Every finding on record at Emerald Nursing & Rehab Legacy Pointe llc

Licensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview; the facility failed to ensure medication was given per physician orders for 3 (Residents 1, 2, and 4) of 5 residents sampled. The facility identified a census of 60. The findings are:A. Record review of Residents 2's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing staff identify health problems) dated 5-7-26 identified the facility admitted the resident on 5-10-26 with the diagnoses of paraplegia (partial or complete paralysis of the lower half of the body with involvement of both legs that is usually due to injury or disease of the spinal cord in the thoracic or lumbar region), renal insufficiency (poor kidney function), orthostatic hypotension (a sudden drop in blood pressure that happens when you stand up from a sitting or lying position), neurogenic bladder (a lack of bladder control caused by damage to the brain, spinal cord, or nerves), and depression. Further review revealed the resident had a Brief Interview for Mental Status (BIMs, a screen that aids in detecting cognitive impairment) of 12. According to the MDS manual a score of 8-12 indicated moderately impaired cognition.Record review of Resident 2's Order Summary Report dated 8-12-26 revealed an order dated 5-5-26 for blood pressure (B/P) QID (four times daily) and if systolic blood pressure (SBP the top number in a blood pressure reading) < (less than) 120 give PRN (pro re nata, a Latin phrase meaning as needed or as the situation demands) midodrine (a medication used to treat low blood pressure) four time a day.Record review of Resident 2's Order Summary Report dated 8-12-26 revealed an order dated 5-4-26 for midodrine 5mg 1 tablet by mouth three times daily as needed for SBP less than 120 with instructions to not give at bedtime for low blood pressure. Record review of Resident 2's Medication Administration Record (MAR) for June of 2026, revealed Resident 2's SBP was less than 120 and the medication midodrine had not been given according to the physician orders 19 times between 6-2-26 and 6-28-26.Record review of Resident 2's MAR for July 2026, revealed Resident 2's SBP was less than 120 and the medication midodrine had not been given according to physician orders 16 times between 7-1-26 and 7-31-26.Record review of resident 2's MAR for August 2026, revealed Resident 2's SBP was less than 120 and the medication midodrine had not been given according to physician orders 4 times between 8-1-26 and 8-10-26.Record review of Resident 2's Order Summary Report dated 8-12-26 revealed an order dated 6/17/26 for clonidine tab (a medication to lower high blood pressure) 0.1 mg take 1 tablet by mouth twice daily as needed for systolic blood pressure (SBP, the top number in a blood pressure reading) greater than 160 for hypertension.Record review of Resident 2's MAR for July 2026, revealed Resident 2's SBP was greater than 160 and the medication clonidine had not been given according to physician orders on 6 occasions between 7-1-26 and 7-31-26.In an interview with the DON and the Administrator on 8/11/26 at 1:45 PM it was confirmed the midodrine and clonidine medications were not given per prescriber orders. B.Record review of Residents 1's admission MDS dated [DATE] identified the facility admitted the resident on 6-8-26 with diagnoses of paraplegia, anemia (a condition where blood lacks enough healthy red blood cells or hemoglobin to carry adequate oxygen to the body's tissues), osteomyelitis of vertebra (bone infection), depression, orthostatic hypotension, neurogenic bladder and diabetes mellitus. Further review revealed the resident had a BIMs of 14 which according to the MDS manual a score of 13-14 indicates intact cognition.Record review of Resident 1's Order Summary Report dated 8-10-26 revealed an order dated 6/10/26 for midodrine tab 10 mg take 1 tablet by mouth three times daily with meals. Instructions were provided to hold if SBP is greater than 110 and do not give at bedtime. Record review of Resident 1's MAR for June 2026, revealed Resident 1's SBP was less than 120 and the medication midodrine had not been given according to the physician orders 13 times between 6-11-26 and 6-28-26.Record review of Resident 1's MAR for July 2026, revealed Resident 1's SBP was less than 120 and the medication midodrine had not been given according to physician orders 5 times between 7-1-26 and 7-31-26.Record review of Resident 1's MAR for August 2026, revealed Resident 1's SBP was less than 120 and the medication midodrine had not been given according to physician orders 2 times between 8-1-26 and 8-10-26.In an interview with the Director of Nursing (DON) and the Administrator on 8/11/26 at 1:45 PM it was confirmed the midodrine was not given per prescriber orders. C.Record review of Residents 4's admission MDS dated [DATE] identified the facility admitted the resident on 6-12-26 with the diagnoses of quadriplegia (one affected with partial or complete paralysis of both the arms and legs especially as a result of spinal cord injury or disease in the region of the neck), orthostatic hypotension, neurogenic bladder, anxiety disorder, depression, dislocation and subluxation of C4/C5 cervical vertebrae. Further review revealed the resident had a BIMs of 15. According to the MDS manual a score of 13-14 indicated intact cognition.Record review of Resident 4's Order Summary Report dated 8-10-26 revealed an order dated 6-17-26 for midodrine tab 5mg take 1 tablet by mouth three times daily. Instructions were provided to hold for SBP greater than 110 and do not give at bedtime, for orthostatic hypotension.Record review of Resident 4's MAR for June 2026, revealed Resident 4's SBP was less than 120 and the medication midodrine had not been given according to the physician orders 12 times between 6-11-26 and 6-28-26.Record review of Resident 4's MAR for July 2026, revealed Resident 4's SBP was less than 120 and the medication midodrine had not been given according to physician orders 33 times between 7-1-26 and 7-31-26.Record review of Resident 4's MAR for August 2026, revealed Resident 4's SBP was less than 120 and the medication midodrine had not been given according to physician orders 7 times between 8-1-26 and 8-10-26.In an interview with the Director of Nursing (DON) and the Administrator on 8/11/26 at 1:45 PM it was confirmed the midodrine was not given per prescriber orders.

Licensure Reference Number 175 NAC 12-006.09(I) and 12-006.09(I)(i)(1,2,3 and 4). Based on observation, record reviews and interviews; the facility failed to ensure residents that were identified as an elopement risk were supervised when leaving the facility for 1 (Resident 1) of 3 residents sampled, failed to ensure prompt follow-up after a resident's whereabouts were unknown for 1 (Resident 2) of 3 residents sampled, failed to identify and implement interventions to prevent elopements and falls and failed to monitor for neurological changes after unwitnessed falls or falls with head injuries for 1 (Resident 1) of 3 residents on sample. The facility staff identified a census of 65.The facility Administrator (ADM) was notified on 6/8/26 at 5:25 PM of an Immediate Jeopardy (IJ) which began on 6/8/26. The IJ was removed on 6/8/26, as confirmed by surveyor onsite verification. The findings are: A. Record review of the facility's policy titled Elopement, Risk reduction strategies and management of missing residents and wandering missing residents dated 01-2024 revealed the facility maintains a process to assess all residents for risk of elopement, implement measures for resident identification at the time of admission, and conduct a coordinated resident search in the event of a missing resident. The policy defines elopement as the ability of a cognitively impaired resident, who in not capable of protecting themselves, to successfully leave the facility unsupervised and unnoticed, potentially coming to harm. Under the section titled Assessment revealed the facility preadmission process referral process includes wandering and elopement history, and whether the resident can be safely cared for at the facility. An elopement risk data collection is completed by the nursing staff on all residents at admission, readmission, quarterly and after an elopement event. The initial resident assessment is conducted at admission if possible and no later than 8 hours after admission. The risk data collection addresses the resident's mobility, psychological, behavioral, physical, and cognitive functions. Specific risk factors included: -an involuntary admission. -a history of wandering prior to admission or details of the wandering history such as when wandering is most common, or activities that trigger exit seeking. -problems noted in the resident's adjustment to the facility. -any cognitive impairment which results in an inability of the resident to appreciate safety risks and an inability to protect himself or herself. -a change in the resident's mental status -interference with risk reduction strategies, including an expressed displeasure with an electronic monitoring bracelet or an attempt to remove it. -behavior problems, including those where the resident is not easily redirected or managed when he or she is agitated or aggressive. Further review of the policy revealed under section Risk Reduction Measures revealed interventions that may be used for residents identified at high risk for elopement include: -frequent observation of the resident's whereabouts to assure he or she remains in the facility. -room placement close to common areas such as the nurse's station and away from exits. -promoting activities that are in full view of staff members -alternative activities to maintain the interest level of the wanderer. -implementation of a wander bracelet -transfer to a more suitable or more secured facility if necessary -notification of physician for changes in behavior, such as increased insistence or attempts to leave. -environmental controls such as functional alarm system for egresses and stairwells, interior courtyards, restricted window openings to six inches to allow ventilation but prevent resident exit and fenced perimeters, additional resident and family involvement and education. A sign-in-and-out system is implemented, which requires responsible parties to sign the resident out when leaving and note an expected return time. B.Record review of the facility policy titled Fall Management dated 01-2024 revealed a risk reduction, falls and injury program will be used to assess residents/patients to determine fall risk factors. The interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Under the section procedure revealed: - the staff are to assess and review resident risk factors for falls and injuries upon admission, quarterly, with a significant change or after a fall. -implement goals and interventions with the resident/family for inclusion in the interdisciplinary plan of care based on individual needs. -communicate interventions to the care giving teams. -provide training to staff as needed and document. -review and revise the interdisciplinary plan of care at subsequent care plan meetings -educate resident and family as indicated. In the event the resident has fallen and/or is found on the ground, a complete head-to-toe assessment must be performed prior to moving the resident unless life-threatening safety concerns are present. Upon arrival of the nurse, a quick head-to-toe scan will be performed without unnecessary movement, palpating and examining all areas for breaks in the skin and/or other abnormal findings. Obtain neurological checks (Neuro Checks) per policy for any unwitnessed fall or any fall with evidence of injury to the head. C.Record review of the facility's policy titled Accidents/Neuro Checks dated 01-2024 revealed the purpose of this procedure is to provide guidelines for a neurological assessment. Neurological assessments are indicated: -upon physician order -following an unwitnessed fall -following a fall or other accident/injury involving head trauma - when indicated by resident's condition. When assessing neurological status always include frequent vital signs. Particular attention should be paid to widening pulse pressure (the difference between the top and bottom blood pressure numbers), this may be indicative of increasing intracranial pressure. Any change in vital signs or neurological status in a previously stable resident should be reported to the physician immediately. D. Record review of Resident 1's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 02-17-2026 revealed the facility staff assessed the following about the resident: -admitted to the facility on [DATE]. -Brief Interview of Mental Status (BIMS) was scored as an 8. According to the MDS Manual a score of 8 to 12 indicates moderate cognitive impairment. -had diagnosis of malnutrition, seizure disorder, depression and anxiety disorder. -had a history of falls -had delusions (a fixed, false belief not shared by others that the resident holds even in the face of evidence to the contrary). -had fluctuating inattention (reduced ability to maintain attention to external stimuli and to appropriately shift attention to new external stimuli. A person seems unaware or out of touch with the environment) -had fluctuating disorganized thinking (evidenced by rambling, irrelevant, or incoherent speech). -required set-up or clean up assistance with eating and dressing. -required supervision or touching assistance with toileting, personal hygiene and toilet transfers. -required supervision or touching assistance with ambulation of 10 to 150 feet, and on uneven surfaces up to 10 feet and when bending over to pick up objects. -required the use of a walker (mobility device). Record review of Resident 1's Nursing admission Data Collection (NADC) dated 02-11-2026 under the section Elopement/Wandering Risk revealed Resident 1 had a history of exit seeking, wandering away or getting lost and had a pertinent diagnosis of anxiety disorder and was capable of independent mobility. Further review of the NADC revealed Resident 1 was a potential elopement risk and directed the staff to initiate elopement risk interventions and document on the care plan. Record review of Resident 1's Comprehensive Care Plan (CCP) printed on 06-08-2026 revealed no interventions for Resident 1's risk for elopement. Record review of the facility's Release of Responsibility for Leave of Absence Sheet (RRLAS) with a date of 02-16-2026 at the top of page revealed Resident 1 signed out of the facility without supervision 234 times between the dates of 02-16-2026 and 05-19-2026. Record review of Resident 1's Progress Notes (PN) dated 03-25-2026 at 12:43 AM revealed a staff member had brought Resident 1 from the parking lot into the facility and stated Resident 1 fell in the parking lot. Further review of the progress notes revealed Resident 1 reported having hit (gender) head. Record review of Resident 1's PN dated 03-25-2026 at 11:06 AM revealed Resident 1 was outside of the facility and noted to be on the ground with a trickle of blood running down the face. Resident 1 was sent to the emergency room (ER) for treatment. Record review of Resident 1's PN dated 03-25-2026 at 4:18 PM revealed Resident 1 returned from the hospital with an update that Resident 1 refused treatment. Record review of Resident 1's CCP revealed no additional interventions were added to prevent further elopements or injuries from falls dated 03-25-2026. Record review of Resident 1's PN dated 04-10-2026 revealed a staff member was driving from the facility and noted Resident 1 was lying on the ground with blood to the side of the head. Resident 1 was sent to the ER for treatment. Record review of Resident 1's PN dated 04-10-2026 at 9:41 PM revealed Resident 1 had returned from the hospital with an abrasion to the left outer eyebrow. Record review of Resident 1's RRLAS dated 04-10-2026 revealed Resident 1 had signed out at 1:55 PM. Record review of Resident 1's CCP revealed no additional interventions were added to prevent further elopements or injuries from falls dated 04-10-2026. Record review of Resident 1's PN dated 05-19-2026 revealed Resident 1 was lying on the ground in the parking lot with a significant amount of blood effusing from the scalp. Resident 1 was sent to the ER. Record review of Resident 1's Emergency Department Notes dated 05-19-2026 revealed Resident 1 had a head Computed Tomography (CT: an advanced imaging test that combines X-rays with computer processing to create detailed, cross-sectional slices of your bones, organs, and soft tissues) with the following findings: -Subdural hematoma on the right side with subarachnoid hemorrhage and midline shift. -scattered small volume subarachnoid hemorrhage -suspected subdural hemorrhage along the left posterior occipital convexity. -mild hypoattenuation along the temporal, parietal, and occipital lobes suspicious of parenchymal hemorrhage. -mass effect results in a right to left midline shift at the septum pellucidum. -prominent hematoma along the right posterior scalp. Record review of Resident 1's PN dated 05-22-2026 revealed Resident 1 returned from the hospital. Record review of Resident 1's PN dated 05-23-2026 at about 2:20 AM revealed Resident 1 left the facility. Record review of Resident 1's PN dated 05-23-2026 at 7:45 AM revealed Resident 1 was found lying on the street, unable to get up and had hit the head. Resident 1 was sent to the ER for treatment. Record review of Resident 1's RRLAS revealed Resident 1 signed out of the facility on 05-23-2026 at 2:20 AM and returned at 3:40 AM. Further review of the RRLAS revealed Resident 1 also signed out of the facility at 10:00 AM on 05-23-2026. Record review of Resident 1's PN dated 05-24-2026 revealed Resident 1 returned from the hospital. Record review of Resident 1's CCP revealed no additional interventions to prevent further elopements or injuries from falls for 05-23-2026. Record review of Resident 1's PN dated 05-31-2026 revealed at 10:00PM the night before a staff member found Resident 1 on the ground behind their car in the parking lot. Record review of Resident 1's RRLAS revealed no documentation Resident 1 had signed out on 05-30-2026 or 05-31-2026. Record review of Resident 1's PN dated 06-01-2026 revealed Resident 1 had fallen in the road and Resident 1 stated I hit my head and I'm hurt. Resident 1 was sent to the ER for treatment. Record review of Resident 1's RRLAS dated 06-01-2026 revealed Resident 1 had signed out and the time of the sign out was illegible. An interview conducted with the facility Administrator (ADM) on 06-08-2026 at 11:47 AM confirmed residents leaving the facility were to sign out on the RRLAS and for residents with a low BIMS score the Power of Attorney (POA) or guardian would have to sign the resident out. An interview conducted with the Director of Nursing (DON) on 06-08-2026 at 4:15 PM confirmed Resident 1 was identified on admission as a potential elopement risk, Resident 1's BIMS on admission was scored as an 8, a care plan for elopement was not implemented and confirmed Resident 1 had been signing out of the facility without supervision. E. Record review of the facility's accident log printed on 06-08-2026 revealed Resident 1 had: -an unwitnessed fall on 04-05-2026, -2 unwitnessed falls on 05-19-2026, -witnessed fall on 05-02-2026. Record review of Resident 1's Progress Notes (PN) revealed from 02-11-2026 to 05-19-2026 Resident 1 had: -an unwitnessed fall on 02-27-2026, -2 unwitnessed falls on 03-25-2026, -an unwitnessed fall 03-26-2026, -an unwitnessed fall on 04-05-2026, -an unwitnessed fall on 04-10-2026. Record review of Resident 1's CCP dated 02-11-2026 revealed Resident 1 was at risk for falls related to diagnosis of convulsions and high-risk medications and a history of falls prior to admission. The goal was Resident 1 would not sustain serious injury through the review date. Interventions listed were: -Physical and Occupational Therapy to evaluate and treat if indicated dated 02-20-2026. -education to ask staff for assistance dated 02-27-2026 -gripper strips placed in room next to the bed dated 04-05-2026. -walker replaced 05-02-2026. -placed in bed, education to not ambulate on (gender) own dated 05-19-2026. -sent to emergency room (ER), will evaluate interventions upon return dated 05-19-2026. -encourage resident to abstain from drinking alcohol for fall on 05-19-2026 dated 05-23-2026. Further review of the CCP revealed no new interventions for the falls on 03-25-2026, 03-26-2026, and 04-10-2026. Record review of Resident 1's Electronic Medical Record (EMR) revealed neurological checks for the following unwitnessed falls: -02-27-2026 no neurological checks present in the EMR. -03-25-2026 at 12:43 AM no neurological checks present in the EMR. -03-25-2026 at 11:06 AM sent to the ER for treatment. -03-26-2025 neurological checks were incomplete. -04-05-2026 neurological checks were incomplete. Record review of Resident 1's PN dated 05-19-2026 at 12:57 PM revealed Resident 1was observed by the ADM sitting on buttocks in the front door corridor area. Resident said Yes I hit my head on the door. Resident 1 was assisted to the room on a wheeled walker as the resident was unsteady to ambulate to the room. Resident 1 was left in room with call light in reach. Record review of Resident 1's neurological checks dated 05-19-2026 revealed Resident 1 was outside, and neurological checks were not done on 05-19-2026 at 2:00 PM, 4:30 PM, 5:30 PM, and the section for 6:30 PM was left blank. Record review of Resident 1's PN dated 05-19-2026 at 7:35 PM revealed Resident 1 was lying on his back in the parking lot, with a significant amount of blood effusing from the scalp. Resident 1 was sent to the ER for treatment. Record review of Resident 1's Emergency Department Notes dated 05-19-2026 revealed Resident 1 had a head Computed Tomography (CT: an advanced imaging test that combines X-rays with computer processing to create detailed, cross-sectional slices of your bones, organs, and soft tissues) with the following findings: -Subdural hematoma (a life-threatening type of bleeding where blood collects between the brain and the dura mater, its outermost protective layer) on the right side with subarachnoid hemorrhage and midline shift. -scattered small volume subarachnoid hemorrhage -suspected subdural hemorrhage along the left posterior occipital convexity. -mild hypoattenuation along the temporal, parietal, and occipital lobes suspicious of parenchymal hemorrhage. -mass effect results in a right to left midline shift at the septum pellucidum. -prominent hematoma along the right posterior scalp. Record review of Resident 1's PN dated 05-22-2026 revealed Resident 1 had readmitted to the facility. Record review of Resident 1's PN dated 05-23-2026 revealed at 2:20 AM Resident 1 left the facility. Record review of Resident 1's PN dated 05-23-2026 at 7:45 AM Resident 1 was found lying on the street, unable to get up and had hit the head. Resident 1 was sent to the ER for treatment. Record review of Resident 1's PN dated 05-24-2026 revealed Resident 1 was readmitted to the facility. Record review of Resident 1's PN dated 05-31-2026 revealed at 10:00PM the night before a staff member found Resident 1 on the ground behind their car in the parking lot. Record review of Resident 1's PN dated 06-01-2026 revealed Resident 1 had fallen in the road and couldn't get up. Resident 1 stated I hit my head and I'm hurt, Resident 1 was sent to the ER for treatment. Record review of Resident 1's Trauma Surgery History and Physical dated 06-02-2026 revealed Resident 1 had been evaluated and found to have a large Subdural Hematoma with a mass effect of 6 millimeters of right to left midline shift. Record review of Resident 1's CCP printed on 06-08-2026 revealed no new interventions for the falls on 05-23-2026, 05-31-2026 and 06-01-2026. An interview conducted with the ADM on 06-09-2026 at 3:20 PM confirmed when Resident 1 fell on [DATE] at 12:45 PM the facility did not implement an intervention to prevent further falls other than assisting the resident into bed, and Resident 1 fell again later that day and sustained a brain hemorrhage. An interview with the DON on 06-09-2026 confirmed neurological checks were incomplete or not conducted for all of Resident 1's unwitnessed falls and confirmed not all of Resident 1's falls were investigated for causal factors with new interventions implemented. The facility was informed to the Immediate Jeopardy status on 06/08/26. The facility abatement plan was implemented on 06-08-26. The specific requirements that were violated were F689 and 175 NAC 12-006.09(I) and 12-006.09 (I)(i) for failure to ensure prompt follow up when a missing person was identified and for failure to ensure adequate supervision for residents identified as a potential elopement risk and residents identified as cognitively impaired. The facility implemented the following actions on 06-08-26 to remove the immediacy of the situation and to protect the residents: -the facility posted a sign at the front desk for residents to go to the [NAME] Side Nurses Station to sign out. -Residents with a BIMS score of 12 or more will be allowed to continue to sign out and go out of the facility unassisted. -Residents in the Secure Dementia Unit will not be allowed to sign out and leave the facility unassisted. -Current facility residents who leave the unassisted had an Elopement Risk Assessment (ERA) reviewed and Care Plans were reviewed and updated and interventions were implemented as appropriate. -The Clinical Interdisciplinary Team (CIT) will review new admit's ERA and the Care Plan during the Daily Clinical Meeting to ensure the ERA had been completed accurately and the Care Plan has been updated with appropriate interventions to prevent an Elopement. This will occur during the Morning Clinical Meeting 3 to 5 times a week and this review will occur indefinitely. -The CIT will review current facility residents' ERA and Care Plan quarterly and with a significant change to ensure the ERA has been completed accurately and Care Plan has been updated with the appropriate interventions to prevent an Elopement. This review will occur during the Morning Clinical Meeting 3 to 5 times a week and this review will occur indefinitely. -When a resident signs out (not an elopement) the resident will be asked the approximate time of return and will be educated if they do not return at the time the facility will do the following: a.Attempt to call the resident if not able to reach the resident b.Notify the ADM and/or DON c. Notify the resident's Emergency Contact/Family d.Document attempts e.Adult Protective Services (APS) will be notified f. Police will be notified. g. Physician and/or Nurse Practitioner will be notified. -Education: The current facility staff were educated via Empeon (facility staffing platform) that residents profiles were updated to show if the resident is not able to sign out or leave the facility unassisted. Agency staff will be notified via the [NAME] App that is visible when the Agency Staff signs up for a shift. The ADM receives Email and App notifications when staff read the education. The facility staff have to read the education to access their schedules. Education was also posted at each Nurses Station. 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. F. Record review of Resident 2's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a residents functional capabilities and helps nursing home staff identify health problems) dated 5/11/26 identified the facility admitted the resident on 5/5/26 with diagnoses of acute post hemorrhagic anemia, End Stage Renal Disease (ESRD) receiving dialysis, diabetes mellitus, hypertension (HTN), congestive heart failure (CHF), and seizure disorder with severely impaired vision. Further review of the MDS revealed the resident required set up/clean up assistance for upper body dressing, supervision or touching assistance for oral hygiene, lower body assistance, sit to stand transfer and chair to bed to chair transfers and partial/moderate assistance for eating, toileting hygiene, shower/bathe self, and putting on and taking off shoes. Review of brief interview for mental status (BIMS, a cognitive screening test used in nursing homes to evaluate orientation) revealed a score of zero. According to the MDS manual a score of zero indicates severe impairment. Further review of the residents MDS section signs and symptoms of delirium revealed Resident 2 was identified with behaviors of inattention and disorganized thinking noted to be present, fluctuated. In an interview with the Social Service Director (SSD) on 6/8/26 at 11:40 AM, it was revealed Resident 2 was not answering the questions for the BIMS when they conducted the interview. According to the MDS manual, if the resident chooses not to participate in the BIMS or if four or more items were coded zero because the resident chose not to answer or gave nonsensical response. Continue to perform the Staff Assessment for Mental Status. The staff assessment for mental status was not completed on the MDS dated [DATE]. Record review of an undated document titled Consent to admission and Treatment scanned into the EMR on 6/9/26 was signed by Resident 2 Record review of a document titled Release of responsibility for leave of absence revealed Resident 2 signed out of the facility on 6/1/26 at 11:05 AM. Record review of a progress note in Resident 2's Electronic Medical Record (EMR) on 6/1/26 at 5:46 PM revealed Resident 2 went out on pass and had not returned at that time. Record review of a progress note in Resident 2's EMR on 6/1/26 at 6:00 PM revealed the facility staff had spoken to both of Resident 2's emergency contacts (daughters) and they were not aware of the residents whereabouts. Record review of a progress note in Resident 2's EMR on 6/2/26 at 1:18 AM revealed the resident was still out of the facility, call was placed to the resident's cell phone without answer. Call was placed to the resident's daughter, who stated the resident was not with the daughter. Record review of a progress note in Resident 2's EMR on 6/5/26 at 8:32 PM revealed a representative from University of Nebraska Medical Center (UNMC) called the facility requesting physician orders on Resident 2. In an interview with the Administrator on 6/8/26 at 11:47 AM it was revealed Resident 2 informed the facility staff [gender] was going to an appointment at the Social Security office on 6/1/26. Resident 2 arranged their own transportation for the appointment and signed out on the facility sign out form. The administrator stated the facility had made attempts to contact the Resident 2 on 6/2/26 and 6/3/26 without success. The administrator spoke with Resident 2's daughters on 6/2/26 and they were unaware of Resident 2's location but were going to check places they thought the resident may have gone. The Administrator spoke with Resident 2's daughters again on 6/3/26 and they had not located the resident. The administrator contacted APS and law enforcement on 6/3/26 at approximately 3:00 PM, 2 days after the resident left the facility for an appointment and their whereabouts were unknown. In an interview with the administrator on 6/8/26 at 4:40 PM it was confirmed the facility did not report the resident was missing to APS or the police until 52 hours after the resident left.

Licensure Reference Number 175 NAC 12-006.02 Based on observations, record reviews and interviews; the facility management failed to utilize its resources to attain or maintain the highest practicable physical and psychosocial well-being of each resident as identified by the deficient practices cited. The facility staff identified a census of 65. Findings are: -F689: The facility failed to ensure residents that were identified as an elopement risk were supervised when leaving the facility, failed to ensure prompt follow-up after a resident's whereabouts were unknown, failed to identify and implement interventions to prevent elopements and falls and failed to monitor for neurological changes after unwitnessed falls or falls with head injuries. These findings placed the facility in a substandard level of care requiring an extended survey. -F725: The facility failed to ensure competency testing for 12 of 12 employees sampled. -843: The facility failed to obtain a transfer agreement with a local hospital.-867: The facility failed to ensure the QAPI program identified and addressed concerns related to deficient practice for elopement and falls prior to a complaint survey.-947: The facility failed to ensure 12 hours of yearly training for 5 of 5 nurse aide/medication aids sampled and failed to ensure 5 of 5 medication aides had the required number of hours for dementia training.

Based on record review and interview; the facility staff failed to have a transfer agreement between the facility and hospital. This had the potential to effect all residents in the facility. The facility staff identified a census of 65. Findings are: Record review of the facility agreements revealed there was no evidence of a transfer agreement between the facility and the hospital.Interview on 06/09/2026 at 1:50 PM with the Administrator (ADM) revealed the facility did not have a hospital transfer agreement.

Licensure reference Number 175 NAC 12-006.07(C)Based on observation, interview, and record review, the facility failed to ensure the QAPI program identified and addressed concerns related to deficient practice for elopement and falls prior to a complaint survey. This had the potential to affect all residents in the facility. The facility identified a census of 65.Findings are:A.Record review of a facility policy titled Quality Assurance and Performance Improvement (QAPI) Program-Governance and Leadership with a revision date of 1/2024 revealed the following:Policy: the Quality Assurance and Performance Improvement Program is overseen and implemented by the QAPI committee, which reports its findings, actions and results to the Administrator and the governing body.Policy Interpretation and Implementation1. The Administrator, whether a member of the QAPI Committee or not, is ultimately responsible for the QAPI Program, and for interpreting its results and findings to the governing body.2. The governing body is responsible for ensuring that the QAPI Program:a. Is implemented and maintained to address identified priorities;d. Is based on data, residents and staff input, and other information that measures performances; and e. Focuses on problems and opportunities that reflect processes, functions and services provided to the residents.4. The responsibilities of the QAPI Committee are to:a. Collect and analyze performance indicator data and other information;b. Identify, evaluate, monitor and improve facility systems and processes that support the delivery and care of services;c. Identify and help resolve negative outcomes and/or care quality problems identified during the QAPI process;d. Utilize root cause analysis to help identify where identified problems point to underlying systematic problems;e. Help departments, consultants and ancillary services implement systems to correct potential and actual issues in quality care;f. Establish benchmarks and goals by which t measure performance improvement;g. Coordinate development, implementation, monitoring and evaluation of performance improvement projects to achieve specific goals; Record review of the facility QAPI minutes and Performance Improvement Plans revealed the facility had not identified the areas of deficient practice. During the recent survey with an exit date of 6/9/26 the following deficiencies were identified:F684-The facility failed to conduct neurological evaluations after unwitnessed falls for Resident 1. F689- The facility failed to ensure prompt follow up after a resident did not return to the facility and their whereabouts were unknown for 1Resident (2) and failed to implement interventions for potential elopement and falls for 1 resident 1.F725- The facility failed to ensure competencies for nursing staff at hire and annually.F835- The facility management failed to utilize its resources to attain and maintain the highest practicable physical and psychosocial well-being of each resident as identified in the deficient practices cited. F843- The facility failed to obtain a transfer agreement with a local hospital. F947-The facility failed to ensure 12 hours of yearly training for 5 of 5 nurse aides/medication aids sampled and failed to ensure 5(MA F, MA G, MA H, MA I, MA J) of 5 medication aides had the required number of hours for dementia training. In an interview with the Administrator on 6/9/26 at 3:30 PM the administrator confirmed the areas of deficient practice had not been identified with a Performance Improvement Plan for QAPI prior to the survey.

Licensure Reference Number 175 NAC 12-006.04(B)(ii)Based on record review and interview, the facility failed to ensure competencies were completed on 12 (Nurse Aide(NA) A,NA B, NA C, NA D, NA E ,Medication Aide (MA F, MA G, MA H, MA I, MA J), Licensed Practical Nurse (LPN) K and Registered Nurse (RN) L) of 12 staff reviewed. The facility identified a census of 65.Findings are:Record review of Nurse A (NA) revealed a hire date of 2/24/2026, further review revealed they had not had competencies completed since the hire date.Record review of NA B revealed a hire date of 3/18/2026 further review revealed they had not had competencies completed since the hire date.Record review of NA C revealed a hire date of 1/13/2026 further review revealed they had not had competencies completed since the hire date.Record review of NA D revealed a hire date of 4/15/2026 further review revealed they had not had competencies completed since the hire date.Record review of NA E revealed a hire date of 4/7/2026 further review revealed they had not had competencies completed since the hire date.Record review of Medication Aid (MA) F revealed a hire date of 7/30/2020, further review revealed they had not had competencies completed in the last year.Record review of MA G revealed a hire date of 3/24/2021 further review revealed they had not had competencies completed in the last year.Record review of MA H revealed a hire date of 11/16/2021 further review revealed they had not had competencies completed in the last year.Record review of MA I revealed a hire date of 4/22/2025 further review revealed they had not had competencies completed in the last year.Record review of MA J revealed a hire date of 3/24/2021 further review revealed they had not had competencies completed in the last year.Record review of Licensed Practical Nurse (LPN) K revealed a hire date of 1/20/2020 further review revealed they had not had competencies completed in the last year.Record review of Registered Nurse (RN) L revealed a hire date of 3/6/2023 further review revealed they had not had competencies completed in the last year. In an interview with the Director of Nursing (DON) on 6/9/26 at 2:30 PM it was revealed no competencies had been completed in the last year, and competencies were not being completed on new hires.

Licensure Reference Number 175 NAC 12.006.04(B)(ii)(1), Licensure Reference Number 175 NAC 12.006.04 (B)(iii) Based on record review and interview, the facility failed to ensure 12 hours of yearly training for 5 of 5 nurse aide/medication aids sampled and failed to ensure 5(MA F, MA G, MA H, MA I, MA J) of 5 medication aides had the required number of hours for dementia training. The facility identified a census of 65.Findings are:Record review of Medication Aid F revealed a hire date of 7/30/2020 revealed they did not have 12 hours of training in the last year. Further review of Medication Aid F revealed they had attended dementia training with no amount of time specified.Record review of Medication Aid G revealed a hire date of 3/24/2021 revealed they did not have 12 hours of training in the last year. Further review of Medication Aid G revealed they had attended dementia training with no amount of time specified.Record review of Medication Aid H revealed a hire date of 11/16/2021 revealed they did not have 12 hours of training in the last year. Further review of Medication Aid H revealed they had no dementia training noted.Record review of Medication Aid I revealed a hire date of 4/22/25 revealed they did not have 12 hours of training in the last year. Further review of Medication Aid I revealed they had no dementia training noted.Record review of Medication Aid J revealed a hire date of 3/24/21 revealed they did not have 12 hours of training in the last year. Further review of Medication Aid J revealed they had attended dementia training with no amount of time specified.In an interview with the Administrator on 6/9/26 at 3:25 PM it was confirmed the nurse aides/medication aids did not have the 12 hours of required annual training, and did not have 4 hours of dementia training.

Licensure Reference Number 175 NAC 12-006.18Based on observation, interview and record review, the facility failed to ensure staff followed hand hygiene procedures during the provision of peri-care (the process of washing the genitals and anal area to maintain hygiene, prevent infection and prevent skin breakdown) for 2 residents (Residents 1 and 2) of 3 residents surveyed. The facility identified a census of 68.Findings are:A record review of the facility's undated Hand Hygiene Policy revealed all staff are responsible for following hand hygiene procedures. - before and after having direct contact with a residents intact skin.- after contact with blood, body fluids or excretions, mucous membranes (a tissue that secretes mucus), non-intact skin, or wound dressings.- when hands move from a contaminated-body site to a clean body site during resident care.- before and after wearing gloves.A record review of the Infection Control Standard Precautions dated 3-20, 2024 revealed Hand Hygiene is performed with alcohol-based hand rub (ABHR) or soap and water. before and after contact with the resident before performing an aseptic (free from contamination caused by harmful bacteria, viruses, or other microorganisms) task, after contact with items in the residents' room and after removing personal protective equipment (PPE). Hands are washed with soap and water after direct or indirect contact with dirt, blood, and body fluids and after removing gloves. Gloves are changed as necessary, during the care of a resident to prevent cross contamination from one body site to another (moving from a dirty site to a clean one).A. Record review of Resident 2's undated Care Plan revealed Resident 2 was admitted to the facility on [DATE] and had the following diagnoses: Age related physical debility (a state of increased vulnerability due to a decline in the body's reserves and function as a person ages), Adult failure to thrive (a state of mental and physical decline in older adults), Anxiety disorder (a mental health condition characterized by persistent and excessive worry and fear), Fibromyalgia (a chronic condition causing widespread musculoskeletal pain, fatigue, sleep problems and cognitive difficulties), Hypertension (high blood pressure), Hyperlipidemia (high cholesterol), venous stasis ulcers on lower leg (a chronic open sore on the lower leg that occurs when the veins are unable to send blood back to the heart properly) and chronic respiratory failure (a long term condition where the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide).A record review of Resident 2's Care Plan revealed Resident 2 is chairfast (Resident 2 is unable to walk and has severely limited mobility but can sit in a chair or wheelchair). Resident 2 required maximum assistance (caregiver to provides 51% to 75% of help) for bed mobility, transfers, and upper body dressing. Resident 2 requires total assistance (the highest level of physical help for a task), for wheelchair mobility, bathing, and lower body dressing.An observation on 11/18/2025 at 10:30 AM of peri-care performed by Nurse Assistant (NA) A and NA-B for Resident 2 revealed the following: NA-A and B donned gowns, gloves, and masks. They knocked on Resident 2's door and stated they were there to provide peri-care. NA-A closed the shades, raised the bed, removed the blankets from Resident 2, removed a pillow from beneath the residents' legs and pulled the residents gown up. NA-A changed their gloves without using hand sanitizer or washing their hands. NA A separated the a pullup adult brief at the waist and rolled the front of the brief down and expose the genitals for cleaning. NA-B handed a personal care wipe to NA-A. NA-A started to clean the resident's peri-area from front to back. NA-A used a second wipe to clean the groin creases on either side of the genitalia. NA-A discarded the wipe, asked the resident to turn towards the window, and gently assisted the resident by placing a gloved hand on her buttock and another on her shoulder. When the resident was secure on their side, NA-B removed the remainder of the pullup from beneath the resident and using several wipes, cleaned the area from the middle to the sides using a fresh wipe on every second pass over the resident's skin. NA-B changed their gloves without using hand sanitizer and assisted NA A with placing and pulling the pull up briefs on (gender) legs. Both NA's assisted the resident to roll back and forth as they pulled the brief into place. NA-B placed a pillow beneath her legs. NA-A pulled the blankets over the resident and both NA's exited the room after removing their gloves. NA-A and NA-B did not complete hand hygiene prior to exiting Resident 2's room.An interview on 11/18/2025 at 10:45 AM with NA -A confirmed they should have used hand sanitizer or washed their hands before and after donning gloves for personal care.An interview on 11/18/2025 at 10:45 AM with NA -B confirmed they should have used hand sanitizer or washed their hands before and after donning gloves for personal care and that Resident 2 was exposed to cross contamination.B. A record review of Resident 1's admission progress note dated 9/24/2025 revealed the resident was admitted for skilled nursing care following a cerebral infarction (the death of brain tissue due to a lack of blood flow).A record review of Resident 1's undated Care Plan revealed the following diagnoses: Cerebral Infarction, Dysphagia (difficulty swallowing), Hemiplegia (loss of muscle function and Hemiparesis (muscle weakness) affecting left side and disorder of the brain (any condition that affects the functioning of the brain).A record review of Resident 1's Minimum Data Set (MDS - a federally mandated tool used to assess nursing home residents receiving Medicare or Medicaid) dated 9/28/2025 revealed Resident 1 had a Brief Interview of Mental Status (BIMS - a federally mandated tool used to assess cognitive function in nursing home residents) of 9 which indicated the resident has moderate cognitive impairment (a significant decline in thinking and memory that impairs daily functioning). A record review of Resident 1's MDS dated [DATE] revealed the resident required substantial assistance (helper provides more than half the effort) with personal hygiene, eating and oral hygiene and requires the assistance of 2 or more helpers for toileting, bathing, and dressing. Resident was always incontinent of bowel and frequently incontinent of urine.An observation on 11/18/2025 at 3:15 PM of peri-care performed by NA-C and NA-D for Resident 1 revealed the following: NA-D knocked on the door and both NA's used hand sanitizer before they entered Resident 1's room. Both NA's donned gloves. Resident 1 was wearing a pullup brief (disposable underwear resembling regular underwear, requiring them to be pulled up). NA-C separated the pullup at the waist and rolled the front of the brief down to expose the genitals. NA-D handed a personal care wipe to NA-C, and they wiped the residents peri area from front to back, using two separate wipes. NA-D used a separate wipe to wipe Resident 1's groin creases. Then both NA's used their gloved hands to guide the resident to turn towards the window. NA-D used several wipes to clean stool from the residents buttocks, discarding each one after one use. When Resident 1 was clean, both NA's placed a clean pullup on the resident and replaced the residents' bedcovers. NA-D returned the side table to the side of the bed. Both NA's discarded their gloves and exited the room. Neither NA C or NA D used hand sanitizer or changed gloves during the time they spent in the residents room providing care.An interview on 11/18/2025 at 4:20 PM with NA-C confirmed they should have used hand sanitizer or washed their hands before and after donning gloves. An interview on 11/18/2025 at 4:20 PM with NA-D confirmed they should have used hand sanitizer or washed their hands before and after donning gloves. An interview with the Director of Nursing on 11/19/2025 at 11:25 AM confirmed it is an expectation of the facility that the NA's will change their gloves during peri-care and that they will use a hand-sanitizer in between or wash their hands between glove changes. The DON confirmed the facility does not have a Peri-Care policy.

Licensure Reference Number 175 NAC 12-006.09 Based on interview and record review the facility failed to update the resident's healthcare practitioner of chest x-ray results for 1 (Resident 1) of 4 residents sampled, resulting in a delay of treatment. The facility census was 69. The findings are:Record review of Resident 1's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 06-25-2025 revealed the facility staff assessed the following about the resident:-was rarely able to make themselves understood. -required total assistance with toileting, bathing, transfers, dressing, bed mobility, eating and hygiene. Record review of Resident 1's progress notes dated 09-06-2025 revealed Resident 1 had audible moist sounding wheezes while breathing, had green nasal drainage and eyes were glassy. Furthermore, the note revealed the healthcare practitioner was called and an order for a chest x-ray was obtained. Record review of Resident 1's telephone orders revealed an order dated 09-06-2025 for a portable chest x-ray, 2 views STAT (urgent). Record review of Resident 1's progress notes dated 09-06-2025 revealed the chest x-ray was ordered and obtained. Record review of Resident 1's radiology report dated 09-06-2025 revealed new left midlung opacities and right lower lobe opacities may represent pneumonia in the clinical setting. Record review of an email dated 09-08-2025 revealed the Director of Nursing (DON) updated the healthcare practitioner of the chest x-ray results and an antibiotic was ordered for pneumonia. An interview with the DON on 10-14-2025 at 2:15 pm confirmed results for a STAT x-ray depending on the time of the x-ray should be 1-2 days and confirmed there was a delay in getting the order for antibiotic based on the chest x-ray results.

Licensure Reference Number 175 NAC 12-006.18, 12-006.18 (C)Based on observation, interview, record review, the facility failed to implement a plan to mitigate the potential growth of Legionella, and failed to implement Enhanced Barrier Precautions (EBP) for Residents 8 and 61. Findings are: A. An interview on 07/22/2025 10:15 AM with the Maintenance Director (MD) confirmed no documentation of flushing holding tanks or areas that have the potential for stagnant water which could promote potential growth of Legionella. Record review of the facility policy titled “Environmental-Infection Control-Legionella Surveillance & Detection”, dated 1/2024. Legionella Surveillance and Detection Policy Statement: Our facility is committed to prevention, detection, and control of water-borne contaminants, including Legionella. Legionnaire’s disease will be included as part of our infection surveillance activities. Legionella Water Management Program Policy Interpretation: Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella. Policy Interpretation and Implementation: 5. The water management program includes the following elements: c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including: - Storage tanks; -Water heaters; -Filters; -Aerators; -Shower heads and hoses; -Misters, atomizers, air washers and humidifiers; -Hot tubs; -Fountains; and -Medical devices such as CPAP machines, hydrotherapy equipment; etc. 7. Water stagnation and; 8. Inadequate disinfection. e. Specific measures used to control the introduction and/or spread of legionella (e.g., temperature, disinfectants); f. The control limits or parameters that are acceptable and that are monitored; g. A diagram of where control measures are applied; h. A system to monitor control limits and the effectiveness of control measures; i. A plan for when control limits are not met and or control measures are not effective; and j. Documentation of the program. B. Record review of Resident 61’s MDS dated [DATE] revealed the facility staff assessed the following about the resident: -required total assistance with toileting and bathing. -required extensive assistance with lower body dressing. -required limited assistance with upper body dressing and transfers. Record review of Resident 61’s Comprehensive Care Plan (CCP) dated 08-22-2024 revealed Resident 61 had an active Multi Drug Resistant Organism (MDRO: an infection caused by bacteria that have developed resistance to multiple classes of antibiotics) or MDRO colonization in the urine. The CCP also revealed the staff were to utilize EBP and wear gowns and gloves during high-contact resident activities. An observation on 07-22-2025 at 8:30 AM revealed a sign on Resident 61’s door indicating EBP was to utilized when caring for the resident. An observation conducted on 07-22-2025 at 9:00 AM of Nursing Assistant (NA) B giving Resident 61 a shower revealed NA B transferred Resident 61 into the bath chair, assisted with the removal of clothes and assisted with incontinence care without wearing a gown. An interview with NA G on 07-22-2025 at 9:45 AM confirmed Resident 61 was on EBP and a gown was not worn during the shower and should have been. C. Record review of Resident 8’s “admission Record” identified the facility admitted the resident on 6-21-2021 and the resident had diagnoses which included extended spectrum beta lactamase resistance (ESBL resistance, a type of antibiotic resistance in bacteria). Record review of Resident 8’s quarterly MDS dated [DATE] identified the resident was dependent upon staff for toileting and the use of an indwelling urinary catheter (a flexible tube inserted through the urethra and into the bladder to drain urine). Record review of Resident 8’s CCP (Care Plan) identified the resident has an active multidrug-resistant organism (MDRO) or MDRO colonization and enhanced barrier precautions were to be utilized during high contact resident care activities. Observation on 7-21-25 at 11:43 AM revealed EBP signage was hung at the door. Observation on 7-21-2025 at 11:50 AM of NA-D performing Resident 8’s catheter care revealed catheter care supplies prearranged on a bedside table with a barrier between the table and supplies. NA-D washed hands with soap and water for 22 seconds and donned (applied) gloves. Without donning a gown, NA-D assisted Resident 8 to roll side-to-side to remove the brief. NA-D doffed (removed) gloves, performed hand hygiene, and donned new gloves. NA-D completed urinary catheter care, doffed gloves, performed hand hygiene, donned new gloves, and applied a clean brief. During an interview on 7-21-2025 at 12:02 PM, NA-D confirmed Resident 8 was on EBP and that EBP included the use of gown. NA-D further confirmed that a gown was not worn during urinary catheter care and should have been. Record review of a facility policy entitled “MDRO PPE-Enhanced Barrier Precautions” dated revised 1-2024 revealed: -Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce the transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. -Framework for applying EBP in this facility is the application of EBP to routine care of residents with wounds or indwelling medical devices. The facility requires that staff participate in initial and on-going training on the facility’s expectations about hand hygiene and gown and glove use, along with proof of competency regarding appropriate use and donning and doffing technique for PPE. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage or similar dressing. -Examples of chronic wounds include, but are not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, venous stasis ulcers. -Indwelling medical device examples: central lines, urinary catheters, feeding tubes, tracheostomies. -For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator), and wound care (any skin opening requiring a dressing).

Based on observations and interviews; the facility kitchen staff failed to ensure foods were at temperatures that was appetizing and palatable. The deficient practice had the potential to effect all residents who eat food from the kitchen. The facility staff identified a census of 63. Findings are: Record review of the current Nebraska Food Code found at 81-2,272.01 for hot and cold holding temperatures revealed the following information:-1. Except during preparation, cooking or cooling or when time is used as a public health control, time/temperature control for safety shall be maintained.-a. At 135 degrees Fahrenheit or above, for hot foods.-41 degrees or less for cold food. Record review of of a facility grievance log from 1-1-2025 through 7-14-25 revealed the following information:-1-01-2025, Multiple Residents , resident not happy with choices for breakfast and complained of cold food.-2-17-2025, Multi resident reported food was cold when they received it in their rooms. -4-4-02-2025, resident unhappy with food. Stated it looked as if it was just thrown on the plate.-6-05-2025, Resident reported did not like diner. The cucumbers were hot and zuchini was cold.On 7-16-2025 at 8:40 AM an interview was conducted with Resident 29. During the interview Resident 29 reported the food doesn't taste good. Record review of a undated Menu at a Glance revealed the lunch meal for 7-17-2025 was as follows:-BBQ meat balls-Smashed red potatoes-Green Beans-Corm bread with margarine-Beverage-PuddingObservation on 7-17-2025 from 12:14 PM to 12:32 PM in the East Dining room revealed Dietary Assistant (DA) C served resident their noon meals. DA C completed the meal service in the East Dining room and began to prepare meal room trays for residents, in addition, a requested meal test tray (meal tray used to evaluate the taste and temperatures of foods served to residents). Further observation on 7-17-2025 from 12:14 PM to 12:32 PM revealed the last room tray was delivered. DA C using the facility thermometer revealed the following information on the evaluation of the meal test tray:-Meat balls 129.0 degrees. -Diced potatoes 107.6.-Ground Meat 110.0.-Green beans 121.4 degrees. -Hot dog alternate 96.0 -Mashed potatoes 120.8, -Pudding 67.8, On 7-17-2025 at 12:32 PM a interview was conducted with DA C. During the interview DA C confirmed hot food were cold and the pudding was too hot. DA C further reported the food did not taste good.On 7-21-2025 at 10:10 AM an interview was conducted with the Dietary Service Manager (DSM). During the interview the DSM reported the facility follows the Nebraska Food code for holding temperatures.

Licensure Reference Number 175 NAC 12-006.11(A)Based on observations, record review and interview, the facility kitchen staff failed to follow the menu serving sizes for 48 resident who have a regular textured diet. The facility staff identified a census of 63. Findings are: Record review of a undated Menu at a Glance revealed the lunch meal for 7-17-2025 was as follows:-BBQ meat balls-Smashed red potatoes-Green Beans-Corm bread with margarine-BeverageRecord review of of the Diet Spreadsheet for the 7-17-2025 noon meal revealed the following information:-Regular texture portion sizes:-BBQ meatballs, 3- 1 ounce (oz) size meat balls.-Smashed Red Potatoes, #8 scoop size.-Green Beans #8 scoop size.-Cornbread with margarine, 1 each.Observations on 7-17-2025 at 11:56 AM revealed Dietary Assistant (DA) E began serving and setting up room trays to be given to resident in their rooms or secured unit dinning room. Further observations on 7-17-2025 revealed DA E did not use dietary card (informational cards that identify diet type, portion, consistency of foods, food preferences and allergies). DA E served 5 meat balls to residents who were on regular textured diets.An interview was completed with DA E on 7-17-2025 at 11:56 AM . During the interview DA E reported residents on regular textured diets received 5 meat balls. Observation on 7-17-2025 at 12:14 PM of meal service in the east dining room revealed DA F serving random portion of 5 to 12 meat balls to residents on regular textured diets. On 7-17-2025 at 12:30 PM an interview was conducted with DA F. During the interview DA F reported not knowing the serving sizes of the meat balls to be given to the residents.On 7-21-2025 at 10:10 AM an interview was conducted with the Food Service Director (FSD). During the interview the FSD reported each meat ball served on 7-17-2025 noon meal was 1/2 ounces and that each resident on regular textured meals should have received 6 meat balls. The FSD confirmed the menu for portion sizes had not been followed.

Licensure Reference Number 175 NAC 12-006.09(H)(i)(3) Based on observation, interview and record review the facility failed to ensure nails were trimmed for 1 (Resident 2) of 2 residents sampled. The facility census was 63. The findings are:Licensure Reference Number 175 NAC 12-006.09(H)(i)(3)Based on observation and interview the facility failed to ensure nails were trimmed for 1 (Resident 2) of 2 residents sampled. The facility census was 63. The findings are:Record review of Resident 2's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 06-11-2025 revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored as a 4. According to the MDS Manual a BIMS score of 0-7 indicates severe cognitive impairment. -had quadriplegia (a condition characterized by paralysis of all 4 limbs and torso).-required total assistance with eating, hygiene, dressing, toileting, bathing, transfers and bed mobility. Record review of Resident 2's Comprehensive Care Plan (CCP) dated 03-06-2024 revealed Resident 2 had a functional deficit with activities of daily living (ADL) due to quadriplegia. The CCP also indicated Resident 2 was dependent on staff for personal hygiene.An observation on 07-21-2025 at 6:15 AM revealed Resident 2 revealed fingernails on both hands were approximately 1 centimeter in length. An observation was conducted on 07-22-2025 at 6:30 AM with Nursing Assistant (NA) A providing care for Resident 2 revealed fingernails to both hands were long. During the observation an interview was conducted with NA A which confirmed Resident 2's fingernails were long and revealed Resident 2 was scheduled for a bath and the bath aid would trim the fingernails. An interview was conducted with NA B on 07-22-2025 at 9:00 AM revealed NA B had given Resident 2 a shower earlier that morning. An observation on 07-22-2025 at 9:30 AM revealed Resident 2 had returned from the bath house and the fingernails had not been trimmed. An interview with the Director of Nursing (DON) on 07-22-2025 confirmed nail care was provided with showers. An observation of Resident 2 with NA B on 07-22-2025 at 9:40 AM revealed Resident 2's fingernails were not trimmed. An interview was conducted with NA B during the observation which confirmed Resident 2's fingernails were long and confirmed fingernails were not trimmed during the bath. During the interview with NA B about the length of the fingernails, Resident 2 clearly stated cut them.

Nebraska Licensure Reference 175 NAC 12-006.05(E)Based on interview and record review, the facility failed to evaluate resident food preferences related to religious beliefs for 1 (Resident 20) of 1 sampled resident. The facility staff identified a census of 63.The findings are:An interview on 7-16-2025 at 10:32 AM with Resident 20 revealed [gender] does not eat pork due to Seventh Day Adventist beliefs and revealed the facility staff offer meals containing pork.An interview on 7-17-2025 at 1:59 PM with the Food Services Director (FSD) revealed the facility performed a food preferences interview at the time of admission and the results of that interview are recorded on the resident's tray card. The FSD confirmed Resident 20's dietary preferences were not listed on the tray card.A record review of Resident 20's admission Record printed 7-17-2025 revealed the facility admitted the resident on 7-21-2021 and identified Resident 20 had diagnoses which included chronic obstructive pulmonary disease (COPD, pulmonary disease that is characterized by chronic typically irreversible airway obstruction resulting in a slowed rate of exhalation), diabetes mellitus (DM) type 2 (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production), heart failure, and major depressive disorder a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks and is accompanied by irritability, fatigue, poor concentration, sleep disturbances, weight gain or loss, feelings of worthlessness or guilt, and sometimes suicidal tendencies).Record review of Resident 20's Annual Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 4-21-2025 identified Resident 20 found religious services or practices somewhat important. Further review of the MDS revealed the Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score for Resident 20 was not assessed.Record review of Resident 20's Physician's Orders printed 7-17-2025 revealed a controlled carbohydrates diet (CCHO, low concentrated sweets) with a regular texture and thin fluids.Record review of Resident 20's Social Services Quarterly Data Collection dated 4-22-2025 identified religious preference of Seventh Day Adventist.Record review of Resident 20's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) revealed no interventions related to Resident 20's religious preferences.Record review of Resident 20's Tray Card dated 7-17-2025 revealed a CCHO diet with a regular texture. The tray card did not include the resident's religious dietary preferences.

Licensure Reference Number 175 NAC 12-006.09(H)(vi)(2). Based on observation, interview and record review the facility failed to implement an individualized activity program for Resident 5. The findings are: Record review of Resident 5's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 07-01-2025 revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored as a 13. According to the MDS Manual a BIMS score of 13 to 15 indicates a person is cognitively intact. -had a diagnosis of End Stage Renal Disease (ESRD: a chronic condition where the kidneys have permanently lost most of their function and can no longer filter waste products from the blood) and Diabetes Mellitus. -was receiving hemodialysis (a treatment for ESRD that helps remove waste and excess fluid from the blood).-required partial assistance with toileting, bathing, dressing and transfers. An interview conducted on 07-16-2025 at 9:45 AM with Resident 5 revealed Resident 5 had recently started going to dialysis on Mondays, Wednesdays and Fridays and does not return to the facility until around 4:00 PM. Resident 5 also reports there are no activities offered in the evening or on the weekends. Record review of the facility activity calendar for July 2025 revealed no activities scheduled in the evening or on the weekends. Record review of Resident 5's Electronic Health Record (EHR) under Clinical Census revealed resident was on hospital leave from 06-13-2025 to 06-26-2025. Record review of Resident 5's Progress Note (PN) dated 06-27-2025 revealed Resident 5 returned to the facility from the hospital and would be going to dialysis 3 days a week. Record review of Resident 5's Activities readmission Data Collection (ARDC) dated 06-30-2025 revealed Resident 5's recreational interests included animals/pets, arts/crafts, bingo, family/friend visits, movies, music, and special events. The ARDC also indicated Resident 5 preferred to have activities 2-5 times a week. Record review of Resident 5's Comprehensive Care Plan (CCP) dated 11-09-2023 revealed Resident 5 was dependent on staff with activity participation, would express satisfaction with the type of activities and level of activity involvement when asked through the review date. The CCP also indicated to provide Resident 5 with materials for individual activities as desired. The resident likes the following independent activities: coloring and family visits. Record review of Resident 5's EHR revealed Resident 5 actively participated in activities on 06-06-2025, 06-10-2025 and 06-11-2025 for the month of June and no participation in activities was documented for July 2025. An interview with the Administrator (ADM) on 07-2025 at 12:33 PM confirmed Resident 5 did not participate in any activities since readmission on [DATE] and confirmed the activity calendar did not indicate any activities in the evenings or on weekends.

Nebraska Licensure Reference 175 NAC 12-006.09(H)(iv)(5)Based on interview and record review, the facility failed to evaluate bowel function and failed to implement interventions to manage bowel function for 1 (Resident 8) of 5 sampled residents. The facility staff identified a census of 63.The findings are:Record review of Resident 8's admission Record printed 7-21-2025 revealed the facility admitted the resident on 6-21-2021 and identified Resident 8 had diagnoses which included dementia with behavioral disturbance (a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia [a language disorder that affects a person's ability to communicate], and the inability to plan and initiate complex behavior), hypertension (high blood pressure), and major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks and is accompanied by irritability, fatigue, poor concentration, sleep disturbances, weight gain or loss, feelings of worthlessness or guilt, and sometimes suicidal tendencies).Record review of Resident 8's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 6-25-2025 revealed the facility staff assessed the resident to have a short-term and long-term memory problem. Further review of the MDS identified the resident was dependent upon staff for assistance with toileting.Record review of Resident 8's Physician's Orders dated 7-21-2025 revealed bowel management orders which included PEG3350 (polyethylene glycol, an osmotic laxative medication that works by drawing water into the colon which softens the tool and makes it easier to pass) to be administered daily for constipation and Senexon-S (a combination of stimulant laxative and stool softener) to be administered twice daily as needed (PRN) for constipation.Record review of Resident 8's Bowel Elimination POC Response History from 6-22-2025 through 7-21-2025 revealed the response No Bowel Movement was recorded on each of the following six consecutive dates: 7-12-2025, 7-13-2025, 7-14-2025, 7-15-2025, 7-16-2025, and 7-17-2025.Record review of Resident 8's Electronic Medication Administration Record (eMAR) dated July 2025 revealed the resident was administered polyethylene glycol daily as ordered. Further review of Resident 8's July 2025 eMAR revealed the Senexon-S medication was not administered at any time in the month of July including from 7-12-2025 through 7-17-2025.Further review of Resident 8's Electronic Medical Record (EMR) including progress notes, forms, and scanned documents showed neither a record of administration of PRN Senexon-S, nor an evaluation of the resident's bowel function.Record review of Resident 8's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) showed no interventions for constipation.An interview on 7-22-2025 at 11:55 AM with the Unit Manager (UM) confirmed Resident 8 had not had a bowel movement for six consecutive days from 7-12-2025 through 7-17-2025. The UM further confirmed there was no documentation of an assessment being performed and no documentation of the PRN laxative being administered. An interview on 7-22-2025 at 1:30 PM with the Director of Nursing (DON) revealed the facility has no policy on bowel and bladder elimination. The DON further revealed that when a resident has had no bowel movement for six consecutive days, facility staff should utilize PRN laxative medications if available, perform an evaluation of the resident's bowel function, or notify the provider.

Licensure Reference Number 175 NAC 12-006.05Based on record review and interview, the facility failed to provide notice of transfer in writing to the resident or resident's representative for 2 (Resident 20 & 64) of 4 residents sampled. The facility staff identified a census of 63.The findings are:Record review of facility policy entitled Transfer and Discharge from the Facility dated 1-2024 revealed: -The facility will provide proper and timely notice to a resident who will be discharged as required by regulations and laws. -C. Contents of the notice: -Before the facility will transfer or discharge a resident, the facility will provide a written notice to the resident and resident representative in a manner and language in which is understood. -At a minimum the notice will include: -a. The reason for transfer/discharge -b. The effective date of the transfer/dischargeA.A record review of Resident 20's admission Record printed 7-17-2025 revealed the facility admitted the resident on 7-21-2021 and identified Resident 20 had diagnoses which included chronic obstructive pulmonary disease (COPD, pulmonary disease that is characterized by chronic typically irreversible airway obstruction resulting in a slowed rate of exhalation), diabetes mellitus (DM) type 2 (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia (high blood sugar) resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production), heart failure, and major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks and is accompanied by irritability, fatigue, poor concentration, sleep disturbances, weight gain or loss, feelings of worthlessness or guilt, and sometimes suicidal tendencies).A record review of Resident 20's Annual 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 4-21-2025 revealed the Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score for Resident 20 was not assessed.A record review of Resident 20's Change in Condition Evaluation dated 5-6-2025 revealed the resident experienced abdominal pain, diarrhea, and was tired, weak, confused, or drowsy.A record review of Resident 20's Progress Notes (PN) dated 5-6-25 showed the facility transferred the resident to an emergency department due to chronic diarrhea and abdominal pain.A record review of Resident 20's Bed Hold/Therapeutic Leave Form (BHTLF) showed the resident wished to bed hold with the hold beginning on 5-6-2025. There was no reason for transfer listed on the form.Further review of Resident 20's electronic health record (EHR), including progress notes and scanned documents, revealed there was no notice of transfer in writing to the resident or resident representative.An interview on 7-22-2025 at 9:36 AM with the Director of Nursing (DON) confirmed the facility did not provide the resident or resident's representative with the reason for transfer in writing and should have.B.A record review of Resident 64's admission Record printed 7-21-2025 revealed the facility admitted the resident on 2-20-2019 and identified Resident 64 had diagnoses which included hemiplegia (total or partial paralysis on one side of the body that results from disease or injury to the motor centers of the brain) and hemiparesis (muscular weakness or partial paralysis restricted to one side of the body), systemic inflammatory response syndrome (SIRS, a severe systemic response to a condition [such as trauma, an infection, or a burn] that provokes an acute inflammatory reaction indicated by the presence of two or more of a group of symptoms including abnormally increased or decreased body temperature, heart rate greater than 90 beats per minute, respiratory rate greater than 20 breaths per minute or a reduced concentration of carbon dioxide in the arterial blood, and the white blood cell count greatly decreased or increased), and COPD.A record review of Resident 64's Discharge MDS identified the resident was transferred to the hospital on 5-13-2025 and was expected to return to the facility. Further review of the MDS identified the resident had intact short-term memory and had severely impaired skills for daily decision making.A record review of Resident 64's BHTLF showed the resident wished to bed hold with the hold beginning on 5-12-2025. There was no reason for transfer listed on the form.Further review of Resident 64's electronic health record (EHR), including progress notes and scanned documents, revealed there was no notice of transfer in writing to the resident or resident representative.An interview on 7-21-2025 at 7:56 AM with the DON confirmed the facility transferred the resident to the hospital on 5-13-2025.An interview on 7-22-2025 at 9:36 AM with the DON confirmed the facility did not provide the resident or resident's representative with the reason for transfer in writing and should have.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5)Based on record review and interview the facility failed to notify the resident's practitioner of omitting the administration of insulin for 3 (Residents 5, 31, and 39) of 3 residents sampled. The facility census was 63. The findings are: A. Record review of Resident 5’s Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 07-01-2025 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as a 13. According to the MDS Manual a score of 13 to 15 indicate a person is cognitively intact. -had a diagnosis of End Stage Renal Disease (ESRD: a chronic condition where the kidneys have permanently lost most of their function and can no longer filter waste products from the blood) and Diabetes Mellitus. -was receiving hemodialysis (a treatment for ESRD that helps remove waste and excess fluid from the blood). -was receiving insulin injections. -required partial assistance with toileting, bathing, dressing and transfers. Record review of the facility policy titled Notification of Changes Policy revealed the following: -it is the policy of this facility that changes in a resident’s condition or treatment are immediately shared with the resident and/or resident representative and reported to the attending physician or delegate. -the objective of the notification policy is to ensure that the facility staff makes appropriate notification to the physician when there is a change in the resident’s condition. -requirements for physician notification include a need to alter treatment such as a need to discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment. Record review of Resident 5’s Medication Administration Record (MAR) for June 2025 revealed an order for Lispro Insulin inject 8 units 3 times a day with meals and an order to complete a pre and post dialysis assessment on Mondays, Wednesdays, and Fridays. The MAR also revealed on 06-30-2025(a Monday) at 12:00PM the facility staff documented OF (Out of Facility) for the administration for of the Lispro insulin at 12:00 PM because Resident 5 was at dialysis. Record review of Resident 5’s MAR for July 2025 revealed an order for Lispro Insulin inject 8 units 3 times a day with meals and an order to complete a pre and post dialysis assessment on Mondays, Wednesdays, and Fridays. The MAR also revealed for the administration of the Lispro insulin at 12:00PM the facility staff documented OF on the following dates: -07-02-2025(Wednesday), -07-04-2025 (Friday), -07-07-2025 (Monday), -07-09-2025 (Wednesday), -07-11-2025 (Friday), -07-14-2025 (Monday) -07-16-2025 (Wednesday). An interview conducted on 07-17-2025 at 2:46 PM with the Agency Nurse (AN) G for the [NAME] Wing of the facility revealed (gender) was unaware of who was responsible to administer insulin while residents were out of the facility for dialysis. Furthermore, AN revealed the resident’s practitioner should be notified any time insulin is not given. An interview conducted on 07-17-2025 at 2:50 PM with Licensed Practical Nurse (LPN) H for the East Wing of the facility revealed (gender) was unaware of any residents with orders for insulin to be administered while residents were out of the facility for dialysis, and confirmed the resident’s practitioner should be notified if a dose of insulin was missed for any reason. B. Record review of Resident 39’s MDS dated [DATE] revealed the facility staff assessed the following about the resident: -BIMS was scored at an 11. According to the MDS Manual a score of 8-12 indicates moderate cognitive impairment. -had a diagnosis of ESRD and Diabetes Mellitus. -was receiving hemodialysis. -was receiving insulin injections. -required substantial assistance with upper body dressing and bathing. -required total assistance with toileting, lower body dressing, bed mobility and transfers. Record review of Resident 39’s Medication Administration Record (MAR) for June 2025 revealed an order for Lispro Insulin inject 5 units 3 times a day with meals and an order to complete a pre and post dialysis assessment on Mondays, Wednesdays, and Fridays. The MAR also revealed an OF was documented at 12:00PM on the following dates: -06-02-2025 (Monday) -06-03-2025 (Tuesday) -06-04-2025 (Wednesday) -06-13-2025 (Friday) -06-16-2025 (Monday) -06-18-2025 (Wednesday) -06-20-2025 (Friday) -06-23-2025 (Monday) -06-25-2025 (Wednesday) -06-27-2025 (Friday) -06-30-2025 (Monday) Record review of Resident 39’s MAR for July 2025 revealed an order for Lispro Insulin inject 5 units 3 times a day with meals and an order to complete a pre and post dialysis assessment on Mondays, Wednesdays, and Fridays. The MAR also revealed for the administration of the Lispro insulin at 12:00PM the facility staff documented OF on the following dates: -07-02-2025(Wednesday), -07-04-2025 (Friday), -07-07-2025 (Monday), -07-09-2025 (Wednesday), -07-11-2025 (Friday), -07-14-2025 (Monday) -07-16-2025 Wednesday. An interview conducted on 07-17-2025 with the Unit Manager (UM) at 3:58 PM confirmed OF on the MAR meant the resident was not given the medication because the resident was out of the facility and the facility staff did not notify Resident 5’s practitioner that the Lispro Insulin at 12:00 PM was not given on dialysis days. An interview conducted on 07-17-2025 with the Unit Manager (UM) at 3:58 PM confirmed the facility staff did not notify Resident 39’s practitioner that the Lispro Insulin at 12:00 PM was no given on dialysis days. C. Record review of Resident 31's Order Summary Report on 7/17/25 revealed Resident 31 admitted to the facility on [DATE] with diagnoses including Atherosclerotic Heart Disease, Ischemic Cardiomyopathy, Chronic Kidney Disease Stage 5, End Stage Renal (Kidney) Disease, Type 2 Diabetes Mellitus with other Diabetic Kidney Complication, Dependence on Renal Dialysis. Record review of Resident 31's Electronic Medication Administration Record (MAR) for July 2025 revealed a practitioner's order for Lispro Insulin, inject 13 units daily before breakfast related to diagnosis of Type 2 Diabetes Mellitus. Further review of July 2025 MAR's for Resident 31 revealed OF (indicating resident is out of facility) on July 2,4,11,14,16. The review further of Resident 31's medical record revealed the facility staff did not notify the practitioner of omitted (not given) insulin orders on days the resident went to dialysis. Resident 31 has dialysis every Monday, Wednesday, and Friday. An Interview on 07/17/2025 3:58 PM The Infection Preventionist (IP) confirmed, Resident 31 had not received scheduled insulin and the Medical Provider had not been notified of the omitted (not given) insulin on dialysis days.

Nebraska Licensure Reference Number 175 NAC 12-006.09(H)(v)Based on observation, interview, and record review; the facility failed to implement interventions to prevent further decrease in range of motion for 1 (Resident 20) of 1 resident sampled. The facility staff identified a census of 63.The findings are:Record review of a facility policy entitled Activities of Daily Living (ADLs) dated 1-2024 revealed: -The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. -2. The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment. -Tips for improving or maintaining ADL skills: involvement of therapy or restorative nursing personnel to retrain resident.Record review of Resident 20's admission Record printed 7-17-2025 revealed the facility admitted the resident on 7-21-2021 and identified the resident had diagnoses which included pain, type 2 diabetes mellitus (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production), heart failure, and major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks and is accompanied by irritability, fatigue, poor concentration, sleep disturbances, weight gain or loss, feelings of worthlessness or guilt, and sometimes suicidal tendencies).Record review of Resident 20's Annual Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 4-21-2025 revealed the Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score for Resident 20 was not assessed. Further review of Resident 20's MDS revealed no restorative nursing program was offered.Record review of Resident 20's Therapy Screening (TS) dated 1-21-2025 revealed: - Pt [patient] would benefit from skilled services due to lack of mobility, however pt adamantly refuses OOB [out of bed] activity. Will continue to monitor, encourage/discuss, and screen PRN [as needed].Record review of Resident 20's TS dated 4-21-2025 revealed: - Resident on OT caseload, no noted ST [speech therapy] or OT [occupational therapy] needs, will cont [continue] to monitor and screen PRN.Record review of Resident 20's electronic health record (EHR) including physician's orders, treatment administration records, and comprehensive care plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) revealed a lack of intervention to prevent further decrease in range of motion.Observation on 7-17-2025 at 9:45 am revealed the fingers of Resident 20's left hand with nodules and decrease range in motion.An interview on 7-17-2025 at 9:45 AM with Resident 20 revealed facility staff did not perform interventions to prevent further decrease in range of motion.An interview on 7-22-25 at 1:07 PM with the Director of Nursing (DON) confirmed there were no identified interventions to prevent further decrease in range of motion for Resident 20.

Licensure Reference Number 175 NAC 12-006.09Based on record review and interview the facility failed to identify and implement a plan to manage medications for residents on dialysis services for 3 (Residents 5, 31 and 39) of 4 residents sampled. The facility census was 63. The findings are: A. Record review of the facility policy titled Special Needs dated 01-2024 revealed the following: -to address special needs, this facility will provide the necessary care and treatment, including medical and nursing care, consistent with professional standards of practice and in accordance with physician’s orders, the comprehensive person-centered care plan, and the resident’s goals and preferences. -this policy pertains to the following needs-dialysis -the facility will communicate relevant information with outside providers to ensure safe, continuous care of the resident. -medical conditions will be monitored and managed to prevent complications. -Registered Nurses (RN) and Licensed Practical Nurses (LPN) will participate in the management of medical conditions by following physician orders, assessment of the resident, and reporting changes in condition to the resident’s physician. -interventions will be modified in the resident’s care plan as needed. -policies and procedures related to special needs will reflect current standards of practice. Record review of Resident 5’s Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 07-01-2025 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as a 13. According to the MDS Manual a BIMS score of 13 to 15 indicates a person is cognitively intact. -had a diagnosis of End Stage Renal Disease (ESRD: a chronic condition where the kidneys have permanently lost most of their function and can no longer filter waste products from the blood) and Diabetes Mellitus. -was receiving hemodialysis (a treatment for ESRD that helps remove waste and excess fluid from the blood). -was receiving insulin injections. -required partial assistance with toileting, bathing, dressing and transfers. Record review of Resident 5’s Medication Administration Record (MAR) for June 2025 revealed an order for Lispro Insulin inject 8 units 3 times a day with meals and an order to complete a pre and post dialysis assessment on Mondays, Wednesdays, and Fridays. The MAR also revealed on 06-30-2025(a Monday) at 12:00PM the facility staff documented OF (Out of Facility) for the administration for of the Lispro insulin at 12:00 PM because Resident 5 was at dialysis. Record review of Resident 5’s MAR for July 2025 revealed an order for Lispro Insulin inject 8 units 3 times a day with meals and an order to complete a pre and post dialysis assessment on Mondays, Wednesdays, and Fridays. The MAR also revealed for the administration of the Lispro insulin at 12:00 PM the facility staff documented OF on the following dates: -07-02-2025(Wednesday), -07-04-2025 (Friday), -07-07-2025 (Monday), -07-09-2025 (Wednesday), -07-11-2025 (Friday), -07-14-2025 (Monday) -07-16-2025 (Wednesday). An interview conducted on 07-17-2025 at 2:46 PM with the Agency Nurse (AN) G for the [NAME] Wing of the facility revealed (gender) was unaware of who was responsible to administer insulin while residents were out of the facility for dialysis. Furthermore, AN G revealed the resident’s practitioner should be notified any time insulin is not given. An interview conducted on 07-17-2025 with the Unit Manager (UM) at 3:58 PM confirmed OF on the MAR meant the resident was not given the medication because the resident was out of the facility. Furthermore, staff did not notify Resident 5’s practitioner that the Lispro Insulin at 12:00 PM was not given in order to modify the insulin regimen. B. Record review of Resident 39’s MDS dated [DATE] revealed the facility staff assessed the following about the resident: -BIMS was scored at an 11. According to the MDS Manual a BIMS score of 8-12 indicates moderate cognitive impairment. -had a diagnosis of ESRD and Diabetes Mellitus. -was receiving hemodialysis. -was receiving insulin injections. -required substantial assistance with upper body dressing and bathing. -required total assistance with toileting, lower body dressing, bed mobility and transfers. Record review of Resident 39’s Medication Administration Record (MAR) for June 2025 revealed an order for Lispro Insulin inject 5 units 3 times a day with meals and an order to complete a pre and post dialysis assessment on Mondays, Wednesdays, and Fridays. The MAR also revealed an OF was documented at 12:00PM on the following dates: -06-02-2025 (Monday) -06-03-2025 (Tuesday) -06-04-2025 (Wednesday) -06-13-2025 (Friday) -06-16-2025 (Monday) -06-18-2025 (Wednesday) -06-20-2025 (Friday) -06-23-2025 (Monday) -06-25-2025 (Wednesday) -06-27-2025 (Friday) -06-30-2025 (Monday) Record review of Resident 39’s MAR for July 2025 revealed an order for Lispro Insulin inject 5 units 3 times a day with meals and an order to complete a pre and post dialysis assessment on Mondays, Wednesdays, and Fridays. The MAR also revealed for the administration of the Lispro insulin at 12:00PM the facility staff documented OF on the following dates: -07-02-2025(Wednesday), -07-04-2025 (Friday), -07-07-2025 (Monday), -07-09-2025 (Wednesday), -07-11-2025 (Friday), -07-14-2025 (Monday) -07-16-2025 Wednesday. An interview conducted on 07-17-2025 at 2:50 PM with Licensed Practical Nurse (LPN) H for the East Wing of the facility revealed (gender) was unaware of any residents with orders for insulin to be administered while residents were out of the facility for dialysis, and confirmed the resident’s practitioner should be notified if a dose of insulin was missed for any reason. An interview conducted on 07-17-2025 with the Unit Manager (UM) at 3:58 PM confirmed the facility staff did not notify Resident 39’s practitioner that the Lispro Insulin at 12:00 PM was not given on dialysis days and confirmed the facility had not notified the resident’s practitioner to modify the insulin regimen for dialysis residents. C. Record review of Resident 31's Order Summary Report on 7/17/25 revealed Resident 31 admitted to the facility on [DATE] with diagnoses including Atherosclerotic Heart Disease (plaque buildup on arterial walls), Ischemic Cardiomyopathy (a condition when the heart muscle is unable to effectively pump blood), Chronic Kidney Disease Stage 5 (most severe stage of kidney impairment), End Stage Renal (Kidney) Disease, Type 2 Diabetes Mellitus with other Diabetic Kidney Complication (occurs when the body cannot use insulin correctly and sugars builds up), Dependence on Renal Dialysis. Record review of Resident 31's Electronic Medication Administration Record (MAR) for July 2025 revealed a practitioner's order for Lispro Insulin, inject 13 units daily before breakfast related to diagnosis of Type 2 Diabetes Mellitus. Further review of July 2025 MAR's for Resident 31 revealed OF (indicating resident is out of facility) on July 2,4,11,14,16. The review further of Resident 31's medical record revealed the facility staff did not notify the practitioner of omitted (not given) insulin orders on days the resident went to dialysis. Resident 31 has dialysis every Monday, Wednesday, and Friday. An Interview on 07/17/2025 3:58 PM The Infection Preventionist (IP) confirmed, Resident 31 had not received scheduled insulin and the Medical Provider had not been notified of the omitted (not given) insulin on dialysis days. Dialysis days are Monday, Wednesday, and Friday.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on observation, record review and interview; the facility staff failed to manage pain for 1( Resident 50) of 1 sampled residents. The facility staff identified a census of 64. Findings are: Record review of an Order Summary Report sheet printed on 11-16-2022 revealed Resident 50 admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 50's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) dated 9-08-2022 revealed the facility staff assessed the following about Resident 50: -Resident 50's cognition was not able to be evaluated. -Resident 50 required extensive assistance with bed mobility, eating, toilet use, personal hygiene and bed mobility. - Pain assessment was not completed with Resident 50 as Resident 50 rarely/never understood. Record review of Resident 50's Comprehensive Care Plan (CCP) dated 10-31-2022 revealed Resident 50 had chronic pain related to arthritis. Interventions to manage Resident 50's pain included the following: -Anticipate Resident 50's need for pain relief and respond immediately to any complaints of pain. -Monitor/record/report to nurse and signs and symptoms of pain such as changes in breathing, grunts, moans or yelling out. -Notify Hospice if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. Record review of a Pain assessment sheet dated 10-11-2022 revealed Resident 50 had a terminal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 50's pain assessment dated [DATE] revealed Resident 50 was assessed as having consistent pain to joints and bones. Observation on 11-16-2022 at 8:50 AM of personal care revealed Nursing Assistant (NA) A and NA B donned gloves . NA A unfastened Resident 50's adult brief and positioned it between Resident 50's legs. NA A completed the frontal personal care for Resident 50. NA A and NA B moved Resident 50's left leg over the right in preparation of turning Resident 50 to the right laying position. Resident 50 moaned and yelled out Ohoo as the left leg was being placed over the right leg. Resident 50's breathing was observed to be heavy and short. NA A and NA B turned Resident 50 onto a right laying position resulting in resident stating Oh Jesus, Oh Jesus. Resident 50's face had furrowed brows and Resident 50 moaned. NA A and NA B did not stop the procedure and report to the nurse. NA A began cleansing Resident 50's buttock area with Resident 50 continuing to moan, groan with brows furrowed and deep grunting breaths. NA B rolled Resident 50 further over on the right laying position causing Resident 50 to yell out Oh Jesus, Oh Jesus with continued moaning. NA A completed cleansing of the buttock and with NA B repositioned the resident onto the left laying position with Resident 50 yelling out oh, oh. NA A and NA B did not stop the care and notify the nurse of the indications Resident 50 was in pain. NA B completed the care and with NA A applied a clean adult brief and positioned Resident 50 into a back laying position. NA A and NA B completed the personal cares and positioned Resident 50 up in bed. On 11-16-2022 at 9:10 AM an interview was conducted with NA A. During the interview NA A confirmed Resident 50 was in pain. NA A reported Resident 50 is always in pain and confirmed care should have been stopped and something given for pain for Resident 50. On 11-16-2022 at 9:10 AM an interview was conducted with NA B. During the interview NA B confirmed Resident 50 was in pain and NA B should have stopped care and Resident 50 should have been given pain medication. Record review of the facility Policy and Procedure for Pain Management dated 11-2017 revealed the following: -Policy: -The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person centered care plan, and the residents goal and preferences. -Policy Explanation and policy guidelines: -#2. Behavioral signs and symptoms that may suggest the presence of pain include but are not limited to the following: -Facial expressions, grimacing, frowning, fear, grinding teeth, groaning, breathing heavily. -Monitoring: -#2. If re-assessment findings indicate pain is not adequately controlled, revise the pain management regimen and plan of care as indicated.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on observation, record review and staff interview; the facility Quality Assessment Performance Improvement Plan (QAPI) failed to identify ongoing issues relevant to F680, F690, F756, F758, F759, F760, F803 and F867 and implement plans of action to identify and correct the deficient practice. The QAPI failed to ensure repeated deficiencies at F697, F812 and F880 were corrected and the correction maintained. This deficient practice had the potential to affect all residents who reside in the facility. The facility staff identified a census of 64. Record review of the facility Quality Assurance and Performance Improvement (QAPI) Policy and Procedure dated 11-2017 revealed the following information: -Policy: -It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. -#10. All identified problems will be address and prioritized, whether by frequency of data collection/monitoring or by the establishment of sub-committees. Considerations include, but are not limited to High-risk, high-volume, or problem-prone areas. -The facility will conduct at least one distinct performance improvement project (PIP) annually. Additional project may be conducted as needed, and may be clinical or non-clinical. On 11-17-2022 at 10:10 AM an interview was conducted with the facility Administrator. During the interview review of the potential citations identified on the facility survey starting 11-14-2022 were reviewed. The facility Administrator reported the QAPI committee had not identified the areas for the potential citation as identified in the above information. During the interview the facility Administrator reported staff are informed by a variety of ways including a bulletin board by the receptionist station. Observation on 11-17-2022 of the bulletin Board for staff information on ongoing activities in QAPI revealed the identified areas were Infection Control, Advance Directives, falls, staffing, MD visits and the QAPI program. On 11-17-2022 at 10:45 AM an interview was conducted with the Director of Nursing (DON). During the interview the DON reported having 1 PIP (Process Improvement Project) in progress related to monthly resident assessments. The facility staff were not able to provide additional information about the QUAPI prior to the exit from the facility on 11-17-2022.

LICENSURE REFERENCE NUMBER 175 NAC ,d+[DATE].02 Based on observations, record review, and interviews; the facility administration failed to ensure effective management of facility resources to maintain the highest practical well being of residents and the facility environment as evidenced by 1) failure to implement an effective plan of action to maintain correction for cited areas of deficient practice, 2) failure to implement plans of action to identify multiple issues of deficient practice. The facility staff identified a census of 60. Findings are: Review of the following information revealed: -F678, the facility staff failed to perform Cardiopulmonary Resuscitation (CPR) for 1 (Resident 3) of 1 resident, failed to identify a residents Advance Directive (AD) upon admission for 2 (Resident 3 and 8) of 2, failed to ensure residents medical records matched residents AD for 3 (Resident 3, 8 and 9) of 4 sampled residents, failed to ensure the facility transportation drive was CPR certified and failed to have a facility process that identified each resident AD and where the location of the information well be located. B. On [DATE] at 7:00 AM an interview was conducted with the facility Administrator. During the interview the Administrator reported being aware of issues with Advance Directive information and accuracy and did not implement a plan of action due to the Director of Nursing and Assistant Director of nursing working the floor. -F689, the facility staff failed to identify and implement interventions to prevent falls resulting in harm for a resident. -F712, the facility staff failed to ensure residents had a physician visit every 30 days for the first 90 days and then every 60 days thereafter. -867, the facility Quality Assessment and Performance Improvement (QAPI) program failed to identify ongoing issues relevant to F678, F689, F712 and F880 and implement plans of action to identify and correct the deficient practice. F947, the facility staff failed to ensure 7 (Nursing Assistants (NA) had completed continuing education for Infection Control, Dementia and Abuse and neglect. F655, the facility staff failed to develop a base line care plan for a newly admitted resident.

LICENSURE REFERENCE NUMBER 175 NAC ,d+[DATE].09 Based on record review and interview; the facility staff failed to perform Cardiopulmonary Resuscitation (CPR) for 1 (Resident 3) of 1 resident, failed to identify a residents' Advance Directive (AD) upon admission for 2 residents (Resident 3 and 8), failed to ensure residents' medical records matched residents' AD for 3 residents (Resident 3, 6, 8 and 9), failed to ensure the facility transportation driver was CPR certified, and failed to have a facility process that identified each residents' AD and where the location of the information was located. The facility failure had the potential to affect all residents in the building. The facility staff identified a census of 60. Findings are: A. Review of Resident 3's electronic record revealed Resident 3 admitted to the facility on [DATE]. Further review of Resident 3's electronic record revealed Resident 3's dashboard (first screen that opens when selecting the resident) revealed Resident 3's AD status was not identified. Record review of Resident 3's AD signed [DATE] revealed Resident 3 was a 'Full Code. According to Resident 3's AD signed on [DATE] a full code was described as I understand that if my heart stops beating, or is inadequate, or that if I stop breathing or my breathing is inadequate, all resuscitation procedures will be provided initiated. The process can include chest compression,intubation, and defibrillation and is referred to as CPR. Record review of Resident 3's Progress Note (PN) dated [DATE] with a time of 8:40 AM revealed Resident 3 was found laying face down on the floor and did not respond when Resident 3's name was called. According to Resident 3's PN dated [DATE] and timed at 8:40 AM, Resident 3 was warm to touch but has no palp (palpatiable) pulse or resp (respirations). Is a DNR (Do Not Resuscitate). On [DATE] at 7:57 AM an interview was completed with Registered Nurse (RN) A. During the interview RN A reported being the nurse on duty and being notified Resident 3 was on the floor. RN A confirmed Resident 3 was found without a pulse and was not breathing. RN A confirmed CPR was not initiated for Resident 3. RN A reported during the interview, there was not information in Resident 3's electronic record that identified Resident 3's AD. RN A further reported the facility did not have a process in place to determine a resident's AD upon admission. On [DATE] at 2:05 PM an interview was conducted with the Assistant Director of Nursing (ADON). During the interview the ADON reported would look at the resident's Dash Board for their code status. On [DATE] at 2:05 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON reported would look at the resident's AD for their code status. On [DATE] at 11:00 AM an interview was conducted with the facility DON. During the interview the DON confirmed Resident 3's AD was not identified in the resident's record and further confirmed Resident 3 should have had CPR initiated. B. Record review of Resident 9's electronic Dash Board revealed Resident 9 identified code status was a full code. Record review of Resident 9's medical record revealed a consent form dated [DATE] which showed Resident 9 was a Do Not Resuscitate (DNR). Record review of Resident 9's Comprehensive Care Plan (CCP) dated [DATE] revealed Resident 9 was identified as being a Full Code. On [DATE] at 6:59 AM an interview was conducted with the DON. During the interview the DON confirmed Resident 9 was a DNR and Resident 9's dash board and CCP was not correct. C. Record review of a undated Nursing Report (NR) sheet revealed Resident 6 was a DNR. Record review of Resident 6's electronic Dash Board and Resident 6's AD dated [DATE] identified Resident 6 as wanting CPR. On [DATE] at 5:52 AM an interview was conducted with RN B. During the interview RN B reported would look at the NR sheet for code status, if not there would look at a dash board. RN B confirmed the NR sheet identified Resident 6 as a DNR. RN B reported not being sure of what the process was for identifying a resident AD . D. Record review of Resident 8's electronic record revealed Resident 8's Dash Board identified Resident 8 as a full Code and admitted on [DATE]. Further review of Resident 8's electronic medical record revealed there was not an AD to identify Resident 8's directions for CPR. On [DATE] at 7:52 AM an interview was conducted with the DON. During the interview the DON reported there was not an AD for Resident 8 and reported staff would not know what to do for Resident 8. The DON reported the facility does not have a process to identify what the residents AD are. Record review of a AD completed on [DATE] revealed Resident 8 was a DNR. E. On [DATE] at 4:14 PM an interview was conducted with the facility Van Driver (VD) C. During the interview VD C reported transporting residents to appointments such as doctors offices and other facility staff did not always go along. VD C stated no when asked if VD C was CPR certified. F. Record review of the facility Policy for Advance Directive revised ,d+[DATE] revealed the following information: -Policy Statement: -Advance Directives will be respected in accordance with state law and facility policy. -Policy Interpretation and Implementation: -1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he/she chooses to do so. -3. If the resident is incapacitated and unable to receive information about his/her right to formulate an advanced directive, the information may be provided to the residents legal representative. -6. Prior to or upon admission of a resident, the Social services Director or designee will inquire of the resident his/her family members and/or his/her legal representative, about the existence of any written advance directive. -7. Information about weather or not the resident has executed an advance directive shall be prominently in the medical record. G. On [DATE] to abate the immediacy of the situation the facility provided the following plan: - Process/Steps to identify others having the potential to be impacted by the same deficient practice: -All staff including agency are educated on the CPR policy with the focus on checking chart-electronic medical record for code status (Dashboard). Assure that no one works until educated on this policy. Competency test will follow. -Sweep of all residents charts to see that advance directives/code status match what is in PCC ( Point Click Care, electronic charting system) and Care Planned all area of chart match. -Audit to assure all nurses and necessary ancillary staff (van driver) are CPR certified and current. -Measures put in to place/systemic changes to ensure the deficient practice does not recur: -Admission Coordinator educated on obtaining advance directives on admission with immediate upload to PCC. -Medical Records will upload final signed copy into miscellaneous. -Assistant Director of Nursing (ADON) or Designee (Director of Nursing ) will be notified of advance directives upon admission to place an order in PCC on the dashboard. -Clinical Stand-up will be initiated to include code status follow up and verification. -Resuscitation Policy reviewed and revised for updated procedure. -Quarterly Education to all staff on resuscitation policy. -CPR certified staff member to accompany van driver on all resident transport initiated immediately. -Papio transport will be arranged for all appointments until greater plan is secured to assure van driver or an accompany is CPR certified. -Plan to monitor performance to ensure solutions are sustained: -Random audits of 6 CPR certified staff questioning procedure when finding a resident without a pulse and respirations. Weekly audit X's 4 weeks for 1 month, then monthly X's 3. -Daily audit in clinical start up to assure code status is accurate in PCC, care plan, dashboard, etc on-going. -On going mock code drills. -The plan of correction will be reviewed monthly by QAPI committee for the next 3 months and longer if needed.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18 Based on observation, record review and interview; the facility staff failed to identify and implement interventions to prevent falls for 5 (Resident 2, 4, 5, 6, and 7) of 5 residents. The facility staff identified a census of 60. Findings are: A. Record review of Resident 4's Comprehensive Care Plan (CCP) dated 5-13-21 revealed Resident 4 was at risk for falls due to a history of fall with a fracture, had cognitive impairment and did not always understand safety issue. Further review of Resident 4's CCP revealed a dated entry of 2-22-2022 that identified Resident 4 as a fall risk related to Dementia and impulsivity, in addition as to not have safety awareness. The goal identified for Resident 4 was not to have a major injury from a fall dated 2-25-2022. Interventions identified on Resident 4's CCP to archive this goal included Resident 4's bed to remain in the lowest position at all times except during checking and changing Resident 4, provide a matt on the floor and to user a scoop mattress on the bed with a initiated date of 8-16-2021 and revised on 3-04-2022. Record review of a facility investigation dated 5-06-2022 revealed Resident 4 was found on the floor with a baseball sized pool of blood on the floor next to Resident 4's right side of the head. Further review of the investigation dated 5-06-2022 revealed Resident 4 had a laceration on the right forehead resulting in Resident 4 being sent to the emergency room resulting in Resident 4 receiving 5 stitches to the right eye brow. Further review of the investigation dated 5-06-2022 revealed a scoop mattress was placed onto resident 4's bed. Observation on 6-27-2022 at 1:10 PM revealed Resident 4's bed was at waist height and not in the lowest position and no mat was on the floor. Observation on 6-28-2022 at 10:15 AM revealed Resident 4 was in bed and the bed positioned at waist height. On 6-28-2022 at 10:15 AM an interview was conducted with Nursing Assistant (NA) D. During the interview NA D confirmed Resident 4's bed was not in the lowest position and lowered the bed to the lowest setting. On 6-28-2022 at 3:45 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON reported Resident 4's bed did not have a scoop mattress on the bed when Resident 4 was found on the floor 5-06-2022. Review of Resident 4's CCP was conducted with the DON. The DON confirmed Resident 4 should have had the scoop mattress on the bed prior to the fall on 5-06-2022. B. Record review of a facility investigation dated 4-06-2022 revealed Resident 2 was found laying on the floor with blood on the floor. According to the investigation dated 4-06-2022 it .appeared resident rolled out of be [NAME] in a high position. According to the investigation, Resident 2 sustained a laceration above the right eye that measured 2 centimeter (cm's). On 6-28-2022 at 3:54 PM an interview was conducted with the DON. During the interview the DON reported Resident 2 had been on hospice and has since discharged from the facility. The DON reported during the investigation, Resident 2 had fallen from the bed in a high position and should have been in the lowest position. C. Record review of Resident 5's medical record revealed Resident 5 had discharged from the facility on 6-15-2022. Record review of Resident 5's CCP dated 12-15-2020 and revised on 3-24-2022 revealed Resident 5 was at risk for falls related to weakness and a unsteady gait. The goal identified for Resident 5 was to have no falls through the next review. Interventions identified on Resident 5's CCP included a scoop mattress, work with therapy and 1 person assist with transfers. Record review of an incident report dated 5-15-2022 revealed Resident 5 was found in another residents room on the floor. According to the incident report dated 5-15-2022 a new intervention to prevent falls was to increase frequency of eye on Resident 5 every 30 minutes. Record review of an incident report dated 5-23-2022 revealed Resident 5 was lying on the floor in the hallway and socks were wet with urine. The intervention identified on the incident report dated 5-23-2022 was that a toileting schedule was implemented. Record review of an incident report dated 6-05-2022 revealed Resident 5 was on the floor. Further review of the incident report revealed there were no additional interventions implemented to prevent further falls. Review of Resident 5's medical record revealed there was no information identified that the 30 minutes checks had been completed or that Resident 5 was placed onto a toileting program. On 6-27-2022 at 1:20 PM an interview was conducted with the DON. During the interview the DON reported the inability to locate the 30 minute checks. On 6-28-2022 at 4:04 PM a follow up interview was conducted with the DON. During the interview the DON reported a toileting program for Resident 5 had not been completed and no additional interventions were implemented for the fall on 6-05-2022. D. Record review of Resident 6's CCP dated 4-19-2021 and revised on 5-23-2022 revealed Resident 5 was at risk for falls. The goal identified for Resident 6 was not to have any falls resulting in injury. The intervention to meet this goal included a scoop mattress, bed locked in the lowest position and fall mats to be placed. Observation on 6-27-2022 at 1:00 PM revealed Resident 6's bed did not have a scoop mattress in place. Observation on 6-28-2022 at 10:50 AM revealed Resident 6 was in bed. Resident 6 did not have a scoop mattress and did not have the fall mats in place for Resident 6. On 6-28-2022 at 11:00 AM an interview was conducted with the DON. During the interview, observation of Resident 6 room was completed. The DON confirmed Resident 6 did not have a scoop mattress in place or a fall mat. E. Record review of Resident 7's CCP revealed Resident 7 had actual falls on 4-14-2021 and 1-07-2021. The goal identified for Resident 7 was to resume usual activities without further incident. intervention identified to meet this goal included non skid pads on floor and bed in lowest position except during check and change. Observation on 6-27-2022 at 1:05 PM revealed Resident 7 was seated in wheelchair with the bed at waist height. Observation on 6-27-2022 at 2:20 PM revealed Resident 7 was in bed and the bed was positioned at waist height. Observation on 6-28-2022 at 5:50 AM revealed Resident 7 was in bed and the bed was at waist height. Observation on 6-28-2022 at 10:15 AM revealed Resident 7 bed was at waist height. On 6-28-2022 at 10:15 AM an interview was conducted with NA E. During the interview NA E confirmed Resident 7's bed was not in the lowest position.

Title 175 NAC 12-006.09D Based on observations, interviews, record review, and review of policy and procedures, the facility failed to have an effective pain management program for two (Resident 55 and Resident 26) of six residents reviewed for pain. Specifically, the facility failed to evaluate Resident 55's and Resident 26's complaints of increased pain, provide non-pharmacological and pharmacological interventions to relieve Resident 55's and Resident 26's pain, and administer pain medications as ordered and in a timely manner for Resident 55 and Resident 26. This failure resulted in Resident 55 having unnecessary, unrelieved pain on a daily basis. The facility census was 67. Findings are: A. A review of the Face Sheet indicated the facility admitted Resident 55 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS) assessment, dated 09/25/2021, indicated the resident had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 12 out of 15. The MDS indicated the resident required supervision to limited assistance of one person for their activities of daily living (ADL). The resident had pain almost constantly that made it hard to sleep at night and limited day-to-day activities. The resident received scheduled and as-needed pain medication but no non-medication interventions for pain. The resident rated their worst pain over the last five days of the assessment period at a 9 on a scale of 1-10. The resident received an opioid seven out of seven days during the assessment period. A review of the comprehensive care plan, dated 01/08/2021, revealed Resident 55 was at risk for pain due to arthritis and PVD. The goal was for the resident to verbalize their pain was controlled. Interventions included to keep the physician and family aware of pain management, conduct a pain assessment as needed, verbally ask the residents pain level at least two times a day, administer pain medication as ordered, apply topical patch for pain as needed (PRN), and report objective signs or voiced complaints of pain to charge nurse for further evaluation. During an interview with Resident 55 on 11/01/2021 at 10:40 AM, the resident stated they were having severe back pain and had been waiting all morning for their routine pain medications. The resident was sitting on the edge of the bed and was observed to be uncomfortable by rocking back and forth on the bed and attempting to adjust their position. The medication aide (MA)-B was notified at 10:45 AM and stated they were going to give Resident 55's medication next. At 11:15 AM, the MA-B had not yet entered Resident 55's room with the resident's medications. During an interview with Resident 55 on 11/02/2021 at 10:20 AM, the resident stated they were waiting to get their morning medications, which included their pain medications. Resident 55 stated their pain was not managed on the medications the staff were giving. The resident stated they had chronic low back pain but approximately three months ago their shoulders started hurting, the right more than the left. The resident stated they had not had any falls or any other trauma. The resident stated they got [MEDICATION(S)] every 12 hours, but it wore off before the next dose was due and that was why the resident requested the PRN oxycodone every evening. Resident 55 stated the [MEDICATION(S)] seemed to help better than anything, so the staff left it in the room for the resident to be able to apply it themself. The resident stated they did not know they had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 55 stated they were not happy with the physician at the facility and wanted to see the physician at the Veteran Affairs (VA). A review of the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] 4% patch. Apply one patch to the skin once daily to painful area, for back pain, and remove after 12 hours. This was ordered 07/07/2021. - [MEDICATION(S)] 15 milligrams (mg). Take one tablet by mouth once daily for inflammation. This was ordered 07/06/2021. - [MEDICATION(S)] sulfate extended release (ER) 15 mg. Take one tablet by mouth twice daily for pain. This was ordered 08/13/2021. - Acetaminophen 500 mg. Take two tablets by mouth three times daily for pain. This was ordered 03/29/2021 - Acetaminophen 325 mg. Take two tablets by mouth every four hours as needed for pain.This was ordered 09/17/2021. - Acetaminophen suppository 650 mg. Insert one suppository rectally every four hours PRN for pain. This was ordered 02/17/2021. - Muscle rub cream 10-15%. Apply to back and shoulders twice daily PRN. May keep at bedside and self-apply for pain. This was ordered 08/26/2021. - Oxycodone immediate release (IR) 5 mg. Take one tablet by mouth once daily as needed for pain. This was ordered 07/06/2021. - [MEDICATION(S)] 1 % gel. Apply two grams to bilateral shoulders twice daily and apply four grams to lower back twice daily. This was ordered 08/02/2021. - Pain rating twice daily: ask resident if having pain, if pain present have resident rate or use PAINAD (pain assessment in advanced dementia) scale and follow up accordingly every, This was ordered 05/26/2021. A review of the October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - One tablet of [MEDICATION(S)] sulfate 15 mg was scheduled to be administered at 8:00 AM and 8:00 PM. - Two tablets of acetaminophen 500 mg were scheduled to be administered at 8:00 AM, 12:00 PM and 5:00 PM. - No PRN acetaminophen was documented as being administered for the month of October 2021. - The muscle rub cream was not administered in the month of October 2021. - The PRN oxycodone was administered every evening for pain rated between 7 and 10, and the effectiveness was documented as being ineffective 26 out of 31 times it was administered. A review of the record revealed no documentation of non-pharmacological interventions being attempted prior to the PRN pain medication being administered and no documentation of any follow up being done to address the resident's continued complaint of unrelieved pain. A review of the controlled drug administration record for Resident 55's [MEDICATION(S)] sulfate 15 mg from 10/17/2021 through 11/03/2021 revealed the following: - On 10/23/2021, one tablet was signed out at 10:00 AM (two hours after it was scheduled to be administered). - On 10/25/2021, one tablet was signed out at 9:03 PM (over an hour after it was scheduled to be administered.) - On 10/26/2021, one tablet was signed out at 10:00 PM (two hours after it was scheduled to be administered). - On 10/27/2021, one tablet was signed out at 9:19 PM (over an hour after it was scheduled to be administered). - On 10/30/2021, no time was documented when one tablet was signed out. - On 10/31/2021, one tablet was signed out at 10:53 AM (almost three hours after it was scheduled to be administered). - On 11/01/2021, no time was documented when one tablet was signed out. - On 11/02/2021, one tablet was signed out at 10:39 AM (over two and a half hours after it was scheduled to be administered). During an interview with Registered Nurse (RN) B on 11/04/2021 at 9:42 AM, the RN stated if a resident's pain medication was not relieving their pain, other medications the resident had ordered should be tried. If they still were not effective, then the physician should be contacted. She stated they did use non-pharmacological interventions also such as repositioning, but they did not document it anywhere. During an interview with MA-B on 11/04/2021 at 2:04 PM, the QMA stated that if a resident was not obtaining pain relief with the routine medications they were receiving, then as-needed (PRN) medications should be used along with non-pharmacological interventions such as heat and ice or repositioning. MA-B stated if the resident was still having pain, the physician should be notified. MA-B stated routine medication could be given from an hour before to an hour after it was due. Otherwise, it was considered a medication error. During an interview with Licensed Practical Nurse (LPN) B on 11/04/2021 at 2:10 PM, the LPN stated a resident's pain level should be evaluated every shift, with every medication pass, and as needed (PRN). They said the resident should be able to tell them what the resident's acceptable pain level was, and if they were not able to then the LPN assumed it was a 0. LPN B stated the resident's pain level should be reevaluated approximately an hour after medication was administered to determine the effectiveness. If the resident was still having pain, then non-pharmacological interventions should be attempted such as repositioning, adding pillows, ice, and heat. If that was not effective, then other medications should be tried if the resident had an order. If not, the physician should be contacted. LPN B stated every resident's pain level was different, and they had to go by what the resident was telling them. During an interview with MA-A on 11/04/2021 at 2:20 PM, the MA stated if a resident was still having pain after receiving medication, then they would give the resident something else if the resident had orders, or if the resident had a routine pain medication that was due soon, they would just wait to administer the routine dose. If the resident did not have any other medications to administer, the MA would notify the charge nurse. MA-A stated medication could be given from an hour before to an hour after it was scheduled. If it was given outside of that time frame, the physician should be notified. During an interview with the Director of Nursing (DON) on 11/04/2021 at 2:59 PM, the DON stated scheduled medications could be given from an hour before to an hour after they were scheduled. If they were given outside of this time frame, depending on the medication and how often it was ordered, the physician should be notified for further instructions. The DON stated any time a resident continued to complain of pain after receiving pain medication, the resident should be reassessed, provided non-pharmacological interventions, and offered other medications if they had orders for them. If the resident continued to have pain, the physician should be contacted for further instructions. The DON stated Resident 55 always rated their pain a 10 out of 10, even after receiving pain medication, and the DON felt it was more behavioral attention seeking than actual pain. The DON stated the staff should be documenting non-pharmacological interventions that they try with the resident. During an interview with the Administrator (ADM) on 11/04/2021 at 3:38 PM, they stated staff should be trying non-pharmacological interventions along with medications to relieve a resident's complaints of pain, and if they were not able to relieve the resident's pain, the physician should be notified for further recommendations. A review of the facility's policy titled, Pain-Clinical Protocol, last revised 03/2018, indicated, The physician will order appropriate non-pharmacological and medication interventions to address the individual's pain. Generally, and to the extent possible, an [MEDICATION(S)] regimen should utilize the simplest regimen and lowest risk medications before using more problematic or higher risk approaches. Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions, for example, local heat or ice, repositioning, massage, and the opportunity to talk about chronic pain .The staff will reassess the individual's pain and related consequences at regular intervals, at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Periodically the physician will evaluate and summarize the status of an individual with chronic or fluctuating pain including the status of any active conditions that exacerbate pain, consequences or complications of pain and effectiveness of current interventions for pain. If the resident's pain is complex or not responding to standard interventions, the attending physician may consider additional consultative support. B. A review of the Face Sheet revealed the facility admitted Resident 26 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) assessment, dated 08/31/2021, indicated Resident 26 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 6 out of 15, and behaviors included inattention and disorganized thinking that fluctuated, verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others that occurred one to three days during the assessment period. The resident was dependent on one to two staff for all activities of daily living (ADL). The resident was always incontinent of bowel and bladder. The resident received scheduled pain medication but not as-needed (PRN) pain medication or non-pharmacological interventions for pain. The resident complained of pain occasionally, rated 2 on a scale of 0-10. The resident received an opioid seven days during the assessment period. A review of Resident 26's comprehensive care plan, dated 01/08/2021, indicated the resident had chronic pain and took scheduled opioid pain medication. The goal was for the resident to verbalize relief of pain. Interventions included to do a pain assessment daily and as needed (PRN), consider physical therapy (PT) and occupational therapy (OT) to treat pain modalities, administer medications and treatments per the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a pain tool, dated 08/30/2021 but not signed as being completed until 10/03/2021, did not indicate the resident's acceptable level of pain or location of pain. The face pain scale was used, and it indicated the resident currently had no pain but was rated Hurts Even More when pain was at its least and affected the resident's sleep and rest, social activities, appetite, physical activity and mobility, emotions, and intimacy. The tool indicated medication made it feel better and was the only intervention listed. A review of a Pain in Advanced Dementia (PAINAD), dated 10/03/2021, indicated a score of four. It indicated total scores ranged from 0 to 10, with a higher score indicating more severe pain. According to the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Acetaminophen 500 milligrams (mg). Take two tablets (1,000 mg) by mouth twice daily for pain. This was ordered 09/13/2020. - [MEDICATION(S)] 10 mg. Take half of a tablet (5 mg) by mouth three times daily for muscle spasms. This was ordered 09/13/2020. - [MEDICATION(S)] 100 mg. Take one capsule by mouth three times daily for pain. This was ordered 09/13/2020. - Oxycodone immediate release (IR) 5 mg. Take two tablets (10 mg) by mouth every six hours scheduled for pain. This was ordered 09/13/2021. - [MEDICATION(S)] patch 100 micrograms (mcg) per hour. Apply one patch every 72 hours for pain. This was ordered 08/16/2021. - Bio-freeze 4% gel. Apply topically to upper back three times daily as needed for pain. This was ordered 10/08/2021. - Acetaminophen 325 mg. Take two tablets by mouth every six hours as needed (PRN) for pain. This was ordered 09/13/2020. A review of the October 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] - The resident received PRN acetaminophen on 10/22/2021 at 12:45 PM after receiving their scheduled oxycodone IR 10 mg at 12:00 PM for pain rated 10 and was documented as being ineffective at 1:31 PM. The resident continued to rate their pain at an eight. A review of the record revealed no further interventions, non-pharmacological or pharmacological, were offered to the resident to relieve their pain. - The resident received PRN acetaminophen on 10/27/2021 at 9:57 AM for pain rated at an eight and their routine oxycodone IR 10 mg at 11:00 AM. The resident's pain was documented as being ineffective at 11:23 PM, and the resident continued to rate their pain at a five. A review of the record revealed no further interventions, non-pharmacological or pharmacological, were offered to the resident to relieve their pain. - The Bio-freeze was never documented as being utilized during the month of October 2021. A review of the controlled drug administration record for Resident 26's oxycodone IR 5 mg from 09/28/2021 through 11/03/2021 revealed the following: - On 09/29/2021 no tablets were signed out for the 12:00 AM scheduled dose. - On 09/30/2021 the 6:00 PM dose was signed out at 7:26 PM. - On 10/01/2021 no tablets were signed out for the 12:00 AM scheduled dose. - On 10/02/2021 the 6:00 PM dose was signed out at 4:00 PM. - On 10/09/2021 the 6:00 PM dose was signed out at 4:51 PM. - On 10/10/2021 only one tablet was signed out for the 6:00 PM dose instead of the ordered two tablets. (A medication error report was completed). - On 10/14/2021 only one tablet was signed out for the 6:00 AM dose instead of the ordered two tablets. (No medication error report was completed.) No tablets were signed out as being administered for the 12:00 PM dose. - On 10/20/2021 the 6:00 PM dose was signed out at 4:42 PM. - On 10/30/2021 the 12:00 PM dose was signed out at 1:43 PM, and then the 6:00 PM dose was signed out at 5:05 PM (less than three and a half hours after the last dose was given). During an interview with Resident 24, who was Resident 26's roommate, on 11/01/2021 at 1:35 PM, the resident stated they had put on the call light for Resident 26 when they were in pain and had to wait over 40-45 minutes for the staff to bring their roommate pain medication. An observation of Resident 26 on 11/04/2021 at 9:28 AM revealed the resident was lying in bed with the head of the bed up 90 degrees. The resident had a pained expression on their face and verbalized pain, rated 10 out of 10. MA-A was notified. A review of the November 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MA documented the medication as being ineffective at 10:32 AM and the resident rated their pain eight out of 10. An administration progress note indicated the resident would be given their routine pain medication at 11:00 AM. No other interventions, non-pharmacological or the bio-freeze, was offered. During an interview with Certified Nurse Aide (CNA) I on 11/04/2021 at 9:32 AM, the CNA stated Resident 26 frequently said they were in pain and would yell out. CNA I stated they would notify the MA so the MA could give the resident some medication. CNA I stated they would also go in and reposition the resident to try and make them more comfortable. During an interview with Registered Nurse (RN) B on 11/04/2021 at 9:42 AM, the RN stated if a resident's pain medication was not relieving their pain, other medications the resident had ordered should be tried. If they still were not effective, then the physician should be contacted. She stated they did use non-pharmacological interventions also such as repositioning, but they did not document it anywhere. During an interview with MA-B on 11/04/2021 at 2:04 PM, the MA stated that if a resident was not obtaining pain relief with the routine medications they were receiving, then as-needed (PRN) medications should be used along with non-pharmacological interventions such as heat and ice or repositioning. M- B stated if the resident was still having pain, the physician should be notified. MA-B stated routine medication could be given from an hour before to an hour after it was due. Otherwise, it was considered a medication error. During an interview with Licensed Practical Nurse (LPN) B on 11/04/2021 at 2:10 PM, the LPN stated a resident's pain level should be evaluated every shift, with every medication pass, and as needed (PRN). They said the resident should be able to tell them what the resident's acceptable pain level was, and if they were not able to then the LPN assumed it was a 0. LPN B stated the resident's pain level should be reevaluated approximately an hour after medication was administered to determine the effectiveness. If the resident was still having pain, then non-pharmacological interventions should be attempted such as repositioning, adding pillows, ice, and heat. If that was not effective, then other medications should be tried if the resident had an order. If not, the physician should be contacted. LPN B stated every resident's pain level was different, and they had to go by what the resident was telling them. During an interview with MA-A on 11/04/2021 at 2:20 PM, the MA stated if a resident was still having pain after receiving medication, then they would give the resident something else if the resident had orders, or if the resident had a routine pain medication that was due soon, they would just wait to administer the routine dose. If the resident did not have any other medications to administer, the MA would notify the charge nurse. MA-A stated medication could be given from an hour before to an hour after it was scheduled. If it was given outside of that time frame, the physician should be notified. During an interview with the Director of Nursing (DON) on 11/04/2021 at 2:59 PM, the DON stated scheduled medications could be given from an hour before to an hour after they were scheduled. If they were given outside of this time frame, depending on the medication and how often it was ordered, the physician should be notified for further instructions. The DON stated any time a resident continued to complain of pain after receiving pain medication, the resident should be reassessed, provided non-pharmacological interventions, and offered other medications if they had orders for them. If the resident continued to have pain, the physician should be contacted for further instructions. The DON stated Resident 26 always rated their pain a 10 out of 10, even after receiving pain medication, and the DON felt it was more behavioral attention seeking than actual pain. The DON stated the staff should be documenting non-pharmacological interventions that they try with the resident. During an interview with the Administrator (ADM) on 11/04/2021 at 3:38 PM, they stated staff should be trying non-pharmacological interventions along with medications to relieve a resident's complaints of pain, and if they were not able to relieve the resident's pain, the physician should be notified for further recommendations. A review of the facility's policy titled, Pain-Clinical Protocol, last revised 03/2018, indicated, The physician will order appropriate non-pharmacological and medication interventions to address the individual's pain. Generally, and to the extent possible, an [MEDICATION(S)] regimen should utilize the simplest regimen and lowest risk medications before using more problematic or higher risk approaches. Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions, for example, local heat or ice, repositioning, massage, and the opportunity to talk about chronic pain .The staff will reassess the individual's pain and related consequences at regular intervals, at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Periodically the physician will evaluate and summarize the status of an individual with chronic or fluctuating pain including the status of any active conditions that exacerbate pain, consequences or complications of pain and effectiveness of current interventions for pain. If the resident's pain is complex or not responding to standard interventions, the attending physician may consider additional consultative support.

Licensure Reference Numbers 175 NAC 12-006.10, 12-006.09D8b, 12-006.09D Based on observation, interview and record review; the facility failed to ensure facility staff competencies were completed to care for residents with tracheostomies for 2 resident (Resident 2 and 3), enteral feedings for 3 residents (Residents 2, 3 and 5), and medication administration. This had the potential to affect all residents in the facility. The facility census was 70. Findings are: Record review of yearly staff competencies revealed the facility was unable to provide documentation that competencies had been completed. Record review of the undated Facility Assessment revealed that the Facility Assessment contained information that staff should be trained and competent in the following areas: Nursing Department Competency Training included: - Medication Administration - 3 checks of each med with the 5 rights and training on each route according to role, including training on portable oxygen tanks and cylinders, and IV procedures. -Specialized care: Cardiac care, Alzheimer's or other dementia care, catheterization insertion/care, [CONDITION(S)] care, diabetic blood glucose testing, 02 (oxygen) administration, suctioning, pre-op and post-op care, [CONDITION(S)] care/suctioning, tube feedings, wound care/dressings, Hospice or palliative care. -Communication: methods of communication and appropriate response to residents. An Interview on 11/12/20 at 1:33 PM with NC (Nurse Consultant) revealed the current administration was unable to locate the education related to the [CONDITION(S)] education, enteral tube feeding education, cough machine education, and Medication administration education. The abatement was received on 11/12/20 and was sent to the Program Manager LTC Facility and was approved. All licensed nursing staff will have competency completed on [CONDITION(S)] care, g tube and enteral tube feedings. All licensed nursing staff will be have this completed before their next worked shift. All licensed nursing staff and medication aide staff will be competencies on medication administration before their next worked shift. If the staff member refuses to compete competencies the staff member will be suspended and/or terminated. See attached Competency Packet.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D6 Based on observation and interviews, the facility failed to ensure supplies necessary to care for a 2 residents (Resident 3 and Resident 2) with a [CONDITION(S)] were available prior to the admission of a resident with a [CONDITION(S)] (an incision in the windpipe made to relieve an obstruction to breathing). Facility census was 70. Findings are: A. An observation on 11/12/20 at 09:47 AM revealed Resident 3 to have oxygen connected directly to the external [CONDITION(S)] tube and being held in place with tape. An interview on 11/12/20 at 09:47 AM with Resident 3 revealed that the night nurse had taped the oxygen tubing to the external [CONDITION(S)] tube as the facility did not have an adapter. An interview on 11/12/20 at 09:47 AM with LPN-A (Licensed Practical Nurse) revealed that the facility did not have the supplies needed to care for residents who were admitted with tracheostomies. An interview with the facility Administrator on 11/12/20 at 1:30 PM revealed that the facility admissions coordinator was unaware of the need to ensure supplies were available prior to admitting residents with special needs. An observation on 11/12/20 at 3:30 PM revealed that the facility Administrator had received 3sets of [CONDITION(S)] supplies that had been borrowed from another facility, for each resident with a [CONDITION(S)] and more supplies had been ordered. B. Record review of Resident 2's PN (Progess Notes) dated 11/6/2020 at 7:16 PM revealed that at 5:40 PM family was called and talked to Resident 2. Resident 2 held phone up to ear. Resident 2 reached down and pulled out [CONDITION(S)]. Resident 2 hits and fights staff when the staff try to reinsert. 5:45 PM, Staff member talked to Resident 2 in preferred language. Resident 2 was turning blue but also took in breaths thru nose. 5:50 PM, Resident 2 allowed this RN (Registered Nurse) to attempt to put [CONDITION(S)] in. No success. Smaller size was inserted small amount and then would go no further. Has breath coming out tube. This RN held in place and reconnected the O2 (oxygen) at 2 liters/minute. 5:55 PM, Ambulance here and preparing for transfer. This RN was finally able to advance endotracheal tube all the way and was being held in place. Record review of Resident 2's PN (Progess Notes) dated 11/6/2020 at 11:23 PM revealed the resident returned to the facility at about 10:20 PM after endotracheal tube replacement. Resident 2 was alert and oriented. Rhonchi noted to lung sounds. Cough productive of clear sputum. Suctioned as ordered. Resident resists care and does not want to be suctioned. Unable to communicate with resident due to language barrier. Call placed to family and message left. Will continue to monitor. An interview with the Nurse Consultant on 11/12/20 at 9:59 AM revealed the Administration in the building was bringing in admissions and did not have supplies for the residents prior to the admissions. An observation on 11/12/20 at 1:32PM with the Administrator and MR I (Medical Records) of the supply room and the respiratory supply closet revealed the facility had no supplies for the management of resident tracheostomies to include replacement cannulas aand cuffless [CONDITION(S)] tubes. An interview on 11/12/20 at 1:32PM with MR- I who ordered the supplies confirmed there were no [CONDITION(S)] supplies in the building for the residents with tracheostomies. C. An observation on 11/12/20 at 12:15 PM revealed LPN-A applied PPE (Personal Protective Equipment including N95 Mask, facesheild, Gown, and gloves. Observation of Resident 2 revealed Resident 2's Humidification oxygen mask was on the resident's chin and not onthe tracheotomy an opening in the neck; for breathing). Resident 2's tracheotomy tube had large amounts of yellow [MEDICATION(S)] present. An interview on 11/12/20 at 12:20 PM with LPN-A revealed LPN-A was not comfortable with adult tracheotomy tubes and had only previously worked with children's tracheotomy tubes. LPN-A stated (gender) had not received any training on suctioning or changinga [CONDITION(S)] tube system for any tracheotomy residents in the facility. LPN-A also revealed that tracheotomy supplies are very limited and that an extra tracheotomy tube/ kit was not available for Resident 2. LPN-A also revealed that Resident 2 has removed the tracheotomy tube 2 times since admission and one time was sent to the hospital. An observation on 11/12/20 at 12:30 PM revealed ADON (Associate Director of Nursing) perform tracheotomy cleaning and suctioning. The ADON confirmed no additional [CONDITION(S)] system was available and also another [CONDITION(S)] collar/ mask was not available- would just suction and clean the best could do. ADON applied gloves, opened saline syringes and gauze packages on to towel on top of overbed table. ADON then removed gloves, no hand hygiene was completed, applied new gloves, opened suctioning kit, removed sterile gloves, applied sterile gloves overtop dirty gloves, performed suctioning of the tracheotomy tube and cleaned the [CONDITION(S)] collar. During suctioning the ADON replaced the [CONDITION(S)] collar and with oxygen and humidification, the resident was able to cough and expelled a large amounts of [MEDICATION(S)]. Resident 2 did not have any vital signs monitored during suctioning. Record review of the Facility policy titled Suctioning the Lower Airway (Tracheotomy Tube) dated 10/2010 revealed resident's pulse and oxygen saturation need to be monitored during suctioning. Note cardio-pulmonary status, including lungs sounds, during the procedure. An interview on 11/12/20 at 5:23 PM with the ADON confirmed gloves should have been removed and hand hygiene preformed prior to applying sterile gloves and the resident's oxygen level and lung sounds should have been monitored prior to suctioning, during and after completion of suctioning. Record review of Resident 2's progress note dated 11/10/20 at 3:00 PM revealed Resident 2 pulled [CONDITION(S)] out. Color is blue and dusky. Reinserted a 6 shiley after unable to reinsert 7. Resident resistive to insertion but finally relaxed and allowed it to be reinserted after was explained what would happen if it didn't go back in as resident cannot take in enough O2. Coughing up copious amt. of white phlegm via [CONDITION(S)] and per mouth. Suctioning completed as needed. 4:00 PM, Resident 2 was suctioned due to large amount of mucous. 4:40PM, Resident 2 has large amount of pink tube feed colored emesis. Comes out mouth and coughing it up in [CONDITION(S)]. Lungs have rhonchi throughout. APRN (Advanced Practice Registered Nurse) made aware of possible aspiration and order for CXR (chest x-ray) obtained. 6:00 PM Resident 2 continues to cough frequently and now thick white/yellow [MEDICATION(S)] is present. Abatement Plan: Based on the information provided on 11/12/20 at 07:00 PM to correct the immediacy of the situation, the facility staff provided the following information to protect the residents: The facility will implement a new admission process immediately that includes securing tube feeding formula before the resident arrives for admission and all staff will be educated on the new process by the next worked shift. The facility will implement an NPO sign that will be displayed in the resident room. All licensed nursing staff will have competency completed on [CONDITION(S)] care, g tube and enteral tube feedings. All licensed nursing staff will be have this completed before their next worked shift. All licensed nursing staff and medication aide staff will be competencies on medication administration before their next worked shift. If the staff member refuses to compete competencies the staff member will be suspended and/or terminated. The scope and severity was lowered to a D.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on observation, interview and record review; the facility failed to A) provide enteral feedings as ordered upon admission for 1 resident (Resident 3); B) prevent significant weight loss for 1 resident (Resident 3) who received enteral feedings and C) maintain enteral feedings while following a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings are: A. A record review of the Admission Record revealed Resident 3 had admitted on [DATE] to the facility. The record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) revealed Resident 3 had a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 15. A record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with the facility Director of Nursing (DON) on 11/12/20 revealed that the facility had changed EMR (Electronic Medical Record) systems and a problem with the new system was the cause for the enteral feeding orders not being provided for Resident 3 after admission. The interview also revealed that the facility did not have the type of enteral feeding which had been ordered for Resident 3 upon admission and had been required to clarify and change the order. A record review of the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . B) A record review of the weights for Resident 3 revealed a weight loss of 5.7% since admission on 11/3/20. The record review revealed an admission weight of 244 pounds on 11/3/20, a weight of 232.8 pounds on 11/9/20 and 230.0 pounds on 11/11/20. An interview with the DON on 11/12/20 at 11:30 AM confirmed the weight loss for Resident 3. The interview revealed that the DON had requested a recheck of Resident 3's weight on 11/11/20 which was 230.0 pounds. During the interview with the DON, it was confirmed that no nutrition assessment existed related to Resident 3's weight loss. An interview on 11/12/20 at 4:00 PM with the facility DON confirmed that no documentation existed related to notifying the physician of Resident 3's weight loss. A record review of the Progress Notes dated 11/3/20 for Resident 3 revealed a nutrition assessment indicating the following: NUTRITION ADMIT: diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Height was 74 inches. CBW: 244pounds, 11-03-2020 BMI of 31.3. Diet: NPO (nothing by mouth). Resident with peg tube related to failed swallow study. Current orders for two cal HN 240mL Bolus 5x daily at 0500, 0900, 1300, 1700, 2100. Water flushes of 240mL 5x daily. This provides: 2400kcal/104g protein/875mL free water. 2125mL total fluids. Hospital labs reviewed. Estimated needs based on adjusted body weight: 93kg 2310-2790cal/93g protein. Recommend [MEDICATION(S)] 2.0 240mL Bolus 5x daily 0500; 0900; 1300; 1700; 2100. This provides: 2400kcal/96g protein/ 843mL free water. 2093mL of fluids. Current nutritional approach is appropriate, will follow as needed, no further recommendations. A record review of active orders for Resident 3 revealed no order to flush the gastrostomy tube (medical device used to provide nutrition to patients who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation) or to give any water. An interview on 11/12/20 at 2:30 PM revealed that LPN-A was preparing to give Resident 3 the bolus enteral feeding scheduled for noon. The interview with LPN-A confirmed that Resident 3 did not have any orders to flush the g-tube or provide water. C) An interview with ST-B (Speech Therapist) on 11/12/20 at 11:30 AM revealed that Resident 3 had tried an oral diet with Speech Therapy and did poorly with water and ice but did well with a pureed consistency foods with nectar consistency fluids and a request had been placed to advance Resident 3's diet on 11/10/20. The interview confirmed that the Physician's Assistant (PA) for Resident 3 had not approved Resident 3 to have an oral diet until having a swallow study completed. During the interview with ST-B it was revealed that ST-B had spoken to the dietary manager regarding the orders from the PA for Resident 3. The record review of Resident 3's Progress Notes for 11/3/20 through 11/11/20, revealed that the PA for Resident 3 had requested a swallow study be completed prior to Resident 3 receiving an oral diet. The review of the Progress Notes revealed that Resident 3 had been fed an oral diet on 11/12/20 with two separate coughing episodes. An interview with the DON on 11/12/20 at 12:52PM confirmed that the Progress Notes for Resident 3 for the evening of 11/11/20 did indicate that Resident 3 had been given an evening meal which resulted in coughing episodes. An observation on 11/12/20 at 12:34 PM revealed Resident 3 had a cup of ice water at the bedside. An interview on 11/12/20 at 12:40 PM revealed NA-C (Nurse Aide) had left ice water for Resident 3 after being instructed by LPN-A to do so. The interview with NA-C confirmed awareness that Resident 3 was not to eat or drink orally. The interview with NA-C revealed that Resident 3 had requested the water just to rinse with. During the interview, NA-C confirmed that staff were not always present and could not ensure that Resident 3 did not drink the water left at the bedside. An observation on 11/12/20 at 12:44PM revealed the facility DON had removed the ice water from Resident 3's room. Abatement Plan: Based on the information provided on 11/12/20 at 07:00 PM to correct the immediacy of the situation, the facility staff provided the following information to protect the residents: The facility will implement a new admission process immediately that includes securing tube feeding formula before the resident arrives for admission and all staff will be educated on the new process by the next worked shift. The facility will implement an NPO sign that will be displayed in the resident room. All licensed nursing staff will have competency completed on [CONDITION(S)] care, g tube and enteral tube feedings. All licensed nursing staff will be have this completed before their next worked shift. All licensed nursing staff and medication aide staff will be competencies on medication administration before their next worked shift. If the staff member refuses to compete competencies the staff member will be suspended and/or terminated.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility staff failed to evaluate, monitor and identify casual factors for the development of a pressure ulcer for 1 (Resident 29) of 4 sampled residents. The facility staff identified a census of 63. Findings are: Record review of Resident 29's Minimum Data Set, (MDS: a Federally mandated assessment tool used for care planning) dated 10-19-2020 revealed the facility staff assessed the following about Resident 29: -Required extensive assistance with bed mobility, transfers, dressing and toilet use. -Required limited assistance with dressing. -Was at risk for the development of pressure ulcers, currently did not have pressure ulcers and would develop a care plan for prevention of pressure ulcers. Record review of Resident 29's Comprehensive Care Plan (CCP) dated 10-23-2020 revealed there was not an identified care plan goal with interventions for the prevention of pressure ulcers for Resident 29. Record review of a Nursing Communication sheet dated 11-19-2020 revealed the therapy department had notified the nursing department that resident 29 .has a large sacral wound that needs to be measured and dressed as soon as possible!. Record review of Resident 29's medical record that included progress notes, practitioners orders and weekly skin sheets revealed there was not evidence the facility staff had completed an evaluation of the sacral wound for Resident 29. Record review of a wound evaluation sheet dated 12-03-2020 revealed Advanced Register Nurse Practitioner (ARNP) A assessed Resident 29's pressure ulcer was un-stageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar (dead tissue). Observation on 1-07-2021 at 11:35 AM of Resident 29's pressure ulcer assessment and treatment by ARNP A and Licensed Practical Nurse (LPN) D revealed Resident 29 had a pressure ulcer to the sacrum. Record review of ARNP A's documented assessment dated [DATE] revealed Resident 29 had a sacrum wound assessed as a stage 4 pressure ulcer (Stage 4 Pressure Ulcer:Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur) with 60 percent of necrotic tissue, foul smelling odor and the length by width measurement of the wound was 9.25 centimeters (cm). According to the ARNP's assessment dated [DATE] the wound condition had deteriorated and directed a surgical consult be arrange for debridement of the pressure ulcer. On 1-11-2021 at 2:10 PM an interview was conducted with Nurse Consultant (NC) C. During the interview NC C confirmed there was not an evaluation and monitoring of the sacral wound identified on 11-19-2020. NC C further confirmed there were no intervention on Resident 29's CCP for pressure ulcer prevention and should have been. Record review of the facility Policy and Procedure for the Prevention of Pressure Ulcers and Skin Assessments dated 9-2015 revealed the following information. -Purpose: -The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. -Preparation: -1. Review the resident's care plan to assess for any special needs of the resident. -General Guidelines: 2. the most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head, around the ears, elbows, shoulder blades,backbone, hips, knees, ankles, toes, Sacrum, buttocks and coccyx. 6. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician and family. Record review of the facility Wound Care sheet dated 10-2016 revealed the following information: -Purpose: -The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. -Documentation: -#5. All assessment data such as wound bed, color, size and drainage when inspecting the wound.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on observation, record review and interview; the facility administrative staff failed to ensure the facility resources were effectively utilized to maintain or improve the physical, psychosocial and mental well-being of the facility residents. This deficient practice had the potential to affect all residents in the building. The facility staff identified a census of 60. Findings are: Review of the following information revealed the following: -F692. The facility staff failed to identify and implement interventions to prevent weight loss. This practice affected 4 of 4 residents that were reviewed for the survey. The facility staff had identified Residents 22 and 24 had weight loss and identified interventions to prevent further weight loss. Observations during the survey revealed those interventions were not carried out for Resident 22 and 24. Resident 20's care plan indicated Resident 20 was to receive large portions and Resident 20 did not during the survey, in addition, Resident 20 had significant weight loss and the loss was not evaluated. Resident 25 had weight loss without interventions and lost a significant amount of weight. -F686. The facility staff failed to identify, evaluate casual factors and implement interventions for the development of a pressure ulcer for 1 (Resident 20) of 1 residents. Resident 20 had a history of [REDACTED]. Observations during the survey revealed Resident 20 developed a pressure ulcer. The facility staff had not identified the pressure ulcer, had not evaluated casual factors or implemented interventions. -F 744. The facility failed to have specific activities for residents with Dementia who reside in a Memory Support Unit, and failed to have specific guidelines on how activity services would be provided and what staff members would be responsible for the activities on the MSU. Observations during the survey revealed individualized activities that were resident centered was not provided to 4 (Resident 21, 22, 23 and 24) of 4 residents reviewed. Observations during the survey revealed residents were not provided activities, facility staff did not engage residents and failed to have qualified staff in the MSU. Review of the Facility Assessment revealed there was criteria for admission and discharge from the Memory Support Unit, however, there was not information of how resident centered services would be provided to those residents with the [DIAGNOSES REDACTED]. -F606. The facility failed to ensure reference checks were completed on 4 of 6 employee files reviewed. The facility had a Policy and Procedure for competing background checks. During the survey an interview with the facility Human resources personal was conducted that revealed reference checks should have been completed. -F880. The facility failed to ensure gloves were worn when removing soiled meal items from the table for Resident 22. Review of Resident 22's CCP revealed management had identified Resident 22 liked to clear the table after meals and that Resident 22 was to wear gloves and wash hands. -F730. Ongoing Nursing Assistant education. Review of 34 nurse aide employee files revealed 24 nurse aide employees did not have the required 12 hours per year of continuing training. -F550. During observation 4 (Resident 20, 21, 22 and 25) dignity was not maintained. On 1-23-2018 at 10:35 AM an interview was conducted with the facility Administrator. During the interview, the administrator confirmed cited deficiencies were not identified as a problem in the facility.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on observation, record review and interview; the facility staff failed to identify significant weight loss and failed to implement interventions to prevent weight loss for 4 of 4 sampled residents (Resident 20, 23, 24, and 25). The facility staff identified a census of 60. Findings are: A. Record review of a Face Sheet dated 8-18-2017 revealed Resident 20 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 20's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) signed as completed on 12-26-17 revealed the facility staff assessed the following about the resident: -Totally depended for bed mobility, transfers, dressing, eating, dressing, toilet use and personal hygiene. Record review of a weight record sheet (WRS) provided by the facility revealed Resident 20's weight on 9-13-17 was 268 pounds. Further review of the WRS revealed Resident 20's weight on 11-8-17 was 233.4 pounds, a loss of 34.6 pound weight loss or 11.39% indicating a significant weight loss. Record review of a Progress Note (PN) dated 12-9-17 (a 31 day span from the significant weight loss identified on 11-8-17) revealed the facility Registered Dietician (RD) identified Resident 20 had lost weight, According to the RD PN dated 12-9-17, Resident 20 had not been hungry and Resident 20's weight loss was greater than 1 pound a week .which indicates a caloric deficit resulting in loss. Further review of Resident 20's RD, PN dated 12-9-17 revealed there was no evaluation of Resident 20's nutritional requirements, no evaluation of Resident 20's medical condition related to the weight loss or what interventions were to be implemented to stabilize Resident 20's weight. Record review of Resident 20's Comprehensive Care Plan (CCP) dated 5-9-16 revealed Resident 20 had impaired nutritional status. According to Resident 20's CCP dated 5-9-17 with an updated intervention dated 7-7-2016 revealed Resident 20 was to have large portions of foods at meal times. Further review of Resident 20's CCP date 5-16-17 revealed there was not an indication any weight loss was planned for Resident 20. Record review of an undated dietary food tray slip revealed Resident 20 was to receive large portions. Observation on 1-9-18 at 8:07 AM revealed Resident 20 was served for breakfast, 2 pancakes, 2 link sausage, small bowel of cut up fruit and several drinks. On 1-9-2018 at 8:10 AM an interview was conducted with the Dietary Services Manager (DSM). During the interview the DSM confirmed Resident 20 was to receive large portions at meals and further confirmed Resident 20 was served a regular sized portion for breakfast on 1-9-18 at 8:07 AM. On 1-9-2018 at 4:45 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed Resident 20 had a significant weight loss and did not have interventions to stabilize Resident 20's weight. B. Record review of Resident 25's CCP dated 11-9-2013 revealed Resident 25 had the potential for a nutritional deficit. The goal identified for Resident 25 was to maintain weight. Interventions identified on the CCP included monitor weights, a lip plate and covers for drinks. Further review of Resident 25's CCP revealed on 7-24-16 a new intervention was identified to give Resident 25 finger foods. Record review of Resident 25's Dietary Card (DC) revealed Resident 25 was on a regular diet that was mechanically altered. There was no indication on Resident 25's DC that Resident 25 was to be offered or receive finger foods. Record review of Resident 25's WRS dated 10-25-17 revealed Resident 25's weight was 170 pounds. Review of Resident 20's WRS dated 12-27-17 revealed a weight of 158 pounds, a loss of 12 pounds or 7.05 percent. Record review of the WRS dated 1-8-18 revealed Resident 25's weight was 149.8, a loss of 20.2 pounds or 11.88% compared to the weight on 10-25-2017. Review of Resident 25's record revealed there was no evidence Resident 25's weight loss on 12-27-17 and again on 1-8-18 had been evaluated or any additional interventions were implemented to stabilize Resident 25's weight. Observation on 1-9-18 at 12:40 PM revealed Resident 25 was served chicken cut up, long noodles, vegetables served on a lip plate, a slice of chocolate cake and several types of drinks. The lip part of the plate had been positioned away from Resident 25. Resident 25 was not able to scoop food up against the raised part of the plate to get food resulting in food being dropped onto Resident 25 or the floor. Further observations revealed Resident 25 was in a wheelchair and positioned as if Resident 25 was sliding out of the wheelchair resulting in Resident 25 struggling to reach the lunch meal, in addition, Resident 25 did not have finger foods provided. On 1-10-18 at 9:00 AM an interview was conducted with the facility Nurse Consultant (NC). During the interview the facility NC confirmed Resident 25 had weight loss with resulting significant weight loss and did not have an evaluation completed or additional interventions implemented to stabilize Resident 25's weight. The NC further confirmed Resident 25 had not received finger foods at lunch on 1-9-18 at 12:40 PM. On 1-10-18 at 11:40 AM an interview was conducted with the facility RD. During the interview, the facility RD reported while the weight identified on 12-27-2017 .is of significant concern as (Resident 25) was trending down wards. The RD reported during the interview Resident 25 should have had an assessment completed at that time and did not. C. Record review of Resident 23's CCP dated 7-22-17 revealed Resident 23 was at risk for nutritional problems. The goal for Resident 23 was to maintain weight. Interventions identified on the CCP included large supper, magic cup and to offer snacks. Record review of Resident 23's PN dated 12-10-17 revealed the facility RD had identified interventions which included magic cup, superceral, fortified potatoes and 2 eggs at breakfast. Record review of an undated DC for Resident 25 revealed Resident 25's staff were to give Resident 23 a large meal in the evening, superceral and 2 eggs for breakfast. In addition, the DC identified Resident 23 was allergic to chocolate and tomatoes. Observation on 1-8-2018 at 6:25 PM revealed Resident 23 was served a BBQ sandwich, baked beans, cooked cabbage, desert and drinks. On 1-8-18 at 6:30 PM the NC replaced Resident 23's meal with 1 ground hamburger, soup and a new desert. Observation on 1-9-18 at 8:20 AM revealed Resident 23 was served cold cereal (cheerio type), 2 pancakes, 2 sausage with gravy and several drinks. On 1-9-18 at 8:35 AM an interview was conducted with Nursing Assistant (NA) A. During the interview NA A confirmed Resident 23 did not have eggs or supercereal. On 1-10-18 at 2:40 PM an interview was conducted with the DSM. During the interview, the DSM reported a large portion would be 1 and ½ portions of a regular sized portion. The DSM confirmed 1 hamburger was not a large portion. D Record review of Resident 24's CCP dated 4-28-17 revealed Resident 24 was at nutritional risk. The goal identified for Resident 24 was to maintain weight. Interventions included double portions at all meals. Record review of Resident 24's DC revealed Resident 24 was to have double portions at meals. Observation on 1-8-18 at 6:27 PM revealed Resident 24 was served 1 BBQ sandwich, baked beans, cook cabbage, desert and fluids. Observation on 1-9-18 at 8:20 AM revealed Resident 24 was served 2 pancakes, 2 sausage, cereal and fluids. On 1-9-18 at 8:36 AM an interview was conducted with NA A. During the interview NA A confirmed Resident 24 did not receive double portions for breakfast. Record review of the facility Policy and Procedure for Weight Assessment and intervention dated 4-2012 reveled the following information: -Analysis: -Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding: -a. Approximate calorie, protein, and other nutrient needs compared with the resident's current intake. -c. The relationship between current medical condition or clinical situation and recent fluctuations in weight.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on record review and interview; the facility staff failed to administer an anticoagulant medication ([MEDICATION NAME]) for 1 resident (Resident 5). The facility staff identified a census of 44. Findings are: Record review of a Resident Admission Record sheet dated 1-16-2014 revealed Resident 5 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of admission orders [REDACTED]. The end date for use of the medication was calculated as 12-28-2013. Further review of the admission orders [REDACTED]. Review of the Davis's Drug Guide for Nurses, Thirteenth Edition by April Hazard Vallerand, Cynthia A. Sanoski with Judith Hipfer Deglin revealed the following information about the use of [MEDICATION NAME]: -Page 647, Indications; -Prevention of Venous [MEDICAL CONDITION] (VTE), [MEDICAL CONDITIONS]. -Page 650, Evaluation/Desired Outcomes; -Prevention of [MEDICAL CONDITION]. According to the national Heart, Lung and Blood Institute at www.nhlbi.nih.gov/health/health-topics/topics/[MEDICAL CONDITION] a [MEDICAL CONDITION] is a blood clot that forms in a vein deep in the body. Most [MEDICAL CONDITION] clots occur in the lower leg or thigh. A blood clot deep in the vein can break off and travel through the bloodstream. The lose clot is called an [MEDICAL CONDITION]. It can travel to an artery in the lungs and block blood flow. This condition is called [MEDICAL CONDITION] embolism (PE). PE is a very serious condition. It can damage the lungs and other organs in the body and cause death. Record review of Resident 5's Administration History sheet revealed on 12-19-2013 and 12-26-2013 the [MEDICATION NAME] was not available for administration for Resident 5. Record review of Resident 5's Resident Progress Notes (RPN) dated 12-16-2013 revealed RN (Registered Nurse) A had assessed Resident 5 "Right lower leg red with two plus [MEDICAL CONDITION] (swelling). Small purple bruise to anterior aspect of right ankle/foot. Site not warm to touch, however, looks quite a bit like [MEDICAL CONDITION]". Record review of Resident 5's RPN dated 12-19-2014 revealed Resident 5 had a reddened right lower extremity which was slightly warm. Record review of Resident 5's RPN dated 12-20-2013 revealed Resident 5's right lower leg was "...bright red and warm to touch". Record review of a Delivery Manifest of the delivery of [MEDICATION NAME] for Resident 5 was conducted with RN B on 1-29-2014 at 10:22 AM. According to the information on the Delivery Manifest sheets dated 11-29-2013, 12-03-2013,12-10-2013, 12-19-2013 and 12-26-2013; [MEDICATION NAME] was not available for use from December 16 through December 19 th. RN B confirmed that the [MEDICATION NAME] was not available to be given to Resident 5. When asked what the [MEDICATION NAME] was used for. RN B stated "to help prevent [MEDICAL CONDITION] (clots)". Record review of an Ultrasound Report sheet dated 12-30-2013 revealed Resident 5 had a [MEDICAL CONDITION] involving the right calf region veins. Record review of a Physician's Telephone Orders sheet dated 12-30-2013 revealed Resident 5's physician ordered the [MEDICATION NAME] be given daily for 5 days starting on 12-31-2013. Record review of Resident 5 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 1-29-2014 at 12:50 PM, an interview was conducted with the facility Nurse Consultant (NC). During the interview the facility NC reported the [MEDICATION NAME] had not been ordered or started for Resident 5.