Every finding on record at Emerald Nursing & Rehab Lancaster LLC

Licensure Reference Number 175 NAC 12-006.12) (1)Based on observation, interview and record review, the facility failed to store medications securely in the medication rooms and failed to ensure medications were not left unattended at the resident's bedside for Residents 5, 12, 87, 111, 125, and 137. This had the potential to affect all the residents receiving medications in the facility. The facility census was 191 at the time of survey. Findings are: A. An observation on 06/16/2026 at 10:40 AM revealed the station 3 medication room with a large refrigerator and no lock on it with controlled substances noted inside. During an interview on 06/16/2026 at 10:45 AM Licensed Practical Nurse (LPN) - H confirmed that the medication room refrigerator should be locked because there are medications in it. An observation on 06/16/2026 at 10:58 AM revealed the station 4 medication room with no lock on the refrigerator with controlled substances noted to be inside. During an interview on 6/16/2026 at 11:02 AM Unit Director (UD) – B confirmed that the medication refrigerator should be locked if there are meds in it. An observation on 06/16/2026 at 12:51 PM revealed the station 1 medication room refrigerator was not locked with meds and narcotics in it. During an interview on 06/16/2026 12:53 PM interview with Medication Aide (MA) - E confirmed that the refrigerators have to be locked if there are medications in it. Record review of the undated facility policy titled Medication Storage and Security, revealed medications and biologicals are stored in a manner that ensures safety, security, integrity, and proper environmental conditions, in accordance with manufacturer recommendations, USP standards, and applicable federal and state regulations. Medication access is limited to authorized personnel only, and storage practices support accurate administration, accountability, and prevention of contamination, degradation, or diversion. During an interview on 06/16/2026 at 3:47 PM Nurse Consultant (NC) confirmed that the refrigerators in the medication rooms need to be locked with meds are in them. B. Record review of facility policy titled Cleaning Respiratory Equipment revised 05/01/2017 revealed that when supplies are not in use, they should be stored in plastic bags and labeled with the resident's name and date. Nebulizers should be rinsed with water and air dried between treatments on the same resident. Record review of the Order Summary dated 06/10/2026 revealed the Resident 83 had an order for Ipratropium/Albuterol inhale one vial per nebulizer four times daily for 14 days that began on 06/08/2026. An observation on 06/16/2026 at 12:15 PM in Resident 83's room revealed the nebulizer chamber full of liquid with no nurse or medication aide present at the bedside or near the resident room. The machine was off and the chamber was sitting unused. An observation on 06/16/2026 at 3:46 PM in Resident 83's room revealed that the liquid was still in the chamber of the nebulizer and the resident was lying in bed. An interview on 06/16/2026 at 12:27 PM with Registered Nurse -A (RN-A) and Licensed Practical Nurse-C (LPN-C) revealed that the process to administer nebulizer treatments was to put the liquid in the chamber and start the medication, go back, and then clean the chamber out after turning the machine off. RN-A confirmed that the last documented nebulizer treatment administered to Resident 83 was on 06/16/2026 at 9:57 AM. During the interview, RN-A and LPN-C entered Resident 83's room and confirmed the nebulizer chamber to still be full of medication. LPN-C confirmed the medication was placed in the chamber in the last 10 minutes even though Resident 83 had changed their mind prior to the administration. They confirmed that they left the medication unattended and did not complete any follow up documentation. An interview on 06/16/2026 at 4:14 PM with the Director of Nursing (DON) confirmed that the expectation for staff when administering nebulizer treatments and a resident changed their mind would be for them to dump out the medication until the resident was ready for the treatment, not document the administration, or they should document a refusal. The DON confirmed that the medication was documented as administered at 2:23 PM. An interview on 06/17/2026 at 1:58 PM with the Nurse Consultant (NC) confirmed that there was no nebulizer administration policy. C. During an observation on 06/16/2026 at 9:30 AM revealed a medication cup of pink cream, and a medication cup of a white powdery substance in Resident 12's room. Record review of Resident 12's admission record revealed an admission date of 06/07/2026. Record review of Resident 12's order summary revealed an order to wash wound care to buttocks with facility cleanser and then pat dry. Mix collagen powder and calmoseptine. Apply to buttocks and buttock crease three times a day and as needed. Apply calmoseptine alone as needed after soiling and bathing. During an observation on 06/16/2026 at 9:40 AM revealed Resident 87 had wound vashe at bedside in a grey basin. Record review of Resident 87's revealed an admission date of 05/21/2026. Record review of Resident 87's order summary revealed the following wound care, to wash wound with facility wound cleanser or foam soap and let dry. Paint the peri wound with skin prep and let dry. Fill the wound with white soaked gauze with vashe. Squeeze out extra vashe. Cover with a white abdominal pad and secure with medipore tape. Change four times a day and as needed. During an observation on 06/16/2026 at 9:50 AM revealed Resident 111 had pink cream at bedside. During an observation on 06/16/2026 at 9:50 AM revealed Resident 111 had a medication cup of a white powdery substance at bedside. Record review of Resident 111's admission record revealed an admission date of 10/31/2018. Record review of Resident 111's order summary revealed calmoseptine to be applied to peri area four times a day and as needed for irritation. Record review of Resident 111's order summary revealed antifungal powder 2% apply 1 gram to affected area twice a day. Record review of Medication and Storage and Security with no revision date revealed medications and biologicals are stored in a manner that ensures safety, security, integrity, and proper environmental conditions. In accordance with manufacturer recommendations, USP standards, and applicable federal and state regulations. -Medication access is limited to authorized personnel only, storage practices support accurate administration, accountability and prevention of contamination, degradation and diversion. -Medication security and access: -Medication rooms, carts and storage areas are locked when not in use. -Access is limited to authorized personnel. -The facility maintains a list of authorized personnel. During an interview on 06/16/2026 at 10:00 AM with Medication aide (MA-E) confirmed that no medication including creams and powders should be in resident's rooms. During an interview on 06/16/2026 at 2:21 PM Licensed practical nurse (LPN-O) confirmed that medications should not be left in resident's rooms. D. Record review of an undated facility policy titled Medication Storage and Security, revealed the following: Procedures.A. General Storage Requirements.1. Medications are stored in pharmacy-dispensed containers that meet regulatory and USP standards. 2. Medications are not transferred between containers or altered by facility staff. A record review of Resident 137's electronic medication record revealed Resident 137 had orders for Triad Paste applied twice a day to the buttocks. An observation on 6/16/2026 at 7:12 AM of Resident 137's room revealed an unlabeled medicine cup with white cream in it sitting on the over-the-bed table. Resident 137 was not present in the room. An interview with Resident 137 on 6/17/2026 at 9:38 AM confirmed the medicine cup on the over-the-bed table was not there before leaving for breakfast. Resident 137 further confirmed the medicine cup had skin cream for the buttocks area and that staff would apply it. An interview on 6/16/2026 from 2:00 PM to 2:15 PM with MA (Medication Aide)-P confirmed the medication cup had Triad Paste and did not know who had left it on the over-the-bed table. MA-P confirmed being the MA for Resident 137 and LPN (Licensed Practical Nurse)-H was the nurse for 6/16/2026 day shift. An interview with DON (Director of Nursing) on 6/16/2026 at 5:02 PM confirmed that medications are not to be left on bedside tables.

The facility failed to ensure Personal Protective Equipment (PPE) was being used as indicated for three residents (Resident 6, 13, and 99) of 5 sampled residents, hand hygiene was done for the 20 seconds for two resident (Resident 12 and 199), wound care to prevent cross contamination for one resident (Resident 4) of 3 sampled residents, catheter care for one resident (Resident 12) of one sampled resident, food prep, and cleaning and storing nebulizer treatment for one resident (Resident 83) of 1 sampled residents were completed within standards of care to prevent the potential for cross contamination and failed to review and update infection prevention and control policies. The facility census was 191. A. A record review of the admission Record revealed Resident 4 was admitted to the facility on [DATE] with the diagnosis of Type 2 Diabetes Mellitus with Diabetic Nephropathy (high blood sugar and high blood pressure damage the kidneys' tiny filtering units), Morbid severe Obesity (a chronic disease characterized by extreme excess body fat), Pressure Ulcer of Sacral Region Stage 3 (a deep, crater-like wound on the tailbone where full-thickness skin loss has occurred, exposing the underlying fatty tissue), Pressure Ulcer of other site, Stage 3 (a deep, crater-like wound that features full-thickness skin loss), Cellulitis of Right Lower limb (serious bacterial skin infection that causes redness, swelling, and pain in the infected skin and underlying tissues). A record review of the Minimum Data Set (MDS) (a comprehensive assessment of each resident's functional capabilities) dated [DATE] revealed Resident 4 had a Brief Interview for Mental Status (BIMS) (a test used to get a quick snapshot of a resident's cognitive function, scored 0-15, the higher the score, the higher the cognitive function) scored a 15 meaning cognitively intact. A record review of the Comprehensive Care Plan (CCP) (a written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) for Resident 4 revealed: The resident has an actual impairment of skin integrity to the right lower extremity related to a vascular wound. -Moisture-Associated Skin Damage (MASD) to bilateral breasts, pannus (A hanging flap of excess skin and subcutaneous fat in the lower abdominal area). -groin area (the crease on either side of the body where the lower abdomen meets the upper thighs). -Venous wound (open sore) right posterior(back) leg with 2 open areas. -Trauma/MASD right medial (middle) upper thigh. -Cellulitis Right lower leg, -MASD with Stage 3 pressure ulcer right groin/upper thigh. -Skin tear right posterior upper thigh, Skin tear left posterior upper thigh, -Stage 3 Sacrum Cellulitis right lower leg. -ENHANCED BARRIER PRECAUTIONS: Utilize contact precautions during high contact resident care activities. Date Initiated: 12/29/2025, Monitor skin areas with treatment/cares and notify provider if complications noted. Date A record review of the physicians orders for Resident 4 revealed: Wound orders : Pannus/groin 1. Wash and dry skin folds 2. Apply Calmoseptine (moisture barrier ointment primarily used to protect, soothe, and heal skin irritations). 3. Apply wicking material (to draw moisture away from your skin and spread it across the fabric's exterior for rapid evaporation) every day and night shift. Wound care skin tear left posterior thigh: Wash with facility cleanser, dry. **Do not scrub the area, do not try to scrub off all the old Triad Paste (wound dressing used to manage moist, weeping wounds, superficial injuries, and severe skin irritations) . It is okay to leave a layer on the skin.** Apply Triad Paste to the wound area. Cover with a waterproof dressing (Mepilex (foam dressings) or equivalent). Change daily and PRN for soiling, saturation or accidental removal. every day shift for Wound Care. Wound Care Stage 3 Pressure Ulcer to Sacrum: Wash with facility cleanser, dry. Apply Triad Paste to the wound area. **Do not scrub the area. Do not try to scrub off all of the Triad Paste. It is okay to leave a layer on the skin.** Okay to leave open to air. Repeat in AM and at HS. Apply facility barrier cream PRN after soiling, bathing, etc. two times a day for Wound Care. An observation of wound cares on 6/16/26 at 3:00 PM with LPN- D for Resident 4 revealed: LPN- D was gathering supplies from the treatment cart. LPN-D gathered 2 plastic medication cups. LPN-D filled one of the medication cup with Triad Paste and the other medication cup LPN-D filled with Calmoseptine. LPN-D gathered several packages of 4x4 gauze that LPN-D torn open but left gauze in package, a bottle of wound cleanser, and the wicking material. LPN-D entered Resident 4 room and explained to Resident 4 that LPN-D would be doing Resident 4 wound dressing change. LPN-D then laid down the supplies on the tray table with no barrier placed before laying down the wound dressings and medication cups. LPN-D did wash hands for 45 seconds and put on a gown. LPN-D applied gloves and assisted with pulling pants and brief down just below the buttocks and removed the old dressings from the sacrum area. LPN-D with the same gloves removed the 4x4 gauze from package then sprayed the gauze with the wound cleanser. LPN-D with the same gloves wet 4 x 4 gauze began to wipe the sacrum area and the inner thigh area. LPN-D with the same gloves gathered another dry 4x4 patted dry the sacrum area and the inner thigh area LPN-D with the same gloves put their fingers in the medication cup with the Triad paste and applied the paste to the sacrum area, then with the same gloves put their fingers in the medication cup with the Calmoseptine cream and applied to the inner thigh area. LPN-D removed the gloves and discarded the gloves in the trash can. LPN-D used hand sanitizer and rubbed hands together for 20 seconds and applied new gloves. LPN-D with gloved hands removed 4x4 gauze from package and sprayed the 4x4 gauze with wound cleaners. LPN-D with the wet 4x4 gauze cleansed the upper thigh area. LPN-D with the same gloved hands gathered a dry 4x4 gauze from package and patted dry the upper thigh. LPN-D with the same gloves put their fingers in the medication cup of Triad Paste and applied to the upper thigh. LPN-D with the same gloves put their fingers in the medication cup of Calmoseptine and applied under the abdomen folds and applied the wicking material. A record review of the policy Skin and wound management with a revised date of 3/20/24 revealed: Dressing change clinical performance evaluation checklist: 14- prepare work area and open the needed supplies, ensure barrier is placed between table and supplies. 15- put on gloves 12- after removing the dressing, remove your gloves and perform hand hygiene. 16 - clean the wound, 17- once the wound is clean, dry the area using gauze sponge apply ointment and apply clean dressing. remove gloves and perform hand hygiene. 06/16/2026 4:00 PM an Interview with the Director of Nursing confirmed that LPN-D did not follow the policy and procedures for wound cares and did not follow the hand hygiene before and after putting on gloves and LPN-D should have. B. An observation on 06/15/2026 6:58 AM revealed Licensed Practical Nurse (LPN)- L hooked up the IV antibiotic for Resident 199. LPN did not wear PPE gown. During an interview on 06/15/2026 at 7:20 AM LPN – L confirmed that (gender) should have had a gown on and that there were no gowns in the resident room. An observation on 06/16/2026 at 7:22 AM LPN - L flushed IV for Resident 199 when the antibiotic was completed and changed gloves. No hand hygiene was performed. During an interview on 06/16/2026 at 7:39 AM LPN – L confirmed they should of completed hand hygiene when changing gloves but there was no hand sanitizer in the room. Observation on 06/16/2026 at 6:58 AM revealed an Enhanced Barrier Precaution (EBP) sign on Resident 199's door that stated to wear gloves and a gown for the high-contact resident care activities including dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, device care or use with central line, urinary catheter, feeding tube, tracheostomy, wound care and any skin opening requiring a dressing. Record review of the facility policy titled MDRO PPE - Enhanced Barrier Precautions, dated 1/2024 revealed EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. Record review of the facility policy titled Infection Control Standard Precautions - Handwashing, dated 1/2024 revealed all personal shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. C. An observation on 06/15/2026 at 11:57 AM Nursing Assistant (NA) – M and NA – N performed peri cares and repositioned Resident 6 without putting on a gowns. An observation on 06/15/2026 at 12:07 PM LPN – O entered room and applied barrier cream to Resident 6 without putting a gown on. During an interview on 06/15/2026 at 12:11 PM LPN – O confirmed that they all should have been wearing gowns while performing cares on Resident 6. It was further confirmed were no gowns in the resident's room. Observation on 06/15/2026 at 11:55 AM revealed an Enhanced Barrier Precaution (EBP) sign on door of Resident 6 that stated to wear gloves and a gown for the high-contact resident care activities including dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, device care or use with central line, urinary catheter, feeding tube, tracheostomy, wound care and any skin opening requiring a dressing. Record review of the facility policy titled MDRO PPE - Enhanced Barrier Precautions, dated 1/2024 revealed EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. D. Record review of facility policy titled Cleaning Respiratory Equipment revised 05/01/2017 revealed that when supplies are not in use, they should be stored in plastic bags and labeled with the resident's name and date. Nebulizers should be rinsed with water and air dried between treatments on the same resident. Record review of the Order Summary dated 06/10/2026 revealed the resident had an order for Ipratropium/Albuterol inhale one vial per nebulizer four times daily for 14 days that began on 06/08/2026. An observation on 06/10/2026 at 6:22 PM revealed the nebulizer chamber, assembled, laying out on the bedside table with no date noted. Resident 83 reported that the staff did not clean after use. An observation on 6/11/2026 at 8:02AM revealed the nebulizer chamber, assembled, laying out on the bedside table in Resident 83's room, not in a bag. An observation on 06/16/2026 at 12:15 PM revealed the nebulizer chamber full of liquid with no nurse or medication aide present at the bedside or near the resident room. The machine was off and the chamber was sitting unused. An observation on 06/16/2026 at 3:46 PM revealed that the liquid was still in the chamber of the nebulizer and Resident 83 was lying in bed. An observation on 06/17/2026 at 7:08 AM revealed the nebulizer chamber, assembled, laying out on the bedside table, not in a bag. An interview on 06/16/2026 at 9:22 AM with Unit Director-B (UD-B) revealed that nebulizer chambers should be cleaned according to policy and as needed. An interview on 06/16/2026 at 12:27 PM with Registered Nurse -A (RN-A) and Licensed Practical Nurse-C (LPN-C) revealed that the process to administer nebulizer treatments was to put the liquid in the chamber and start the medication, go back, and then clean the chamber out after use. An interview on 06/16/2026 at 4:14 PM with the Director of Nursing (DON) confirmed that the expectation for staff would be to rinse the nebulizer chamber and dry after each use, then store in a bag, dated and labeled with the resident name. E. Record review of facility policy Infection Prevention and Control Program, last revised on 05/2020 revealed the following: 3. Surveillance. a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff .b. Surveillance will include but not limited to Name. c. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee. A record review of the facility tracking of infections revealed no tracking for surveillance was completed for staff, visitors, or volunteers using standard or transmission-based precautions to prevent the spread of infections. A record review of Resident 198 and 68 revealed both had Clostridioides difficile (C. diff, a highly contagious bacterium that infects the large intestines, causing severe inflammation and watery diarrhea) diagnosed three days apart. Resident 198 and 68's rooms were right next to each other. An interview with the Infection Preventionist (IP) on 6/16/2026 from 4:10-4:40 PM confirmed that no surveillance tracking had been conducted for Enhanced Barrier Precautions (EBP) or transmission-based precautions. The interview further confirmed no resident chart audits were being conducted or tracked for possible signs and symptoms for infections. The IP revealed EBP rounds were conducted on Friday's each week, no evidence was provided of this being done. When Resident 198 and 68 were discussed, the IP confirmed the same traveling nurse was taking care of both residents and was observed not utilizing proper personal protective equipment to prevent the possibility of cross contamination within assigned resident rooms. F. A record review of facility infection prevention and control plan or policies revealed no identified documentation of infection prevention and control policies being reviewed or revised. A record review of facility policy Infection Prevention and Control Plan was last revised on 5/2020. An interview on 6/16/2026 at 4:15 PM with IP (Infection Preventionist) revealed no newer revisions or reviews were known. An interview on 6/17/2026 at 12:00 PM with ADM (Administrator) confirms no review or revision tracking system in place for the infection prevention and control plan. The interview further revealed the Infection Prevention and Control policy was reviewed in QAPI within the last year, but no date was provided. G. Record review of Facility MDRO (Multidrug-Resistant Organism) PPE (Personal Protective Equipment)-Enhanced Barrier Precautions, dated January 2024, revealed: Policy statement: Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. - EBP may be indicated for residents with any of the following: - Wounds or indwelling medical devices - Policy Interpretation and Implementation - Framework for applying enhanced barrier precautions in this facility is the application of EBP to routine care to residents with wounds or indwelling medical devices - Examples of chronic wounds include pressure ulcers - Examples of indwelling medical devices include urinary catheters - For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: - Providing Hygiene - Device care or use: Urinary catheter - Wound Care Record review of Resident 13's admission Record revealed that they were admitted to the facility on [DATE] with diagnoses of unspecified mononeuropathy of bilateral lower limbs (damage, compression, or entrapment affecting single nerve in both legs. It causes localized pain, numbness, tingling, or weakness), type 2 diabetes mellitus with hypoglycemia (a chronic metabolic disorder where the body either resists the effects of insulin or doesn't produce enough to maintain normal glucose levels. Low blood sugar readings are dangerous and requires immediate treatment to prevent seizures or unconsciousness ), complex regional pain syndrome of bilateral lower limbs (a rare and highly debilitating presentation of a chronic neurological condition characterized by severe, disproportionate pain, swelling, and dysfunction of the autonomic nervous system in both legs), and presence of urogenital implants (a medical device surgically placed to support or replace the function of the urinary systems, such as a cuff placed around the tube that carries urine from the bladder that inflates to prevent urine leakage). Review of Resident 13's physician orders revealed that the resident receives loperamide (a medication to treat chronic diarrhea), gabapentin (a medication primarily used to manage nerve pain), degludec (a long-acting prescription injection used to treat diabetes), ondansetron (a prescription medication used to prevent and treat nausea and vomiting), glipizide (a medication used to lower blood sugar in adults with Type 2 diabetes) , FUROSEMIDE ( a medication that works to eliminate excess fluid, water, and salt through urine), benzonatate (a medication to suppress coughing), ATORVASTATIN (a prescription medication used to lower bad cholesterol and triglycerides in the blood, while increasing good cholesterol), acetaminophen (medication used to relieve mild to moderate pain), and tramadol (a prescription painkiller used to treat moderate to moderately severe pain) as needed. Review of Resident 13's Minimum Data Set (MDS, a standardized assessment required for all nursing home residents) dated 4/23/2026 revealed a Brief Interview for Mental Status score of 15 (indicating resident 13 is cognitively intact), a Resident Mood Interview score of zero (indicating that Resident 13 does not have depression). MDS further reveals that resident 13 has limitations to the range of motion to both lower extremities and has a foley catheter to drain urine from the bladder. MDS shows that Resident 13 could feed themself but required assistance with all other cares. Observation of Resident 13's door on 6/16/2026 at 7:30 AM revealed a sign indicating the need for enhanced barrier precautions (EBP). Observation of area immediately inside Resident 13's door revealed a cart that contained personal protective equipment necessary for EBP. Observation on 6/16/26 7:30 AM of care provided to Resident 13 prior to wound care to the crease of the buttocks. This observation revealed that NA-I wore gloves but did not wear a gown while cleaning Resident 13's buttocks. LPN-D wore gloves but did not wear a gown while holding Resident 13 for the cleaning process. Interview with LPN-D following the care provided for Resident 13, revealed that LPN-D stated that NA-I should have worn a gown since that individual performed the peritoneal care and was in contact with the wound and catheter. LPN-D stated that they did not believe that it was necessary wear a gown since they were assisting to hold the resident. LPN-D was asked what the facility policy was for EBP. LPN-D stated they would review the facility policy and confirm what needs to be done going forward. Interview with RN-K on 6/16/26 at 8:30AM confirmed that a gown should have been worn to provide peri care for a resident on EBP and that LPN-D and NA-I should have worn a gown and followed EBP when providing wound, catheter and incontinence care for Resident 13. H. Record review of Resident 12's admission record revealed an admission date of 02/25/2026. Record review of Resident 12's Minimum data set (MDS-a federally mandated clinical assessment tool used in Medicare and Medicaid certified nursing homes) dated 03/22/2026 revealed section C Brief Interview for Mental Status (BIMS- is a screening tool to assess the resident's short term memory, recall and basic temporal orientation a score of 13-15 indicated that the resident's cognition is intact). Resident 12's BIMS was 15. Record review of Resident 12's MDS dated [DATE] section H revealed that Resident 12 had an indwelling catheter. Record review of Resident 12's MDS dated [DATE] section I revealed a diagnosis of neurogenic bladder. Record review of Resident 12's diagnosis list revealed a diagnosis of neuromuscular dysfunction of bladder (occurs when nerve damage disrupts the communication between your brain and urinary tract. This prevents the bladder muscles and sphincters from tightening or relaxing at any right time, leading to urinary retention, leakage or urinary tract infections.) During an observation on 06/16/2026 at 10:30 AM of Nursing Assistant (NA-M and NA-R) emptying a catheter of urine and providing catheter cares. Nursing Assistants NA-M and NA-R had on isolations gowns and then placed their gloves. NA-M ensured that the privacy curtain was pulled and informed Resident 12 of the procedure that staff provided. NA-M asked Resident 12 to pull down her pants and then NA- M unfastens incontinence brief, NA-M begins catheter care by wiping the tubing in a circular motion away from the entrance site. NA-M folds incontinence wipe in half and then wipes each side of the groin area, folds wipe again and then wipes down the labia. NA-M throws wipe away and puts on a new white brief. NA-R then has a graduate and sits on a dry paper towel on the floor, NA-M opens the drain port to drain urine in graduate urine spills on the floor. NA-M dumps urine in toilet and flushes, NA-R wipes up urine with paper towel that was on the floor. NA-M then removed gloves and placed in trash can, NA-R removed gloves and placed in trash can. NA-M exits room and does hand hygiene with an alcohol-based hand rub (ABHR). NA-R exits room and performed hand hygiene with ABHR. Record review of Infection Control Standard Precautions Handwashing last revised on 1/2024 revealed: Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of infections. All personnel should be trained regularly in serviced on the importance of hand hygiene in prevention of the transmission of healthcare-associated infections. Wash hands with soap and water for the following situations: a. when hands are visibly soiled b. after contact with residents with infectious diarrhea including but not limited to infections caused by norovirus, salmonella, shigella and C-diff Use ABHR contains at least 62 percent alcohol or alternatively soap and water for the following situations: -before and after coming on duty -before and after contact with residents -before preparing or handling medications -before performing any non-surgical invasive procedures -before and after handling an invasive device (urinary catheters, IV access sites) -before putting on sterile gloves -before handling clean or soiled dressings, gauze pads, etc. -before moving from a contaminated body site to a clean body site during resident's care -after contact with a resident's intact skin -after contact with blood or bodily fluids -wet hands first with water then apply an amount of product recommended by the manufacturer to hands -rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. -rinse hands with water and dry thoroughly with a disposable towel. -use towel to turn off the faucet -avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis. During an interview on 06/16/2026 at 12:30 PM NA-M CNA confirmed that hand hygiene should have been done for 20 seconds prior to placing a clean incontinence product on resident. During an interview on 06/16/2026 at 12:35 PM with Licensed Practical Nurse (LPN-O) confirmed that hand hygiene should have been done for 20 seconds prior to placing a clean incontinence product on resident or use an ABHR.

Licensure reference number 175 NAC 12-006.09BBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) accurately reflected the resident's status for 1 (Resident 87) of the 6 sampled residents. The facility census was 191.Findings are:Record review of Resident 87's admission Record revealed Resident 87 admitted to the facility 05/21/2026 with an admitting diagnosis of unspecified protein calorie malnutrition.Record review of Resident's 87 MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS- is a quick, 15-point cognitive screening test used by healthcare providers to evaluate memory, learning, and orientation. The higher the score means that there is little to no cognitive impairment). Resident 87's BIMS was 15. Under Section I of the MDS dated [DATE] revealed the following diagnoses: cancer, heart failure, renal insufficiency, diabetes mellitus, depression. Further record review of the MDS dated [DATE] under Section 1 revealed that the facility did not check I5600 Malnutrition (protein or calorie) or at risk for malnutrition.Record Review of facility's Expanded Assessment Areas and policy and procedure last revised 1-2024 revealed:-The accuracy of the assessment- means that the appropriate qualified health professional correctly documents the resident medical functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status. The initial comprehensive assessment provides baseline data for ongoing assessment of resident progress.-Resident assessment instrument- a facility must make a comprehensive assessment of a resident's needs, strengths, goals life history and preferences, using the resident assessment instrument specified by CMS.-Total health status- includes functional status, medical care, nursing care, nutritional status, rehabilitation and restorative potential, activities potential, cognitive status, oral health status, psychosocial status, sensory and physical impairments. During an interview on 06/16/2026 at 1:15 PM with Minimum Data Set Licensed Practical Nurse (MDS-LPN) confirmed that under Section I of the MDS dated [DATE] the diagnosis of malnutrition should have been marked for Resident 87.

Licensure reference number 175 NAC 12.006.09(H)(iv)(4)Based on observation, record review and interview, the facility failed to provide incontinence care after completing wound care for 1 (Resident 87) of 3 sampled residents. The facility census was 191.Findings are:Record review of Resident 87's admission face sheet revealed an admission date of 05/21/2026.Record review of Resident 87's medical diagnoses revealed: asthma, unspecified protein calorie nutrition, pressure ulcer stage 3 to sacral area, hyperlipidemia, hypertension, and malignant neoplasm of right female breast.Record review of Resident 87's order summary revealed: wash wound with facility wound cleanser or foam soap, paint the peri wound with skin prep (preparing the skin surface for medical adhesives protect the skin barrier and increase comfort) let dry. Fill the wound with white gauze soaked wound Vashe, squeeze out excessive Vashe. Cover with white abdominal pad and secure with medi pore white tape. Change dressing four times a day and as needed for soiling saturation or accidental removal.Record review of Resident 87's order summary revealed an order for active critical liquid protein 30 cc three times a day.Record review of Resident 87's Braden (is a clinical assessment tool used to predict a patient's risk of developing pressure injuries, lower scores indicated a higher risk for developing pressure injuries while a higher score indicates lower risk) Resident 87's score was a 17 indicating mild risk for pressure sores.Record review of Resident 87's Minimum Data Set (MDS-a federally mandated clinical assessment tool used in Medicare and Medicaid certified nursing homes) dated 05/27/2026 revealed that Resident 87's Brief Interview for Mental Status (BIMS is a screening tool to assess a patient's short-term memory, recall and basic temporal orientation, it is a scale from 0-15. The higher the score 13-15 cognition appears intact]. Resident 87's BIMS was 15. Section H on the MDS revealed that Resident 87 was incontinent of bowel and urine. Section M of MDS revealed Resident 87 admitted with a pressure ulcer. Record review of Resident 87's care plan dated 05/21/2026 revealed: Resident 87 has a pressure ulcer Stage 3 to coccyx present upon admission. Date Initiated: 05/21/2026 Revision on: 05/26/2026. Resident 87's pressure ulcer (s) will show signs of improvement and remain free from infection through the next review date. Date Initiated: 05/21/2026 Target Date: 08/19/2026 Avoid positioning Resident 87 on coccyx. Date Initiated: 05/21/2026 Revision on: 05/26/2026. ENHANCED BARRIER PRECAUTIONS: Utilize contact precautions during high contact Resident 87's care activities. Date Initiated: 05/26/2026. Provide pressure reducing/relieving device to bed- Air Mattress. Date Initiated: 05/21/2026 Revision on: 05/26/2026. Provide wound treatment per current physician orders. Date Initiated: 05/26/2026. Resident 87's wounds are being followed by [NAME], APRN- NHCP Wound. Date Initiated: 05/21/2026 Revision on: 05/26/2026. Resident 87 's has a bladder incontinence related to weakness, need for assistance with personal care and general pain and discomfort Date Initiated: 05/21/2026 Revision on: 06/02/2026. Resident 87 will remain clean and dry through the next review date. Date Initiated: 05/21/2026 Target Date: 08/19/2026. Incontinent: routine check and change as required for incontinence. Date Initiated: 05/21/2026 Revision on: 05/21/2026. Brief use: Resident 87 used adult disposable briefs. Change (SPECIFY FREQ) and prn. Date Initiated: 05/21/2026 Revision on: 06/02/2026.During an observation on 06/16/2026 at 9:35 AM of Wound Care Registered Nurse (WCRN) provided wound care to Resident 87. WCRN tucked a white soiled brief under the resident, WCRN then followed the wound care orders. WCRN then placed a new white brief on Resident 87.Record review of facility's policy on Peri-Care with no last revised date revealed: that staff should remove soiled brief and discard in trash can, staff wash resident from front to back and change side of wash cloth with each swipe, if a female wash middle first then sides. Buttocks wash sides first then the middle. Remove gloves, perform hand hygiene and apply clean gloves. Apply barrier cream, clean brief/incontinent product and re dress resident. Clean work area, dispose of soiled linen, remove gloves and perform hand hygiene.In an interview on 06/16/2026 at 9:50 AM WCRN confirmed that the brief on Resident 87 was soiled with wound drainage and urinary incontinence. Further observation revealed WCRN left Resident 87's room at 9:52 AM with surveyor.During a continuous observation on 06/16/2026 from 09:52 AM through 10:20 AM no facility staff in room to provide Resident 87 incontinent care.During an interview on 06/16/2026 at 12:25 PM with nursing assistant (NA-Q) confirmed that Resident 87 does not get out of bed, and that staff provide all cares including incontinence care.In an interview on 06/16/2026 at 1:30 PM with WCRN confirmed that incontinence care should have been provided to Resident 87.In an interview on 06/16/2026 at 4:54 PM with the Director of Nursing(DON) confirmed it is an expectation that if a brief is soiled with urine, feces or other drainage that incontinence care should have been provided.

Licensure Reference Number 175 NAC 12-006.09 Based on record review, observation and interview the facility failed to follow wound care orders for 1 (Resident 125) of 10 sampled and administer as needed blood pressure medication for 1 (Resident 125) of 5 sampled. The facility identified a census of 191. Findings are: A record review of facility policy Charting and Documentation last revised 01/01/2024 revealed staff will document procedures and treatments along with the resident's refusals in the resident's electronic medical record (EMR). The record review further revealed that medication administered, withheld, not administered, or refused will be documented in the resident's EMR. A record review of Resident 125's admission Record revealed that the resident was admitted to the facility on [DATE] with diagnoses of a bacterial skin infection, chronic wounds, body mass index (BMI, a screening tool used to estimate body fat based on a person's height and weight) of 70 or greater (a healthy BMI range is 18.5 to less than 25), swelling of the lower legs and high blood pressure. A record review of Resident 125's Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 05/11/2026, revealed a Brief Interview for Mental Status (BIMS, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 15. According to the MDS manual, a score of 15 indicated the resident was cognitively intact. A record review of Resident 125's Order Summary Report dated 06/11/2026, revealed the resident was to have wound care to the left posterior lower leg every day and night shift as follows:-wash with wound cleanser-dry and paint the wound with skin prep-apply MediHoney (antibacterial honey) on the wound-place an Alginate Ag dressing (a type of wound dressing) over the wound-cover with an absorbent pad-wrap the lower leg with gauze A record review of Resident 125's Order Summary Report dated 06/11/2026, revealed medication Clonidine (treats high blood pressure) with a start date of 03/02/2026, as needed every six hours for a systolic blood pressure (the top number of a blood pressure) greater than 169. A record review of Resident 125's EMR revealed no wound care was provided to Resident 125 on the following days: 03/10/2026, 03/19/2026, 03/26/2026, 04/09/2026, 04/21/2026, 05/08/2026, 06/08/2026, and 06/12/2026. A record review of Resident 125's EMR revealed medication Clonidine was not given for blood pressures of 177/91 on 05/24/2026, 183/95 on 05/27/2026, 180/77 on 05/29/2026, 170/72 on 05/30/2026, 173/82 on 05/31/2026, 175/88 on 06/06/2026, 177/94 on 06/12/2026, and 173/89 on 06/13/2026. On 06/16/2026 at 8:54 AM to 9:30 AM an observation was made of Resident 125's wound care completed by Wound Care Registered Nurse (WCRN). An interview with LPN-H on 06/16/2026 at 3:15 PM confirmed that wound care for Resident 125 on 03/10/2026, 03/19/2026, 03/26/2026, 04/09/2026, 04/21/2026, 05/08/2026, 06/08/2026, and 06/12/2026 was not completed and the provider was not notified. An interview with charge nurse LPN (Licensed Practical Nurse)-H, on 06/16/2026 at 3:15 PM confirmed PRN Clonidine should have been given on 05/24/2026, 05/27/2026, 05/29/2026, 05/30/2026, 05/31/2026, 06/06/2026, 06/12/2026 and 06/13/2026 and if Resident 125 refused the medication, it should be documented in the EMR. During an interview with the DON (Director of Nursing) on 06/16/2026 at 5:15 PM when discussing missing wound treatments and lack of administrating the as needed Clonidine for Resident 125, the DON viewed Resident 125's EMR and confirmed the staff did not follow the facility policies or provider orders.

Licensure Reference Number 175 NAC 12-006.09(F)(ii) Based on record review and interview, the facility failed to ensure new interventions where put in place to prevent falls for one (Resident 115) of 5 sampled residents. The facility census was 191.Findings are: A record review of the admission record reveals that Resident 115 was admitted to the facility on [DATE] with the diagnosis of Hypotension (abnormally low blood pressure), Repeated falls, Dementia (decline in mental ability severe enough to interfere with daily life), Depression (mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities), Anxiety (feelings of tension, worried thoughts), Insomnia (difficulty falling asleep, staying asleep, or waking up too early) . A record review of the Minimum Data Set (MDS) (a comprehensive assessment of each resident's functional capabilities) dated May 4, 2026 revealed Resident 115 had a Brief Interview for Mental Status (BIMS) (a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function). with a score of 4 meaning severely impaired. A record review of the fall assessment for Resident 115 revealed: On 3/20/26 Resident 115 was getting out of bed and slipped and fell with no injuries. What is the resident's description of what happened?Resident stated she went to get out of bed and her feet slipped from under her and she fell to the floor she stated she didn't hit her head, and she stated she wasn't in any pain Intervention: Resident 115 was assisted back to bed and the aid put Resident 115 on some slip resistant socks On 4/24/26 Resident 115 was self transferring out of bed and slipped and fell with skin tears to Left hand and left forearm. What is the resident's description of what happened: Resident reports attempting to self-transfer out of bed and feet slipping on floor. Interventions: Encouraged to call for assistance when attempting to transfer. On 4/26/26 Resident 115 was found sitting on the floor with no injuries.What is the resident's description of what happened? unable to give clear description due to advanced dementia.Interventions: encourage resident to use gripper sock at night and shoes during the day when up On 5/3/25 Resident 115 was sitting on the floor besides the bed with a skin tear to chest What is the resident's description of what happened?Resident reports slipping on blanket and falling forward hitting chest against walker handle then falling backwards and sitting onto the floor.Interventions: encouraged resident to use call light for assistance when transferring A record review of the Fall Data Collection in the progress notes for Resident 115 revealed:5/3/26-Initial intervention that was implemented to prevent reoccurrence: encouraged resident to use call light for assistance when transferring4/26/26-Initial intervention that was implemented to prevent reoccurrence: encourage resident to use gripper sock at night and shoes during the day when up.4/24/26-Initial intervention that was implemented to prevent reoccurrence: Resident encouraged to call for assistance when attempting to transfer.3/20/26-Initial intervention that was implemented to prevent reoccurrence: Resident was assisted back to bed and the aid put her on some slip resistant socks. A record review of the Comprehensive Care Plan (CCP)( written instructions needed to provide effective and person centered care of the resident that meets professional standards of quality care). for Resident 115 revealed:The resident is at risk for falls:4/24/26 -unwitnessed fall out of bed5/3/26- witness fall in roomInterventions: 4/24/26 staff to encourage Resident 115 to wear non skid footwear in bed, 2/6/26 Ensure that Resident 115 is wearing appropriate footwear ie(in other words) non skid socks or shoes when ambulating or mobilizing with walker.5/4/26 Staff to round every 1-2 hours. A record review of the Policy Fall Management with a revised date of 1/24 revealed:Fall injury Prevention-post fall3) Review Fall Risk Assessment for any changes in fall risk, reassess post fall6) Adjust/add interventions on the Plan of Care-Fall Risk Reduction An interview on 6/16/26 at 3:30 PM with the DON confirmed that new interventions should of been in place with each fall for Resident 115 and new interventions had not been put in place.

Licensure reference number 175 NAC 12-006.11 (D)Based on record reviews, observations, and interviews, the facility failed to ensure recipes for pureed foods (a pudding like consistency for residents who are unable to eat solid foods due to a variety of medical conditions) was followed. This had the potential to affect the 7 residents who eat pureed foods from the kitchen. The total census at the time of the survey was 191.Findings are:Record review of the facility's policy titled Food Preparation Guidelines dated 11/2017 revealed in the section titled Policy Explanation and Compliance Guidelines subsection 1. The cook or designee should prepare menu items following the facility's written menus and standardized recipes.Record review of the facility's recipe for Pureed Macaroni & Cheese with a copyright date of 2026 revealed that 10 servings required: 1-quart plus 1-cup of Macaroni and Cheese blended with 2 1/2 cups of milk.Record review of the facility's recipe for Pureed Choc Chip Cookie Bar with a copyright date of 2026 revealed that 10 servings require: 10 bars blended with 2 1/2 cups of milk.Observation of lunch preparation on 06/11/2026 at 10:00AM revealed the cook gathering the ingrediencies needed to prepare the pureed foods to be served at the next meal. The cook scooped the macaroni and cheese mixture into a clean food processor (FP, a motorized kitchen appliance that blends food into the desired consistency) and added milk without measuring either ingredient. The cook then turned the FP on and let the mixture blend for approximately 60 seconds. The cook then removed the lid, scraped the sides of the FP bowl, and proceeded to add more milk after revealing it was too thick. The cook did not measure the additional milk. The cook turned the FP on again and processed for an additional 30-45 seconds. The cook then removed the lid, stirred the mixture and revealed that it was still too thick and added more milk without measuring, and turned the FP back on. The cook then walked over to the book that contained the recipes and began to look for the pureed recipes. The cook then decided the macaroni and cheese was good and placed the mixture in 2 small containers.The cook then proceeded to prepare the next dish of Pureed Chocolate Chip Cookie Bars. The cook revealed that there should be a recipe for the pureed chocolate chip cookie bars but was not able to find it. The cook also revealed that they know that they are supposed to follow the recipes but don't. The cook placed an unmeasured amount of chocolate chip cookie bars into the FP along with an unmeasured amount of milk and began to blend, repeating the process of adding unmeasured milk until the mixture was deemed good.Interview with the cook on 06/11/2026 at 10:45 AM confirmed that the recipe was not followed for either of the pureed dishes and should have been.Interview with the Kitchen Manager on 06/11/2026 at 11:00 AM revealed that it is the facility's expectation that recipes are followed for all foods prepared in the kitchen including pureed foods. Interview on 06/15/2026 at 3:21 PM with the DON revealed that there are currently 7 residents on pureed diets that eat from the kitchen.

Licensure Reference Number 175 NAC 12-006.19 Based on observations and interviews, the facility failed to ensure an uncluttered physical environment that is neat and well-kept for rooms 211, 215, 230, 234, 235, 412, 415, 428, and 436. The facility census was 191. Record review of facility Operations Management Policy on Physical Environment, dated 01/2024 revealed: -Policy: The facility will maintain all mechanical, electrical and patient care equipment in a safe operational condition. -Policy Explanation and Compliance Guidelines: 3. Routine rounding will include observations of the facility to determine whether the areas are large enough to comfortably accommodate the needs of the residents who usually occupy the space. Observations of resident rooms conducted on June 16, 2026, revealed the following: room [ROOM NUMBER] had a bulletin board in front of and blocking the ventilation system. This room also had multiple plastic storage boxes on top of the vent. This blockage limited airflow and temperature control to the room and created an obstacle for the facility maintenance department to view the system during rounds and to maintain the ventilation system. room [ROOM NUMBER] had many garments and blankets on top of and blocking the ventilation system in the room. This blockage limited airflow and temperature control to the room and created an obstacle for the facility maintenance department to view the system during rounds and to maintain the ventilation system. room [ROOM NUMBER] had a blanket on top of and blocking the room's ventilation system. This blockage limited airflow and temperature control to the room and created an obstacle for the facility maintenance department to view the system during rounds and to maintain the ventilation system. room [ROOM NUMBER] had a blanket on top of and blocking the room's ventilation system. There were also several plants placed on top of the fabric covering which was blocking the vent. This blockage limited airflow and temperature control to the room and created an obstacle for the facility maintenance department to view the system during rounds and to maintain the ventilation system. Facility tour of environment on 6/16/26 at 1:40 PM with Associate Administrator (ADM-2) and Director of Environmental Services (MD-G). Facility observation revealed that rooms 412, 415, 428 and 436 continued to have large amounts of clutter obscuring the vents in these rooms. During interview following environmental tour, MD-G confirmed that their expectation would be that there is no clutter in the rooms and that the air conditioner/heating vents would not be covered. MD-G stated that Social Services and Housekeeping should assist with the cleanup of clutter. The ADM-2 confirmed that their expectation would be that all departments assist with keeping the rooms clutter free and to ensure that vents are not being covered up. Findings are: On 06/10/2026 at 5:30 PM an observation of rooms revealed: -room [ROOM NUMBER] blankets, bags and clutter on the floor. -room [ROOM NUMBER] Bags of clothes and boxes and clothes baskets coving the vent to the air conditioner/heater. -room [ROOM NUMBER] Suit case, 3 drawer plastic cabinet, and a white coat covering the vent to the air conditioner/heater. -room [ROOM NUMBER] 2 plastic totes and coat and cushion up against the vent. -room [ROOM NUMBER] dresser blocking more than 1/2 the vent. -room [ROOM NUMBER] blanket covering vents. On 06/15/2026 at 2:00 PM on observation of rooms revealed: -room [ROOM NUMBER] blankets, bags and clutter on the floor. -room [ROOM NUMBER] Bags of clothes and boxes and clothes baskets coving the vent to the air conditioner/heater. -room [ROOM NUMBER] Suit case, 3 drawer plastic cabinet, and a white coat covering the vent to the air conditioner/heater. -room [ROOM NUMBER] 2 plastic totes and coat and cushion up against the vent. -room [ROOM NUMBER] dresser blocking more than 1/2 the vent. -room [ROOM NUMBER] blanket covering vents. An interview on 06/16/2026 at 9:46 AM with Medication aide-E confirmed that everyone is responsible for picking up residents personal items. Housekeeping can't mess with any personal items. An interview on 06/15/2026 2:01 PM with the Medication aide - F confirmed that the clutter is always that way in the rooms. Record review of facility Operations Management Policy on Physical Environment, dated 01/2024 revealed: -Policy Explanation and Compliance Guidelines: 3. Routine rounding will include observations of the facility to determine whether the areas are large enough to comfortably accommodate the needs of the residents who usually occupy the space. During an environmental tour on 6/16/26 at 1:30 PM with the Administrator-2 and Maintenance Director confirmed that their expectations would be no clutter in the rooms or having the air conditioner/heating vents covered. The Maintenance Director confirmed that Social Services/housekeeping should be assisting with the clean up of clutter. The Administrator-2 confirmed that their expectation would be all departments assist with keeping the rooms clutter free and vents not being covered up.

Licensure Reference Number 175 NAC 12-006.11(E)Based on observations and record reviews, the facility failed to maintain ice machines on Stations 1 and 3 in a clean and sanitary manner in order to prevent the spread of foodborne illness. This had the potential to affect 55 residents on Station 1 and 33 residents on Station 3. The facility census was 191.Findings are:An observation on 04/21/2026 at 11:19 AM of the ice machine on Station 1 revealed the white plastic piece over the ice had red stains and a black and brown substance on it.An interview on 04/21/2026 at 11:19 AM with Nurse Aide (NA) A confirmed that the ice machine was used to obtain ice for residents on Station 1. The NA further confirmed that the white plastic piece was not clean. The NA stated that they did not know how often the ice machines were cleaned, but that maintenance was responsible for it.An observation on 04/21/2026 at 11:44 AM of the ice machine on Station 3 revealed the white plastic piece over the ice had a grey film on it.An interview on 04/21/2026 at 11:44 AM with Licensed Practical Nurse (LPN) B confirmed the ice machine was used to obtain ice for the residents on Station 3. The LPN further confirmed that the white plastic piece was not clean. LPN B stated they did not know when the ice machine was last cleaned and was not sure who was responsible for cleaning it.An observation on 04/21/2026 at 2:11 PM of the ice machine on Station 3 revealed the machine was partially disassembled with the evaporator (the grid shaped piece where the ice cubes are formed) visible. The surfaces of the evaporator grid and of the area around it were coated with a brown fuzzy substance.An interview on 04/21/2026 at 2:11 PM with Maintenance Worker (MW) C, confirmed the fuzzy substance on the evaporator to the ice machine on Station 3. MW C confirmed they had disassembled the machine for cleaning. MW C stated they had six ice machines in the building and cleaned one a month.An observation on 04/21/2026 at 2:47 PM revealed the ice machine on Station 1 was still up and running.An interview on 04/21/2026 at 2:52 PM with the Administrator (ADM) confirmed the ice machine on Station 1 had red stains and a black and brown substance on the plastic piece over the ice.An interview on 04/21/2026 at 3:05 PM with the ADM confirmed they had not been following a process for maintaining the ice machines in a clean and sanitary condition.

Licensure Reference Number 175 NAC 12-006.04 (F) (i) (5)Based on interviews and record review, the facility failed to notify the physician and family representative of one resident (Resident 1) of 3 sampled residents of a change in condition. The facility census was 190.Findings are:A record review of the admission Record revealed Resident 1 was admitted to the facility on [DATE] with the diagnosis of Subarachnoid Hemorrhage(blood vessel on the brain's surface ruptures), Hypoglycemia (Blood sugar (glucose) drops below normal levels), Anxiety Disorder (excessive fear or worry that interferes with daily life, such as work, school, or relationships), Hypotension (occurs when blood flow to vital organs is reduced, often causing dizziness, fainting, or fatigue), Shortness of Breath (not getting enough air), Chronic Congestive Heart Failure (the heart cannot pump efficiently, causing fluid buildup in the lungs and body), Non-St Elevation- Myocardial Infarction (a serious, life-threatening heart attack caused by partial, rather than full, blockage of a coronary artery), Transient Ischemic Attack (a mini stroke-a temporary blockage of blood flow to the brain, lasting from a few minutes to 24 hours), and Edema (swelling caused by excess fluid trapped in body tissues, commonly occurring in the legs, feet, or hands).A record review of Resident 1's progress notes of a nursing assessment dated [DATE] at 3:52 AM for an assessment performed on 4/1/26 at 8:30 PM revealed the following regarding Resident 1:-Resident was lethargic-Denied being in pain-Resident was alert and oriented x 3. Resident responded incorrectly on the day of the week.-Blood sugar on resident's CGM (a wearable device that tracks blood sugar levels) was 234.-Resident was not diaphoretic but did say they were hot.-Vital signs were: left arm blood pressure was 78/64, pulse was 105, and oxygen saturation was 83% on room air.-Blood pressure in right arm was 128/76.-3 liters of oxygen via concentrator was stated. -Resident denied shortness of breath but breathing was labored.-Oxygen saturations came up to 93% after the oxygen was applied.A record review of progress notes dated 4/2/26 revealed there was no progress notes for Resident 1 updating the Physician or the family representative after the change of condition noted on 4/1/2026 at 8:30 PM. An interview on 4/13/26 at 10:34 AM with the Nurse Practitioner (APRN) confirmed that the Physicians office had not been notified of Resident's 1 change in condition on 4/1/2026. An interview on 4/13/26 at 1:15 PM with the Family Representative for Resident 1 confirms that (gender) had not been updated on the change in condition for Resident 1. The Family Representatives were notified when Resident 1 had passed away.An interview on 4/13/26 at 2:15 PM with the Director of Nursing confirmed that the charge nurse should of notified the physician and the family representative for Resident 1 with the change in condition and the charge nurse did not notify the physician or the family representative of the change in condition.

Licensure Reference Number 175 NAC 12-006.04(D) (i) (3)Based on record review and interview the facility failed to maintain a professional standard of practice with assessing one (Resident 1) of 3 sampled residents after Resident 1 had a change in condition. The facility census was 190. Findings are:A record review of the admission Record revealed Resident 1 was admitted to the facility on [DATE] with the diagnosis of Subarachnoid Hemorrhage(blood vessel on the brain's surface ruptures), Hypoglycemia (Blood sugar (glucose) drops below normal levels), Anxiety Disorder (excessive fear or worry that interferes with daily life, such as work, school, or relationships), Hypotension (occurs when blood flow to vital organs is reduced, often causing dizziness, fainting, or fatigue), Shortness of Breath (not getting enough air), Chronic Congestive Heart Failure (the heart cannot pump efficiently, causing fluid buildup in the lungs and body), Non-St Elevation- Myocardial Infarction (a serious, life-threatening heart attack caused by partial, rather than full, blockage of a coronary artery) , Transient Ischemic Attack (a temporary blockage of blood flow to the brain, lasting from a few minutes to 24 hours), and Edema (swelling caused by excess fluid trapped in body tissues, commonly occurring in the legs, feet, or hands). A record review of the progress notes dated [DATE] revealed: An aide went and got the charge nurse at 8:30 PM (on [DATE]). The aide stated that Resident 1 did not look right. The Charge nurse went into Resident 1 room and noticed Resident 1 seemed lethargic. Resident 1 denied pain. Resident 1 responded to all questions. The charge nurse took Resident 1 vital signs with Resident 1 blood pressure 78/64, Pulse 105, oxygen level being 83% on room air. The charge nurse then asked the Aide to bring a concentrator and was placed on 3 liters of oxygen. Resident 1 oxygen level came up to 93% with the oxygen remaining on. Around 1:00 AM the Aide came and told the charge nurse to check on Resident 1 again. When the charge nurse entered the room, Resident 1 was laying on the bed with Resident 1 feet on the floor. Resident 1 color was gone. The charge nurse checked for a pulse and respirations. Resident 1 was unresponsive. Resident 1 code status was Do Not Resuscitate. The charge nurse called the emergency department (EMT) and when the EMT arrived the EMT pronounced the time of death for Resident 1. The charge nurse noticed the nurse manager on call. The nurse manager notified the provider and resident's family of the death of Resident 1.A record review of the progress notes dated [DATE] revealed: Resident 1 passed away (died) at 1:30 AM, Resident 1 family was notified at 1:45 AM, police notified at 1:40 AM and the body was released to the mortician at 4:00 AM.An interview on [DATE] at 9:00 AM with the Director of Nursing confirms that the charge nurse should of done another assessment ([DATE] after 8:30 PM and before [DATE] at 1:00 AM) and should have checked on Resident 1 more often due to the change in condition and the charge nurse did not do another assessment or check on Resident 1.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5)Based on record review and interview, the facility failed to notify the physician of a urinary analysis results (UA-analyzing urine's physical, chemical, and microscopic properties to detect disorders like UTIs {urinary tract infections}, kidney disease, and diabetes) and the culture and sensitivity (detects infection-causing germs (bacteria or fungi) and identifies the most effective antibiotic to treat them) for one resident (Resident 3) of 3 sampled resident. The facility census was 190.Findings are: A record review of the admission record with the printed date of 4/14/26 revealed Resident 3 was admitted to the facility on [DATE] with the diagnosis of Parkinson's Disease (progressive movement disorder of the nervous system), Major Depressive Disorder (a common, serious mental health condition characterized by persistent sadness, loss of interest in activities, and fatigue, lasting at least two weeks), Edema (swelling caused by excess fluid trapped in body tissues, commonly occurring in the legs, feet, or hands), Dysphagia (difficulty swallowing), Dementia (a progressive syndrome causing cognitive decline-memory loss, communication issues, and personality changes-severe enough to disrupt daily life), and Attention-Deficit Hyperactivity disorder (persistent patterns of inattention, hyperactivity, and/or impulsivity that interfere with daily functioning).A record review of a fax dated 3/12/26 to the physician revealed: Family concerned about a UTI (Urinary Tract Infection) and dysuria (pain, burning or discomfort during urination), with a response to obtain a UA with C&S as indicated. A note on the order read: noted UA obtained.A record review of [NAME] Laboratory dated 3/12/26 for a Urinalysis revealed a culture is indicated and a C&S was completed on 3/14/26. The Lab was noted by the facility nurse on 3/16/26.A record review of a fax dated 3/26/26 to the physician revealed: Family here, says Resident 3 has another urinary infection (confusion)- Asked why Resident 3 has another despite getting an antibiotic a week ago (no antibiotic -was waiting culture). Family wanting answers and new urinary analysis and more antibiotic ordered. The Physicians response was : C&S was not provided for review. Now done. Start Bactrim DS 1 tab by mouth twice a day for 7 days. Nurse noted 3/26/26.A record review of the progress notes dated 3/26/26 with the Director of Nursing (DON) revealed: DON spoke with the Power of Attorney regarding Resident 3 UA. The DON apologized for results not being communicated or followed up on in a timely manner. Assured family an antibiotic was ordered by the provider that was to start today (3/26/2026).An interview on 4/14/26 at 10:00 AM with the DON confirmed that the labs had not been sent to the physician and it should have been. The DON confirmed that the antibiotic should of been started before the 3/26/26 and it wasn't. The DON confirmed that the facility's nurses station has to have all orders reviewed by (gender).

Licensure Reference Number 175 NAC 12-006.11(E) Based on observations, interviews, and record review, the facility failed to drain the standing water and sanitize four (station one, station two, station three, and station four) out of four observed dining room steam tables, and to clean and sanitize the toaster in the station four dining area. This had the potential to affect 170 residents that utilized the dining area for meals. The facility census was 171. Findings are: A record review of the Facility Policy Resident Rights dated 11.2017 and a revision date of 10.2022 revealed that the residents have a right to a safe, clean, comfortable environment. A record review of the undated Facility Policy Cleaning Instructions: Steam Tables (commercial kitchen equipment that keeps pre-cooked food at safe temperatures by using steam from heated water) revealed: Remove the serving pans and wash according to the guidelines for pots and pans. Clean the inside and outside of each unit of the steam table. Use hot water and detergent. Rinse and dry thoroughly. If the unit is heated by steam, drain the water and remove the top section to clean. Water should be drained out and the tank cleaned at least once a day. De-[NAME] may be needed to remove the lime deposits. If units are heated by electricity, be careful not to get water into the sockets. Carefully clean around the electrical elements weekly. A record review of the National 2022 Food Code Chapter 4-601.11(B)(C) objective revealed the food-contact surfaces of equipment and pans shall be kept free from encrusted grease deposits and other soil accumulations and non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. An observation on 1.7.2026 at 9:00 AM during the facility tour revealed: Station one, two, and three steam tables had brown liquid substance with floating particles in the compartments, the sides had brown corrosion, and dried food present. Station four steam table had dark brown liquid substance with floating particles in all compartments, and the toaster was covered with food crumbs, stained black with dry food on top and the sides, and on the counter below. An observation on 1.7.2026 at 11:00 AM with the Food Service Manager (FSM) of the steam table water on all stations (one, two, three, and four) revealed the compartment water was brown in color with floating particles. During an interview on 1.7.2026 at 1:10 PM with the cook confirmed the steam table is to be cleaned daily, including changing the water, but that is not happening and could not confirm when the water was last changed. During an interview on 1.7.2026 at 1:15 PM the FSM confirmed all unit steam tables had brown water with floating particles, the steam tables should be cleaned and sanitized daily, being unaware of the last time the water was changed, and confirmed no active process improvement in place. FSM also confirmed the toaster on station four was soiled with food crumbs, stained black, and had dried food on top, and all sides, and needed to be replaced. During an interview on 1.7.2026 at 2:15 PM with the Administrator (Adm) confirmed the dietary sanitation needs improvement and there is currently no process improvement plan in place and there should be.

Licensure Reference Number 175 NAC 12.006.09(I) Based on observation, interview, and record review, the facility failed to implement interventions to prevent potential accidents for 1 (Resident 1) of 3 sampled residents. The facility census was 174. Findings are: A record review of Resident 1's Clinical Census dated 02/14/2025 - 06/24/2025 revealed the resident was admitted to the facility 02/14/2025. A record review of Resident 1's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 05/21/2025 revealed the resident was admitted to the facility on [DATE]. The resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 11, which indicated the resident was moderately cognitively impaired (somewhat confused). The resident had limited range of motion on one side of the lower extremities (shoulder to hand or hip to toe). The resident was independent for most activities of daily living and mobility. A record review Resident 1's Care Plan with and admission date of 02/14/2024 revealed the resident had an invoked Power of Attorney (POA)(a person to make financial and/or medical decisions for a resident) for healthcare. The resident used a manual wheelchair for mobility. A record review of Resident 1's Order Summary Report dated 06/24/2025 revealed the resident had diagnoses of Chronic Kidney Disease, Personal History Transient Ischemic Attack (disruption of blood flow to the brain) And Cerebral Infarction (stroke) Without Residual Deficits, Insomnia (difficulty falling and staying asleep), Acquired Absence Of Right Leg Above Knee, Other Diabetes Mellitus With Other Circulatory Complications (uncontrolled blood sugar levels with blood flow problems), Chronic Obstructive Pulmonary Disease, Chronic Systolic (Congestive) Heart Failure (CHF), Depression, Atherosclerotic Heart Disease (hardening of the arteries) and Tobacco Use. A record review of Resident 1's Nebraska Power of Attorney For Health Care dated by Resident 1 on 03/26/2021 revealed I direct that my attorney-in-fact comply with the following instructions or limitations: Medical decisions will be made by the POA. A record review of Resident 1's Order Summary Report dated 06/24/2025 revealed the resident had an order of: May have alcoholic beverages on holidays/special events. It did not reveal the provider order from 06/12/2025 to send the resident to the emergency room (ER) for toxicology screen (tests used to detect the presence and amount of drugs, alcohol, and other potentially harmful substances in the body) and well check due to being taken out of the facility by unknown person. A record review of Resident 1's admission History and Physical (H&P) dated 01/30/2024 revealed that Resident 1 had a history of methamphetamines (meth)(an illegal drug) use, smoked cigarettes every day, used marijuana, and used alcohol socially. A record review of the facility's Emerald Rehabilitation Fax dated 06/12/2025 revealed Resident 1 had a provider order to send the resident to the ER for toxicology screen and well check due to being taken out of the facility by unknown person. A record review of Resident 1's Drug Screen, Drugs of Abuse, Urine dated 06/12/2025 revealed the results of the drug screen was negative. It did not reveal an alcohol toxicology test had been completed. A record review of Resident 1's Progress Notes dated 06/12/2025 at 9:00 PM revealed Social Services (SS) was notified that the resident was in the resident's room intoxicated. The SS staff member spoke with the resident and the resident gave the SS worker the bottle of alcohol to throw away. The SS worker and unit manager put orders on the board for Physical Therapy (PT)/Occupational Therapy (OT) to evaluate as well and psych orders. A record review of Resident 1's Progress Notes dated 06/12/2025 did not reveal the resident brought back alcohol when the resident returned to the facility and did not reveal the resident's room had been searched for drugs or alcohol when the resident returned to the facility. A record review of an email that the SSD provided on 03/24/2025 revealed SS staff contacted our Ombudsman (an independent official who investigates complaints and works to resolve disputes) to get more information about confiscating (taking) alcohol that residents have in their rooms due to a resident drinking that has an invoked POA and a low score on their BIMS assessment. Per the Ombudsman, the facility is not able to confiscate the alcohol even if the consumption is detrimental to residents' health and continue to have physician educate resident on the health impacts these choices make. The Ombudsman verified that the facility should ensure it is not staff providing the alcohol, as that would be an issue, but resident or family/friends of the residents' have the right to purchase with or for the resident. A record review of Resident 1's Electronic Medical Record (EMR) did not reveal: - Notification to the invoked POA that the resident had an unsecured bottle of alcohol in the resident's room. - Notification to the provider that the resident had an unsecured bottle of alcohol in the room available for consumption (drinking or eating) outside of the provider's order of holidays/special events. - A self-administration (taking without supervision) assessment to determine if the resident was safe to self-administer the alcohol. - Education from the provider to the resident on the risks versus benefits of using alcohol. In an interview on 06/23/2025 at 3:45 PM, Resident 1 confirmed the resident did not bring alcohol back to the facility when the resident returned on 06/12/2025. The resident confirmed the resident has had a bottle of alcohol on the shelf in the resident's room and not locked up for a long time. In an interview on 06/24/2025 at 9:30 AM, Nursing Assistant (NA)-D confirmed NA-D was the NA that had Resident 1 when the resident returned to the facility on [DATE] and the resident did not bring back any bags or have any alcohol on the resident. NA-D confirmed NA-D had seen a bottle of Vodka (clear alcohol) in the resident's room, unsecured and on a shelf a couple of days prior to the resident getting intoxicated and NA-D notified the former nurse (FN)-E that was on that day, and FN-E told NA-D that it was okay, the resident had an order for it. In an interview on 06/24/2025 at 10:28 AM, NA-D confirmed that FM-E, SSD, and LPN-F were all aware Resident 1 had a bottle of alcohol in the room but said the resident had an order for it. NA-D was not aware of any other residents that had alcohol in their rooms. In an interview on 06/24/2025 at 10:47 PM, LPN-I confirmed LPN-I was training with FN-E when one of the NAs notified FM-E that Resident 1 had a bottle of alcohol in the resident's room, and FN-E just responded it was okay, the resident had an order for it. In an interview on 06/24/2025 at 12:45 PM, the SSD confirmed the resident did not return to the facility with any bags or anything in Resident 1's pockets that the SSD was aware of. The SSD confirmed the SSD was not aware that the resident had alcohol in the room. The resident would not tell the SSD where the resident got the alcohol, just that the resident had it forever so the SSD was not sure when the resident got it. The SSD confirmed the SSD was not aware of the resident having alcohol in the room prior to the incident on the evening of 06/12/2025. The SSD confirmed the SSD searched the room while the resident went to the ER to see if the resident had brought any drugs back to the facility because the resident had a history of having a pipe, drugs and a lighter in the room, but did not see any alcohol in the room at that time. The SSD confirmed that some residents were allowed to keep alcohol in their room if they had a provider's order for it, but Resident 1's order was just for special events and holidays, and the resident should not have had alcohol in the room. The SSD confirmed that there was a similar incident with a different resident awhile ago and the SSD contacted the Ombudsman, and the Ombudsman told the SSD that the facility could not confiscate alcohol from a resident unless the resident said they could. Later in the interview the SSD confirmed a couple of days to a week before the incident on the evening of 06/12/2025, the SSD was told the resident had alcohol in the room by an NA and the SSD told the NA the resident could have alcohol in the room if there was an order for it. The SSD confirmed the resident allowed the SSD to throw away the bottle of alcohol the evening of 06/12/2025 when the resident was intoxicated and it looked like the same bottle, Barton's Vodka. The SSD confirmed the SSD did not find the bottle of alcohol when the SSD searched the room and the resident was clever. The SSD confirmed that prior to the incident, the SSD saw the resident had orders for alcohol, so the SSD did not take the Vodka. After the resident was found intoxicated, the resident said it was okay to dump it out. In an interview on 06/24/2025 at 11:04 AM, Medication Aide (MA)-G confirmed MA-G was not aware of any other residents in the facility that had alcohol in the room but was aware of a resident in room [ROOM NUMBER]B that had a bottle of alcohol in the nurse's station refrigerator. The resident had an order for it and the nurse had to measure it out and give it to the resident. In an interview on 06/24/2025 at 11:18 AM, LPN-H confirmed LPN-H was not aware of any residents that had alcohol in their rooms. In an interview on 06/24/2025 at 10:37 AM, Resident 1's invoked POA confirmed that the invoked POA was not aware that Resident 1 had a bottle of alcohol in the room until after the invoked POA had been contacted that the resident had been intoxicated, and he should not have had. The invoked POA confirmed the invoked POA was not even aware the resident drank alcohol. The invoked POA confirmed following the notification that the resident was intoxicated, the invoked POA's family member told the invoked POA the resident had a bottle of Vodka in the room on the counter, and it was out in the open and could be accessed anytime. In an interview on 06/24/2025 at 1:33 PM, the DON confirmed that when the DON wrote the telephone order from the provider for a toxicology screen, that would include screening for alcohol, but it was not done. The DON confirmed that the DON was not aware that Resident 1 had an unsecured bottle of alcohol in the resident's room until after it was reported the resident was intoxicated. The DON confirmed that Resident 1 should not have been allowed to have a unsecured bottle of alcohol in the resident's room. The DON was not aware of any residents that were allowed to have alcohol in the room.

Licensure Reference Number 175 NAC 12.006.04(F)(i) Licensure Reference Number 175 NAC 12.006.04(G) Based on interview, and record review, the facility failed to ensure a sufficient number of nursing staff were present on all shifts. This had the potential to affect all residents in the facility. The facility census was 176. Findings are: A record review of the facility's Facility Assessment Policy dated 01/2024 revealed the facility would do an assessment annually and determine what resources were needed to care for the residents. A record review of the facility's Nursing Services and Sufficient Staff policy dated 01/2024 revealed the facility would provide sufficient staff to assure resident safety and needs of each resident. The facility's census, acuity (level of care), and diagnosis would be considered based in the facility assessment. The facility would provide services, by sufficient numbers of personnel types, on a 24-hour basis to provide nursing care to all residents. A record review of the facility's undated Facility Assessment revealed the facility resources needed to provide care to the resident population every day included the following staff to resident ratios: Registered Nurse (RN)/Licensed Practical Nurse (LPN) Charge Nurse: - Day Shift - 1 nurse for every 35 residents - Night Shift- 1 nurse for every 35 residents Nursing Direct Care Staff Nursing Assistants (NA): - Day Shift - 1 NA for every 7 residents - Evening Shift - 1 NA for every 9 residents - Night Shift - 1 NA for every 21 residents A record review of the Posting of Nursing Staff dated 03/28/2025 - 04/09/2025 revealed the following numbers of staff worked and the census for that shift which worked out to be: • 03/28/2025 census of 178, 16 day shift NAs, for a ratio of 1 NA for every 12 residents • 03/28/2025 census of 178, 15 evening shift NAs, for a ratio of 1 NA for every 12 residents • 03/29/2025 census of 177, 4 night shift nurses, for a ratio of 1 nurse for every 44 residents • 03/29/2025 census of 177, 15 day shift NAs, for a ratio of 1 NA for every 12 residents • 03/29/2025 census of 177, 16 evening shift NAs, for a ratio of 1 NA for every 11 residents • 03/30/2025 census of 177, 4 night shift nurses, for a ratio of 1 nurse for every 45 residents • 03/30/2025 census of 177, 14 day shift NAs, for a ratio of 1 NA for every 13 residents • 03/31/2025 census of 178, 4 night shift nurses, for a ratio of 1 nurse for every 45 residents • 03/31/2025 census of 178, 15.5 evening shift NAs, for a ratio of 1 NA for every 11 residents • 04/01/2025 census of 179, 4 night shift nurses, for a ratio of 1 nurse for every 45 residents • 04/01/2025 census of 179, 16 evening shift NAs, for a ratio of 1 NA for every 11 residents • 04/02/2025 census of 179, 4 night shift nurses, for a ratio of 1 nurse for every 45 residents • 04/02/2025 census of 179, 16.5 evening shift NAs, for a ratio of 1 NA for every 11 residents • 04/03/2025 census of 179, 4 night shift nurses, for a ratio of 1 nurse for every 45 residents • 04/03/2025 census of 179, 17 evening shift NAs, for a ratio of 1 NA for every 11 residents • 04/04/2025 census of 179, 4 day shift nurses, for a ratio of 1 nurse for every 45 residents • 04/04/2025 census of 179, 4 night shift nurses, for a ratio of 1 nurse for every 45 residents • 04/04/2025 census of 179, 17 evening shift NAs, for a ratio of 1 NA for every 11 residents • 04/05/2025 census of 179, 4 day shift nurses, for a ratio of 1 nurse for every 45 residents • 04/05/2025 census of 179, 4 night shift nurses, for a ratio of 1 nurse for every 45 residents • 04/05/2025 census of 179, 13 day shift NAs, for a ratio of 1 NA for every 14 residents • 04/06/2025 census of 178, 4 day shift nurses, for a ratio of 1 nurse for every 45 residents • 04/06/2025 census of 178, 3 night shift nurses, for a ratio of 1 nurse for every 59 residents • 04/07/2025 census of 177, 4 day shift nurses, for a ratio of 1 nurse for every 44 residents • 04/07/2025 census of 177, 4 night shift nurses, for a ratio of 1 nurse for every 44 residents • 04/07/2025 census of 177, 16 evening shift NAs, for a ratio of 1 NA for every 11 residents • 04/08/2025 census of 181, 2 night shift nurses, for a ratio of 1 nurse for every 91 residents • 04/08/2025 census of 181, 19 evening shift NAs, for a ratio of 1 NA for every 10 residents • 04/09/2025 census of 180, 3 night shift nurses, for a ratio of 1 nurse for every 60 residents • 04/09/2025 census of 180, 18 evening shift NAs, for a ratio of 1 NA for every 10 residents A record review of the facility's un-named list of grievances filed in 2025 revealed 18 grievances for long call light times. In an interview on 04/09/2025 at 3:45 PM, Resident 4 confirmed that the resident had to wait for long periods of time to have their call light answered due to the floor was short on staff. The resident confirmed that the night nurse got pulled to a different floor a lot and they had a lot of staff that called in sick. Weekends seemed to be the worst. In an interview on 04/10/2025 at 9:45 AM, Resident 2 confirmed the facility was short staffed and the facility had a lot of staff turnover. The resident confirmed the resident had to wait long periods of time on a regular basis to get their call light answered. The resident confirmed there were a few times it took the staff over an hour to answer their call light. In an interview on 04/10/2025 at 6:10 AM, NA-A confirmed the majority of the night shift they had enough staff to take care of all of the residents, but the last 2 hours of the shift got crazy because the residents were needing to get up and ready for the day. In an interview on 04/10/2025 at 6:28 AM, NA-B confirmed they experienced a lot of staff calling in sick. NA-B confirmed most of the time on the day shift, 2 NAs cared for 26 residents on the wing. In an interview on 04/10/2025 at 6:32 AM, NA-C confirmed the night NAs worked 1 wing of the 400 rooms by themselves. There were 21 residents on the hall that NA-C had. The NAs had to get the resident up and dressed and then wait for the other NA on the other wing if the resident required a Hoyer lift (full body lift) transfer. In an interview on 04/14/2025 at 7:32 AM, the Director of Nursing (DON) confirmed the DON reviewed the Posting of Nursing Staff dated 03/28/2025 - 04/09/2025 and the facility did not have sufficient staffing and personnel types on certain shifts according to the Facility Assessment.

Licensure Reference Number 175 NAC 12-006.09(H)(i)(3) Based on observation and interview, the facility failed to ensure soiled bed linens was changed for 1 resident (Resident 2). The sample size was 5. The census was 183. Findings are: A record review of the 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 1/25/25 revealed that Resident 2 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15/15, indicating the resident was cognitively intact. A record review of the Care Plan (CP-a written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) dated 11/01/24 revealed the following for Resident 2: -Focus has bladder incontinence related to impaired mobility. -The resident will remain clean and dry. -Routine check and change at routine standard intervals and as required for incontinence. An observation on 3/4/25 at 5:15 AM of Nursing Assistant (NA)-A and NA-B providing peri cares for Resident 2. NA-A had rolled Resident 2 to their right side to position the lift pad, draw sheet and the incontinent pad. An observation of the draw sheet revealed yellow stains in several areas on the draw sheet and yellow stains on the fitted sheet that fit over the mattress. NA-A continued to roll Resident 2 back over to Residents 2 left side so that NA-B could straighten out the lift pad, draw sheet and the incontinent pad. NA-B stated to NA-A that a new draw sheet was needed because the current draw sheet was dirty. NA-A left the room and returned with a clean draw sheet. NA-A and NA-B continued to position the lift pad, clean draw sheet and incontinent pad under Resident 2. NA-B asked if Resident 2 was comfortable and Resident 2 revealed yes I am comfortable. NA-B gathered the dirty linens and trash. NA-A stated when asked about the yellow stains on the fitted sheet, NA-A confirmed that (gender) did not change the fitted sheet due to Resident 2 getting a bath later that morning. NA-A confirmed that (gender) should of changed the yellow stained fitted sheet regardless if it was a bath day or not. NA-B confirmed that the yellow stained fitted sheet should of been changed. An interview on 3/4/25 at 1:30 PM with the Director of Nursing (DON) confirmed that the DON expectations of the Nursing Assistants is to change any kind of linens if soiled to clean linens. DON confirmed that NA-A and NA-B should have changed the soiled fitted sheet.

Licensure Reference Number 175 NAC 1-005.06(D) Based on observations, record reviews and interviews the facility failed to prevent the potential for cross-contamination between residents by not performing hand hygiene at the required intervals during the provision of care for 3 (Residents 1, 2, and 3) of 3 sampled residents and failed to apply and remove gloves using infection control practices while performing cares for 1 (Resident 2) out of 3 sampled residents. The facility census was 183. Findings are: An observation on 3/4/25 at 5:15 AM revealed Nursing Assistant (NA)-A was walking down the hallway with gloves on their hands and entered into Resident 2's room. Upon entering Resident 2's room, observed NA-B on the side of bed holding Resident 2 on their left side and NA-A entered the room and on the right side of the resident and began to perform peri care with peri wipes and had not removed the gloves or performed hand hygiene prior to the start of cares. NA-A completed the cares and gathered the dirty linens and trash and proceeded down the hallway to the trash room with the same gloves on. NA-A did remove the gloves at the nurses desk. NA-A did not perform hand hygiene after placing the trash bag in the trash room. NA-A then proceeded to Resident 1's room. NA-A did not perform hand hygiene. NA-A did put on gloves before starting peri-cares on Resident 1. NA-A finished putting brief on resident and gathered the trash and dirty linens and left Resident 1's. NA-A removed gloves after throwing the trash bag in the trash room. NA-A did not perform hand hygiene after throwing trash bag away. NA-A entered Resident 3's room and did not perform hand hygiene. NA-A did put on gloves and proceeded to provide peri-care to Resident 3 and assisted with dressing. NA-A gathered the trash and linens and removed their gloves. NA-A did not perform hand hygiene after leaving the room. NA-A did not perform hand hygiene after throwing the trash in the trash room. An interview on 3/4/25 at 6:00 AM with NA-A confirmed that (gender) should of changed gloves when entering Resident 2's room and that NA-A should of performed hand hygiene before and after entering each resident's room. A record review of the Infection Control Standard Precautions-Handwashing with a revised date of 1/24 revealed: -Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations A) when hands are visible soiled, B) after contact with a resident with a infectious diarrhea including but not limited to infections caused by norovirus, salmonella, C.difficile, and shigella. -Use an alcohol-based hand rub containing at least 62% alcohol or alternatively soap (antimicrobial [NAME] non-antimicrobial) and water for the following situations, A) before and after coming on duty, B) before and after direct contact with residents, I) after contact with a resident's intact skin, M) after removing gloves -The use of gloves does not replace hand washing/hand hygiene. -Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers -apply generous amount of alcohol-based hand rubs to palm of hands and rub hands together, cover all surfaces of hands and fingers until hands are dry. An interview on 3/4/25 at 2:30 PM with the Director of Nursing (DON) confirmed that the facility had an audit for handwashing dated 12/13/24 with staff members name and education provided for hand washing, 1/25 audit for handwashing dated 1/25 revealed staff members who had been educated on proper handwashing and audit for handwashing dated 2/25 revealed staff members name who had been educated on proper handwashing. The DON confirmed that the aide should not of been wearing gloves down the hallway and should of removed them before entering the room. DON confirmed that hand washing should have been done prior to and after cares and the dirty sheet should have been changed regardless of, if it was bath day or not.

Licensure Reference Number 175 NAC 12-006.04(B)(ii) Based on record review and interview, the facility failed to provide the required 12 hours of ongoing training for 5 (Nursing Assistants (NA): NA-N, NA-O, NA-P, NA-R and Unit Director: UD-Q) of 5 sampled direct care staff. This had the potential to affect all the residents in the facility. The facility had a census of 174. Findings are: Record review of the facility policy titled Training Requirements dated 1/2024 revealed: -the staff Development Coordinator will maintain a training schedule and documentation system for completed training of the required individuals, -documentation of the required training will be forwarded to the HR Department to be placed into the individual's personnel file, -an individuals failure to complete required training will result in termination. Record review of the facility policy titled Required Training, Certification and Continuing Education of Nurse Aides dated 1/2024 revealed: -documentation of in-services will be maintained in the employee's personal file, -the in-services are required to maintain employment status with the facility. A. Record review of the employee file for Nursing Assistant (NA) - N with a hire date of 3/12/2019 did not reveal continuing education hours. Record review of the binder with monthly in services revealed NA - N did not have 12 hours of continuing education required and sign in sheets revealed that NA - N had attended 10 out of 12 in services during 2024, which equaled 10 hours. B. Record review of the employee file for NA - O with a hire date of 10/21/2022 did not reveal continuing education hours. Record review of the binder with monthly in services revealed NA - O did not have 12 hours of continuing education required and the sign in sheets revealed that NA - O attended 9 out of 12 facility in services during 2024, which equaled 9 hours. C. Record review of the employee file for NA - P with a hire date of 3/12/2023 did not reveal continuing education hours. Record review of the binder with monthly in services revealed NA - P did not have 12 hours of continuing education required and the sign in sheets revealed that NA - P attended 5 out of 12 facility in services during 2024, which equaled 5 hours. D. Record review of the employee file for Unit Director (UD) - Q with a hire date of 10/23/2008 did not reveal continuing education hours. Record review of the binder with monthly in services revealed UD - Q did not have 12 hours of continuing education required and the sign in sheets revealed that UD - Q attended 10 out of 12 facility in services during 2024, which equaled 10 hours. E. Record review of the employee file for NA - R with a hire date of 10/3/2023 did not reveal continuing education hours. Record review of the binder with monthly in services revealed NA - R did not have 12 hours of continuing education required and the sign in sheets revealed that NA - R attended 8 out of 12 facility in services during 2024, which equals 8 hours. In an interview on 01/28/25 at 03:14 PM the Chief Operating Officer (COO) confirmed there is no documentation of ongoing education for NA's for the past 12 months and that 5 out of the 5 sampled staff did not complete 12 hours of ongoing education and should have. Interview on 01/29/25 at 12:22 PM the Administrator confirmed there is no documentation that the sampled employees received 12 hours of continuing education, and it should have been in their employee files. Interview on 1/30/25 at 7:45 AM the Administrator confirmed that they review continuing education hours on an annual basis for the calendar year, not based upon hire date.

Licensure Reference Number 175 NAC 12-006.11C Based on interviews, observations, and record reviews, the facility failed to perform hand hygiene for 20 seconds and wear a hair restraint while in the kitchen to prevent the potential for food-borne illness. The facility failed to ensure the ice machine was clean, food items were sealed, labeled, and dated, and outdated food were disposed of. The facility failed to ensure the scoop was not left in an ice cooler to prevent cross contamination. Facility reported that 173 residents receive food from kitchen. The facility census was 174. Findings are: A. Observation on 1/27/25 at 7:30 AM in the kitchen revealed the following: Foods found that were undated and/or opened or out of date: -In the dry storage area - chicken breaded powder not sealed and no date. - bag of macaroni open and not dated. In the walk-in freezer - 2 pieces of cake uncovered and not dated. - turkey patties opened and not dated. - grilled chicken breast fillets open and not dated. - Precooked pork breaded patties open and undated. In the walk-in refrigerator -5 bowls with lettuce uncovered and not dated. - 4 pieces of cake not dated. - Lemonade in a large pitcher dated 1/14/25 indicating out of date. - Coleslaw in a bowl dated 1/19/25 indicating out of date. Interview with Cook-T on 1/27/25 at 8:04 AM revealed that the foods should be sealed and dated, the lemonade and coleslaw were out of date, and the lettuce bowls should be thrown away. Interview with Director of Food Service (DOFS) on 1/27/25 at 9:55 AM confirmed all the food items listed above should not have open, undated or outdated. B. Observation on 1/27/25 at 7:20 AM of DA-S scooping ice out of ice machine without a hairnet in the kitchen, and looked over at surveyor standing inside the kitchen door. DA-S stopped scooping ice, then touched [gender] hair, went over to sink, and put a hair net on. DA-S performed hand hygiene with soap and water x 15 seconds. Interview on 1/28/25 at 12:30 PM with DOFS revealed kitchen staff should wear a hair net while in the kitchen and wash hands for 20 seconds. C. Observation of food preparation on 1/29/25 at 8:34 AM for lunch by Cook-T. Cook-T prepared ham and beans. The vegetables were already cut up when surveyor arrived in kitchen and Cook-T said the lids of the cans of beans were washed. Cook-T divided the beans into 5 pans. Cook-T performed hand hygiene with soap and water for 15 seconds and donned (put on) gloves. Cook-T continued to follow the recipe and divided the precut ham, diced onions, and black pepper into all 5 pans. Cook-T performed hand hygiene for 13 seconds. Interview with DOFS on 1/30/25 at 9:55 AM revealed the staff should wash hands for 20 seconds. Record review of Preventing Forborne Illness-Employee Hygiene and Sanitary Policy revised 1/2024 revealed: Policy statement - Food and Nutrition Services employees will follow appropriate hygiene and sanitary procedures to spread prevent the spread of foodborne illness. Employees must wash their hands: -Whenever entering or reentering the kitchen. -Before coming in contact with any food services. -After handling raw meat, poultry or fish and when switching between working with raw food and working with ready to eat food. -After handling soiled equipment or utensils. -During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks: and/or. -After engaging in other activities that contaminate the hands. -Hair Nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. D. Observation on 1/30/25 at 7:19 AM of the kitchen ice machine revealed gray-blackish debris on the ice chute over the ice. Interview with RD-U on 1/30/25 at 7:21 AM stated the ice machine certainly needs cleaned. Interview with Director of Maintenance on 1/30/25 at 7:22 AM confirmed that the ice machine is dirty but unsure when maintenance last cleaned it. Record review of the maintenance PM's (preventative maintenance- indicating when the kitchen equipment was cleaned or maintained) dated December 26, 2024, revealed the last De-lime of the ice machine was 8/2024. Record review of facility's Ice Policy dated 2010 revealed: Ice will be produced and handled in a manner to keep it free from contamination. Procedure: Ice machines will be maintained in a clean and sanitary condition to prevent ice contamination. 47312 E. An observation on 1/28/25 at 12:21 PM revealed Nurse Assistant (NA)-C opened the lid of a small cooler, took a scoop filled with ice out, put the ice in a cup, placed the scoop back in the cooler and closed the lid. The observation further revealed that no hand hygiene was completed by NA-C before or after handling the ice scoop. An observation on 1/28/25 at 12:29 PM revealed NA-C opened the lid of the cooler of ice again, took a scoop filled with ice out, put the ice in a cup, placed the scoop back in the cooler and closed the lid. The observation further revealed that no hand hygiene was completed by NA-C before or after handling the ice scoop. In an interview on 1/28/25 at 1:04 PM, NA-C confirmed that the ice scoop should not have been placed back in the cooler after getting ice out of it and that hand hygiene should have been completed before and after using the scoop. Review of the facility's Ice policy, undated, revealed the following: -Ice will be produced and handled in a manner to keep it free from contamination. -Staff will wash hands prior to handling ice. Ice will not be handled with bare hands, but rather with a sanitized scoop and container for transport and distribution.

Statute 71-6018.02 Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) was present in the facility for at least 8 consecutive hours on 1/4/25 and 1/5/25. This had the potential to affect nursing care for all the residents that reside in the facility. The facility census was 174 at the time of survey. Finding are: Record review of nursing staffing schedules from 11/1/24 through 1/30/25 revealed no RN scheduled to work the weekend on 1/4/25 and 1/5/24. During an interview on 1/30/25 at 7:35 AM Nursing Assistant (NA) - M who was working as the staffing coordinator, confirmed that nursing staff titles were not listed on the staffing schedules and was unaware of which staff were RN's. Record review of the nursing schedule dated 1/4/25 revealed there was no RN in the building. Record review of the nursing schedule dated 1/5/25 revealed there was no RN in the building. Record review of daily posted nursing schedule for 1/4/25 revealed there were no RN hours marked. Record review of daily posted nursing schedule for 1/5/25 revealed there were no RN hours marked. An interview with the Director of Nursing (DON) on 1/30/24 at 8:52 AM confirmed that if the RN on the weekends calls in sick they are supposed to call other RN's to come into work and are supposed to offer incentives. Interview on 1/30/25 at 9:21 AM with DON confirmed that on the weekend of 1/4/25 and 1/5/25 there was no RN in the building and there should have been one.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(2) Based on interview and record review; the facility failed to follow the medical practitioner's orders regarding wound care and failed to ensure wound treatment was completed for 1 (Resident 1) of 4 sampled residents. The facility census was 177. Findings are: Record review of facility's Skin and Wound Management Policy, last revised 1/2024, revealed the nursing staff and the medical practitioner: -Will assess and document regarding all current wound care treatments, -will identify type and characteristics of a pressure sore, -will identify and define complications of healing regarding pressure sores, -the practitioner will order wound treatments and identify medical interventions related to wound management. Record review of the undated facility admission record revealed that Resident 1's most recent admission to the facility was on 6/28/24 with a diagnosis of Chronic Obstructive Pulmonary Disease and Type 2 Diabetes. Record review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 9/27/24 revealed: -The resident's cognitive assessment indicated no cognitive impairment, -the resident received substantial assistance with transfers (moving from one surface to another), bed mobility, dressing, and toileting hygiene, -the resident used a wheelchair for mobility, -the resident had a Stage 2 (partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed) pressure ulcer, -the resident did not participate in Restorative Nursing (type of nursing care designed to assist residents of nursing homes to maintain or improve their functional abilities). Record review of Resident 1's Comprehensive Care Plan (CCP- written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) date initiated 6/28/24 the resident was at risk for skin breakdown and has an open area on coccyx. Record review of Resident 1's Order Summary Report printed on 10/29/24 revealed no orders for wound care. Record review of Resident 1's weekly skin observation dated 8/30/24 revealed a pressure issue noted to coccyx with measurements of 2 centimeters (cm) long by 2 cm wide and .1 cm in depth. Record review of Resident 1's weekly skin observation dated 10/01/24 revealed a Stage 2 pressure issue, to coccyx with measurements of 7 cm long, by 6 cm wide and .25 cm in depth. Record review of the Tissue Analytics wound evaluation assessment dated [DATE] revealed the following visits from the Advanced Practice Registered Nurse (APRN): -On 9/18/24 Resident 1 was seen for a stage 2 linear wound on the coccyx down the crease of buttocks and the plan was to wash with facility cleanser, pat dry. Apply a thick layer of Triad cream to the wound area change or re-apply dailiy and as needed. Apply facility barrier cream as needed after bathing, changing, and in between treatments after soiling. Check and change every 2 hours. turn every 2-3 hours to relieve pressure. Resident needs to be on an air mattress and needs a Roho cushion (a pressure relieving cushion) for the wheelchar. -On 9/25/24 Resident 1 was seen and the document noted that the wound is larger, the resident still needs an air mattress, and to be propped off [gender]'s bottom. The plan is to continue current treatment. -On 10/2/24 the wound was staged at a Stage 3 (a wound that involves full thickness skin loss, exposing fat tissue but not muscle, tendon, or bone) pressure ulcer. Notes revealed to wash the wound with facility cleanser, pat dry. Apply a thick layer of Triad cream to the wound area. Cover the entire area with a sacral mepilex dressing or 2 4 x 4's large enough to cover the entire wound area. Change or re-apply daily and as needed. Check and change every 2 hours and change the dressing if it is soiled or wet. Turn resident every 2-3 hours to relieve pressure. Obtain an air mattress and a Roho cushion for Resident 1's chair. Record review of Resident 1's Treatment Administration Record (TAR) from 8/1/24 through 10/4/24 revealed no wound care treatments were ordered or completed. Interview on 10/29/24 at 1:38 PM Licensed Practical Nurse (LPN) - A confirmed that Resident 1 did have a wound to [gender]'s coccyx. It was also confirmed there were no documented treatment orders on the TAR, or documentation that any wound care had been done from when wound was found on 8/30/24 until the resident discharged out to the hospital on 10/4/24. LPN-A further revealed there was a treatment but could not confirm what the treatment was or if the treatment was completed for the wound. Interview on 10/29/24 at 2:47 PM the Director of Nursing confirmed that Resident 1 did not have any wound treatment orders on the TAR. It was also confirmed that the wound had been getting bigger. DON further confirmed that there was no documentation that the wound treatment had ever been completed while the resident was at the facility.

Licensure Reference Number 175 NAC 12.006.09(I) Based on observation, interview, and record review, the facility failed to ensure interventions were implemented to prevent elopement (when a resident leaves the premises or a safe area without authorization) for 2 (Residents 1 and 2) of 3 sampled residents. The facility census was 198. The facility Administrator for Emerald Nursing and Rehab [NAME] was notified on 07/02/2024 at 5:30 PM of an Immediate Jeopardy (IJ) which began on 06/29/2024. The IJ was removed on 07/02/2024, as confirmed by surveyor onsite verification. Findings are: A record review of the facility's undated Missing Resident/Elopement Procedure revealed all nursing staff were responsible for knowing the whereabouts of residents for which they were assigned. Each resident was required to advise the nurse in charge when the resident left the building. Residents were not permitted to leave the building alone unless a physician order was present. Residents identified as cognitively impaired and assessed as an elopement risk were to be provided with an elopement prevention device and all personnel were responsible for promptly going to the location and determining the cause of an activated audible door alarm. In the event a resident cannot be located the charge nurse of the missing resident was to activate the elopement procedure, contact the Administrator and Director of Nursing immediately, and assign staff to search the building and grounds. The Administrator/Designee was responsible for initiating (starting) detailed documentation of all actions taken and efforts made to locate the resident immediately after or at the time of the event and contacting the State Department of Public Health. A record review of the facility's Elopement Education dated 03/28/2024 revealed that lists were provided at the nurse's stations for residents that were currently at risk for elopement. If the staff had concerns of a resident wandering or wanting to leave, management needed notified. An elopement book at the receptionist desk identified residents as well. For residents that wanted to leave the building, staff was to notify the reception desk to ensure they sign out and were safe to do so. A. A record review of Resident 1's Clinical Census dated 07/02/2024 revealed the resident was admitted to the facility 06/17/2024. A record review of Resident 1's Medical Diagnosis dated 07/02/2024 revealed the resident had diagnoses of: Unspecified Sequelae Of Nontraumatic Subarachnoid Hemorrhage (a brain bleed), Alcohol Dependence, Uncomplicated, Alcoholic Liver Disease, Other Seizures (uncontrolled jerking or shaking events), Unspecified, Type 2 Diabetes Mellitus Without Complications (uncontrolled blood sugar), Depression, and Pain. A record review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment used to develop a resident's care plan) with a Target Date of 06/24/2024 revealed the resident had a Brief Interview for Mental Status (BIMS, a score of a residents cognitive abilities) 9 of 15 which indicated the resident was moderately cognitively impaired (difficulty with mental function and skills). The resident was independent with mobility and all activities of daily living (ADL) except eating. The resident had wandered (walked around aimlessly) 1 to 3 days in the lookback period. A record review of Resident 1's Nursing Admission Data Collection - V 2 dated 06/17/2024 revealed the resident had a history of exit seeking, wandering away, or getting lost. The resident had a pertinent diagnosis of Dementia (confusion) Alzheimer's disease, Anxiety disorder, or Delusions and was capable of independent mobility. The resident was a potential elopement risk. A record review of Resident 1's Clinical Physician's Orders dated 07/02/2024 revealed the resident had a wanderguard safety device (device worn that would set off an alarm if the resident got close to an alarmed door). The Clinical Physician's Orders did not reveal the resident had a physician order to leave the building alone. A record review of Resident 1's Care Plan with an admitted [DATE] revealed the resident had impaired cognitive function or impaired decision making. The resident was at risk for elopement related to cognition and wandering with a goal of the resident would not exit the facility unaccompanied by staff or family through the next review date. The risk for elopement intervention was the resident was currently wearing a wandering device on the left wrist. A record review of Resident 1's Progress Note dated 06/17/2024 at 12:40 PM revealed Social Services (SS) documented the resident was unaware why he was at the facility, and nobody told the resident anything, they just dropped the resident off. SS did tell the resident there was concerns with memory and cognition. SS encouraged the resident to check out the building and that the resident could not exit the front door alone. The resident was observed checking out various areas of the building and getting familiar with things. SS notified the front desk that the resident may be checking out the building and if the resident was in the lobby unsure which direction to go, help guide Resident 1. A record review of Resident 1's Progress Note dated 06/17/2024 at 5:59 PM revealed Resident 1 was assessed as an elopement risk. A record review of Resident 1's Progress Note dated 06/27/2024 revealed the resident believed the resident had a flight to catch in Omaha and packed up belongings. The resident was not easy to redirect. The resident was confused and unaware what city the resident was in. The resident went to the first floor looking for the main entrance. The resident was assisted back to the 2nd floor by a Nursing Assistant (NA) and was not able to find own way back. A record review of the facility's Waunderguard Master Resident List dated 06/28/2024 revealed Resident 1 was on the list for having a wanderguard. A record review of Resident 1's Progress Note dated 06/29/2024 at 12:07 PM revealed the resident had increased confusion and constantly seemed lost. The resident had been packing belongings all night and the staff was not able to redirect. The resident was constantly wandering in the hallways without direction or purpose. The management was notified, and the resident was being moved to Station 5 (the locked memory care unit) for safety related to increased confusion and wandering. A record review of the facility's Incidents By Incident Type dated 01/02/2024 to 07/02/2024 did not reveal resident 1 had an Elopement Incident. A record review of the facility's unnamed reportable incidents list dated 04/03/2024 through 07/01/2024 did not reveal Resident 1 had an elopement. A record review of the facility's undated Elopement list for the previous 6 months did not reveal Resident 1 had eloped. A record review of Resident 1's Progress Notes dated 06/17/2024 to 7/1/2024 did not reveal the resident had eloped from the facility. A record review of the facility's unnamed resident sign-out list dated 06/27/2024 - 06/28/2024 did not reveal Resident 1 signed out of the facility with Resident 2 on 06/29/2024 at 9:47 AM. An observation on 07/02/2024 at 7:00 AM revealed the front door to the facility was unlocked and no staff was in sight until entering the administrative offices. In an interview on 07/02/2024 at 10:14 AM, Rec-F confirmed there is a book kept in the cabinet at the receptionist's desk that contained a list of residents with wanderguards and a list of residents with Community Access Passes, a photo of the resident, and the resident's demographic information. The book indicated if a resident could leave the facility and where they were allowed to go, and the wanderguard list indicated the resident was not to leave the facility without staff or family. Rec-F confirmed Rec-F does not refer to the binder that contained the wanderguard list, Community Access Passes, resident photos, and resident demographics. In a telephone interview on 07/02/2024 at 11:50 AM, Nursing Assistant (NA)-B that was scheduled to be working Station 4 on 06/29/2024 confirmed NA-B was not working on Station 4, NA-B was transferred to Station 5. NA-B confirmed NA-B knew Resident 1 and the resident had a wanderguard on that should have gone off when the resident attempted to leave the facility. NA-B confirmed the staff on Station 4 was running around looking for the resident on that date after being unable to locate [gender]. NA-B confirmed Resident 2 went in and out of the facility all day. In a telephone interview on 07/02/2024 at 12:07 PM, NA-C that was scheduled to be working Station 4 on 06/29/2024 confirmed that NA-C left for a break and Residents 1 and 2 were outside as NA-C left the facility. NA-C confirmed Resident 1 had a wanderguard and should not have been outside of the facility, but NA-C confirmed NA-C did not notify anyone. When NA-C returned to the facility after the break, NA-C heard Residents 1 and 2 were at Zestos on the other side of South Street. NA-C reported the incident to the charge nurse. NA-C was then instructed to take Resident 1 to station 5 as soon as possible. NA-C confirmed there was supposed to be a list of residents with wanderguards but NA-C doesn't check it and NA-C did not know what residents were on the list. NA-C revealed nobody was checking the wanderguards and NA-C was unsure who was supposed to be checking the wanderguards. In a telephone interview on 07/02/2024 at 12:23 PM, NA-D that was scheduled to be working Station 4 on 06/29/2024 confirmed that NA-D was very busy that day and heard that Residents 1 and 2 had gone across the street but was not sure when Resident 1 took Resident 2 across the street. NA-D confirmed that none of the staff realized the residents were gone. NA-D confirmed the staff let Resident 1 and 2 do what they want. NA-D confirmed that after the incident, the staff took Resident 1 directly to Station 5, the locked unit. NA-D confirmed some residents could go out and some could not. NA-D confirmed NA-D was unaware how to determine what each resident was allowed to do. NA-D confirmed the nurse lets the staff know who can go out by themselves. NA-D confirmed the staff is unaware of when the residents leave the floor. In an interview on 07/02/2024 at 12:48 PM, Unit Director (UD)-E confirmed UD-E was on call at the time of the incident, but not at the facility. The Social Worker was at the facility and reported to UD-E. UD-E confirmed that Resident 2 talked Resident 1 into taking Resident 2 across South Street to Zestos. UD-E confirmed that Resident 1 had a wanderguard bracelet on at the time and was not sure why it did not trigger the alarm system. UD-E confirmed that every nurse's station had a list of residents that wear a wanderguard. UD-E confirmed UD-E tested the wanderguard and it worked, but if the wanderguard bracelets get close to expiration, they get glitchy and don't always read correctly. UD-E confirmed that Resident 1 was younger, ambulates without an assistive device unhindered (without being slowed or more difficult), and talked like the resident knew what they were saying. Resident 1 was very deceptive and that may be why the staff allowed the resident to leave the facility. UD-E revealed the Director of Nursing (DON) confirmed [gender] was working on the investigation and report on 06/29/2024. In an interview on 07/02/2024 at 3:56 PM, the DON confirmed that while investigating the Resident 1 and Resident 2 incident on 06/29/2024, the DON reviewed the progress notes for Resident 1 and seen Resident 1 had increased confusion, was exit-seeking more, and was packing the resident's things up to leave, so the DON decided it was best to get Resident 1 to a locked unit. In an interview on 07/08/2024 at 3:28 PM, Resident 2 confirmed that Resident 2 did not know that Resident 1 had a wanderguard bracelet on or that Resident 1 was not supposed to leave the facility. Resident 2 confirmed that Resident 2 had gone across the street several times before and it was not an issue. Resident 2 confirmed that Resident 2 was in a wheelchair at the time and Resident 1 pushed [gender] across the street. Resident 2 confirmed Resident 2 signed in and out but was unaware if Resident 1 did. Resident 2 confirmed 2 staff members from the facility came to Zesto's to tell the residents to go back to the facility. Resident 2 confirmed Resident 2 had not been told they could not go across the street. In a telephone interview on 07/02/2024 at 11:37 AM, Rec-A confirmed Resident 1 came to the reception desk where Resident 2 withdrew 60 dollars to go across the street to Zesto's to get ice cream. Resident 2 signed themselves out in the unnamed resident sign-out list dated 06/27/2024 - 06/28/2024 and went outside. Resident 2 then came back in the facility and Resident 1 and Resident 2 got together and were leaving the facility. Rec-A confirmed that another resident with a wanderguard set off the alarm. Rec-A then cleared the alarm and a line of people left the facility that included Resident 1 and Resident 2. Rec-A confirmed that Resident 2 was sitting outside smoking and Resident 1 was also there. Rec-A confirmed that Rec-A thought Resident 1 was just a visitor and did not think anything about it. Later, 2 staff entered the building and told Rec-A that Resident 1 was out and had a wanderguard on. The 2 staff went to get the residents and the residents were at Zesto's. Rec-A confirmed there is a list of residents that says where the resident is allowed to go at the receptionist desk and Resident 1 was not on there yet due to Resident 1 was a new resident. Rec-A again confirmed Rec-A thought Resident 1 was just a visitor pushing Resident 2 around. Rec-A confirmed it can get too busy in the lobby and 1 person cannot watch all the people coming and going. Rec-A confirmed there was a master list of residents with wanderguards in the computer and that the staff has to pull up the resident's Electronic Medical Record to see a picture of a resident. In an interview on 07/02/2024 at 1:35 PM, the facility's Administrator confirmed the facility has the security video of Residents 1 and 2 leaving the facility and the receptionist knew where the residents were going, so the Administrator confirmed that the facility's management group determined it was not an elopement. The Administrator confirmed that it was not until 10:55 AM that the Administrator was contacted by the facility. The Administrator confirmed that the facility's receptionist was the one that made the determination that it was safe for Resident 1 and Resident 2 to leave the grounds to go across South Street to Zesto's. In an interview on 07/02/2024 at 8:01 PM, the Clinical Consultant (CC) confirmed that the receptionist that was working on 06/29/2024 should not have turned off the wanderguard alarm system to let Resident 1 leave the facility. B. A record review of Resident 2's Clinical Census dated 07/02/2024 revealed the resident was admitted to the facility 11/10/2023. A record review of Resident 2's Medical Diagnosis dated 07/02/2024 revealed the resident had diagnoses of: Presbyopia (eye disease), Myopia, Unspecified Eye (nearsighted), Nonexudative Age-Related Macular Degeneration, Bilateral, Stage Unspecified (chronic eye disease), Morbid (Severe) Obesity Due To Excess Calories (very overweight), Non-Pressure Chronic Ulcer Of Other Part Of Left Foot Fat Layer Exposed (deep left foot wound), Acquired Absence Of Other Left Toe(s), Chronic Obstructive Pulmonary Disease (COPD), Unspecified, Chronic Combined Systolic (Congestive) And Diastolic (Congestive) Heart Failure (CHF), Unspecified, Type 2 Diabetes Mellitus Without Complications (uncontrolled blood sugar), Depression, and Pain. A record review of Resident 2's MDS dated of 04/23//2024 revealed the resident had a BIMS score of 13 of 15 that indicated the resident was cognitively aware. The resident was needed partial/moderate staff assistance with most ADL's except eating and oral hygiene (cleaning). The resident needed setup assistance with all areas of mobility. The resident required the use of a walker or wheelchair. The resident had 2 or more falls with injury in the lookback period. The resident did not wander. Resident 2 did have oxygen. A record review of Resident 2's Care Plan with an admitted [DATE] revealed the resident had the following focus areas: functional deficit with current ADL's, at risk for falls, impaired visual function, appropriate for long term care related to the need for 24/7 (24 hours per day, 7 days per week) supervision/care and the potential for a mood problem related to depression. A record review of Resident 2's Nursing Admission Data Collection - V 2 dated 04/23/2024 did not reveal the resident had a history of exit seeking, wandering away, or getting lost. The resident did not have a pertinent diagnosis of Dementia (confusion) Alzheimer's disease, Anxiety disorder, or Delusions and was capable of independent mobility. A record review of Resident 2's Clinical Physician's Orders dated 07/02/2024 revealed a provider order of: May go out of facility with responsible person with all meds (medications) PRN (as needed). A record review of the facility's Incidents By Incident Type dated 01/02/2024 to 07/02/2024 did not reveal resident 2 had an elopement incident. A record review of the facility's unnamed reportable incidents list dated 04/03/2024 through 07/01/2024 did not reveal Resident 2 had an elopement. A record review of the facility's undated Elopement list for the previous 6 months did not reveal Resident 2 had eloped. A record review of the facility's unnamed resident sign-out list dated 06/27/2024 - 06/28/2024 revealed Resident 2 signed out of the facility on 06/29/2024 at 9:47 AM but did not sign back in. A record review of the Community Access Pass Master List dated 06/21/2024 revealed Resident 2 was on the list and was approved to sit out front only. An observation on 07/08/2024 at 3:28 PM revealed Resident 2 was exiting the public restroom walking with a 4 wheeled walker. The resident went to the receptionist desk and got the resident's cigarettes, then continued to the smoking area in the facility's courtyard. The resident walked very slowly and was short of breath. In an interview on 07/02/2024 at 10:14 AM, Rec-F confirmed there is a book kept in the cabinet at the receptionist's desk that contained a list of residents with wanderguards and a list of residents with Community Access Passes, a photo of the resident, and the resident's demographic information. Rec-F confirmed Rec-F does not refer to the binder that contained the wanderguard list, Community Access Passes, resident photos, and resident demographics. The book indicated if a resident could leave the facility and where they were allowed to go, and the wanderguard list indicated the resident was not to leave the facility without staff or family. Rec-F confirmed Resident 2 had a Community Access Pass, but the resident was approved to sit out front only. In a telephone interview on 07/02/2024 at 11:50 AM, Nursing Assistant (NA)-B that was scheduled to be working Station 4 on 06/29/2024 confirmed NA-B was not working on Station 4, NA-B was transferred to Station 5. NA-B confirmed NA-B knew Resident 2. NA-B confirmed the staff on Station 4 was running around looking for the residents (Resident 1 and 2). NA-B confirmed Resident 2 went in and out of the facility all day. In a telephone interview on 07/02/2024 at 12:07 PM, NA-C that was scheduled to be working Station 4 on 06/29/2024 confirmed that NA-C left for a break and Residents 1 and 2 were outside as NA-C left the facility. NA-C confirmed Resident 1 had a wanderguard and should not have been outside of the facility, but NA-C confirmed NA-C did not notify anyone. When NA-C returned to the facility after the break, NA-C heard Residents 1 and 2 were at Zestos on the other side of South Street. NA-C reported the incident to the charge nurse. In a telephone interview on 07/02/2024 at 12:23 PM, NA-D that was scheduled to be working Station 4 on 06/29/2024 confirmed that NA-D was very busy that day and heard that Residents 1 and 2 had gone across the street but was not sure when Resident 1 took Resident 2 across the street. NA-D confirmed that none of the staff realized the residents were gone. NA-D confirmed the staff lets resident 1 and 2 do what they want. NA-D confirmed the nurse lets the staff know who can go out by themselves. NA-D confirmed the staff is unaware of when the residents leave the floor. In an interview on 07/02/2024 at 12:48 PM, Unit Director (UD)-E confirmed UD-E was on call at the time of the incident, but not at the facility. The Social Worker was and reported to UD-E. UD-E confirmed that Resident 2 talked Resident 1 into taking Resident 2 across South Street to Zestos. UD-E confirmed that Resident 1 had a wanderguard bracelet on at the time and was not sure why it did not trigger the alarm system. UD-E confirmed that every nurse's station had a list of residents that wear a wanderguard. UD-E confirmed UD-E tested the wanderguard and it worked, but if the wanderguard bracelets get close to expiration, they get glitchy and don't always read correctly. UD-E confirmed that Resident 1 was younger, ambulates without an assistive device unhindered (without being slowed or more difficult), and talked like the resident knew what the resident was saying. Resident 1 was very deceptive and that may be why the staff allowed the resident to leave the facility. UD-E confirmed that the Director of Nursing (DON) confirmed the DON was working on the investigation and report on 06/29/2024. In an interview on 07/08/2024 at 3:28 PM, Resident 2 confirmed that Resident 2 did not know that Resident 1 had a wanderguard bracelet on or that Resident 1 was not supposed to leave the facility. Resident 2 confirmed that Resident 2 had gone across the street several times before and it was not an issue. Resident 2 confirmed that Resident 2 was in a wheelchair at the time and Resident 1 was nice to push me across the street. Resident confirmed the only place the residents went was to Zesto's to get ice cream. Resident 2 confirmed Resident 2 signed in and out but don't know if Resident 1 did. Resident 2 confirmed 2 staff members from the facility came to Zesto's to tell the residents to go back to the facility. Resident 2 confirmed Resident 2 had not been told they could not go across the street. Resident 2 confirmed the resident has gone across the street several time to the liquor store to get cigarettes, the Mexican restaurant and to Zesto's and has never been told the resident was not supposed to leave the property. In a telephone interview on 07/02/2024 at 11:37 AM, Rec-A confirmed Resident 1 came to the reception desk where Resident 2 withdrew 60 dollars to go across the street to Zesto's to get ice cream. Resident 2 signed self out in the unnamed resident sign-out list dated 06/27/2024 - 06/28/2024 and went outside. Resident 2 then came back in the facility and Resident 1 and Resident 2 got together and were leaving the facility. Rec-A confirmed that another resident with a wanderguard set off the alarm. Rec-A then cleared the alarm and a line of people left the facility that included Resident 1 and Resident 2. Rec-A confirmed that Resident 2 was sitting outside smoking and Resident 1 was also there. Rec-A confirmed that Rec-A thought Resident 1 was just a visitor and did not think anything about it. Later, 2 staff entered the building and told Rec-A that Resident 1 was out and had a wanderguard on. The 2 staff went to get the residents and the residents were at Zesto's. Rec-A confirmed there is a list of residents that says where the resident is allowed to go at the receptionist desk and Resident 1 was not on there yet due to Resident 1 was a new resident. Rec-A again confirmed Rec-A thought Resident 1 was just a visitor pushing Resident 2 around. Rec-A confirmed it can get too busy in the lobby and 1 person cannot watch all the people coming and going. Rec-A confirmed there was a master list of residents with Community Access Passes and where the residents were allowed to go and there was a master list of wanderguards in the computer and that the staff has to pull up the resident's Electronic Medical Record to see a picture of a resident. In an interview on 07/02/2024 at 1:35 PM, the facility's Administrator confirmed the facility has the security video of Residents 1 and 2 leaving the facility and the receptionist knew where the residents were going, so the Administrator confirmed that the facility's management group determined it was not an elopement. The Administrator confirmed that it was not until 10:55 AM that the Administrator was contacted by the facility. The Administrator confirmed that the facility's receptionist was the one that made the determination that it was safe for Resident 1 and Resident 2 to leave the grounds to go across South Street to Zesto's. In an interview on 07/02/2024 at 4:35 PM, the facility's Manager of Operations (MOO) confirmed that when a resident was issued a Community Access Pass, Social Services has a conversation with the UD and the resident's physician to determine the extent to where the resident is allowed to go. The facility's Manager of Operations confirmed that when it was decided that the resident was approved to sit out front only, meant the resident was to stay on the facility grounds. In an interview on 07/02/2024 at 1:42 PM, the DON confirmed the facility's Community Access Pass Master List dated 06/21/2024 revealed Resident 2 was approved to sit out front only. C. Emerald Nursing and Rehab [NAME] was previously cited on 03/28/2024 at the immediate jeopardy level J for an elopement of a resident who walked out the front door and the facility staff were unaware who was at risk for elopements or who wore wanderguards. Abatement Statement was received 07/02/2024 at 9:50 PM. Identified Opportunity for Improvement/Deficient Practice: -Resident 1 currently resides on a locked unit. -Resident 2 is currently hospitalized . Community Pass has been revoked Process/Steps to Identify others having the potential to be impacted by the same deficient practice: -Staff member who shut the Wanderguard system off has been suspended pending investigation related to supporting documentation that (gender) had been educated on facility procedures. -Immediate Education to Receptionist with Competency on 7/2/24. -Community Pass Policy revised as a Best Practice of the facility and not a physician's order. -Current Community Pass residents will be evaluated for prior restrictions to ensure following revised policy by 7/5/24. Measures put into place/systematic changes to ensure the deficient practice does not recur: -Receptionist staff will be re-educated with Competency by the Administrator or designee on resident safety with community passes and wanderguards prior to next immediate shift. -All staff will be re-educated by the Administrator or designee on resident safety with community passes and wanderguards immediately. -Competency will be placed in Orientation for all new hires and agency staff. Plan to monitor performance to ensure solutions are sustained. -Audits to be completed to ensure receptionist are knowledgeable about resident safety with community passes and wanderguards 3 times per week for 1 month and then monthly times 3. -The Plan of correction will be reviewed bu QAPI committee for the next 3 months. At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level.

Licensure Reference Number 175 NAC 12-006.09D7 Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 1) of 3 sampled residents was assessed for the ability to safely use the resident's recliner/chair lift to prevent a fall with major injury. The facility census was 203. Findings are: A record review of the facility's Accidents and Incidents policy with a last revised date of 1/2024 revealed Accident/Incidents may include a fall or suspected fall. Should an accident/incident occur, the facility strived to prevent such occurrence from happening again. The facility's procedure should be to protect resident from further immediate harm or potential harm. A record review of Resident 1's Clinical Census sheet dated 05/07/2024 revealed Resident 1 was admitted to the facility 05/05/2022. A record review of Resident 1's Electronic Medical Record Medical Diagnosis list dated 05/07/2024 revealed the resident had diagnoses of History of Falling, Unspecified, Initial Encounter, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety (confusion), Cerebrovascular Disease, Unspecified (problem with blood flow to the brain)Unspecified Sequelae of Nontraumatic Subarachnoid Hemorrhage (altered sensation following a stroke), Other Speech And Language Deficits Following Other Cerebrovascular Disease, Memory Deficit Following Cerebral Infarction (poor memory following a stroke), Insomnia (sleep disorder), Anxiety Disorder, Depression, and Pain. A record review of Resident 1's Minimum Data Set (MDS),a comprehensive assessment used to develop a resident's care plan) dated 02/02/2024 revealed the resident had a Brief Interview for Mental Status (BIMS, a score of a residents cognitive abilities) 9 of 15 that indicated the resident was moderately cognitively impaired. The resident was dependent on staff for mobility and all activities of daily living (ADL) except eating and oral hygiene and did not have impairment to the upper or lower extremities. A record review of the facility's Fall Scene Investigation Report V 2 dated 08/25/2022 at 6:42 AM revealed Resident 1 was found to have slid out of the recliner to the floor. The root cause was the resident was repositioning self. The intervention put in place to prevent this fall from happing again was [NAME] (a sticky pad) in place. The conclusion of the investigation was Resident 1 was impulsive. A record review of the facility's Fall Scene Investigation Report V 2 dated 01/12/2023 at 4:48 PM revealed Resident 1 was found on the floor in front of the recliner while the NA performed rounds. The root cause was impulsiveness. The intervention put in place to prevent this fall from happing again was to encourage the resident to call for help before trying to get out of the chair. The conclusion of the investigation was Resident 1 attempted to get out of the recliner unassisted without calling for help. A record review of the facility's Fall Scene Investigation Report V 2 dated 01/12/2023 at 5:06 PM revealed Resident 1 was found sitting in front of the recliner. The root cause was the resident was wanting to lay down. The intervention put in place to prevent this fall from happing again was to lay the resident down after supper. The conclusion of the investigation was Resident 1 was tired and wanted to lay down. A record review of the facility's Fall Scene Investigation Report V 2 dated 10/31/2023 at 8:54 PM revealed Resident 1 was found with the recliner lifted and tilted forward. The resident was laying on the floor with the pillow from the recliner under the resident's head. The root cause was impulsiveness and needing to use the bathroom. The intervention put in place to prevent this fall from happing again was to toilet after supper and gripper socks on while in the recliner. The conclusion of the investigation was toilet after supper and gripper socks or shoes on while in the recliner. A record review of the facility's Fall Scene Investigation Report V 2 dated 03/26/2024 at 5:22 PM revealed Resident 1 was found sitting on the floor in front of the recliner. The root cause was confusion and the resident slid out of the recliner. The intervention put in place to prevent this fall from happing again was the resident was transferred to the wheelchair and took out of the resident's room. The conclusion of the investigation was Resident 1 slid out of the recliner and needed to toilet. A of record review of Resident 1's Progress Note dated 04/28/2024 revealed a NA called for the nurse and the nurse entered the resident's room to find the resident lying on the floor on the resident's right side in a pool of blood under the head. Resident 1's power recliner was in the lifted position and tilted forward. The remote to the recliner was laying on the floor. There was a laceration above the right eyebrow measuring 2 centimeters (cm) by 1 cm. The resident also had a laceration on the bridge of the nose measuring 0.5 cm by 0.5 cm. Pressure was applied to the lacerations until Emergency Medical Services (EMS) arrived. A record review of the facility's Fall Scene Investigation Report V 2 dated 04/28/2024 at 6:40 PM revealed Resident 1 was found with the recliner tilted in the air and the tray table was pushed to the side. The resident was laying on the resident's right side and had a medium pool of blood under the resident's head. The root cause was the recliner remote. The intervention put in place to prevent this fall from happing again was to place the remote out of reach so that the resident was not able to tilt self. The conclusion of the investigation was to keep remote out of reach due to the resident's cognition. A record review of the [NAME] Trauma History & (and) Physical dated 04/28/2024 revealed the resident fell out of the recliner striking the front of the head. Upon arrival at the Emergency Department (ED) Resident 1 was found to have a large supraorbital (above the eye) laceration on the right side and imaging showed a likely frontal brain contusion. A wound over the left eye was closed in the ED. The principal problem was a subdural hematoma (pool of blood between the brain and it's outermost covering). The resident was admitted to the Intensive Care Unit. The resident was discharged [DATE]. A record review of the facility's Nursing Readmission Data Collection dated 05/01/2024 revealed Resident 1 had a 4 cm in length above the right eye that had approximately 8 sutures and bruising around both eyes. A record review of Resident 1's Care Plan with an admitted [DATE] revealed the resident had a Focus area of at risk for falls related to dementia, impulsive, and incontinence (inability to control bowels or bladder). The Care Plan revealed the resident had interventions of: -08/01/2021 - Recliner after lunch -08/05/2023 - Encourage frequent toileting -10/31/2023 - Toilet after supper -03/24/2024 - Signage placed in room to remind resident to use call light if needing assistance -03/27/2024 - Encourage with staff to toileting schedule approximately 3:00 PM -Date Initiated 03/27/2024 - Encourage use of call light -Date Initiated 04/28/2024 - Transfer: Dependent -05/01/2024 - Per POA (Power of Attorney) please keep remote of recliner in the side pocket of chair out of reach when the resident is in the chair to prevent future falls. Discussed with gender and declined manual recliner at this time. A record review of Resident 1's Electronic Medical Record that included progress notes, care plan entries, Practitioners orders, therapy notes and fall scene investigation sheets revealed the facility staff had not assessed the ability of Resident 1 to safely use a recliner/lift chair. An observation on 05/06/2024 at 1:43 PM revealed Resident 1 was sitting in the lift chair with the legs elevated and the lift chair control in the chair's pocket on the right side of the chair. The resident's right eye was bruised all the way around. The resident had a sutured laceration (cut with stitches) along the right brow that had 2 steri strips (a wound closure) on it and a golf ball sized hematoma (a raised area from blood leaks). The resident also had a sutured laceration on the bridge of the nose. An observation on 05/07/2024 at 10:55 AM revealed Resident 1 was sitting in the wheelchair and was transferred to the lift chair by Nursing Assistant (NA)-A and NA-B. NA-A elevated Resident 1's legs with the lift chair control and placed the lift chair control in the chair's pocket on the right side of the chair. In an interview on 05/06/2024 at 2:57 M, Resident 1's POA confirmed the facility notified the POA by telephone of the resident's fall on 04/28/2024 and the POA met the resident at the hospital. The POA confirmed Resident 1 told the POA that he thought the lift chair control was the television controller and pressed the up arrow. The daughter confirmed the resident had a history of sliding out of both manual and lift chair style recliners at the facility. The POA stated the resident is most comfortable in this chair, so the decision was made to let the resident keep the lift chair and hide the controller. The POA confirmed the POA has seen the controller next to the resident on at least 1 occasion since the fall on 04/28/2024 and has had to put it in the recliner's pocket. In an interview on 05/07/2024 at 11:08 AM, NA-C confirmed that NA-C had assisted Resident 1 with a meal in the recliner on 4/28/2024 due to the resident refused to go to the dining room. NA-C confirmed NA-C left the resident to go downstairs to the kitchen to get a tray for another resident. NA-C was off the floor for 30-40 minutes. When NA-C returned to the unit, NA-C was doing rounds when NA-C found Resident 1 lying on the floor and called for the nurse. NA-C confirmed Resident 1 was alert and was easy to have a conversation with when NA-C assisted the resident with the meal but was appeared confused following the fall. NA-C confirmed NA-C was unaware that the other staff would place the controller for the recliner in the side pocket and not near the resident so the resident would not play with the buttons until after the fall. In an interview on 05/07/2022 at 10:22 AM, the Director of Nursing (DON) confirmed the facility did not have a recliner or mechanical lift chair policy and they do not assess the ability of the resident to use a mechanical lift chair or recliner. In an interview on 05/07/2024 at 2:13 PM, Resident 1's POA confirmed the facility had not discussed with the family the resident's ability to safely use a recliners or mechanical lift chair until after the resident fell on [DATE]. In an interview on 05/07/2024 at 2:20 PM, the DON confirmed the facility did not assess Resident 1 for the ability to safely use a recliner or mechanical lift chair.

Licensure Reference Number 175 NAC 12-006.09D7 Licensure Reference Number 175 NAC 12-006.18B Based on record review and interviews, the facility failed to ensure elopement (unsupervised wandering that leads to the resident leaving the facility without facility staff knowledge) door alarms were functioning, which affected 1 (Resident 3) of 14 sampled residents. The facility failed to ensure all staff were aware of residents who were at risk for elopement which affected 1 (Resident 3) out of 5 sampled residents. This had the potential to affect 14 residents identified at risk for elopement. The facility census was 206. Findings are: A record review of Resident 3's Admission Record dated 3/8/2023 revealed that Resident 3 was admitted to the facility on [DATE] with diagnoses of: Ataxia (have problems coordinating how your muscles work, leading to awkward, unwieldy or clumsy movements) following unspecified cardiovascular disease (conditions that affect blood flow and the blood vessels in the brain), Cerebral infarction ( clot blocks a blood vessel that feeds the brain) due to unspecified occlusion of the left cerebellar artery, Attention and concentration deficit (forgetfulness, problems staying on task, easily distracted, easily bored, easily confused and difficulty following instructions), Metabolic Encephalopathy(chemical imbalance in the blood, when the imbalance affects the brain, it can lead to personality changes), Chronic heart failure, Type 2 diabetes, and Urinary Tract Infection. A record review of the Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a residents plan of care) dated 12/ 31/ 2023 revealed Resident 3 had a Brief Interview for Mental Status(BIMS-a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 10 which indicates Resident 3 was moderately cognitively impaired. In Behaviors Section E the question has the resident wandered, was answered no behavior exhibited. In Section GG of the MDS revealed that Resident 3 required some help from another person with all activities of daily living (ADL's). A record review of the Nursing Admission Data Collection form dated 12/15/2023 revealed there was no indication or history of exit seeking, wandering away or getting lost and was the resident was determined not to be an elopement risk. A record review of the Social Services Admission Data Collection form dated 12/18/2023 revealed that Behavior factors was marked as none above, indicating the resident had no wandering or exit seeking behaviors. A record review of the Comprehensive Care Plan (CCP-written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) dated 12/21/2023 revealed Resident 3 was not an elopement risk. A record review of the Progress Notes dated 3/22/2024 at 2:15 PM revealed Resident 3 had increased confusion and agitation, and was exit seeking. A Wander Guard (A Wander Guard system relies on three components: bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time. When a resident with a bracelet approaches a monitored door, the system alerts the caregivers), bracelet had been placed on Resident 3's wrist per the Unit Manager. A record review of the Progress Notes and the Nursing assessment forms revealed no documentation from 3/22/2024 through 3/27/2024 of an Elopement Assessment after placement of the wander guard on Residents 3's wrist. A record review of the Facility Investigation Report dated 3/28/2024 for Resident 3 revealed that on 3/27/2024 at 7:17 PM Resident 3 had left the facility through the front door without staff supervision or knowledge. At 7:37 PM Resident 3 was returned to the facility after a bystander assisted Resident 3 when Resident 3 tipped over in the wheelchair on South Street while Resident 3 was trying to cross South Street. Resident 3 received a skin tear to left elbow and left arm from the fall. Resident 3 was wearing sweat pants and T-shirt when [gender] left the facility. The weather at the time when the resident left the facility was 45 degrees per channel 10/11 news. The front door Wander Guard system failed to alarm when Resident 3 was close to the front door. A record review of the Maintenance log in the Tel's (technology is designed specifically for Senior Living to create safer environments and increase Life Safety compliance. Boost the efficiency of your maintenance teams and gain control over your operations) system for checking the Wander Guard system on the doors revealed that on 2/29/2024 a test of the doors,locks and alarms was documented as completed. The next due date to check functioning of the doors, locks and alarms was scheduled for 3/31/2024. A record review in the Progress Notes dated 3/27/2024 at 7:45 PM revealed Resident 3's Wander Guard bracelet on the resident's wrist was functioning. An interview on 3/28/2024 at 11:30 AM with the Unit Manager (UM) revealed Resident 3 had never been an elopement risk before, and was able to go down to the bistro or activities, and would always come back up to [gender] room. UM confirmed that [gender] received a call on 3/22/2024 regarding Resident 3 exit seeking and increased agitation and informed the staff to put a Wander Guard bracelet on Resident 3. An interview on 3/28/2024 at 3:30 PM with Maintenance Director (MD) confirmed [gender] got a call on 3/27/2024 at 8:00 PM from the facility regarding the malfunction of the Wander Guard door alarm, which was not alarming when a resident with a Wander Guard went through the front door. MD arrived at the facility at 9:00 PM and reset the Wander Guard system. MD confirmed that [gender] did not know why the wander guard system did not alarm. MD also confirmed the wander guard system on the doors are checked monthly. An interview on 3/28/2024 at 4:45 PM with the Electrical contract company (EC) came out to check the Wander Guard system to make sure the system was functioning properly. EC confirmed that [gender] is not sure why the wander guard system malfunctioned. EC checked the timing and wires and verified set up and tested the system and everything was functioning properly. An interview on 3/29/2024 at 11:30 AM with Medication Aide (MA)-A confirmed that [gender] is not aware of how often the Wander Guards are checked on residents who have a bracelet. MA-A confirmed [gender] is not aware of which residents have a Wander Guard on, or the residents who are at risk for elopement. An interview on 3/29/2024 at 11:45 AM with Licensed Practical Nurse (LPN)-G confirmed that the nurses check the function of the Wander Guard bracelets on the residents who are risk for elopement every shift. LPN -G also confirmed that nursing assistants do not necessarily know which residents are at risk for elopement, but the nurses do know. LPN-G confirmed that the wander guard system had this little device that when put up to the wander guard bracelets it would turn green if the wander guard was working and if it turned red the wander guard bracelet would be replaced. LPN-G confirmed that the wander guard bracelets had expiration dates on them. An interview on 3/29/2024 at 2:30 PM with Nursing Assistant (NA)-D, confirmed that Wander Guards are on the resident's wrist, ankle, or wheelchair. NA-D further confirmed [gender] is not aware if there is a list of residents who have Wander Guard on, and is not aware of the residents who are at risk for elopement. NA-D confirmed that the nurses check the Wander Guards with a machine. If the machine turns green, then its working and if it turns red then the wander guard is not working. An interview on 3/29/2024 at 2:45 PM with MA-B confirmed that [gender] is not aware of which residents are at risk for elopement or which residents are wearing a Wander Guard. MA-B does know that the nurses are checking them on the evening shift but not aware of what other shifts do. An interview on 3/1/20204 at 3:30 PM per phone call with Receptionist who monitors the front desk by the front door revealed, that on 3/27/2024 at 7:17 PM, the Receptionist did not notice Resident 3 in the front lobby, nor did [gender] notice that Resident 3 went out the front door. The Receptionist confirmed that Resident 3 may have went out the front door when [gender] went to the bathroom. The Wander Guard system did not alarm when Resident 3 exited through the front door. The Receptionist further confirmed [gender] is not aware of any residents who are at risk for elopement or which residents have a Wander Guard on. The Receptionist also revealed that [gender] is aware of who the smokers are and the residents who have the Resident community access/pass. An interview on 3/28/2024 at 3:30 PM with the Administrator confirmed that Resident 3 was able to leave the unit that Resident 3 lives on to go to the Bistro, or activities provided in other areas of the building. The Administrator confirmed that Resident 3 has the right to go any where in the building. An interview on 3/28/2024 at 12:30 PM with the Director of Nursing (DON) confirmed that on 3/22/2024 an Elopement Assessment was not done for Resident 3 and should have been done. The DON confirmed that the nurses check that the Wander Guard bracelet is functioning every shift, but they do not check the functioning of the Wander Guard system on the doors. The DON confirmed that Resident 3 was able to attend activities and go to the Bistro but that Resident 3 did not leave Unit 4 by self. An interview on 3/28/2024 at 1:30 PM with the Clinical Consultant (CC) confirmed that on 3/22/2024 an Elopement Assessment should of been completed and was not done for Resident 3. The CC confirmed that after the Elopement of Resident 3, during the Risk Management meeting areas of concern were identified. The CC revealed that there was no Policy and Procedure for Wandering/Behavior or Elopement for residents at risk. The CC confirmed that Nursing Assessments are to be done quarterly and that the Nursing Assessments are not being done quarterly. The CC also confirmed that the Nursing Assessments consisted of; elopement/wandering risk, Lifestyle, cognition, communication, hearing, vision and oral, skin conditions, pain, Braden scale, bowel, and bladder, fall risk, hot liquid safety, Safely/Bed enablers/entrapment, mediation use, and Immunization/TB. A record review of the Abatement Statement to remove the immediacy of the situation on 3/28/2024 revealed the following: -Preventative Maintenance checklist will check doors weekly vs monthly due to the malfunction. -Re-education to the DON and Social Worker on the elopement policy by the consultant on 3/28/2024 to include orders, accurate forms, and care plans. -Staff education on 3/28/2024 on residents who are at risk. Provide current list to all stations on residents who are identified at risk. -All new staff will be educated in orientation upon hire. -Agency staff will be educated upon 1st shift in building. -The receptionist in the evening will check the functioning of the wander guard before the end of the shift.

Licensure Reference Number 175 NAC 12-006.09D2 Licensure Reference Number 175 NAC 12-006.09D2a Licensure Reference Number 175 NAC 12-006.09D2b Based on interview and record review, the facility failed to identify, monitor, and implement treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Three residents were sampled for pressure ulcers. The facility had a total census of 207 residents. The findings are: A. A review of an H & P (history and physical) from a local hospital dated 7/9/22 revealed Resident 2 was seen in the ER (emergency room ) on 7/9/22 at 12:50 PM and subsequently admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the H & P revealed the following comment in the skin assessment, Buttock with multiple wounds, pressure injuries with [CONDITION(S)] (redness) and areas of purple/black skin/wounds. A review of Resident 2's medical record, which included paper and electronic records, revealed no documentation related to wounds on Resident 2's buttocks prior to 7/9/22. A review of Weekly Skin Integrity Reviews for Resident 2 revealed the following documentation: -5/24/22 - No evaluation completed by nursing as resident evaluated this week by wound doctor. -5/31/22 - No evaluation completed by nursing as resident evaluated this week by wound doctor. -6/7/22 - No evaluation completed by nursing as resident evaluated this week by wound doctor. -6/14/22 - No evaluation completed by nursing as resident evaluated this week by wound doctor. -6/21/22 - No evaluation completed by nursing as resident evaluated this week by wound doctor. -6/28/22 - No evaluation completed by nursing as resident evaluated this week by wound doctor. -7/5/22 - Completed by LPN B - 1). Skin Intact? Yes. 2). Observations: Redness. 3). Skin Issue Type: No answer given. 3a). Is this a new skin issue type? No. 4). Site - Left toe(s); Description - Left great toenail is bloody and bruised. In an interview on 7/27/22 at 8:55 AM, LPN B reported they had completed Resident 2's Weekly Skin Integrity Review on 7/5/22 and Resident 2 had no open areas at that time. LPN B further reported LPN B was the nurse who sent Resident 2 to the hospital on the morning of 7/9/22 due to Resident 2 refusing to go to [CONDITION(S)] because they didn't feel well. LPN B stated the hospital called over to the facility around lunchtime on 7/9/22, as they were concerned about some wounds to Resident 2's buttocks. LPN B reported they informed the hospital the facility was not aware of any wounds to Resident 2's buttocks. In an interview on 7/27/22 at 11:27 AM, NA C (Nurse Aide) reported Resident 2 had previously been fairly independent, but had started requiring assistance from staff with ADLs (activities of daily living) and the assistance of a mechanical lift sometime prior to going to the hospital on 7/9/22. NA C stated they assisted Resident 2 with toileting on 7/7/22 and noticed an open area on Resident 2's left buttock. NA C reported they had first noticed the open area because they saw blood on the wipe when assisting Resident 2 with hygiene after toileting. NA C stated they reported the open area to the charge nurse working on Station 1 that day. In an interview on 7/27/22 at 11:34 AM, NA D reported they had assisted Resident 2 with bathing on 7/1/22. NA D stated they noted Resident 2 had some redness and excoriation to their buttocks and under their abdominal folds during bathing that day, but did not recall any open areas. A review of Resident 2's progress notes revealed the following: -7/9/22 at 11:19 AM - .1040 - resident left facility via Midwest Ambulance. -7/15/22 at 4:58 PM - Resident returned to facility (from hospital) with the following skin areas- .Resident also has areas to buttocks that have not been measured d/t (due to) facility wound vac not working at this time. Did receive T.O. (telephone order) for a wet to dry dressing until vac is fixed. Currently awaiting supplies to complete wet to dry. Once supplies arrive and wet to dry is completed areas are to (be) measured. ADON (Assistant Director of Nursing) and DON (Director of Nursing) are aware. -7/18/22 at 6:01 PM - Wound vac attempted to be applied, unable to adhere properly. DON present during this time. Was able to measure areas on buttocks. Left side - 7.1 x 2.9 x 2.8 Coccyx - 5.5 x 6 x 0.1 Right side - 4.7 x 1.6 x 3.1. Due to not being able to apply wound vac, wet to dry order was applied instead. All other tx (treatments) done at this time. -7/25/22 at 12:46 PM - Hospital called at 12:30 PM and updated that (Resident 2) was being admitted for [CONDITION(S)]. -7/27/22 at 8:23 AM - Discharge Note: Resident passed in hospital on 7/26 at 10am. An interview was conducted with the DON on 7/27/22 at 12:44 PM. During the interview, the DON reported on 7/9/22 Resident 2 had refused to go to [CONDITION(S)] and was not feeling well. The DON stated facility staff were not aware Resident 2 had any pressure wounds on their buttocks. The DON reported the facility learned of Resident 2's buttock pressure wounds from the hospital on 7/9/22 after Resident 2 was sent to the hospital. The DON confirmed the pressure wounds to Resident 2's bilateral buttocks had to have developed at the facility due to the hospital discovering the wounds the same day the facility sent Resident 2 to the hospital. The DON also reported the wound care APRN (Advanced Practice Registered Nurse) did not complete weekly skin observations. The wound care APRN only evaluated wounds for residents they were following. The DON reported the facility nurses were supposed to complete the weekly skin observations. The DON confirmed the weekly skin observations for Resident 2 were not completed from 5/24/22 - 6/28/22. A review of Resident 2's medical record revealed no wound assessments for Resident 2's pressure wounds to bilateral buttocks and coccyx following Resident 2's return to the facility from the hospital on 7/15/22. In an interview on 7/27/22 at 2:26 PM, the DON reported Resident 2's bilateral buttock and coccyx pressure areas were measured and the measurements were put into the progress notes on 7/18/22. The DON confirmed no wound assessments were documented for Resident 2's pressure areas to bilateral buttocks and coccyx after their return to the facility from the hospital on 7/15/22. The DON further confirmed that assessing and documenting the wound bed, drainage, odor, etc. in addition to measurements was important so the facility could identify if the wounds were healing. A review of the facility's Wound Care Policy, last revised October 2010 revealed the following: -Documentation -The following information should be recorded in the resident's medical record: -1. The type of wound care given. -2. The date and time the wound care was given. -3. The position in which the resident was placed. -4. The name and title of the individual performing the wound care. -5. Any change in the resident's condition. -6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. -7. How the resident tolerated the procedure. -8. Any problems or complaints made by the resident related to the procedure. -9. If the resident refused the treatment and the reason(s) why. -10. The signature and title of the person recording the data. B. An observation on 7/26/22 at 10:07 AM revealed LPN A (Licensed Practical Nurse) provided wound care to a pressure ulcer in a fold on Resident 1's sacrum. LPN A entered Resident 1's room and laid all wound care supplies onto a tissue box on top of Resident 1's bedside table. Resident 1's bedside table was covered with personal items. LPN A did not clean the bedside table and no barrier was used to create a clean field on the bedside table. LPN A washed their hands in the bathroom and applied gloves, then opened 2 packages of sterile gauze and wet the gauze in running water in the bathroom sink. LPN A then put soap from the hand soap dispenser onto 1 of the moistened packages of sterile gauze. LPN A returned to Resident 1's bed and opened one more package of sterile gauze and laid it on Resident 1's bed. LPN A used the sterile gauze pieces to cleanse, rinse and dry a pressure ulcer to Resident 1's sacrum (a bony structure at the base of the spine, connected to the pelvis). LPN A removed their gloves and performed hand hygiene with hand sanitizer, then applied new gloves. LPN A moved some of the wound care supplies previously placed on the tissue box onto the bedside table and then moved the remaining supplies into Resident 1's bed. LPN A opened a package of collagen powder and used gloved fingers to pinch the collagen powder and place it on the wound bed of Resident 1's pressure ulcer. LPN A then finished dressing the wound with calcium alginate (a wound dressing derived from seaweed that is highly absorbent) cut to size, covered with an absorbent dry dressing, and taped to Resident 1's skin. LPN A removed their gloves and performed hand hygiene. Further observation at this time revealed the skin on Resident 1's bilateral buttocks surrounding the sacral pressure ulcer was red and excoriated. No treatment was provided to the surrounding skin. A review of a wound evaluation dated 7/18/22 and completed by APRN F (Advanced Practice Registered Nurse) for Resident 1 revealed Resident 1 had a stage 2 pressure ulcer to the sacrum that measured approximately 1.93 cm (centimeters) x 1.87 cm with a depth of 0.1 cm. Further review of the wound evaluation revealed the following wound care orders: -1. Cleanse daily with mild soap and water and pat completely dry. -2. Apply collagen to open area to the center (all open areas in center) -3. Apply calcium alginate cut to wound size -4. Apply Triad Paste (a protective ointment to protect and heal skin from incontinence and wound exudate) to the entire peri-wound -5. Cover with ABD (an absorbent dry dressing) In an interview on 7/26/22 at 10:35 AM, LPN A confirmed they did not apply the Triad Paste as ordered during Resident 1's wound care. LPN A stated they forgot. C. A review of Weekly Skin Integrity Reviews for Resident 1 revealed the following documentation: -5/25/22 - No evaluation completed by nursing as resident evaluated this week by wound doctor. -6/1/22 - No evaluation completed by nursing as resident evaluated this week by wound doctor. -6/7/22 - No evaluation completed by nursing as resident evaluated this week by wound doctor. -6/14/22 - No evaluation completed by nursing as resident evaluated this week by wound doctor. -6/21/22 - 1). Skin intact? No. 3). Skin issue type? Pressure 3a). Is this a new skin issue type? No. 4). Site? Coccyx - healing pressure injury . -6/28/22 - No evaluation completed by nursing as resident evaluated this week by wound doctor. -7/5/22 - No evaluation completed by nursing as resident evaluated this week by wound doctor. -7/12/22 - No evaluation completed by nursing as resident evaluated this week by wound doctor. -7/19/22 - No evaluation completed by nursing as resident evaluated this week by wound doctor. In an interview on 7/27/22 at 12:44 PM, the DON reported the wound care APRN (Advanced Practice Registered Nurse) did not complete weekly skin observations. The wound care APRN only evaluated wounds for residents they were following. The DON reported the facility nurses were supposed to complete the weekly skin observations. The DON confirmed the weekly skin observations for Resident 1 were not consistently being completed. D. An observation on 7/27/22 at 8:46 AM revealed LPN B provided wound care to a pressure ulcer on Resident 4's left buttock. Observations at this time revealed Resident 4 had a circular shaped ulcer to the left buttock. The wound bed could not be observed due to the depth of the ulcer. A review of Resident 4's Progress Note dated 7/8/22 revealed Resident 4 returned from the hospital on that date. A review of Resident 4's Weekly Skin Integrity Review dated 7/12/22 revealed Resident 4 had a pressure wound on left buttock measuring 2 cm [centimeter] in length, 2.5 cm in width, and 3.3 cm deep. The pressure wound was identified as not being new. A review of Resident 4's Weekly Skin Integrity Review dated 7/14/22 revealed Resident 4 had a pressure wound. The Weekly Skin Integrity Review did not reveal where the pressure wound was located, stage, measurements, or any description of the wound. A review of Resident 4's Weekly Skin Integrity Review dated 7/26/22 revealed Resident 4 had a pressure wound to left gluteal fold. Under the description section of the Weekly Skin Integrity Review was noted that Resident 4 was being seen at wound clinic and had a treatment on the Treatment Administration Record. The Weekly Skin Integrity Review did not reveal where the pressure wound was located, stage, measurements, or any description of the wound. A review of Resident 4's physician orders from the wound clinic dated 7/18/22 revealed facility was to schedule Resident 4 for a pre-operation history and physical with procedure to be an excisional debridement of left buttock stage 4 pressure ulcer. The orders did not include any measurements or description of the wound. A review of Resident 4's electronic medical record did not include any Weekly Wound data Collection Flow sheet completed after 6/3/22. A review of the Weekly Wound Assessment form includes the following items: -measurements -an evaluation of wound base -an evaluation of wound edges -drainage -odor -evaluation of undermining/tunneling -pain associated with wound -treatment order In interviews on 7/26/22 at 2:20 PM and 7/27/22 at 11:55 AM, the Director of Nursing reported if residents are not being followed by wound APRN [Advance Practice Registered Nurse], a weekly wound assessment is to be completed by the Unit Coordinator and documented on the Weekly Wound Assessment Form. The Director of Nursing confirmed a weekly wound assessment should include all elements identified on the Weekly Wound Assessment form. A review of the facility policy titled Wound Care revised 10/2010 revealed the following documentation should be recorded in the resident's medical record: -All assessment date (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound.

Licensure Reference Number 175 NAC 12-006.09 Based on interview and record review, the facility failed to monitor a wound for 1 (Resident 2) sampled resident and failed to implement hypoglycemic (low blood sugar) protocol for 1 (Resident 2) sampled resident. The facility had a total census of 207 residents. The sample size was 5. The findings are: A. A review of Resident 2's progress notes revealed the following: -7/15/22 at 4:58 PM - Resident returned to facility (from hospital) with the following skin areas- .open area to pannus (refers to the fatty tissue that hangs over the abdomen) 8 x 7.1 cm (centimeters) . -7/24/22 at 2:04 PM - Resident wound to right abdominal fold noted to have slough (dead tissue) and odor. Cleansed and dressed with dry dressing per facility protocol. MD (Physician) notified for wound care orders. -7/25/22 at 12:46 PM - Hospital called at 12:30 PM and updated that (Resident 2) was being admitted for [CONDITION(S)]. -7/27/22 at 8:23 AM - Discharge Note: Resident passed in hospital on 7/26 at 10am. A review of a Transfer Form dated 7/25/22 at 9:21 AM for Resident 2 revealed Resident 2 was transferred to a local hospital via ambulance for a decline in condition. A review of Resident 2's July 2022 TAR (Treatment Administration Record) revealed the following order: -Right Pannus: Three times weekly - 1. Cleanse with [MEDICATION(S)] (a topical antiseptic solution, used to prevent skin infections); 2. Apply [MEDICATION(S)] (used in wound care to help remove dead tissue and encourage development of healthy tissue) to open areas; 3. Cover with [MEDICATION(S)] (a soft, foam dressing used to seal wound edges to prevent leakage and protect wound). Scheduled for Monday, Wednesday, and Friday weekly. A review of Resident 2's electronic medical record revealed no documented assessments of a wound to Resident 2's pannus or abdomen. A review of Resident 2's medical record, which included the paper and electronic records, did not reveal any documentation of an update to Resident 2's physician on 7/24/22 or a response or new orders from Resident 2's physician on 7/24/22. A review of the facility's Wound Care Policy, last revised October 2010 revealed the following: -Documentation -The following information should be recorded in the resident's medical record: -1. The type of wound care given. -2. The date and time the wound care was given. -3. The position in which the resident was placed. -4. The name and title of the individual performing the wound care. -5. Any change in the resident's condition. -6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. -7. How the resident tolerated the procedure. -8. Any problems or complaints made by the resident related to the procedure. -9. If the resident refused the treatment and the reason(s) why. -10. The signature and title of the person recording the data. In an interview on 7/26/22 at 2:19 PM, the DON (Director of Nursing) reported the wound assessments were supposed to be done weekly by the unit coordinators. The DON stated the facility did not currently have unit coordinators on Station 1 (Resident 2's unit), Station 4, or Station 5. The DON then stated, I guess I should be doing them. The DON confirmed they had not been doing the weekly wound assessments. In an interview on 7/27/22 at 12:44 PM, the DON confirmed no documentation could be located with the information given to Resident 2's physician or a response from Resident 2's physician on 7/24/22 regarding the slough and odor to Resident 2's abdominal wound. The DON also confirmed no wound assessments were being completed for Resident 2's abdominal wound, so there was no way to know what the wound bed looked like or if there was an odor present prior to 7/24/22. B. A review of Resident 2's blood glucose records revealed the following documented blood glucose checks on 7/8/22 and 7/9/22: -7/8/22 at 7:29 AM - 77 -7/8/22 at 7:43 AM - 77 -7/8/22 at 11:28 AM - 70 -7/8/22 at 11:36 AM - 70 -7/8/22 at 7:51 PM - 50 -7/9/22 at 7:27 AM - 77 A review of Resident 2's progress notes revealed the following: -7/8/22 at 5:14 PM - Resident is lethargic, needs orientation to time. Family was here this morning and is aware of condition. All vital signs within defined limits, will continue to monitor every 15 minutes. -7/8/22 at 7:53 PM - Resident still lethargic b/g (blood glucose) 50: held insulin and provided snack. Will continue Q (every) 15 minute rounds and recheck b/g at 2200 (10:00 PM). -7/8/22 at 9:04 PM - Resident at baseline mood/comfort, tolerated snacks well but refused insulin because resident states no, I'm tired. A review of the facility's Management of [CONDITION(S)] Policy, last revised November 2020 revealed the following: -Symptoms of [CONDITION(S)] -1. Signs and symptoms of [CONDITION(S)] usually have a sudden onset and may include the following: -a. Weakness, dizziness, or faintness; -b. Restlessness and/or muscle twitching; -c. [CONDITION(S)] (increased heart rate); -d. Pale, cool, moist skin; -e. Excessive perspiration; -f. Irritability or bizarre changes in behavior; -g. Blurred or impaired vision; -h. Headaches; -i. Numbness of the tongue and lips/thick speech; -j. (More severe) stupor, unconsciousness and/or convulsions; and -k. (More severe) coma. -Management of [CONDITION(S)] 1. Classification of [CONDITION(S)] -a. Level 1 [CONDITION(S)]: blood glucose <70 mg/dL (milligrams/deciliters) but >54 mg/dL -b. Level 2 [CONDITION(S)]: blood glucose is <54 mg/dL; and -c. Level 3 [CONDITION(S)]: altered mental and/or physical status requiring assistance for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . -2. For Level 1 [CONDITION(S)] (<70 mg/dL) -a. Give the resident an oral form of rapidly absorbed glucose (15 - 20 grams); -b. Notify the provider immediately; -c. Remain with the resident; -d. Recheck blood glucose in 15 minutes: -(1) If blood glucose is within established reference range, provide the resident with a meal or a snack; (2) If blood glucose is greater than established reference range (rebound [CONDITION(S)]) administer diabetic medications as ordered; or (3) If blood sugar remains <70 mg/dL repeat oral glucose and notify physician for further orders. -3. For Level 2 [CONDITION(S)] (<54 mg/dL): -a. Administer [MEDICATION(S)] (intranasal, intramuscular, or as provided); -b. Notify the provider immediately; -c. Remain with the resident; -d. Place resident in a comfortable and safe place (bed or chair); -e. Monitor vital signs; and -f. Recheck blood glucose in 15 minutes (as above). -Documentation -1. Document the resident's blood glucose before intervention. -2. Note blood sugar after each administration of rapid acting glucose and the follow-up blood sugar. -3. Record the resident's level of consciousness before and after intervention. -4. Document the provider instructions. A review of Resident 2's July 2022 MAR (Medication Administration Record) revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] Kit 1mg (an injectable medication used to quickly treat very low blood sugar) - inject 1 mL (milliliter) IM (intramuscularly - into the muscle) as needed for [CONDITION(S)]. Further review of Resident 2's July 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's medical record did not reveal any blood glucose results for Resident 2 from 7/8/22 at 7:51 PM when blood glucose was 50 until the following morning on 7/9/22 at 7:27 AM when blood glucose was 77. In an interview on 7/27/22 at 12:44 PM, the DON (Director of Nursing) reported the expectation was that staff follow the facility's [CONDITION(S)] protocol. The DON confirmed Resident 2 did not receive a [MEDICATION(S)] injection as ordered and outlined in the [CONDITION(S)] protocol and there were no follow-up blood glucose checks done after Resident 2's blood glucose was 50 on 7/8/22 at 7:51 PM.

Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on interview and record review, the facility failed to notify the provider of changes in condition for 1 (Resident 2) of 5 sampled residents. The facility had a total census of 207 residents. The findings are: A. A review of Resident 2's progress notes revealed the following: -7/15/22 at 4:58 PM - Resident returned to facility (from hospital) with the following skin areas- .open area to pannus (refers to the fatty tissue that hangs over the abdomen) 8 x 7.1 cm (centimeters) . -7/24/22 at 2:04 PM - Resident wound to right abdominal fold noted to have slough (dead tissue) and odor. Cleansed and dressed with dry dressing per facility protocol. MD (Physician) notified for wound care orders. -7/25/22 at 12:46 PM - Hospital called at 12:30 PM and updated that (Resident 2) was being admitted for [CONDITION(S)]. -7/27/22 at 8:23 AM - Discharge Note: Resident passed in hospital on 7/26 at 10am. A review of a Transfer Form dated 7/25/22 at 9:21 AM for Resident 2 revealed Resident 2 was transferred to a local hospital via ambulance for a decline in condition. A review of Resident 2's July 2022 TAR (Treatment Administration Record) revealed the following order: -Right Pannus: Three times weekly - 1. Cleanse with [MEDICATION(S)] (a topical antiseptic solution, used to prevent skin infections); 2. Apply [MEDICATION(S)] (used in wound care to help remove dead tissue and encourage development of healthy tissue) to open areas; 3. Cover with [MEDICATION(S)] (a soft, foam dressing used to seal wound edges to prevent leakage and protect wound). Scheduled for Monday, Wednesday, and Friday weekly. A review of Resident 2's electronic medical record revealed no documented assessments of a wound to Resident 2's pannus or abdomen. A review of Resident 2's medical record, which included the paper and electronic records, did not reveal any documentation of an update to Resident 2's physician on 7/24/22 or a response or new orders from Resident 2's physician on 7/24/22. In an interview on 7/27/22 at 12:44 PM, the DON (Director of Nursing) confirmed no documentation could be located with the information given to Resident 2's physician or a response from Resident 2's physician on 7/24/22 regarding the slough and odor to Resident 2's abdominal wound. The DON also confirmed no wound assessments were being completed for Resident 2's pannus (abdominal) wound, so there was no way to know what the wound bed looked like or if there was an odor present prior to 7/24/22. -B. A review of Resident 2's blood glucose records revealed the following documented blood glucose checks on 7/8/22 and 7/9/22: -7/8/22 at 7:29 AM - 77 -7/8/22 at 7:43 AM - 77 -7/8/22 at 11:28 AM - 70 -7/8/22 at 11:36 AM - 70 -7/8/22 at 7:51 PM - 50 -7/9/22 at 7:27 AM - 77 A review of Resident 2's progress notes revealed the following: -7/8/22 at 5:14 PM - Resident is lethargic, needs orientation to time. Family was here this morning and is aware of condition. All vital signs within defined limits, will continue to monitor every 15 minutes. -7/8/22 at 7:53 PM - Resident still lethargic b/g (blood glucose) 50: held insulin and provided snack. Will continue Q (every) 15 minute rounds and recheck b/g at 2200 (10:00 PM). -7/8/22 at 9:04 PM - Resident at baseline mood/comfort, tolerated snacks well but refused insulin because resident states no, I'm tired. Further review of Resident 2's progress notes did not reveal any documentation that Resident 2's physician was updated regarding Resident 2's low blood glucose and lethargy. A review of the facility's Management of [CONDITION(S)] Policy, last revised November 2020 revealed the following: -Symptoms of [CONDITION(S)] -1. Signs and symptoms of [CONDITION(S)] usually have a sudden onset and may include the following: -a. Weakness, dizziness, or faintness; -b. Restlessness and/or muscle twitching; -c. [CONDITION(S)] (increased heart rate); -d. Pale, cool, moist skin; -e. Excessive perspiration; -f. Irritability or bizarre changes in behavior; -g. Blurred or impaired vision; -h. Headaches; -i. Numbness of the tongue and lips/thick speech; -j. (More severe) stupor, unconsciousness and/or convulsions; and -k. (More severe) coma. -Management of [CONDITION(S)] 1. Classification of [CONDITION(S)] -a. Level 1 [CONDITION(S)]: blood glucose <70 mg/dL (milligrams/deciliters) but >54 mg/dL -b. Level 2 [CONDITION(S)]: blood glucose is <54 mg/dL; and -c. Level 3 [CONDITION(S)]: altered mental and/or physical status requiring assistance for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . -2. For Level 1 [CONDITION(S)] (<70 mg/dL) -a. Give the resident an oral form of rapidly absorbed glucose (15 - 20 grams); -b. Notify the provider immediately; -c. Remain with the resident; -d. Recheck blood glucose in 15 minutes: -(1) If blood glucose is within established reference range, provide the resident with a meal or a snack; (2) If blood glucose is greater than established reference range (rebound [CONDITION(S)]) administer diabetic medications as ordered; or (3) If blood sugar remains <70 mg/dL repeat oral glucose and notify physician for further orders. -3. For Level 2 [CONDITION(S)] (<54 mg/dL): -a. Administer [MEDICATION(S)] (intranasal, intramuscular, or as provided); -b. Notify the provider immediately; -c. Remain with the resident; -d. Place resident in a comfortable and safe place (bed or chair); -e. Monitor vital signs; and -f. Recheck blood glucose in 15 minutes (as above). -Documentation -1. Document the resident's blood glucose before intervention. -2. Note blood sugar after each administration of rapid acting glucose and the follow-up blood sugar. -3. Record the resident's level of consciousness before and after intervention. -4. Document the provider instructions. In an interview on 7/27/22 at 12:44 PM, the DON (Director of Nursing) reported the expectation was that staff follow the facility's [CONDITION(S)] protocol. The DON confirmed Resident 2's provider was not notified of Resident 2's low blood glucose on 7/8/22.

Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review, observation, and interviews, the facility failed to notify the physician of change of condition for 1 of 36 sampled residents, Resident 76 related to recurrent episodes of epistaxis (nose bleeds) resulting in transfer to the ER for treatment . The facility census was 208. Findings are: Resident #74 Notification of Change An observation on 02/18/20 at 01:43 PM revealed Resident 76 to be sitting up in wheelchair with nose bleed occurring, call light was on due resident needing more washcloths. MA-M (Medication Aide) brought more washcloths, MA-M leaned head out of door and stated you know they have a nose bleed right? LPN-K (Licensed Practical Nurse), answered yes. Nurse did not come in to assess Resident 76 at that time. Resident stated this was 3rd nose bleed of the day. Resident 76 was noted to wear oxygen continuously at 4 l/m, (liters per minute) with no humidity (provides moisture to nasal cavity). A record review of medications revealed Resident 76 taking Xeralto ( medication which thins the blood and reduces the risk of blood clots forming). A record review on 02/19/20 of Resident 76's Progress Notes for 02/18/2020 revealed no assessment documentation in place regarding nose bleeds and no documentation of physician notification. An observation on 02/19/20 at 11:58 AM revealed Resident 76 to be lying in bed with washcloth to face due to another epistaxis episode. LPN-K entered room and informed Resident 76 of plan to get a fax out to MD today. An interview on 02/19/20 at 02:10 PM with LPN-K, revealed that this nurse was Medication Nurse on 02/18/2020 7-3 shift, and confirmed they were aware of nose bleeds on 02/18/2020. Record review of Resident 76's Progress Notes dated 02/19/2020 as follows: 02/19/2020 03:28 PM Humidifier added to oxygen concentrator at this time 02/19/2020 05:41 PM Resident has two nose bleeds today. Water added to 02. Fax out for an order for [REDACTED].>Record review of policy dated (MONTH) (YEAR) for Change in a Resident's Condition or Status indicated that the facility shall promptly notify the Attending Physician or on call physician when there has been c. A reaction to a medication and d. a significant change in the resident's physical condition. A record review of Resident 76's Progress Notes for evening of 02/19/2020 are as follows: 02/20/2020 02:56 AM Patient continued to have bloody noses this evening starting around 07:00 PM, attempts to stop the bleeding were successful at times by applying pressure and ice to nose, but resident would later break the clot by picking their nose. At 07:40 PM, resident nose began to bleed again and pressure and ice were ineffective. At 10:00 PM, house supervisor notified and informed nurse to call PCP (Primary Care Physician), call placed to PCP at 10:07 PM and spoke to NP (Nurse Practioner) who was on call and was given a T.O (telephone order) to send to ER (emergency room ) for evaluation. 10:16 PM, resident's son and POA (Power of Attorney) called and informed of the change of condition and pending transportation to ER. No complaints were voiced. 11:36 PM, Midwest transportation arrived at building and began to evaluate patient. 11:51 PM, patient was being transported to Bryan West ER. 11:52 PM, call placed to Bryan West ER and spoke to RN (registered nurse) and report was given. 02/20/20 07:14 AM for 02/20/2020 03:16 AM Patient returned from Bryan West with no new orders and nose packed with gauze, Vitals 140/84, 66, 97.6, 92% 4L, 16. An interview on 02/20/20 at 07:45 AM with UM-D (Unit Manager) and DON (Director of Nursing) confirmed resident being sent to ER last evening as they could not get nosebleed to stop. UM-D indicates resident returned with no new orders and resident instructed to stop picking their nose. An interview on 02/24/20 at 10:45 AM, with DON confirmed that there was not prompt notification to physician in regards to nose bleeds that occurred on 02/18/20 for Resident 76. Physician was notified on 02/19/20 by fax. An interview on 02/24/20 at 11:30 AM, with UM-D confirmed that the physician was not notified of nose bleeds for over 24 hours.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observation, interview, and record review; the facility failed to ensure that one resident (Resident 276) received the care and services to alleviate the resident's dental pain from a resident sample size of 47. The facility census was 219. Findings are: Review of Resident 276's History and Physical dated 4/11/12 revealed that the resident had a [DIAGNOSES REDACTED]. Review of Resident 276's Significant Change MDS (Minimum Data Set: a federally mandated comprehensive tool used for care planning) dated 10/1/12 revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 14 (cognitively intact). The resident had a mood score of 3 and did not display behaviors. The resident required extensive to total assistance with bed mobility, transfers, toilet use, dressing, and personal hygiene. The resident was non-ambulatory and had impaired balance. The resident had constant pain rated at a six. The resident was on antipsychotic, antidepressant, and anticoagulant medications. Review of Resident 276's Quarterly MDS dated [DATE] revealed that the resident had a BIMS score of 15 (cognitively intact). The resident had a mood score of 10. The resident had [MEDICAL CONDITION] and was verbally abusive one to three days out of seven. The resident had occasional pain rated at a three. Review of Resident 276's Pain assessment dated [DATE] revealed that the resident's pain was described as: aching, sharp, nagging, tingling in the resident's left shoulder, left hip and teeth. The resident rated the pain as a five. The resident's pain was worse in the morning. The pain was helped with [MEDICATION NAME]/ APAP (narcotic pain medication) 5/325 mg (milligrams) 1 to 2 tablets every 4 hours prn (as needed) for pain and [MEDICATION NAME] (medication to treat nerve pain) 150 mg three times daily, repositioning, decreasing activity. The resident's pain did cause [MEDICAL CONDITION] and difficulty to concentrate. Review of Resident 276's Care Plan dated 1/25/13 revealed that the resident had pain related to left [MEDICAL CONDITION], decreased mobility, use of a sit to stand lift. The resident went to a pain clinic on 11/1/12 and was diagnosed with [REDACTED]. The resident's care plan goal was to not any voiced daily pain above tolerable pain level of three. Care plan interventions included: pain assessment quarterly and as needed, sit to stand lift, pain clinic prn, direct care staff to report pain prn, resident to rate pain, monitor for non-verbal signs and symptoms of pain and offer non-pharmacological interventions for pain. Review of Resident 276's February MAR (Medication Administration Record) revealed: -The resident took [MEDICATION NAME] 10 mg twice daily for pain. The resident's [MEDICATION NAME] was increased to 15 mg twice daily on 2/20/13. -The resident had an order for [REDACTED]. -The resident had an order for [REDACTED]. -The resident took 2 [MEDICATION NAME] 7.5/500 mg tablets for mouth or tooth pain on 2/1/13 rated as a 6, 2/6/13 rated as 7, 2/8/13 rated as twice, 2/11/13 rated as an 8, 2/12/13, 2/14/13, 2/19/13 rated as an 8, 2/21/13, 2/24/13, and 2/25/13. Review of Resident 276's March MAR indicated [REDACTED] -The resident's [MEDICATION NAME] was increased to 15 mg twice daily. The resident's [MEDICATION NAME] remained 15 mg in the morning and increased to 30 mg in the evening. -The resident had an order for [REDACTED]. -The resident took 2 [MEDICATION NAME] 5/325 mg tablets for mouth or tooth pain on 3/3/13 twice rated as 7, 3/4/13 rated as a 7, 3/6/13, 3/8/13, 3/9/13, 3/10/13, 3/12/12 twice, 3/14/13 rated as a 9, 3/17/13 rated as a 9, 3/20/13 rated as an 8, 3/21/13 rated as a 7. Interview with Resident 276 on 3/18/13 at 10:16 am revealed that the resident was having mouth pain that did not go away. The resident stated that dental work was going to be down the following day to alleviate some pain. Interview with Resident 276 on 3/20/13 at 3 pm stated that the resident was very angry that dental procedure could not be done yesterday due to the fact the resident had eaten. Review of Resident 276's Physician order [REDACTED]. The resident's [MEDICATION NAME] (blood thinner) was to be held 3/14/13 and to be restarted on 3/19/13 after the procedure. The resident was given [MEDICATION NAME] (blood thinner) by injection 60 mg daily in the morning 3/15/13 - 3/18/13. Interview with RN (Registered Nurse) A on 3/20/13 at 3:35 pm revealed that the resident's dental work was not done on 3/19/13 due to the resident not being NPO. The RN stated that the appointment was rescheduled. Review of Resident 276's Progress Notes on 3/19/13 revealed: -On 3/19/13 at 12:27 pm revealed that a message was left with the dental college that the resident was not NPO. -At 3:14 pm rescheduled dental appointment. The earliest that the resident could get in was 4/22/13 at 1 pm. Interview with Resident 276 on 3/21/13 at 12:45 pm revealed that the resident was still having pain and was having difficulty eating. The resident stated that the resident could not even eat a ripe banana today. Interview on 3/21/13 at 12:30 pm with the DON (Director of Nursing) revealed that when the order was received on 3/8/13 for the NPO after midnight order, the resident's appointment had not been scheduled yet. The resident's NPO status was placed in the wrong place. The facility had undergone changes in the appointment scheduling and it was missed.