Gait while holding onto the right side of the head, crying and very agitated. According to the Resident 1's PN dated 5-20-2023, Resident 1 reported to CMA E that Resident 1's head hurt and was burning with CMA noticing a large bruise on the right side of Resident 1's head. Further review of Resident 1's PN dated 5-20-2023 revealed CMA E notified Resident 1's family member who transported Resident 1 to the hospital. Record review of Resident 1's PN dated 5-20-2023 revealed LPN D had spoken to the hospital were Resident 1 was admitted . According to Resident 1's PN dated 5-20-2023 Resident 1 was admitted to the Intensive Care unit (ICU) with a subdural hematoma (a pool of blood between the brain and its outermost covering). According to [NAME]-[NAME].org sysmtoms of subdural hematoma may include the following: -Balance or walking problems. -Confusion. -Dizziness. -Headache. -Nausea or vomiting.

LICENSURE REFERENCE NUMBER 175NAC 12-006.09D2b Based on observation, record review and interview; the facility staff failed to complete weekly skin monitoring and implement interventions to prevent the development of pressure ulcers for 1(Resident 2) of 4 sampled residents. The facility staff identified a census of 51. Findings are: Record review of Resident 2's Minimal Data Set(MDS: a federally mandated comprehensive assessment tool used for care planning) dated 2-04-2021 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was a 12. According to the MDS Manuel a score of 8 to 12 indicates modernly impaired cognition. -Required extensive assistance with bed mobility, transfers, dressing and toilet use. -Required limited assistance with personal hygiene. -Was at risk for the development of pressure ulcers. -Had 1 stage 2 (Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister) pressure ulcer. Record review of Resident 2's Comprehensive Care Plan (CCP) dated 2-08-2021 revealed Resident 2 was not at risk for pressure ulcers. The goal identified on Resident 2's CCP revealed Resident 2 would be free of pressure ulcer development. Interventions identified on Resident 2's CCP to meet this goal included keep linens clean and day and to conduct a systematic skin inspection weekly on Tuesdays. Record review of a Wound Management Details Report sheet dated 2-02-2021 revealed Resident 2 was identified as having an abrasion to the right buttocks. Review of Resident 2's medical record that included Progress Notes, practitioners orders, skin sheets, Medication Administration Records (MAR) and Treatment Administration Records (TAR) for February 2021 revealed there was no information identifying the weekly skin inspections had been completed Observation on 2-25-2021 at 1:47 PM with Licensed Practical Nurse (LPN) I of Resident 2's buttocks area revealed LPN I identified a stage 2 pressure ulcer to Resident 2's gluteal fold measuring 0.3 centimeters(cm) by 0.2 cm's with drainage identified as bloody. In addition, LPN I during the observation identified a ulcer to the left buttocks that measured 0.2 cm by 0.2 cm with light bloody drainage. On 2-25-2021 at at 1:47 PM an interview was conducted with LPN I. During the interview LPN I reported the area to Resident 2's left buttock and gluteal folds were new pressure ulcers. On 2-25-2021 at 3:40 PM an interview was conducted with the Director of nursing (DON). During the interview the DON confirmed the pressure ulcers to Resident 2's left buttocks and gluteal folds were new. The DON reported the expectation is each resident will have weekly skin checks completed and if skin issues were identified a skin sheet be completed. The DON confirmed the weekly skin checks for Resident 2 had not been completed for 2-16-2021 and 2-23-2021 and should have been .

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7B Based on observation, record review and interview; the facility staff failed to implement interventions to prevent additional falls for 1 (Resident 16) and failed to implement interventions to safely transfer a resident when using a mechanical lift for 1 (Resident 10) of 10 residents. The facility staff identified a census of 51. Findings are: A. Record review of Resident 16's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 11-04-2020 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) score was an 11. According to the MDS Manuel a score of 8 to 12 indicated moderately impaired cognition. - Limited assistance of 1 staff person for transfers. Record review of Resident 16's Comprehensive Care Plan (CCP) dated 11-13-2020 revealed Resident 16 was at risk for falls. The goal for Resident 16 was not to have more than 2 falls or sustain an injury from a fall. Interventions identified on the CCP dated 11-13-2020 included giving Resident 16 verbal reminders not to ambulate/transfer without assistance, re-educate Resident 16 to the call light system and remind Resident 16 to utilize the call light and wait for assistance. Record review of an Incident&Investigation (I&I) sheet dated 12-04-2020 revealed Resident 16 was found on the floor with no injuries. The intervention initiated was to remind Resident 16 to use the call light for assistance. Record review of an I&I sheet dated 1-28-2021 revealed Resident 16 was found on the floor in Resident 16's room. Record review of an Office Visit sheet dated 2-01-2021 revealed Resident 16 had sustained a left wrist fracture from the fall on 1-28-2021. On 3-01-2021 at 12:02 PM an interview was conducted with the Director of Nursing (DON) and Registered Nurse (RN) F. During the interview, review of Resident 16's CCP dated 11-13-2020 and falls on 12-04-2020 and 1-28-2021 were completed. RN F reported a different intervention should have been implemented for the fall on 12-04-2021. RN F confirmed the intervention to remind Resident 16 was on the CCP dated 11-13-2020 and the intervention identified on the I&I dated 12-04-2020. B. Review of the facility incident and investigation dated 11/20/2020 for Resident 10 revealed during a transfer using a mechanical lift Resident 10 hit the middle of Residents 10 forehead on the lift apparatus causing a 4 centimeter (cm) x 1.5 cm bruise. The intervention intiated at that time was to use 2 staff when using the mechanical lift. Review of Resident 10's care plan revealed to use 2 staff when available to complete the mechanical lift transfer. Observation on 2/25/2021 at 9:50 AM revealed 3 staff standing at the nurses station. Two staff left the station and Nursing assistant (NA)-E stated Resident 10 needed to be transferred to the bed. NA-E perform hand hygiene and donned gloves. NA-E then broughtthe mechanical lift into Resident 10's room. The sling used for the lift was under Resident 10 in the wheelchair and the straps were hooked to the lift bar. NA-E completed the lift and transferred Resident 10 into the bed with no assistance of a second staff. Review of the facility policy dated 6/2017 titled Resident Transfer Program revealed the purpose is to establish the requirements for safe resident lifting and transferring in the facility. Review of Item 3 of the policy revealed Mechanical Lift transfers for heavy or difficult to move residents require two or more staff members to be involved with the transfer procedure. Interview with RN-F revealed there is always enough staff to complete transfers with 2 with the mechanical lift and there should have been two staff to transfer Resident 10 to ensure safety.

Licensure Reference Number 175 NAC ,d+[DATE].02(8) Based on observations, interviews, record reviews and review of policy and procedures, it was determined the facility failed to initiate an investigation for injuries of unknown source for two (Residents 16 and 46) of two sampled residents reviewed for injuries of unknown origin. This affected 2 residents (Resident 16 and Resident 46) of 24 residents. This had the potential to affect all of the residents. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. The Immediate Jeopardy was related to State Operations Manual, Appendix PP, 483.12 (freedom from abuse, neglect, and exploitation) at a scope and severity of J. On [DATE] at 4:24 PM, the Administrator, Assistant Administrator, and Director of Nursing, were informed of the Immediate Jeopardy situation. At the time of survey exit, on [DATE] at 1:10 PM, a Removal Plan had not been accepted by the state agency. Findings are: Resident 16 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders, dated [DATE], indicated the resident had been prescribed 81 mg (milligrams) of aspirin (a blood thinner) to be taken once a day. A quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was severely impaired in cognitive skills for daily decision making. The resident required extensive assistance from one staff member with bed mobility, transfers, and personal hygiene. The resident was not steady on their feet and only able to stabilize with staff assistance when moving from a seated to a standing position, moving on and off the toilet, and transferring between surfaces. The resident used a wheelchair for mobility. A care plan, dated [DATE], indicated Resident 16 had a poor memory and used a mechanical lift for transfers. A Nurses' Progress Note dated [DATE] at 10:21 PM, by Registered Nurse (RN)-V indicated at 7:50 PM, they were summoned to the tub room where the resident was receiving a bath. The resident was observed to have a baseball size purple bruise to the left inner thigh. The Progress Note documented, Resident does not remember how [gender] obtained the bruise. A Nurses' Progress Note dated [DATE] at 10:23 PM, by Licensed Practical Nurse (LPN)-W indicated, on [DATE] at 8:00 PM, they were summoned to the resident's room while the resident was being readied for bed. The note indicated the nurse observed a bruise measuring 5 cm (centimeters) by 6.5 cm on the resident's left inner thigh. It was documented the bruise was purple with a raised area in the center and yellowing edges. The note documented the resident didn't know how it happened. The note indicated, at times, the resident became combative with cares and sit to stand lift. A Nurses' Progress Note dated [DATE] at 10:57 PM, by RN- indicated this nurse had not observed any bruises on the resident's arms or hip area; however, the note did not refer to the resident's left inner thigh. The note indicated the resident fought staff as they got the resident up into the s/s (sit to stand, a piece of equipment used for positioning or lifting the resident), the resident stated the machine was hurting them, and the resident's legs were hitting the s/s bar. The note documented, so I think using the total lift would prevent and brusing [sic. bruising]. A facility document, dated [DATE], titled, Nursing Home Rounds, indicated a large bruise the size of baseball was located on the resident's left inner thigh and was tender to touch. A physician's signature, dated [DATE], documented a 4 x 4 cm (centimeter) old hematoma was located on the Resident's left thigh. Hot packs had been ordered daily as tolerated. The medical record was reviewed, and it was noted there were no indications a thorough investigation had been conducted regarding this injury of unknown origin. No investigative report could be found in the medical record. No staff interviews, with staff associated with the resident prior to the discovery of the bruise, were documented to determine the injury's root cause. Based on the lack of an investigation, abuse and neglect could not be ruled out as causes for the bruise. On [DATE] at 4:02 PM, the Assistant Administrator (Staff-K), was asked for some examples of injuries of unknown origin, and they replied, Bruising. Staff-K was asked what actions were expected from staff if an injury of unknown origin had been identified. Staff K stated staff were expected to report the injury of unknown origin to the Director of Nurses (DON), to call and report the injury immediately, or within two hours, to the State, and to start an investigation to determine the cause of the injury. Staff K stated staff was expected to fill out a 24-hour Incident Report. On [DATE] at 5:29 PM, the Administrator (ADM) was asked if any investigative reports had been completed for Resident 16 during the month of [DATE]. The ADM stated there were none. On [DATE] at 2:15 PM, the ADM was asked for the phone numbers of some staff who were not scheduled to work during the survey period but had been involved in the incident for interviews. The ADM refused to provide staff phone numbers saying, No, that is inappropriate. On [DATE] at 2:47 PM, the Director of Nurses (DON) was asked what actions were expected from staff when they discovered an injury of unknown origin. The DON stated staff were expected to report injuries of unknown origin to the DON and the ADM. The DON stated injuries of unknown origin should be brought to the attention of the Charge Nurse and APS (Adult Protective Services) should be called about it. The DON stated an internal investigation was expected to be done which would include talking with staff from different shifts about who saw it first and seeing if they can come up with reason for it. The DON was asked who was responsible for completing the Investigative Report. The DON stated the nurse who first discovered the injury of unknown origin was responsible for reporting it and starting an investigation. The DON stated, if the injury of unknown origin was determined to be abuse, APS and the state agency would be notified. The DON stated, otherwise, documentation would be found in the Nurses' Notes. The DON was asked to review the Nurses' Progress Notes to determine when Resident 16's injury of unknown origin occurred. The DON replied it was first noted on [DATE]. The DON stated another staff member remembered seeing it on [DATE]. The DON was asked if a thorough investigation into the event had been conducted. The DON stated they had done their own investigation but replied, I did not document it anywhere. The DON stated they, along with Staff-K and the ADM, had watched the resident during a transfer using the sit-to-stand lift. They determined that was the cause of the bruise. The DON stated they decided not to use the sit-to-stand lift anymore for the resident. The DON was requested to share any investigative documentation that existed. On [DATE] at 11:25 AM, the DON provided two pages from a personal calendar with notes handwritten diagonally across the pages. The DON stated this was the entire investigation for Resident 16's injury of unknown origin. The handwritten notes did not include documentation of a complete investigation that included staff interviews prior to the finding of the bruise to determine its root cause. On [DATE] at 11:50 AM, the ADM was interviewed regarding abuse and was asked to list the elements of a complete investigation. They answered: bios, records, witness interviews and precipitating factors. No mention was made of interviewing other staff members or residents, except witnesses. I would always contact [Staff-K] who heads up investigations. The ADM stated this type of investigation would be given to the DON. The ADM also stated, Who it goes to depends on what department it is in. The ADM said, We have a meeting together and go over everything found and make conclusions. The ADM clarified this was an informal meeting. The ADM stated, They [staff] have their own ways of documenting, the DON is a calendar girl. The ADM further stated If it was not a formal investigation staff could document in their own style The ADM said, If at all possible, I want it in the progress notes. The ADM stated, I have my own way of doing investigations. The ADM stated staff usually met on Wednesdays to discuss incidents like falls and Medicaid issues. The ADM was asked if there was documentation from those meetings. The ADM replied those meetings were just administrative meetings for information gathering and minutes were not kept. The ADM stated investigations into injuries of unknown origin were handled exactly the same way our other investigations are handled. The ADM also mentioned calling the family. On [DATE] at 12:54 PM, Resident 16 was asked if they had a bruise. The resident stated, I told them it wasn't on my arm. It's on my leg! The resident pulled up their left pants leg and a below the knee amputation was observed as well as a 2 ,d+[DATE] inch round, grey/yellow bruise, which was slightly raised in the middle. When Resident 16 was asked if they knew how they got the bruise, the resident stated they did not know how the bruise got there. A facility form, dated [DATE], titled, Weekly Skin Documentation/Care Tracker Back Up Sheet, indicated the bruise on the left inner thigh had healed. On [DATE] at 2:00 PM, RN-BB, stated they had been off for three days, and, on returning to work on [DATE], the DON asked them to assess the resident's bruise. They stated, the DON told me the Resident resisted the lift. On [DATE] at 8:38 AM, Certified Nursing Assistant (CNA)-CC was interviewed. CNA-CC stated they had transferred Resident 16 many times and used the sit-to-stand lift. CNA-CC stated they had never observed the resident to get bumped or hurt with the lift. They stated the resident did not like the lift and sometimes became angry when it was used, but CNA-CC stated the resident only became verbally angry. [Gender] stated that the resident did not strike or swing out with limbs. On [DATE] at 8:44 AM, CNA-DD was interviewed. CNA-DD stated they had never seen the resident get hurt or the inner thighs touch the sit-to-stand lift while using it. CNA-DD stated the only resistance they had seen from the resident was verbal resistance. On [DATE] at 8:52 AM, CNA-EE stated they had often transferred Resident 16 with the sit-to-stand lift and had never seen the resident get hurt using the lift. CNA-DD stated they thought Resident 16 should be using the Hoyer lift as the resident, cannot help with the lifting process at all, and it is hard on [gender]. On [DATE] at 9:37 AM, the surveyor observed Resident 16 being transferred to the toilet with the sit-to-stand lift. While the resident only required one staff for transfer assistance, both CNA-CC and CNA-DD were present. The resident's foot was placed correctly on the platform. The resident was correctly secured with the two lift straps. The resident was asked to grip the lift, but the resident was weak and could only lay their hands on the designated area. The resident was safely lifted to the toilet, and when the resident finished on the toilet was lifted back. At no time did the resident's inner thigh touch any part of the lift. On observing the resident's bruise, CNA-CC stated, That bruise is way higher than the lift part. I don't see how it could have caused that bruise. CNA-DD stated, I don't see how in the world the lift could have caused that bruise. She would have had to swing that leg over that piece [part of the lift], or she was twisted. CNA-DD went on to say if the resident had been injured by the lift, the resident would have been more likely to suffer an injury to the outside of the leg - not the inner thigh. An Incident Report Log provided by the facility, dated from February 2020 through [DATE], was reviewed. All 65 incidents recorded on the log were related to falling. No other type of incident, including injuries of unknown origin, was captured on the Facility's Incident Log. No investigations or reports could be found, or were provided, related to Resident 16's injury of unknown origin. A review of records did not contain a thorough investigation of Resident 16's injury of unknown origin. A facility policy, dated ,d+[DATE], and titled, [Named Facility] Abuse Policy, documented: .An injury should be classified as an injury [of] unknown source when both of the following conditions are met .the source of the injury was not observed by any person or the source of the injury could not be explained by the resident .The injury is suspicious because of the extent of the injury or the location of the injury .the injury is located in an area not generally vulnerable to trauma or the number of injuries observed at one particular point in time or the incidence of injuries over time .The following is a list (not all inclusive) of indicators of abuse/neglect that may help you determine if abuse/neglect should be suspected .Bruises on the inner arm or thigh . The policy further states, .[Named facility] has 7 components in place to prevent Abuse/Neglect of our residents .5. Investigation: [Named facility] has procedures in place to: Investigate different types of incidents Identify staff members responsible for the initial report, investigation of alleged violations and reporting results to proper authorities . The Abuse Policy stated, .Points to Remember: .The facility has a responsibility to protect the residents from abuse/neglect .The facility has a responsibility to identify, to intervene in the abuse and take measures to prevent further occurrences and to immediately report the suspected abuse to the proper authorities . There were no specific investigation instructions or requirements for the topic of Injuries of Unknown Origin. 2. Review of Resident 46's face sheet revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 46 had elected the hospice benefit prior to admission and remained on hospice care. Review of the annual Minimum Data Set (MDS), dated [DATE], revealed Resident 46 score 99 on the Brief Interview for Mental Status (BIMS)., indicating the resident is severely cognitively impaired and was unable to participate in decision making. The MDS also documented Resident 46 required the assist of one or two staff for position changes, transfers, and activities of daily living. Review of Resident 46's, Weekly Skin Documentation/Care Tracker Back Up Sheet, revealed the following: [DATE], Resident 46 had a bruise to the left forehead (site 1) measuring 1.0 x 1.0 (no measurement units specified); and an explanation of the causal factor of bump on lift during transfer; and, a current treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] [DATE], the nurse documented a left forehead bruise (site 1) measuring 1.0 x 1.0 (no measurement units specified) with a causal factor of bump on lift during transfer and current treatment to monitor. [DATE], the nurse documented site 2 as a right forehead scab measuring 2.0 x 0.7 (no measurement units specified) with casual factor bumped in bed and current treatment to monitor. [DATE], the nurse documented site 3 as the right lateral (outer) nose measuring 0.8 x 0.3 (no measurement units specified) with causal factors bumped in bed and current treatment to monitor. [DATE], the nurse documented site 4, an abrasion (scrape) on Resident 46's mid nose with measurements of 2.0 x 1.0 (no measurement units specified), with casual factor of bumped in bed and current treatment to monitor. [DATE], the nurse documented site 5, with no type of injury documented, measuring 1.0 x 0.4 (no measurement units specified), with casual factor bumped in bed and current treatment to monitor. [DATE], the nurse documented site 5 on Resident 46's left forehead, a bruise measuring 0.5 x 0.4 (no units of measure specified), no causal factors were identified and current treatment to monitor. [DATE], the nurse documented site 1, a bruise to Resident 46's left forehead measuring 1.0 x 1.0 (no units of measure specified), causal factor of bump on lift during transfer and current treatment to monitor. [DATE], the nurse documented site 2, a scab to Resident 46's right forehead measuring 0.1 x 0.1 (no units of measure specified), no casual factor identified and current treatment to monitor. [DATE], the nurse documented site 3, a scab to Resident 46's right lateral nose measuring 0.5 x 0.4 (no units of measure specified) with no casual factors and current treatment to monitor. [DATE], the nurse documented site 4, and unspecified injury to Resident 46's mid nose measuring 2.0 x 1.0 (no units of measure specified) with no casual factors and current treatment to monitor. [DATE], the nurse documented site 1, the bruise to Resident 46's left forehead measured 1.0 x 1.0 (no units of measure specified) with a causal factor of bumped on lift during transfer and current treatment to monitor weekly. On [DATE], the nurse documented site 2, the right forehead scab was healed. On [DATE], the nurse documented site 3, the scab to the right lateral nose measured 0.1 x 0.1 (no units of measure specified) with no causative factors listed, improving and current treatment to monitor weekly. On [DATE], the nurse documented site #4, the red area to Resident 46's mid nose, with no casual factors, and current treatment to monitor weekly. The Director of Nursing (DON) and Administrator (ADM), were interviewed on [DATE] at 10:45 AM. They stated the cause of the injuries was explained by staff. The DON denied investigating the injuries to determine if staff provided care as directed and confirmed the injuries were not investigated as potential abuse. Observation of a sign taped on the wall in Resident 46's room that directed staff, Please put pillow on left so resident does not bump head. An interview with Registered Nurse (RN)-D was done on [DATE] at 5:03 PM. RN-D stated that when one staff member transferred the resident with the mechanical lift, staff was to place a pillow to manage leaning to the right. An observation of Certified Nurse Aide (CNA)-AA transferring Resident 46 was done on [DATE] at 10:42 AM. CNA-AA performed the transfer without an assistant. Resident 46 was transferred from the wheelchair to the toilet using the mechanical lift. CNA-AA did not place a pillow on the lift as directed by the sign taped to the wall in the resident's room. In an interview with the DON on [DATE] at 10:45 AM, the DON stated the reporting and investigative tool used by the facility when a resident had an injury was not retained by the facility. The document was stored off-site and was not available for review. When asked to provide evidence the injuries were investigated, the DON stated that information was not available. The DON confirmed the facility did not have evidence of a thorough investigation including root cause analysis and implementation of preventative measures to prevent further injury to Resident 46. On [DATE] at 1:00 PM the State Agency received an abatement plan via email and approved the abatement. The Immediate Jeopardy was abated to a level G

Licensure Reference Number 175 NAC 12-006.09D7 Based on observations, interviews, record reviews and review of policy and procedures, it was determined the facility failed to provide adequate supervision for two residents who left the building unsupervised for two of 24 sampled residents (Resident 24 and Resident 28) reviewed for adequate supervision. This affected 2 residents (Resident 24 and Resident 28) of 24 residents. This had the potential to affect all 4 of the residents who wander. Four residents were at risk for elopement. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. The Immediate Jeopardy was related to State Operations Manual, Appendix PP, 483.25 (quality of care) at a scope and severity of J. On 08/11/20 at 4:24 PM, the Administrator, Assistant Administrator, and Director of Nursing were informed of the Immediate Jeopardy situation. At the time of survey exit, on 08/17/20 at 1:10 PM, a Removal Plan had not been accepted by the state agency. Findings are: 1. Resident 24 had diagnoses that included non-Alzheimer's dementia. Physician's orders, dated 10/30/19, indicated the resident's Wanderguard was to be checked every shift to make sure working. A Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was severely impaired in cognitive skills for daily decision making. The resident required supervision for walking and locomotion off the unit. The resident used a walker for a mobility. A care plan, dated 06/01/20, documented a Category of Cognitive Loss/Dementia. A care plan approach dated 06/01/20 documented, Wander-guard placed on resident. Check function per MAR [Medication Administration Record]. The Care Plan Category of Activities indicated it was important for the resident to be outside when the weather was nice to get fresh air, and an approach date of 06/01/20, documented, .Assist to go outdoors as weather permits . A late entry Nurse's Progress Note, dated 07/09/20 at 8:53 PM, indicated at 6:30 PM the resident had been found in the facility parking lot walking with [gender] walker. The care plan documented, on 07/09/20, the resident's Wandering Assessment score was 7 (definite risk for elopement). Resident wandered into the facility parking lot and care plan approach, dated 07/09/20, documented, Discuss the need for additional alarms on exit doors of building. A Nurse's Progress Note, dated 07/10/20 at 1:00 PM, indicated the resident did not remember going outside by (gender) the day before. A Nurse's Progress Note, dated 07/21/20 at 8:47 PM, indicated the resident had been found, at 8:40 PM, walking with [gender] walker in the parking lot after exiting the facility through a door on the south side of the building. A Nurse's Progress Note, dated 07/24/20 at 10:29 PM, indicated the resident continued to be confused, frequently mentioned going home, and would attempt to leave the facility if not redirected. On 08/06/20 at 5:27 PM, the Administrator (ADM) was asked if an investigation or incident report had been completed for Resident 24 during July 2020, and [gender] said, No. The ADM stated incident reports were not kept on the premises. On 08/10/20 at 9:54 AM, the Director of Nurses (DON) stated Resident 24 had been found outside the facility building on 07/09/20 and 07/21/20, but Staff C stated the resident had not eloped because they were still on facility grounds. Staff C stated both times the resident exited the building, they were on the south side of the facility, the same place. The DON was asked what new interventions had been put into place after the resident left the building on 07/09/20, and the DON stated they had discussed the need for additional alarms. The DON was asked if the installation of alarms had been followed up on, and the DON said, We are still in discussion on that since that area is now the grey zone. On 08/10/20 at 10:36 AM, Maintenance (Staff-FF) was asked if the facility had a system to ensure the Wanderguard system was intact, and they said, No, not really. Staff FF stated the resident had exited from the south wing of the building and the Wanderguard alarm on the wall near the fire doors should have initiated an alarm to alert staff the resident had passed it. Staff FF clarified the Wanderguard system would have only set off an alarm; the Wanderguard system would not lock the door, and the resident could have, just gone through it. Staff FF stated the resident would then have had to pass through the grey unit to reach the doors that exited to the outside. Staff FF was asked if there were alarms on the outside doors of the south/grey unit, and Staff FF said, No. Staff FF added the outside doors only opened one way so once someone was on the outside, they would not be able to get back in without assistance. Several staff members, who were not in the facility at the time of the survey, were noted, in Nurses' Progress Notes, to have been involved in the resident's care around the time of the discovery. On 08/10/20 at 2:17 PM, the DON was asked how long the resident had been outside on 07/09/20 before being found and [gender] said, I do not know. The DON was asked how long the resident had been outside on 07/21/20 before being found and she said, I have no idea. On 08/11/20 at 11:00 AM, it was observed the parking lot on the south side of the facility was intersected by a street that was a main access to facility. It was used to drive around the facility, access other facility parking areas and provided access to a small residential area adjacent to the facility. It was observed the city street that bisected the facility's south parking lot was frequented with vehicles. It was also observed, the South Wing had four doors, with outside access, that did not have any alarms on them. Two doors, at the end of each of the Red and Grey Zones, emptied into stairwells before exiting the building. Neither of the doors to the stairwells or the doors to the outside were fitted with alarms. Additionally, a door by the nurses' station and a door in the therapy room had direct access to outside the building and did not have alarms. On 08/17/20 at 2:34 PM, it was observed the four doors on the south wing directly off of the hall had magnetic alarms installed that sounded for as long as the door was open. But, the two doors off the stairwells that exited the building did not have alarms. On 08/17/20 at 2:34 PM, Certified Nursing Assistant (CNA)-GG stated they were concerned because, if they were in a room at one end of the unit, they would not be able to hear the new alarms that had been installed. They stated they were also concerned as the alarms only sounded the few seconds the door was opened. CNA-GG stated they were concerned as one of the residents on the hall, really wanted to get out. An Incident Report Log provided by the facility, dated from February 2020 through July 2020, was reviewed. All 65 incidents recorded on the log were related to falling. No other type of incident, including elopements, was captured on the Facility's Incident Log. No investigations or reports could be found, or were provided, related to Resident 24's two episodes of elopement. A facility policy, dated 07/18 and titled, Wandering Residents, documented: Every effort will be made to prevent wandering episodes .Interventions into elopement episodes will be entered onto the resident's care plan . Surveyor: [NAME], [NAME] 2. Resident 28 was admitted to the facility on [DATE]. Diagnoses included dementia, muscle wasting and [CONDITION(S)]. Review of Resident 28's admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate impairment. Locomotion did not occur during the review period. Review of nursing progress notes for Resident 28 revealed that on 05/14/20 at 10:13 PM, Nurse-P wrote, Resident propels self in wheelchair and wheels self throughout facility. Will not confine self to room. Attempts to leave facility numerous times through any doors that [gender] sees. Has a WanderGuard (electronic device to alert if a resident attempts to go to a restricted area) on wrist. Very confused. Talks of going home and going to grocery store. Staff attempts to explain why [gender] cant (sic) go home and why [gender] is here and [gender] disagrees. Doesn't know where [gender] is. Review of the facility Wandering risk document for Resident 28, dated 05/14/20, noted a score of 8. The document noted a score of 3 or above indicated an elopement risk. Review of nursing progress notes dated 05/25/20 at 10:45 AM, noted Resident 28 was readmitted from a hospital stay. On 05/25/20 at 11:15 AM, Nurse-N noted that the WanderGuard was placed back on Resident 28. No documentation was provided to show when the WanderGuard was removed after 05/25/20. On 07/14/20, an updated Wandering risk screening was completed for Resident 28, resulting in a score of 7. Review of the Medication Administration Record (MAR) for May 2020 to July 2020 revealed a physician's order stating, May use wanderguard if appropriate. For the Month of June 2020, the WanderGuard was initialed as in place 64 times and the initials had parenthesis around them 26 times. From 07/01/20 to 07/10/20, 21 entries were initialed and 9 had parenthesis. On 08/05/20 at 2:45 PM, Nurse-D verified that initials with parentheses meant a task wasn't done. Nurse-D verified on days in June and July prior to July 11, their initials had parenthesis. Nurse-D also verified that Resident 28 did not have a WanderGuard on during those times. Nurse-D could not explain why the documentation would show the WanderGuard was on and off on various shifts since it would not be removed and replaced routinely. Review of a nurse progress note, dated 07/11/20 at 9:08 PM by Nurse-D, revealed that Resident 28 had been found outside the facility on the sidewalk at 8:20 PM. Resident 28 had a skin tear to the elbow. On 08/05/20 at 5:37 PM, an interview was completed with a family member of Resident 28. The family member was aware of the elopement and was told Resident 28 went outside looking for a truck. The family member said they were told a WanderGuard was placed on Resident 28 after the incident. On 08/06/20 at 8:45 AM, an interview was completed with Medication Aide (MA)-Q. MA-Q reported being familiar with Resident 28. MA-Q said that Resident 28 was very mobile and would go up and down the halls. MA-Q had not seen Resident 28 attempt to elope; but was aware that Resident 28 had eloped in the past. MA-Q also reported being aware that Resident 28 had removed the WanderGuard in the past. Review of physician's orders, dated 07/11/20, noted an order to apply a WanderGuard and check the functioning every shift. No documentation was found to indicate functioning or placement was monitored. An interview was completed with Nurse-D on 08/06/20 at 2:25 PM. Nurse-D reported being familiar with Resident 28. Nurse-D reported she was the charge nurse on 07/11/20. She was called by Nursing Assistants (NA)-H and NA-R to report Resident 28 had been found outside. Nurse-D said they thought Resident 28 went out a door just outside of the unit where Resident 28's room was located. Resident 28 was found laying on the sidewalk about 10 feet from the door. Nurse-D thought Resident 28 stepped off the sidewalk and fell . Nurse-D also indicated NA-H stated Resident 28 had been seen about 20 minutes before being found and that Resident 28 had a history of wandering around inside the building, but was not known to try and exit the building. Nurse-D further reported Resident 28 did not have a WanderGuard on because there was an order to use it if appropriate. Nurse-D said Resident 28 had not been feeling well since going to the hospital in May, but was feeling better. Prior to the elopement, Nurse-D did not feel like Resident 28 was well enough to wander. Resident 28 required a mechanical lift to transfer and hadn't been observed walking but did walk independently until the fall outside. Nurse-D initiated an order on 07/11/20 to apply the WanderGuard and to check it every shift. That order could not be located on any monitoring documents. Nurse-D reported the order should have appeared on the MAR to be signed off every shift. After reviewing the record, Nurse-D reported that a data entry error caused the order not to appear on the MAR. On 08/06/20 at 2:39 PM, an interview was completed with NA-H. NA-H reported providing care for Resident 28 on 07/11/20. NA-H reported not seeing Resident 28 in (gender) room. NA-H started looking for Resident 28. Resident 28 was found outside on the ground. NA-H stated Resident 28 had been left in the room recliner 15-20 minutes before and had walked out to the courtyard and fell . NA-H said Resident 28 did not have a WanderGuard on. NA-H said Resident 28 previously had a WanderGuard, but it had been removed when Resident 28 went to the hospital. On 08/06/20 at 3:10 PM, an observation was completed of the area were Resident 28 had been found. Multiple doors opened into a courtyard. Resident 28 was found near one of the doors. The area Resident 28 was found in was approximately 30 feet from (gender) room. There were no alarms on the door. The courtyard that Resident 28 was found in exited to the street. An investigation for Resident 28 signed by the Director of Nurses (DON) dated 07/11/20 was reviewed. The investigation presented was a one-page document printed on the front and back sides. During interview on 08/06/20 at 3:53 PM, the DON verified the two-page document was the entire investigation. There were no witness statements or other documents. The DON said they determined the root cause was Resident 28 had dementia and walked out the door. The DON also said they did not consider this incident an elopement because Resident 28 did not leave the facility property. The DON also stated Resident 28 had not previously used a WanderGuard. To complete the investigation, the DON stated the incident report completed at the time of the elopement would be reviewed. No other data sources were utilized including witness interviews. When asked for a copy of the incident report, the DON stated they were not kept at the facility and would not be retrievable. During a follow up interview on 08/06/20 at 5:16 PM, the DON stated there had been no other elopements since January 2020. On 08/11/20 at 2:00 PM, another interview was completed with DON. The DON reported the facility had a Falls Committee that meets and would have discussed Resident 28's fall, but the committee does not document minutes or create progress notes in the medical record. The DON verified they have an investigation sheet, but that it only addressed falls and the only reason there was an investigation for this incident was because Resident 28 fell . If the incident requires State reporting, those documents are filled out, but there are no internal documents. The DON also stated, If a fall isn't witnessed, [they] wouldn't get any statements [from staff present]. Interviews would not be completed with anyone who did not see a fall. On 8/20/2020 at 1:00 PM the State Agency received an abatement plan via email and approved the abatement. The Immediate Jeopardy was abated to a level G

Licensure Reference Number 175 NAC 12-006.02 Based on observations, interviews, record review and facility policy review, the facility's Administration failed to manage the facility in a way to ensure the facility was in substantial compliance with federal regulatory requirements. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. Findings are: Failure to provide oversight resulted in an Immediate Jeopardy (IJ) during the Recertification and Complaint survey under F610 for failing to initiate investigations for injuries of unknown source. The Immediate Jeopardy was related to State Operations Manual, Appendix PP, 483.12 (freedom from abuse, neglect, and exploitation) at a scope and severity of J. Failure to provide oversight resulted in a second IJ situation during the survey under F689 for failing to provide adequate supervision for two residents who left the building unsupervised. The Immediate Jeopardy was related to State Operations Manual, Appendix PP, 483.25 (quality of care) at a scope and severity of J. The Administrator, interviewed on 08/17/20 at 9:15 AM, acknowledged the Administrator was responsible for the effective and efficient day-to-day operations of the facility, and for the provision of resident care. On 8/20/2020 at 1:00 PM the State Agency received an abatement plan via email and approved the abatement. The Immediate Jeopardy was abated to a level G

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and interview; the facility staff failed to identify specific fall interventions and failed to re-evaluate the use of a recliner remote for 1 (Resident 3) of 3 sampled residents. The facility staff identified a census of 67. Findings are: A. Record review of Resident 3's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 9-6-2017 revealed the facility staff assessed the following about the resident: -BIMS (Brief Interview for Mental Status) score of 3. According to the MDS manual a score of 0-7 indicates severe cognitive impairment. -Limited assistance with eating. -Extensive assistance with dressing. -Total dependence with bed mobility, transfers, locomotion on and off the unit, toilet use and personal hygiene. Record review of Resident 3 Comprehensive Care Plan (CCP) dated 12-13-2017 revealed Resident 3 was at risk for falling related to use of narcotics, antidepressant and unsteadiness during transitions related to [MEDICAL CONDITION]. According Resident 3's CCP dated 12-13-2017, Resident 3 used a mechanical lift for transfers and a wheelchair for transportation. The goal for Resident 3 was not to have a fall or have any fall related injuries through next review. Approaches include, complete a fall assessment quarterly, instruct in transfer techniques such as bed to chair, chair to toilet and sit to stand. Resident 3 cannot see what you are doing related to [MEDICAL CONDITION]. Staff were also to monitor medications ([MEDICATION NAME]) (a medication used for Depression) for adverse reactions/side effects including: dizziness, confusion, [MEDICAL CONDITION], abnormal thinking. Record review of Resident 3's medical record revealed there was no evidence the facility had completed the fall assessment. On 7-11-2018 9:23 AM an interview was conducted with the Director of Nursing (DON) during the interview the DON reported fall assessments were taken to the fall committee meetings to evaluate specific interventions to prevent falls. The DON was unable to provide fall assessments for Resident 3 and was unable to provide specific fall interventions for Resident 3. Record review of an Incident Report dated 2-1-2018 revealed Resident 3 was found on the floor in a W Shape Res (Resident) had knees bent back and torso backwards and head. Resident 3 C/O (complained of) pain to bilateral (both) hips. Both feet turned to the left (with) R (right) leg shorter than the L (left). Record review of a Diagnostic report dated 2-02-2018 revealed Resident 3 was diagnosed with [REDACTED]. Record review of a second Diagnostic report dated 2-02-2018 revealed Resident 3 was diagnosed with [REDACTED]. Record review of the facility Fall risk Policy and procedure dated 4-2015 revealed the following: -The objective was to identify residents who are at risk for falls. -1. A fall risk assessment will be completed upon admission, in addition to according to the MDS schedule as needed. B. Review of an Incident Investigation Worksheet (IIW) dated 2-05-2018 revealed the facility staff identified the Root Cause of the fall was the recliner remote was left inside of the armrest next to Resident 3's right leg. According to the IIW dated 2-05-2018, the intervention to prevent recurrence was for staff to place the remote in the side pocket of Resident 3's recliner. Record review of Resident 3's medical record revealed there was not an evaluation of the ability of Resident 3 to use the recliner remote safely. On 7-11-2018 at 9:23 AM an interview was conducted with the DON. During the interview the DON reported an evaluation of Resident 3's ability to use the recliner remote had not been completed.

Based on observation, record review and interview; the facility staff failed to evaluate bowel function for 1 (Resident 10) and failed to evaluate pain intervention for 1 (Resident 3) of 17 sampled residents. The facility staff identified a census of 83. Findings are: LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D3(5) A. Record review of a Physicians Orders sheet signed 3/17/2010 revealed Resident 10 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Further review of the Physician order [REDACTED]. Record review of Resident 10's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated and signed as completed on 9/30/2010 revealed the facility staff assessed the following about the resident: -Resident 10 had short and long term memory problems. -Moderately impaired decision making. -Required extensive assistance with dressing and personal hygiene. -Total dependence for bed mobility, transfers and toilet use. -Incontinent of bowel and bladder. Record review of Resident 10's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"promote BM (bowel movement)". The MAR indicated O results yet". The [MEDICATION NAME] suppository was given at 7:30 PM per the MAR. The documentation on Resident 10's MAR indicated Res (Resident) unable to expel BM-full rectum". Resident 10 had a "Lg (large) BM" at 8:30 PM. Record review of Resident 10's record did not contain evidence that Resident 10's bowel function had be evaluated, or any additional interventions to prevent further complications of Resident 10's bowel function. Record review of a fax sheet sent to Resident 10's physician on 5/16/2010 revealed Resident 10 had increased " constipation, digital removal of large hard stool this noon with relief, May we try to give [MEDICATION NAME] (stool laxative) 100 mg, 1 PO (by mouth) q (every) AM and 1 PO daily PRN constipation. On 11/03/2010 at 9:05 AM an interview was conducted with Licensed Practical Nurse (LPN) K. Review of the 5/07/2010 bowel complications was conducted with LPN K. During the interview, LPN K stated the "Resident had been sitting on the toilet, couldn't push it out (BM)". LPN K stated " I checked and (gender) was full of BM.". When asked if (gender) had to manually remove the BM, LPN K stated "yes". When asked if an evaluation of Resident 10's bowel function had been completed, LPN K stated " no, (gender) was impacted though". According to LPN K during interview, "no changes were conducted for Resident 10" until the second bowel complication. An interview was conducted with the Director of Nursing (DON) on 10/04/2010 at 10:10 AM. During the interview, the DON confirmed that an "evaluation had not been completed" for Resident 10's bowel complications. The facility was not able to provide documentation at the time of exit or after of Resident 10's bowel function being evaluated. LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09 B. Record review of an Crowell home Physician admission orders [REDACTED]. Record review of Resident 3's MDS dated and signed as completed on 9/28/2010 revealed the facility staff assessed the following about the resident: -Resident 3 had short and long term memory problems. -Was understood and could usually understand. -Required extensive assistance with bed mobility, transfers, dressing, eating and toilet use. -Occasionally incontinent of bowel and had an indwelling catheter. -Pain daily and of moderate level. Record review of a Pain Assessment sheet dated 1/22/2010 and reviewed on 4/16/2010, 7/09/2010 and 10/01/2010 revealed Resident 3 had pain. According to the assessment, Resident 3 pain was chronic and was rated 4-6 on a scale of 1 to 10. Observations on 11/02/2010 at 7:00 AM of personal cares revealed Nursing Assistant (NA) E explained the need for personal cares. NA E donned gloves, changed a catheter bag to a leg bag, lifted Resident 3's legs, Resident 3 moaned, groaned and stated "Oh that hurts". NA E preceded to cleanse Resident 3 groin area. NA E using a wash cloth wiped down wards from front to back. At this time Resident 3 state "oh that really hurts". Resident 3 then moan and groaned as NA E continued with the personal cares. NA E turned Resident 3 onto a right laying position. Observation at this time revealed Resident 3 moan, groaned and yelled out. NA E stated " I know that hurts, I am almost done". NA E completed the personal cares, placed pants on to Resident 3 and sat Resident up into a sitting position. Resident 3 yelled out and stated" Oh boy that hurt". On 11/02/2010 at 7:20 PM an interview was conducted with NA E. During the interview, NA E was asked if Resident 3 was always painful. NA E stated "(Gender) is always painful". On 11/03/2010 at 10:10 AM an interview was conducted with LPN K. During the interview, LPN K confirmed Resident had pain daily LPN K confirmed that Resident 3 did not have scheduled pain medications prior to the AM cares. LPN K stated "that would be a good idea". LPN K stated "no" when asked if Resident 3's pain interventions had be evaluated.

Licensure Reference Number 175-NAC-12-006.09 Based on interview and record review, the facility failed to implement pain interventions for Resident 18. The facility census at the time of survey was 82 and the sample size was 10. Findings are: According to Resident 18's care-plan dated 11/09/2010, Resident 18 had the following Diagnoses: [REDACTED]. History and Physical done by the Geriatric Psychiatrist dated 11/29/2010 also added the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 11/01/2010 indicated Resident 18 ' s long term and short term memory was OK.The MDS identified that Resident 18 had been on a scheduled pain medication regimen and received medication as needed for pain and also non-medication interventions for pain. The MDS asked Resident 18 interview questions regarding pain. In the responses to these questions, Resident 18 indicated frequently there was a presence of pain over the previous 5 days, it was hard to sleep at night because of the pain, and pain had limited day to day activities. Resident 18 stated pain was at a level 6 intensity on a scale of 0-10 scale where 0 is none and 10 is the worst imaginable pain. B. A pain assessment was done on both 11/09/2010 and on 12/ 18/2010. On the November date, the Resident noted pain being at 4-6. The December assessment showed the pain intensity being rated by Resident 18 between 7-8. Resident 18's care-plan dated 11/09/2010 stated Resident 18 experienced pain frequently related to [MEDICAL CONDITION] disease of the spine with chronic back pain. It stated the goal was "pain will be controlled with use of routine and PRN (as needed) medications." The care-plan listed 4 approaches to attempt to control the pain. 1) Monitor medication ([MEDICATION NAME] ) for adverse reactions/side effects 2) Pain assessment quarterly and PRN 3) Monitor medication (Tylenol ) for adverse reactions/ side effects. 4) Chronic pain clinic (FYI) There was no update to the care-plan after the December 18 pain assessment. There was no evidence Resident 18 was referred to a chronic pain clinic as stated in the care-plan. C. Record review revealed a Geriatric Psychiatrist order dated 09/27/2010 and noted 11/29/2010 which stated, " Resident 18 has a difficult time with pain. The source of the frequency and intensity of pain is likely from anxiety. Resident 18 was so far unaware of the source of anxiety required a plan to help focus thoughts and feelings at the time the pain/anxiety seems most intense. " The physician ordered the following to be completed for Resident 18: 1) " Anytime the Resident seeks medication for pain , (Resident 18 ) is to write down current thoughts and feelings ... " 2) " The nursing staff will complete a pain scale daily on the patient which is only from observation. Also once a day there should be a subjective scale that assessed the residents perception of the pain. " 3) " After receiving any ' as needed ' pain medication the resident should be asked every 5-10- minutes about relief. .. " 4) " As well, providing alternative, non-pharmacological interventions to aid in relieving pain should be explored. Massage, exercise, relaxation therapy, recreational activities may lessen the patient ' s pain and provide a safer alternative than medication for this resident " . Record review revealed no daily pain scale was completed for Resident 18 that was by observation of the staff. In an interview on December 29, 2010 at 09:50AM, Staff RN (Registered Nurse) B stated Resident 18 was doing the journaling as ordered before she was given pain medication. Information from the December MAR (Medication Administration Record) revealed that from December 17 until the date of survey, Resident 18 had received PRN (as needed) medication 16 times for pain. Resident 18's record did not contain evidence of Resident 18 being asked every 5-10 minutes about pain relief following administration of PRN medication. In an interview , on December 29, 2010 at 12:05, the Case Manager of Medicare, RN A stated Physical therapy had been working with Resident 18 with various types of alternative pain interventions such as deep tissue massage and electrical stimulation. However, the daughter kept taking Resident 18 out of the building so Resident 18 eventually quit physical therapy. A telephone order form dated December 10, 2010 read, "Patient to discontinue therapy. Pt (Patient) has not attended enough to do any good. States (gender) in " too much pain " . No other evidence of non-pharmalogical interventions attempted could be found in the record.