Every finding on record at Emerald Nursing & Rehab Omaha

Licensure Reference Number 175 NAC 12-006.10(D)Based on record review and interview, the facility failed to ensure 1 (Resident 6) of 6 sampled was free from significant medication errors. The facility identified a census of 65.Findings are:Record review of Resident 6's Quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 3/18/26 identified the facility admitted the resident on 12/10/25 with diagnosis of cerebral palsy(CP) a neurological disorder that affects movement, muscle tone, balance, and posture), cellulitis(a bacterial infection of the skin and underlying deep tissue) of right and left lower limb, and venous insufficiency. Further review of Resident 6's MDS revealed they required set up/clean-up for upper body dressing, lower body dressing and putting on and taking off footwear, partial/moderate assist for shower/bathing, substantial/max assist for toileting hygiene, and was dependent for sit to stand and chair to bed transfers, who is frequently incontinent of urine and always incontinent of bowel.Record review of Resident 6's electronic medical record (EMR) document by an Advanced Practice Registered Nurse (APRN) with a date of service of 5/26/26 revealed the following: -Chief Complaint-acute visit- bilateral lower extremity (BLE) pain and erythema (redness). History of present illness-Patient expresses concern about their right lower extremity and cellulitis (skin infection). (Gender) reports they have had cellulitis in the past and that this felt similar. Skin-Bilateral lower extremities have several small bandages covering venous ulcers. Plan-Doxycycline hyclate (an antibiotic used to treat bacterial infections) 100 milligrams (mg) take one capsule by mouth twice daily for 7 days for right lower extremity cellulitis'.Record review of Resident 6's electronic medical record Electronic Medication Administration Record (EMAR) revealed the first dose of the Doxycycline was given on 5/28/26 at 9:00 PM, 2 days after it was ordered. Record review of Resident 6's Tissue Analytics (TA) Wound Notes dated 5-29-2026 revealed the APRN assessed Resident 6 with extensive erythema, swelling to the right lower leg was showing significant signs of cellulitis. Further review of the Resident 6's TA note dated 5-29-2026 revealed the APRN identified Resident 6 was supposed to start on a oral antibiotic 4 days ago, however, the antibiotic was not delivered. Resident 6's TA note dated 5-29-2026 further identified the resident remained [NAME] oral antibiotic with the resident physician planning on starting the resident in an intravenous (IV) antibiotic. Record review of the order summary report revealed an order on 5/29/26 for Zosyn (an antibiotic used to treat moderate to severe bacterial infections) solution 3-.0375 Grams infuse 3.375 grams IV every 6 hours for 7 days for cellulitis.Record review of an Emergency Department (ED) Provider note by Medical Doctor (MD) with an encounter date of 6/1/26 revealed Resident 6 was seen for pain in right leg. Further review of note revealed the patient had extensive cellulitis of the right lower leg. Vitals are within normal limits but white blood count (which measures immune system cells) is 31 ( according to the Mayo Clinic normal is 3.4-9.6, an elevation is indicative of the body fighting an infection) and C-Reactive protein (a test to detect, diagnose and monitor conditions like infections) is 149 (according to the Mayo Clinic a CRP level greater than 50 is considered severe elevation) and lactate (which measures your lactic acid level in the blood) 3.4 (according to the Mayo Clinic normal is 0.5-2.2, an elevated levels can be indicative of sepsis) concerning for systemic inflammatory response (SIRS criteria)/ meeting sepsis criteria. Deep Vein Thrombosis (DVT) study was negative. IV Vancomycin (antibiotic), cefepime (antibiotic) and Flagyl (antibiotic) were ordered and the patient was admitted given failure of outpatient antibiotics. An interview was conducted with Licensed Practical Nurse (LPN) A on 6-02-2026 at 9:30 AM. During the interview LPN A reported confirmed the antibiotic medication was not administered as ordered. LPN A further reported the facility Director of Nursing and reported to the residents practitioner on 5/29/2026 the antibiotic that had been ordered on 5-26-2026 was not started until 5/28/2026. LPN A further reported staff had not followed up on 5-27-2026 on that status of administering the antibiotic and should have. In an follow up interview with LPN A on 6/2/26 at 4:20 PM it was confirmed not giving the antibiotic for 2 days after it was ordered would be considered a significant medication error.In an interview with the Director of Nursing on 6/2/26 at 5:00 PM it was confirmed that not giving the antibiotic for 2 days after it was ordered would be considered a medication error.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1) & 12-006.09(H)(iii)(2)Based on observation, interview and record review the facility failed to implement preventative measures to prevent a pressure ulcer, failed to provide treatment as ordered to promote healing of a pressure ulcer and failed to ensure weekly skin evaluations were completed for 1 (Resident 13) of 2 sampled residents. The facility identified a census of 65.Findings are:Record review of a facility policy entitled Skin and wound management-Prevention of Pressure with a revised date of 6/4/26 revealed the following: Prevention of Pressure InjuriesPurpose The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors.Risk Assessment1. Assess the resident on admission (within 8 hours) for existing pressure injury risk factors. Repeat the risk assessment weekly x 4 weeks and upon any changes in condition. (Risk Assessment Braden) Skin Assessment Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge. Record review of Resident 13's Significant Change 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 3/24/26 identified the facility readmitted the resident on 3/18/26 from the hospital with diagnosis of right hip fracture, diabetes mellites, liver transplant status, congestive heart failure (CHF), peripheral vascular disease, and chronic obstructive pulmonary disease (COPD) who required substantial/max assist to roll right to left, sit to lying, sit to stand, chair to bed transfers and was dependent for toileting hygiene, lower body dressing and putting on and taking off footwear. Further review of the MDS revealed a brief interview for mental status (BIM's) of 13/15, according to the MDS manual 13-15 indicates a person is cognitively intact.Record review of clinical document entitled Braden Scale (a clinical assessment tool used to predict a patient's risk of developing pressure injuries dated 3/18/26 revealed a score of 15 indicating mild risk according to the Braden Scale form. According to the Braden Scale form if score is less than 16, initiate skin integrity interventions and document on the baseline care plan. Review of Resident 13's record revealed no interventions were implemented to prevent pressure ulcer/injury to Resident 13's heels.Review of Resident 13's comprehensive care plan copied on 6/1/26 revealed there was no focus (problem) area to identify the resident was at risk for pressure ulcer/injuries.Record review of Resident 13's Electronic Medical Record section identified as Clinical Assessments revealed no Skin/Wound weekly observation was completed between 3/18/26 and 4/3/26, a two-week time frame.Record review of a progress note for Resident 13 dated 4/7/26 revealed facility staff observed a 4 x 3 (centimeter) cm open blister to the right heel.Record review of a document from Tissue Analytics Advanced Practice Registered Nurse (APRN) for Resident 13 dated 4/10/26 revealed a right heel pressure ulcer-Stage III (a deep full thickness skin loss) with measurements length 4.05-centimeter (cm) x width 3.06 cm x depth 0.10 cm. Further review of note by the APRN revealed 'New wound. [gender] has an open, stage III to [gender] heel. There is some slough (dead skin) in the wound. Will use Alginate Ag alone for now. Plan: Wash with facility cleanser, pat dry, paint the periwound with skin prep and let dry, cover the wound with alginate ag, cut to fit size and shape, cover with Mepilex 9generic equivalent) or non-stick dressing and wrap with gauze. Change daily and PRN for soiling, saturation or accidental removal.Record review of a document from Tissue Analytics dated 5/15/26 revealed 'The periwound is very macerated (when the skin around a wound is exposed to too much moisture for too long). The skin prep needs to be applied all around the wound for protection. Medihoney was added last week (5/8/26), but it does not appear the order was updated in Point Click Care (PCC, electronic medical record). Please make sure orders are updated to reflect the latest orders.Record review of the Order Summary Report revealed an order dated 5/22/26 for wound care as follows: right heel wash with facility cleanser, pat dry, paint the peri wound with skin prep, let dry, cover the wound with Alginate Ag(an absorbent antimicrobial wound dressing) , cut Alginate to fit size and shape apply medihoney ( a medical grade, sterilized honey used in wound care) to the wound bed (ok to apply directly to alginate and then apply to wound) cover with mepilex (an absorbent silicone foam pad) (generic equivalent) or non-stick dressing and wrap with gauze, change daily and PRN for soiling, saturation or accidental removal as needed.Observation on 6/1/26 at 11:10 AM of Resident 13's wound care revealed Licensed Practical Nurse (LPN) B entered Resident 13's room, placed supplies on bedside table, performed hand hygiene, donned gloves, LPN B did not don a gown, a barrier was placed under Resident 13's right heel, sock were removed to reveal a saturated dressing dated 5/30/26. LPN B removed the soiled dressing, removed gloves, performed hand hygiene, donned new gloves, donned a gown, cleansed the wound to right heel with facility wound cleanser and gauze. Resident 13's right heel wound had a gray/yellow base, wound edges were macerated. LPN B removed gloves, performed hand hygiene, donned gloves, cut alginate to fit the wound base, applied medihoney to the alginate and placed it on the wound, covered the wound with bordered gauze. LPN B placed the sock back on resident 13's foot and applied the prevalon boot.In an interview with LPN B on 6/1/26 at 11:20 AM it was confirmed the dressing removed from Resident 13 was dated 5/30/26 indicating the treatment was not completed as ordered on 5/31/26. LPN further confirmed they did not paint the peri wound with skin prep and did not wrap the heel with gauze and should have.In an interview with LPN A on 6/2/26 at 3:21 PM it was confirmed Resident 13's Braden on 3/18/26 indicated they were at risk and there was no evidence interventions were put in place.In an interview with the Director of Nursing (DON) on 6/2/26 at 5:00 PM confirmed Resident 13's Braden on 3/18/26 indicated they were at risk and there was no evidence interventions were put in place.An interview with the Regional Nurse Consultant on 6/3/26 at 7:17 AM revealed the facility policy is to do Skin Assessments weekly and Braden Risk Assessments are completed on admission, weekly x 4 weeks and then quarterly.

Licensure Reference Number 175 NAC 12-006.18 Based on observation, record review and interview, the facility failed to perform wound care in a manner to prevent potential cross contamination for 2 (Resident 6 and Resident 13) of 3 residents sampled. The facility identified a census of 65.Findings are:A.Record review of Resident 6's Quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 3/18/26 identified the facility admitted the resident on 12/10/25 with diagnosis of cerebral palsy(CP) a neurological disorder that affects movement, muscle tone, balance, and posture), cellulitis(a bacterial infection of the skin and underlying deep tissue) of right and left lower limb, and venous insufficiency. Further review of Resident 6's MDS revealed they required set up/clean up for upper body dressing, lower body dressing and putting on and taking off footwear, partial/moderate assist for shower/bathing, substantial/max assist for toileting hygiene, and was dependent for sit to stand and chair to bed transfers, who is frequently incontinent of urine and always incontinent of bowel.Observation of wound care for Resident 6 on 6/1/26 at 9:11 AM revealed Resident 6 lying on the bed. The right lower extremity was noted to have drying blood on back of leg and foot, the fitted sheet on the bed under the leg was noted to have a large dry brown spot and fresh red spot. LPN B donned gloves, and gown, and without placing a barrier between the right lower leg and the soiled sheet completed the treatment to the lower leg allowing an open wound on the posterior lower leg and dressing once applied to touch the soiled sheet. In an interview with LPN B on 6/1/26 at 9:36 AM it was confirmed she should have placed a barrier between Resident 6's leg and the soiled sheet to prevent cross contamination. B.Record review of Resident 13's Significant Change 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 3/24/26 identified the facility readmitted the resident on 3/18/26 from the hospital with diagnosis of right hip fracture, diabetes mellites, liver transplant status, congestive heart failure (CHF), peripheral vascular disease, and chronic obstructive pulmonary disease (COPD) who required substantial/max assist to roll right to left, sit to lying, sit to stand, chair to bed transfers and was dependent for toileting hygiene, lower body dressing and putting on and taking off footwear. Further review of the MDS revealed a brief interview for mental status (BIM's) of 13/15, according to the MDS manual 13-15 indicates cognitively intact.Observation on 6/1/26 at 11:10 AM of Resident 13's wound care revealed Licensed Practical Nurse (LPN) B entered room, placed supplies on bedside table, performed hand hygiene, donned gloves, did not don a gown. LPN B removed the soiled dressing, removed gloves, performed hand hygiene, donned new gloves, donned a gown and completed wound care to Resident 13's right heel.Record review of Resident 13's order summary revealed and order dated 5/19/26 for the following: Enhanced Barrier Precautions (EBP) Staff to use enhanced barrier precautions (gloves and gowns) during high contact activities due to wounds every shift.In an interview with LPN B on 6/1/26 at 11:20 AM it was confirmed the gown should have been donned before starting wound care.

Licensure reference: 175 NAC 12-006.09(H); 175 NAC 12-006.09(H) (iii) Based on record review and interview, the facility failed to ensure assessment was completed after a fall, failed to ensure X-ray results were obtained, failed to ensure a orthopedic appointment was scheduled for 1 [Resident 5] of 3 residents sampled for medical care and failed to ensure weekly skin observations were complete for 2 [Resident 6 and 7] of 3 sampled residents. The total survey sample was 15. The facility had a total census of 65 residents. Findings are: A. A review of Resident 5's admission record revealed Resident 5 was admitted to the facility on [DATE] with a diagnosis of hemiplegia and hemiparesis following other cerebrovascular disease affecting left non-dominant side [stroke]. A review of Resident 5's quarterly MDS [Minimum Data Set; a comprehensive assessment tool used for care planning] dated 2/26/26 revealed the following: -Brief Interview for Mental Status score of 15. A review of MDS manual revealed a score of 13-15 means cognitively intact A review of Resident 5's Care Plan revealed a focus area related to having a functional deficit with activities of daily living related to cerebrovascular accident, weakness, seizure disorder, and frequent falls with the following interventions: -CAM boot [Controlled Ankle Motion boot] tall related to left foot fracture on at all times until seen by orthopedics initiated 5/29/26 -Non weight bearing order until seen by orthopedics initiated 5/29/26 In an interview on 6/1/26 at 11:22 AM, Resident 5 reported that Resident 5 is non-weight bearing and has been staying in bed since the fall due to needing to use a Hoyer lift to get out of bed. A review of Fall Data Collection from dated 5/18/26 revealed Resident 5 found sitting with back to the bed legs extended out with wheelchair in front of Resident 5. The Fall Data Collection form revealed Resident 5 was slid out of bed and Resident 5 reported pain in left ankle. Resident 5 was assisted back to bed with help of 2 staff members and bed placed in low position. Resident 5's personal items and call light were within reach. A review of Resident 5's Progress Notes did not reveal any additional assessment of Resident 5 for injuries on 5/18/26 or 5/19/26. A review of physician order for Resident 5 dated 5/18/26 revealed an order for lateral left ankle x-ray, 3 views. A review of Resident 5's Radiology Report dated 5/19/26 at 9:10 Am revealed Resident 5 had a fracture to left involving the distal fibula and medial malleolus [ankle] with tissue swelling. A review of Resident 5's Progress Note dated 5/20/26 at 12:43 PM revealed Nurse contacted portable x-ray company for results of x-ray results and results were called to practitioner. A review of Resident 5's Order Summary revealed an order dated 5/20/26 to wrap and keep wrapped affected ankle to remind Resident 5 of non-weight bearing status. A review of Resident 5's Order Summary revealed an order dated 5/23/26 for Cam boot tall related to left foot fracture on at all times until seen by orthopedics. A review of Resident 5's Progress Note dated 5/23/26 at 3:47 PM revealed CAM boot was delivered and fitted to Resident 5's left foot. In an interview on 6/2/26 at 4:16 PM, LPN Unit Director A confirmed there should have been a follow-up assessment note within 24 hours of Resident 5's fall. In interviews on 6/2/26 at 8:48 AM and 3:55 PM, Medical Records Clerk confirmed that no appointment had yet been made for Resident 5 to be seen by Orthopedics. Medical Records Clerk report orthopedics had been contacted on 6/2/26 and requested copies of the x-rays for their review before setting up an appointment with Resident 5. In an interview on 6/2/26 at 4:16 PM, LPN Unit Director A confirmed that an orthopedic appointment should have been made as soon as possible for Resident 5. In an interview on 6/2/26 at 5:06 PM, the Director of Nursing confirmed that the facility should have contacted the portable x-ray company to get the results of the x-ray on 5/19/26 and should have contacted orthopedics within a couple of days for an appointment. A review of facility policy titled Falls Management policy last revised 1/2024 revealed the following: -Resident fall will be documented for 24 hours for post fall monitoring. B. Record review of Resident 6's Quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 3/18/26 identified the facility admitted the resident on 12/10/25 with diagnosis of cerebral palsy(CP) a neurological disorder that affects movement, muscle tone, balance, and posture), cellulitis(a bacterial infection of the skin and underlying deep tissue) of right and left lower limb, and venous insufficiency. Further review of Resident 6's MDS revealed they required set up/clean up for upper body dressing, lower body dressing and putting on and taking off footwear, partial/moderate assist for shower/bathing, substantial/max assist for toileting hygiene, and was dependent for sit to stand and chair to bed transfers, who is frequently incontinent of urine and always incontinent of bowel. Record review of Resident 6's Electronic Medical Record (EMR) the section identified as Clinical Assessments revealed no Skin/Wound weekly observation was completed between 4/24/26 and 5/22/26. A four-week timeframe. C. Record review of Resident 7's Quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 3/29/26 identified the facility admitted the resident on 3/23/26 with diagnosis of end stage renal disease receiving dialysis, type II diabetes, coronary artery disease, and hypertension. Further review of Resident 7's MDS revealed they required set up/clean up assistance for eating, oral hygiene, upper body dressing, lower body dressing, and putting on/taking off footwear, partial assistance for toileting assistance, sit to stand and chair to bed transfers, and substantial/maximal assist for bathing, who was occasionally incontinent of urine. Record review of Resident 7's EMR the section identified as Clinical Assessments revealed no Skin/Wound weekly observation was completed between 4/24/26 an 5/11/26 a two-week time frame and between 5/11/26-5/30/26 a two and a half week time frame. Interview with LPN A on 6/1/26 at 2:10 PM revealed that skin assessments should be completed weekly. An interview with the Regional Nurse Consultant on 6/3/26 at 7:17 AM revealed the facility policy is to do Skin Assessments weekly and Braden Risk Assessments are completed on admission, weekly x 4 weeks and then quarterly. Record review of a facility policy entitled Skin and Wound Management-Prevention of Pressure with a revised date of 6/4/26 revealed the following: Prevention of Pressure Injuries Purpose The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Risk Assessment 1. Assess the resident on admission (within 8 hours) for existing pressure injury risk factors. Repeat the risk assessment weekly x 4 weeks and upon any changes in condition. (Risk Assessment Braden) Skin Assessment Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge.

Based on interview and record review, the facility failed to ensure significant injury was reported to Adult Protective Services within 2 hours for 1 [Resident 5] of 15 sampled residents. The facility had a total census of 65 residents. Findings are:A review of facility Abuse/Neglect Report dated 5/26/26 revealed Resident 5 was found on the floor on 5/18/26. A x-ray was ordered on 5/18/26 and the results were obtained on 5/20/26 which identified that Resident 5 had a distal fibula and medial malleolus fracture with minimal displacement. A further review of Abuse/Neglect Report dated 5/26/26 revealed a report was called to Adult Protective Services regarding Resident 5's fracture on 5/22/26 at 5 PM. In an interview on 6/2/26 at 5:16 PM, the Administrator confirmed that Resident 5's injury was not reported within the required 2 hours. A review of facility policy titled Abuse, Neglect and Exploitation dated 1/2024 revealed the following:- Serious bodily Injury-2 Hour Limit: If the events that cause the reasonable suspicion result in serious bodily injury to a resident, the covered individual shall report the suspicion immediately, but not later than 2 hours after forming the suspicion (unless the State has a shorter reporting time.)

Licensure Reference Number 175 NAC 12-006.18Based on observations, record reviews and interviews: the facility failed to utilize hand washing and gloving techniques and failed to implement A record review of the Enhanced Barrier Precautions ( EBP, an infection control strategy designed to prevent the spread of multi-drug-resistant organisms) for 2 (Residents 1 and 3) of 3 sampled residents. The facility had a census of 62. Findings are: A. A record review of Resident 3's Electronic Clinical Resident Profile sheet revealed Resident 3 was admitted to the facility on [DATE].A record review of Resident 3's Minimum Data Set ((MDS - a federally mandated, standardized assessment tool used in Medicare/Medicaid-certified nursing homes to evaluate a residents functional, medical, psychosocial and cognitive status) dated 2/26/2026 revealed Resident 3 had a Brief Interview for Mental Status (BIMS - a standardized assessment used in nursing homes to assess cognitive function, specifically memory and orientation) of 14 indicating Resident 3 was cognitively intact.A record review of Resident 3's Care Plan (CP - a personalized, actionable document that outlines a patient's health needs, goals and specific interventions to manage their care) with the following diagnoses: Type 2 Diabetes Mellitus ( a chronic condition where the body cannot effectively use insulin leading to high blood sugar levels) Chronic venous insufficiency (a condition where leg veins cannot efficiently return blood to the heart, causing blood to pool in the legs), localized edema (swelling confined to a specific body part) and Cellulitis (a common, potentially serious bacterial skin infection affecting deep dermis (thick layer of skin located between the epidermis - outermost skin layer and subcutaneous tissue - the deepest layer of skin) and subcutaneous tissues) of right lower limb.A record review of Resident 3's progress note dated 4/21/2026 by Licensed Practical Nurse (LPN) A revealed the following: New area noted to Lt (left) LE (lower extremity - leg) today during cares. Advanced Practice Registered Nurse (APRN)-wound care provider was updated. New orders for x-ray to rule out fluid at wound site and tx (treatment) orders until visit on Friday. Resident updated.A record review of Resident 3's order summary revealed the following order dated 4/21/2026: Wound care: Cleanse with facility cleanser or soap and water. Rinse and pat dry. Apply xeroform (a sterile, non-stick, fine mesh gauze dressing) cut to fit bed of wound, then cover with bordered gauze wound dressing (a sterile adhesive bandage with a central nonstick absorbent pad surrounded by a breathable, adhesive border) every day and as needed if dislodged or soiled. An observation on 4/22/26 at 12:25 PM by of wound care provided by Registered Nurse (RN) B to Resident 3 revealed the following: RN B washed their hands and dried them with paper towels. RN B turned off the faucet with their bare hands. and approached Resident 3.RN B had placed wound supplies on a towel on the bedside table for Resident 3's wound care. RN B donned gloves and removed Resident 3's shoe and edema wear from Resident 3's leg and repositioned the leg on the wheelchair pedal to provide access to the wound. RN B removed their gloves, used hand sanitizer, and donned clean gloves. RN B removed the old dressing from the wound and discarded it along with their gloves. RN B performed hand hygiene and donned clean gloves. RN B sprayed wound cleaner on a 4x4 gauze pad and cleaned the wound, starting at the center and moving outward, using a clean gauze pad with each wipe. RN B changed gloves using hand sanitizer in between and rinsed the wound with a gauze pad wet with normal saline. RN B changed gloves and used hand sanitizer. RN B patted the area dry with clean gauze pads and changed gloves, using hand sanitizer in between. RN B held Resident 3's leg with their left hand. RN B picked up a precut piece of xeroform dressing and attempted to place it on the wound with their right hand but the xeroform gauze folded back on itself. RN B used their contaminated left gloved hand to unfold the xeroform dressing before they placed it in the wound bed with their right gloved hand. RN B placed a dated bordered gauze dressing over the xeroform dressing. RN B removed their gloves, used hand sanitizer, and replaced Resident 3's shoe and edema wear, gathered their supplies, discarded the trash, and exited the room. An interview on 4/22/26 at 12:35 PM with RN B confirmed they had turned off the faucet with their bare hand and should have used a towel to turn off the faucet. RN B confirmed they had used their contaminated left hand to touch the dressing that was then applied directly to the wound. B. A record review of Resident 1's Clinical Resident Profile sheet revealed they were admitted to the facility on [DATE].A record review of Resident 1's MDS dated [DATE] revealed Resident 1 had a BIMS of 14, indicating Resident 1 was cognitively intact.A record review of Resident1's undated CP revealed Resident 1 has the following diagnoses:Quadriplegia (a paralysis caused by cervical spinal cord injury or illness, resulting in partial or total loss of function in all 4 limbs and the torso, Neuralgia (intense, sharp pain caused by damaged, irritated or compressed nerves) and Neuritis ( inflammation of a nerve or group of nerves resulting in pain, numbness, muscle weakness and loss of reflexes), Extended spectrum Beta Lactamase resistance infection (infection caused by bacteria resistant to many common antibiotics), Acquired absence (amputation) of left foot, Acquired absence (amputation) of right leg above the knee, Cervicalgia (pain in the neck region), Sepsis (a life-threatening medical emergency caused by the body's extreme, overactive response to an infection). A record review of Resident 1's Skin/Wound Weekly observation, dated 4/14/2026 revealed they had the following wounds: venous (shallow, slow-healing open area) wound on left lower leg, surgical wound to right knee from an amputation, abrasion (superficial skin wound) to the left hand, palm, back of the hand and fingers, a Stage II Pressure Ulcer (a shallow, open ulcer with a pink/red wound bed or an intact/ruptured serum-filled blister) to the sacrum (wound to the skin over the tailbone), venous wound to the left arm and a skin tear (traumatic wound caused by friction) to left scapula (shoulder blade). A record review of Resident 1's wound care orders revealed the following order dated 4/6/2026: Wound Care: Left Hand Wash with soap and water, rinse, and pat dry. Apply Betadine pt entire left hand and leave it open to air. Daily every day shift A record review of Resident 1's Order Summary revealed the following order dated 2/26/2026: EBP: Staff to use enhanced barrier precautions (gloves/gown) during high contact activities d/t wounds. An observation on 4/27/26 at 9:30 AM of wound care provided by Licensed Practical nurse (LPN) C for Resident 1 revealed the following: LPN C entered Resident 1' s room and asked Resident 1 if they could do the wound care to Resident 1's left hand. Resident 1 agreed to having the treatment completed. LPN C washed their hands and donned gloves and did not gown. Resident 1's arms were both contracted (a permanent physical shortening of muscle, tendon, or scar tissue, resulting in joints becoming fixed in a bent position) with the left fingers pressed firmly together and left thumb tucked beneath the fingers. Visible portions of Resident 1's left hand had dark purplish/red scab tissue with gray edges. LPN C placed a clean chux pad underneath Resident 1's left arm. LPN C soaked several 4x4 gauze pads in a wound cleaning solution of soap and water and used separate pads to wash Resident 1's left hand, using one pad for each pass over the scabbed area until the hand was clean. Large pieces of scab tissue separated from Resident 1's hand, leaving pink intact skin beneath. LPN C removed their gloves, used hand sanitizer and donned clean gloves, then patted Resident 1's left hand dry with clean gauze. LPN C removed the chux from underneath Resident 1's arm and disposed of it in the trash. LPN C removed their gloves, using hand sanitizer, donned clean gloves and placed a clean chux pad under Resident 1's left hand. LPN C removed their gloves, used hand sanitizer, and donned clean gloves. LPN C used gauze pads and a clear cup of water to rinse Resident 1's left hand. LPN C changed their gloves, using hand sanitizer in between and patted Resident 1's hand dry with clean gauze. LPN C changed gloves, using hand sanitizer in between and placed gauze pads to soak in the cup with betadine and then wiped the pads one at a time over Resident 1's left hand. When the hand was completely painted with betadine LPN A held the hand to allow it to dry before placing it on a clean chux pad. LPN C discarded the trash, washed their hands, and exited the room. LPN C did not wear a gown during wound care as required by EBP precautions.An interview on 4/27/26 at 12:47 PM with LPN C confirmed they had not donned a gown when providing wound care to Resident 1. LPN C confirmed Resident 1 was on EBP precautions and they should have worn a gown.

Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview, and record review, the facility failed to ensure causal factors (reason the event happened) were completed on 1 (Resident 3) of 3 sampled residents, interventions (what was put in place to prevent it from happening again) were implemented for falls on 2 (Residents 2 and 4) of 3 sampled residents, and post fall assessments to include neurological assessments (neuro checks)(focused assessments to monitor a resident's brain and nervous system function), when indicated, were completed on 2 (Residents 1 and 3) of 3 sampled residents. The facility census was 71. Findings are:A record review of the facility's Falls Management policy dated 04/2015 revealed that in the event a resident had fallen and /or was found on the ground, a complete head-to-toe assessment must be performed prior to moving the resident. The nurse would palpate (feel) and examine all areas for breaks in the skin or other abnormal findings, obtain vital signs including blood pressure pulse, and respirations. The staff would obtain neuro checks for any unwitnessed fall or any fall with evidence of an injury to the head. The nurse would complete an incident report and the resident fall would be noted on the 24 hour report for 3 days for post fall monitoring, including vitals every 8 hours. Fall Injury Prevention – Post Fall included assess the resident an immediately implement appropriate measure to prevent injury, initiate and complete the Accident/Incident Protocol, review the Plan of Care, and adjust or add interventions on the Plan of Care. A. A record review of Resident 3's Resident Census dated 03/12/2026 revealed the resident was admitted on [DATE] and sent to the hospital on [DATE]. The resident returned to the facility 02/24/2026. A record review of Resident 3's Medical Diagnosis dated 03/11/2026 revealed the resident had diagnoses of Metabolic Encephalopathy (brain dysfunction), Repeated Falls, and Muscle Weakness. A record review of Resident 3's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 03/02/2026 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 9 which indicated the resident was moderately cognitively impaired (difficulty thinking and comprehending). The resident required setup or clean-up assistance with eating and upper body dressing, supervision with oral hygiene (cleaning), and partial/moderate assistance with bathing, lower body dressing, footwear, and toileting and personal hygiene. The resident was partial/moderate assistance with all bed mobility and transfers. The resident had no falls in the lookback period. A record review of Resident 3's Care Plan Report with an admission date of 02/06/2026 revealed a focus area of the resident had functional deficit (loss) with current ADLs and interventions included the resident 1 staff assist with ambulating with a walker. 1 staff assist partial with bed mobility, 1 staff assist partial with transfers, 1 staff assist partial with toileting hygiene, 1 assist supervisions with toilet transfers. The resident had a focus area of bladder incontinence related to impaired mobility and ambulation and interventions included establish voiding patterns and the resident used disposable briefs, change as needed (PRN). The resident was on a diuretic (medication that increased urine production to remove excess fluids from the body). The resident had a focus area of the resident was at risk for falls related to weakness, limited mobility due to recent infection, new environment, use of medications that have the potential for adverse drug reactions, and confusion. The interventions were Physical Therapy (PT)/Occupational Therapy (OT) to evaluate and treat if indicated with a date initiated of 02/06/2026, and the resident had poor safety insight at that time and staff would conduct routine visual rounding with a date initiated of 03/05/2026. A record review of Resident 3's Progress Notes dated 02/09/2026 revealed at 9:15 PM the resident was found on the floor by the Nursing Assistant (NA) and resident said the resident was trying to get out of bed to go home. The resident denied hitting head. Assessment was done that included vitals. No noted or reported injury or pain. For education, the resident was advised to use the call light if the resident wanted to get out of bed. The Progress Note did not reveal neuro checks were started or causal factors for the fall. A record review of Resident 3's Progress Notes dated 02/10/2026 at 12:46 AM revealed the resident was seen by staff sliding out of bed onto the floor. Resident did not hit the resident's head. No injury was seen and denied pain or discomfort. Assessment included range of motion (ROM) and vital signs. The staff would continue to monitor, and the resident was encouraged to use call light if needed anything. The Progress Note did not reveal causal factors of the fall or a new intervention to prevent the fall from happening again. A record review of Resident 3's Progress Notes dated 02/10/2026 at 5:52 AM revealed the resident was found lying on the floor next to the bed on top of blankets and a pillow under the resident's head. The resident denied hitting the resident's head. ROM and vital signs were assessed, and neuro checks were started. The resident had spilled urine on the floor and it was not known what the resident was attempting to do. The resident was confused and unable to be re-orientated. The staff would continue to monitor, and the resident was encouraged to use call light if needed assistance but does not use it. The Progress Note did not include causal factors of the fall or a new intervention to prevent the resident from falling again. A record review of Resident 3's Progress Notes dated 02/10/2026 at 2:18 AM revealed the Physician Assistant (PA) seen the resident for the recent falls and confusion. The PA ordered Melatonin (a dietary supplement used to treat insomnia) and a urinalysis (urine test for infection). A record review of Resident 3's Progress Notes dated 02/10/2026 at 22:03 revealed the resident was found on the floor next to the bed. The resident refused the assessment, and the resident was sent to the Emergency Department. The Progress Note did not contain causal factors of the fall. A record review of the facility's State Report dated 02/16/2026 revealed the facility notified the State of Nebraska of the fall Resident 3 had on 02/10/2026 that led to the transfer to the Emergency Department and noted the multiple falls since admission. The State Report included interventions that were in place at the time of the fall but did not include the causal factors of the falls. The State Report revealed the interventions that were put in place to prevent the falls from re-occurring were on 02/09/2026 at 9:15 PM they educated the resident to use the call light and final one, the resident was sent to the Emergency Department, but it did not reveal new interventions for the 02/10/2026 at 12:30 AM or 02/10/2026 at 5:30 AM falls. A record review of the facility's Omaha Operations LLC pages the facility provided with a locked date of 02/25/2026 revealed they were 1 page of the Fall (Un-witnessed) on 02/09/2026 at 9:15 PM, Fall (Witnessed) on 02/10/2026 at 12:30 AM, Fall (Un-witnessed) on 02/10/2026 at 5:30 AM, and the Fall (Un-witnessed) on 02/10/2026 at 9:30 PM incidents that included the Incident Description and Immediate Action Taken, but not the entire document. The bottom of each page revealed Privileged and Confidential – Not part of the Medical Record – Do not Copy. They did not reveal causal falls or what interventions were put in place to prevent the resident from falling again other than the 02/10/2026 at 9:30 PM Fall (Un-witnessed) when they sent Resident 3 to the Emergency Room. The only incident that documented neuro checks were started was on the Incident on 02/10/2026 at 5:30 AM. A record review of Resident 3's Neurological Evaluation Flow Sheet – V2 dated 02/10/2026 at 5:56 AM revealed neuro checks were started on the resident 02/10/2026 at 5:30 AM. They did not reveal neuro checks were started for the unwitnessed fall on 02/09/2026 at 9:15 PM. An observation on 03/12/2026 at 4:30 AM – 8:55 AM revealed staff did not enter Resident 3's room to check and change the resident except at 8:32 AM Nursing Assistant (NA)-H entered the room, placed the resident breakfast tray on the resident's bedside table, and exited the resident's room without checking the resident or asking the resident if the resident needed anything. An observation on 03/12/2026 at 8:56 AM revealed Licensed Practical Nurse (LPN)-C entered Resident 3's room to deliver the resident's medications, the resident was sleeping. At 8:59 AM an observation revealed the resident sat up on the side of the bed, stood up, grabbed the walker, and walked the resident's self to the restroom, and closed the door. LPN-C was standing in the doorway to the room at the med cart with LPN-C back to the resident. LPN-C heard the resident's walker move and LPN-C looked back and watched the resident get up and transfer self to the restroom without assistance. LPN-C did not ask the resident if the resident needed assistance or supervise the resident transfer on and off the toilet or offer toileting hygiene. At 9:04 AM Resident 3 exited the resident and transferred self to the recliner. In an interview on 03/12/2026 at 9:26 AM, NA-H confirmed NA-H had not checked on Resident 3 until NA-H delivered the breakfast tray, then just left the tray. NA-H confirmed residents were supposed to be checked and changed every 2 hours and they had not. In an interview on 03/12/2026 at 9:53 AM, the facility's Director of Nursing (DON) confirmed staff should check residents every 2 hours. The DON confirmed that staff should have assisted a resident with transfers that was listed on the MDS as needing partial/moderate assistance and on the Care Plan as 1 assist partial with transfers. The DON confirmed LPN-C or staff should have supervised Resident 3 with toilet transfers. In an interview on 03/12/2026 at 12:45 PM, the DON confirmed the Care Plan did not include interventions for the falls the resident had. The DON confirmed the facility did have an internal fall document, but it was not part of the medical record, so they could not provide that document to review. The DON confirmed the resident's medical record should have included the causal factors for the falls and interventions that were put in place to prevent the falls from happening again except the final fall went the resident was sent to the hospital. The DON confirmed it because the falls happened back-to-back and the facility did not have enough time in between the falls to come up with interventions. The DON confirmed neuro checks were not started after the 02/09/2026 at 9:15 PM fall and should have been. B. A record review of the facility's Falls Management policy dated 4/2015 revealed the following: Fall Injury Prevention – Post Fall 1. Assess the resident/patient and immediately implement appropriate measures to prevent injury. a. EX. Wipe up spills, improve lightening, call light in reach, appropriate footwear. b. Document in medical record 2. Initiate and complete the Accident/Incident Protocol 3. Review Fall Risk Assessment for any changes in fall risk, reassess post fall. 4. Review the Plan of Care – Fall Risk Reduction 5. Discuss findings and interventions with the resident/patient/family for inclusion in the Interdisciplinary Plan of Care (IPOC). 6. Adjust/add interventions on the Plan of Care- Fall Risk Reduction. 7. Present resident/patient at the next scheduled IPOCC meeting: a. Review current assessment and reports. b. Compare data from previous assessments. c. Discuss identified trends or potential new risk factors. 8. Review and revise Interdisciplinary Plan of Care. 9. Update and communicate interventions. 10. Provide appropriate training for caregivers, noting any changes implemented. 11. Educate resident /patient/family, as appropriate. 12. Verify completion of the Accident/Incident Process. 13. Verify referral to therapy for screen. A record review of the facility's Fall Data Collection dated 1/14/2026 revealed that the root cause of the fall was the air mattress. The initial intervention that was implemented to prevent reoccurrence was to request the air mattress changed to a regular mattress. A record review of Resident 4's undated Care Plan Report revealed the following: 1/14/26 new fall with right femur fracture (a break in the long, strong bone between your hip and knee) and surgical aftercare. The intervention listed was working with therapy post-surgery on right femur with an initiation date of 1/22/2026. A record review of Resident 4's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 1/1/2026 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14/15 indicating the resident is cognitively intact (the ability to make ones own decisions and think for oneself). An observation on 3/11/2026 at 12:23 PM revealed Resident 4 lying in bed on an air mattress. An observation on 3/12/2026 at 6:58 AM revealed Resident 4 lying in bed on an air mattress. In an interview on 3/11/2026 at 12:41 PM Physical therapy Assistant (PTA)-G confirmed that the order for Occupational Therapy (OT) was placed on 3/4/2026 and Resident 4 was evaluated on 3/5/2026. PTA-G confirmed that OT has been working with the resident twice a week since 3/5/2026. The order for Physical Therapy (PT) was also placed on 3/4/2026 and Resident 4 was scheduled to be evaluated by PT on 3/12/2026. In an interview on 3/11/2026 at 12:59 PM Director of Nursing (DON) confirmed that the Fall investigation in the charting system said the air mattress was the reason for the fall and the resident was switched to a regular mattress. The DON said that no other intervention was seen besides the therapy evaluation. In an interview on 3/11/2026 at 1:10 PM Medication Aide (MA)-F confirmed that Resident 4 is on an air mattress. In an interview on 3/11/2026 at 1:24 PM DON confirmed that the PT evaluation was to assess for change due to the resident being in the hospital. The DON confirmed that the air mattress was changed to a regular mattress, and then Resident 4 stated that Resident 4 could not sleep on the regular mattress, so it was changed back to the air mattress per resident request. In an interview on 3/12/2026 at 11:29 AM DON confirmed that the air mattress was switched to a regular mattress on 3/4/2026. The DON confirmed that there was no additional evidence of any other interventions regarding the fall besides therapy. C. Record review of Resident 1's admission Record showed the facility admitted the resident on 02/24/2026. Further review of the admission record revealed Resident 1 had diagnoses that included hemiplegia (complete or severe loss of movement on one side of the body) and hemiparesis (weakness or partial paralysis on one side of the body) following a nontraumatic intracerebral hemorrhage (stroke). Record review of Resident 1's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 03/02/2026 revealed Resident 1 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 13. According to the MDS manual, a score of 13-15 indicated the resident had intact cognition. Further review of the MDS identified Resident 1 had one non-injury fall since admission to the facility. Record review of Resident 1's Fall Data Collection dated 02/27/2026 revealed the resident sustained a witnessed fall when Resident 1 slipped and fell during a self-transfer in the bathroom. Record review of Resident 1's Progress Notes (PN) revealed a PN dated 02/27/2026 at the time of the fall, and a follow-up note dated 02/28/2026 at 12:52 PM. Record review of Resident 1's Electronic Health Record (EHR) including progress notes, skilled services documentation, and scanned documents revealed no further evidence of post-fall injury monitoring and documentation. Interview on 03/11/2026 at 3:51 PM with RN-A confirmed a resident should be monitored for post-fall injury for 72 hours after a fall, and a progress note should be entered. Interview on 03/12/2026 at 5:43 AM with LPN-I confirmed a resident should be monitored for post-fall injury for 72 hours after a fall, and a progress note should be entered. Interview on 03/12/2026 at 8:26 AM with the DON confirmed a post-fall evaluation should be completed on a resident to include vital signs every shift for 72 hours. The DON further confirmed there was additional evidence an assessment was completed for the 72 hours after Resident 1's fall.

Licensure Reference Number 175 NAC 12-006.09(H)(i) Based on observation, interview, and record review, the facility failed to ensure activities of daily living (ADLs) and voiding patterns (habits, behaviors, and physical processes of how a person empties their bladder) completed per the Care Plan on 1 (Resident 3) of 3 sampled residents. The facility census was 71. Findings are:A record review of Resident 3's Resident Census dated 03/12/2026 revealed the resident was admitted on [DATE] and sent to the hospital on [DATE]. The resident returned to the facility 02/24/2026. A record review of Resident 3's Medical Diagnosis dated 03/11/2026 revealed the resident had diagnoses of Metabolic Encephalopathy (brain dysfunction), Repeated Falls, and Muscle Weakness. A record review of Resident 3's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 03/02/2026 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 9 which indicated the resident was moderately cognitively impaired (difficulty thinking and comprehending). The resident required setup or clean-up assistance with eating and upper body dressing, supervision with oral hygiene (cleaning), and partial/moderate assistance with bathing, lower body dressing, footwear, and toileting and personal hygiene. The resident was partial/moderate assistance with all bed mobility and transfers. The resident had no falls in the lookback period. The resident was occasionally incontinent (lack of control) of bladder and frequently incontinent of bowels. The resident was not on a toileting program. A record review of Resident 3's Care Plan Report with an admission date of 02/06/2026 revealed a focus area of the resident had functional deficit (loss) with current ADLs and interventions included the resident 1 staff assist with ambulating with a walker. 1 staff assist partial with bed mobility, 1 staff assist partial with transfers, 1 staff assist partial with toileting hygiene, 1 assist supervisions with toilet transfers. The resident had a focus area of bladder incontinence related to impaired mobility and ambulation and interventions included establish voiding patterns and the resident used disposable briefs, change as needed (PRN). The resident was on a diuretic (medication that increased urine production to remove excess fluids from the body). A record review of Resident 3's Electronic Medical Record did not reveal a voiding patterns assessment had been completed. A record review of Resident 3's Progress Notes dated 02/09/2026 revealed the resident had an unwitnessed fall at 9:15 PM and resident said they were trying to get out of bed. A record review of Resident 3's Progress Notes dated 02/10/2026 at 12:46 AM revealed the resident had a witnessed fall and the staff seen the resident sliding out of bed. A record review of Resident 3's Progress Notes dated 02/10/2026 revealed the resident had an unwitnessed fall at 5:30 AM and the resident was found laying on the floor next to the bed. A record review of Resident 3's Progress Notes dated 02/10/2026 at 22:03 revealed the resident had an unwitnessed fall and the resident was found on the floor next to the bed. An observation on 03/12/2026 at 4:30 AM - 8:55 AM revealed staff did not enter Resident 3's room to check and change the resident except at 8:32 AM Nursing Assistant (NA)-H entered the room, placed the resident breakfast tray on the resident's bedside table, and exited the resident's room without checking the resident or asking the resident if the resident needed anything. An observation on 03/12/2026 at 8:56 AM revealed Licensed Practical Nurse (LPN)-C entered Resident 3's room to deliver the resident's medications, the resident was sleeping. At 8:59 AM an observation revealed the resident sat up on the side of the bed, stood up, grabbed the walker, and walked the resident's self to the restroom, and closed the door. LPN-C was standing in the doorway to the room at the med cart with LPN-C back to the resident. LPN-C heard the resident's walker move and LPN-C looked back and watched the resident get up and transfer self to the restroom without assistance. LPN-C did not ask the resident if the resident needed assistance or supervise the resident transfer on and off the toilet or offer toileting hygiene. At 9:04 AM Resident 3 exited the resident and transferred self to the recliner. An observation on 03/12/20226 at 9:30 AM revealed Resident 3 was picking at the breakfast tray and the resident's spouse was changing the resident bed and picking up the room. In an interview on 03/12/2026 at 9:30 AM, Resident 3's spouse confirmed the spouse was picking up the room and changing the bed because the staff don't do anything and there was dried blood on the bedding because (gender) picks at (gender). The spouse was only aware that the resident had fallen twice before being sent to the hospital. In an interview on 03/12/2026 at 9:26 AM, NA-H confirmed NA-H had not checked on Resident 3 until NA-H delivered the breakfast tray, then just left the tray. NA-H confirmed residents were supposed to be checked and changed every 2 hours and they had not. In an interview on 03/12/2026 at 9:53 AM, the facility's Director of Nursing (DON) confirmed staff should check residents every 2 hours. The DON confirmed they did not complete a voiding patterns assessment on Resident 3. The DON confirmed that staff should have assisted a resident with transfers that was listed on the MDS as needing partial/moderate assistance and on the Care Plan as 1 assist partial with transfers. The DON confirmed LPN-C or staff should have supervised Resident 3 with toilet transfers.

Licensure Reference Number 175 NAC 12-006.02(H)Based on record review and interview, the facility failed to report an allegation of potential neglect to the State Agency (SA) within the required timeframe for 1 (Resident 1) of 1 sampled resident. The facility staff identified a census of 71.Findings are:Record review of a facility policy entitled Abuse, Neglect and Exploitation dated revised 1/2024 revealed: - 6. Identification of Abuse, Neglect, and Exploitation - The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including, but not limited to, the following possible indicators: -a. Resident, staff, or family report of abuse. - h. Failure to provide care needs such as feeding, bathing, dressing, turning & positioning. - 7. Investigation of Alleged Abuse, Neglect and Exploitation - When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include: -a. Interview the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses. - c. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area, and visitors in the area. Obtain witness statements, according to appropriate policies. All statements should be signed and dated by the person making the statement. -d. Document the entire investigation chronologically. - 13. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: -a. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the advents (sic) that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other official (including the State Survey Agency and adult protected services where state law provides for jurisdiction in long-term care facilities) in accordance with state law. -b. Have evidence that all alleged violations are thoroughly investigated. -c. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in process. -d. Report the results of all investigations to the administrator or his or her designated representative and to the other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriation corrective action must be taken. - 14. The Administrator should follow up with government agencies, during business hours, to confirm the report was received, and to report the results of the investigation when final, as required by state agencies.Record review of a facility policy entitled Grievance Policy dated revised 1/2024 revealed: - G. Response: Any employee of this facility who receives a complaint shall immediately attempt to resolve the complaint within their role and authority. If a complaint cannot be immediately resolved the employee shall escalate that complaint to their supervisor and the facility Grievance Official.Upon receipt of a grievance or concern, the Grievance Official will review the grievance, determine immediately if the grievance meets a reportable complaint. Consistent with the facility's Abuse Prevention Policy the facility Administrator and Grievance Official will immediately report all alleged violations involving resident neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law. The Grievance Official will initiate the appropriate notification and investigation processes per individual circumstance and facility policies. The investigation will consists of at least the following: a review of the completed complaint report; an interview with the person or persons reporting the incident if applicable; interviews with any witnesses to the incident or concern; a review of the resident medical record if indicated; a search of resident room (with resident permission); an interview with staff members having contact with the resident during the relevant periods or shifts of the alleged incident; interviews with the resident's roommate, family members, and visitors; and a root-cause analysis of all circumstances surrounding the incident.Record review of Resident 1's admission Record showed the facility admitted the resident on 02/24/2026. Further review of the admission record revealed Resident 1 had diagnoses that included hemiplegia (complete or severe loss of movement on one side of the body) and hemiparesis (weakness or partial paralysis on one side of the body) following a nontraumatic intracerebral hemorrhage (stroke).Record review of Resident 1's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 03/02/2026 revealed Resident 1 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 13. According to the MDS manual, a score of 13-15 indicated the resident had intact cognition. Further review of the MDS identified Resident 1 was frequently incontinent of bladder and was not on a toileting program.Record review of a Grievance Form dated 02/27/2026 involving Resident 1 revealed a grievance was heard by the facility social worker. The grievance was filed by Resident 1's Family Member (FM-1) who reported Resident 1 stayed wet for over 4 hours today. When I asked for assistance, I was ignored and had to find different staff to assist my [family member].Record review of a facility provided Reportable Incident Log from 01/21/2026 to 03/11/2026 revealed no reportable incident that involved Resident 1.An interview on 03/11/2026 at 12:57 with Resident 1 revealed Resident 1 at times had been incontinent in an incontinence brief due to waiting for help to use the restroom after Resident 1 had activated the call light. Resident 1 reported the longest they have waited for help to the bathroom was approximately 45 minutes. Resident 1 reported [gender] was frustrated when this happened because it was an extra mess that would need to be cleaned up.An interview on 03/11/2026 at 1:01 PM with Resident 1's Family Member (FM-2) in the resident's room revealed an instance of waiting up to four hours for the call light to be answered once activated. FM-2 was unsure of the date of occurrence.An interview on 03/12/2026 at 8:26 AM with the Director of Nursing revealed an investigation into the grievance was conducted but was not documented. The DON confirmed the grievance dated 02/27/2026 related to Resident 1 was an allegation of potential neglect. The DON further confirmed allegations of potential neglect were to be reported to the State Agency within required timeframes and confirmed this allegation of potential neglect was not reported.An interview on 03/12/2026 at 11:52 AM with the Facility Administrator (ADM) revealed the allegation of potential neglect was not reported because the ADM understood if there was no resident outcome, the allegation did not require a report.

Licensure Reference Number 175 NAC 12-006.09(H)(iii) Based on observation, interview and record review facility failed to follow provider orders during wound care to promote healing of incisions/wounds and failed to ensure wound care was completed as ordered on 2 (Resident 2 and 4) of 3 sampled residents. The facility census was 71. Findings are: A. A record review of Resident 4's admission Record dated 3/11/2026 revealed the following diagnosis: Chronic Venous Hypertension (Idiopathic) with Ulcer of Right Lower Extremity (the blood pressure inside the blood vessels in the leg is too high), Venous Insufficiency (Chronic) (Peripheral) (difficulty in blood moving back to the heart resulting in blood staying in the lower legs) and Peripheral Vascular Disease (narrowing of the blood vessels resulting in difficulty for blood to flow back to the heart). A record review of Resident 4's Skin assessment dated [DATE] revealed that the resident had a venous ulcer (a slow-healing, shallow sore) on the right ankle. A record review of Resident 4's Treatment Administration Record (TAR) dated 3/2026 revealed the following orders: Wound Care: RT (right) lateral Ankle: Wash area foam soap and water, rinse and pat dry, apply Xeroform (a petroleum-jelly-soaked mesh cloth that does not stick to the wound, making dressing changes much less painful) gauze to wound bed, cover with ABD (abdominal) pad and secure with kerlix (a soft, absorbent, and stretchy bandage used to wrap and protect wounds). Change daily and as needed for excess drainage. every day shift for wound care An observation on 3/12/2026 between 6:58 AM and 8:10 AM revealed that there is a red open area on Resident 4's right lateral ankle. An observation on 3/12/2026 between 6:58 AM and 8:10 AM revealed Licensed Practical Nurse (LPN)-E cleansed the wound on the right lateral ankle, applied the xeroform gauze to the wound bed, wrapped the wound with kerlix and secured the kerlix with paper tape. In an interview on 3/12/2026 between 6:58 AM and 8:10 AM LPN-E confirmed that ABD pad was not placed while completing wound care to the right lateral ankle and should have been. LPN-E confirmed that the dressing completed on the right lateral ankle was ordered to be completed for Resident 4's right toes. B. A record review of the facility's undated How To Guide Wound VAC (vacuum)(Negative Pressure Wound Therapy revealed the staff would confirm Wound VAC orders and always follow the physician orders and facility policy. A record review of Resident 2's Resident Census dated 03/11/2026 revealed the resident was admitted on [DATE]. A record review of Resident 2's Medical Diagnosis dated 03/11/2026 revealed the resident had diagnoses of Type 2 Diabetes Mellitus Without Complications (uncontrolled blood sugars), Peripheral Vascular Disease (poor blood flow in the arms or legs), Encounter For Orthopedic Aftercare Following Surgical Amputation (care following removal of a body part), and Acquired Absence Of Other Left Toe (S). A record review of Resident 2's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 02/16/2026 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 14 which indicated the resident was cognitively aware (able to think and comprehend). The resident required setup or clean-up assistance with eating and upper body dressing, supervision with oral hygiene (cleaning), and partial/moderate assistance with bathing, lower body dressing, footwear, and toileting and personal hygiene. The resident was supervision or touching assistance with all mobility and transfers. The resident had a recent major orthopedic surgery and had surgical wounds and wound care. A record review of Resident 2's Care Plan Report with an admission date of 02/10/2026 revealed a focus area of the resident had impairment (damage or harm) of the skin integrity and was admitted with a surgical amputation to the 3rd toe of the left foot. Interventions included wound vac to left foot as ordered and back up wet to dry dressings as ordered in case would vac malfunctioned. The Care Plan Report did not reveal impairment to the left lower leg. - A record review of Resident 2's Clinical Physician Orders dated 03/11/2026 revealed the resident had orders for: - Wound vac dressing to the left 3rd toe changed every 3 days and as needed that had a start date of 02/13/2026 and an end date of 02/13/2026. - Wound vac dressing to the left 3rd toe changed every 3 days and as needed that had a start date of 02/16/2026 and an end date of 02/26/2026. - Wound vac to left foot 3rd toe at 100mmhg (millimeters of mercury, a unit of pressure) with constant suction. Check for function and change canister as needed (PRN) with a start date of 02/11/2026 and an end date of 02/26/2026. - Wound care: OK to apply wet to dry dressings if unable to apply wound vac or wound vac malfunctions with a start date of 02/17/2026 and an end date of 02/26/2026. -Wound care left foot, 1st and 2nd toes, wash area with soap and water, rinse, pat dry, paint with betadine (an antiseptic used to treat infections) 2 times per day (BID) and PRN with a start date of 02/11/2026 and an end date of 03/08/2026. -Wound care left 3rd toe amputation site: cleanse with cleanser, pat dry, lightly pack with betadine moistened gauze, then cover with rolled gauze. Change daily and PRN with a start date of 02/26/2026 and an end date of 3/3/2026. -Wound care left leg, wash area with soap and water, rinse, and pat dry. Secure with gauze, then edemawear (stockings to reduce swelling from excess fluid). Keep left leg incision clean and dry every day (QD) and PRN with a start date of 02/11/2026 and an end date of 02/27/2026. -Wound care: Paint left thigh and calf incisions with betadine and cover with bordered gauze daily and PRN with a start date of 02/26/2026 and an end date of 03/08/2026. A record review of Resident 2's Progress Note dated 02/10/2026 revealed that the resident was to have a wound vac placed on the left foot on 02/11/2026. A record review of Resident 2's Progress Note dated 02/12/2026 at 12:37 AM revealed that the resident's wound vac was not running, the battery appeared to be dead without a charger. The resident reported that the charger possibly went with the resident to Dialysis (treatment for Kidney Failure) on 02/11/2026. The staff would pass onto the day shift nurse to call the Dialysis Center. The Progress Note did not reveal how long the wound vac had gone without suction if or if the staff done anything for the wound dressing. A record review of Resident 2's Progress Note dated 02/16/2026 at 7:51 PM revealed that the resident returned from Dialysis with the machine off and no charge. The facility was unable to find the cord. The Progress Note did not reveal how long the wound vac went without suction. The staff removed the wound vac and applied the wet to dry dressing. The 02/16/2026 progress notes did reveal a Skilled Note entry at 6:12 PM and an abdominal (stomach assessment was completed at 6:18 PM. A record review of Resident 2's Progress Note dated 02/17/2026 revealed that the resident had a wet to dry dressing and the staff were waiting for the wound care nurse to do the wound vac. A record review of Resident 2's Progress Note dated 02/18/2026 revealed that the resident's wound vac was removed at an appointment 02/17/2026 and it was never re-applied. Wet to dry CDI (clean, dry, and intact). A record review of Resident 2's Progress Note dated 02/23/2026 revealed that the resident told the nurse the resident did not want the wound vac dressing changed because the resident was more comfortable with the dressing being completed by someone who had done it successfully in the past. A record review of Resident 2's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated February 2026 revealed: Indent Wound vac dressing to the left 3rd toe changed every 3 days and as needed that had a start date of 02/13/2026 and an end date of 02/13/2026 was not completed. Wound vac dressing to the left 3rd toe changed every 3 days and as needed that had a start date of 02/16/2026 and an end date of 02/26/2026 was entered to change every Monday, Wednesday, and Friday, not every 3 days. It was marked refused 02/23/2026. Wound vac to left foot 3rd toe at 100mmhg (millimeters of mercury, a unit of pressure) with constant suction. Check for function and change canister as needed (PRN) with a start date of 02/11/2026 and an end date of 02/26/2026 was not marked as completed on 02/13/2026 on the day shift or the 2:00 PM – 10:00 PM shift or the 02/17/2026 day shift. It was marked n or no 23 of 45 shifts. Wound care: OK to apply wet to dry dressings if unable to apply wound vac or wound vac malfunctions with a start date of 02/17/2026 and an end date of 02/26/2026 was not marked as being completed. Wound care left leg, wash area with soap and water, rinse, and pat dry. Secure with gauze, then edemawear (stockings to reduce swelling from excess fluid). Keep left leg incision clean and dry every day (QD) and PRN with a start date of 02/11/2026 and an end date of 02/27/2026 was not marked as completed 02/11/2026 or 02/13/2026. Wound care: Paint left thigh and calf incisions with betadine and cover with bordered gauze daily and PRN with a start date of 02/26/2026 and an end date of 03/08/2026 was not marked completed 03/03/2026 air 03/04/2026. A record review of the facility's Reason For Visit form dated 02/26/2026 revealed the resident's provider documented that Resident 2's left 3rd toe amputation site was macerated (softened or broken-down skin) with a large amount of slough (dead tissue). The resident reported that the wound vac had only been changed weekly instead of 3 times per week which was completely inappropriate and unsafe. New skin breakdown on the bottom of the foot because of that. The provider discontinued (stopped) the wound vac and just ordered betadine fluffed gauge to left 3rd toe amputation site, cover with rolled gauze and it MUST BE CHANGED DAILY. In a telephone interview on 03/11/2026 at 1:17 PM, Resident 2 confirmed the facility only had a couple of people the knew how to work with a wound vac or change a dressing on an amputated toe. The resident confirmed the resident's doctor was med and took off the wound vac because it was not being managed right and was doing more harm than good. Resident 2 confirmed there were 3, six day stretches where the staff did not change the wound dressing at all. Sometimes the staff could not get the wound vac dressing to seal, one time, there were 3 different nurses in the room, and they had to change it 3 times before they could get it to seal. In a telephone interview on 03/11/2026 at 3:23 PM, Licensed Practical Nurse (LPN)-B confirmed that LPN-B was working on 2/13/2026 and did not know why the order for wound vac dressing to the left 3rd toe changed every 3 days and as needed that had a start date of 02/13/2026 and an end date of 02/13/2026 did not get completed. LPN-B confirmed the only reason LPN-B could think of that it did not get completed was that LPN-B got pulled to do admissions. LPN-B confirmed one day, but LPN-B could not remember the date, the resident returned from Dialysis without the wound vac cord, but LPN-B found it at the bottom of a bag attached to Resident 2's wheelchair. LPN-B could not confirm how long the wound vac had not worked before she found it. LPN-B confirmed LPN-B changed the wound vac dressing on 02/16/2026 and had problems getting the dressing to seal because the pressure readings were not consistent, so LPN-B had another nurse look at it, so the resident refused to let LPN-B change the wound vac dressing on 02/23/2026 because of the problems before. In a telephone interview on 03/12/2026 at 11:04 AM, LPN-B confirmed LPN-B was an agency nurse and the facility did not do a formal competency (education and skills evaluation) on wound vacs or wound vac dressing changes. One time there was another nurse in the room with (gender) when LPN-B completed the wound vac dressing change, but no formal education or evaluation. In an interview on 03/12/2026 at 11:33 AM, the facility's Director of Nursing (DON) confirmed the facility did not have a policy or competencies on wound vacs, just the How To Guide. In an interview on 03/12/2026 at 11:55 AM, the DON confirmed Resident 2's wound care orders were not completed as ordered by the physician and should have been.

Licensure Reference Number 175 NAC 12-006.09(H)(iv)(2)Based on observations, interviews, and record reviews, the facility failed to establish voiding patterns to develop a toileting program for 1 (Resident 1) of 3 sampled residents. The facility staff identified a census of 71.Findings are:Record review of Resident 1's admission Record showed the facility admitted the resident on 02/24/2026. Further review of the admission record revealed Resident 1 had diagnoses that included hemiplegia (complete or severe loss of movement on one side of the body) and hemiparesis (weakness or partial paralysis on one side of the body) following a nontraumatic intracerebral hemorrhage (stroke).Record review of Resident 1's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 03/02/2026 revealed Resident 1 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 13. According to the MDS manual, a score of 13-15 indicated the resident had intact cognition. Further review of the MDS identified Resident 1 was frequently incontinent of bladder and was not on a toileting program.Record review of Resident 1'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 the following interventions related to toileting: -Resident 1 required partial assistance of one staff for toilet transfers dated revised 03/06/2026; -Resident 1 required substantial assistance of one staff for toileting hygiene dated revised 03/06/2026; -Establish voiding patterns dated revised 03/06/2026. -Incontinent: Routine check and change on rounds and as required for incontinence dated revised 03/06/2026.Record review of Resident 1's Nursing admission Data Collection - V 2 Section 6. Bladder dated 02/24/2026 revealed the facility assessed Resident 1 to have functional urinary. Further review of the bladder evaluation showed Resident 1's treatment program included routine check and change and prompted voiding. Review of Resident 1's Electronic Health Record which included scanned documents, progress notes, and forms revealed no evidence of Resident 1's voiding patterns.Observation on 03/12/2026 at 7:06 AM revealed Nurse Aide (NA)-H assisted Resident 1 out of bed, to get dressed, and to the toilet. There was a bed pad with a yellow wet area, and Resident 1's brief was noted to be wet.Interview on 03/11/2026 at 12:57 PM with Resident 1 revealed Resident 1 was aware of the urge to use the restroom. Resident 1 reported they must turn on the call light and wait for toileting assistance. Resident 1 reported they would like to be on a toileting program to restore continence but it had not been offered.Interview on 03/12/2026 at 7:12 AM with NA-H confirmed Resident 1's brief and bed pad were wet with urine. NA-H reported Resident 1 was not on a toileting program and further reported Resident 1 is toileted when [gender] calls for help.Interview on 03/12/2026 at 8:26 AM with the Director of Nursing revealed there was no bladder diary or established voiding patterns to aid in the development of an effective toileting program for Resident 1. The DON confirmed the established voiding patterns should have been completed.

Licensure Reference Number 175 NAC 12-006.18 Based on observations, interviews and record review the facility staff failed to follow infection control practice to prevent the potential for cross contamination on 1 (Resident 4) of 3 sample residents. The facility census was 71. Findings are:A.A record review of the facility's Infection Control Standard Precautions- Handwashing with a revision date of 1/2024 revealed the following: 7. Use an alcohol-based hand rub containing at least 62 percent alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. before and after direct contact with residents; h. Before moving from a contaminated body site to a clean body site during residents care; i. After contact with residents intact skin; j. After contact with blood or bodily fluids; k. After handling used dressings, contaminated equipment, etc.; m. After removing gloves. Applying and Removing Gloves 1. Perform hand hygiene before applying non-sterile gloves. 2. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff. 3. When removing gloves, pinch the glove at the wrist and peel away from the hand turning the glove inside out. 4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. 5. Perform hand hygiene. An observation on 3/11/2026 at 2:52 PM revealed Licensed Practical Nurse (LPN)-D, completed hand hygiene with soap and water, grabbed gloves out of the box, put the gloves on and removed the wound dressing. LPN-D removed gloves, pulled gloves out of the pocket on LPN-D scrub top, put the gloves on and cleansed the wound. LPN-D removed the gloves, pulled gloves out of the pocket on the scrub top, put the gloves on and placed the xeroform (a petroleum-jelly-soaked mesh cloth that does not stick to the wound, making dressing changes much less painful) over the wound and wrapped the wound with kerlix (a soft, absorbent, and stretchy bandage used to wrap and protect wounds). LPN-D removed the gloves, got new gloves out of the box, put them on and cleansed Resident 4's toes. In an interview on 3/11/2026 at 2:52 PM LPN-D confirmed that LPN-D should have completed hand hygiene between glove changes and did not. LPN-D confirmed that LPN-D should not have utilized the gloves from LPN-D's pocket and should have gotten clean gloves out of the box of gloves. B.A record review of the facility's MDRO (Multidrug-Resistant Organisms) PPE (Personal Protective Equipment)-Enhanced Barrier Precautions with a revision date of 1/2024 revealed the following: Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs target gown and glove use during high contact resident care activities. EBP may be indicated (when contact precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling (inside the body) medical devices, regardless of MDRO colonization (carrying the germ) status Residents known to be infected or colonized with an MDRO (that is CDC (Center for Disease Control) MDRO targeted); will be placed on EBP and signage on door placed. A record review of the facility's Enhanced Barrier Precaution signage revealed the following: Everyone Must: Clean their hands, including before entering and when leaving the residents room. Providers and staff must also: Wear gloves and a gown for the following high contact resident care activities. Dressing Bathing/Showering Transferring Changing linens Providing Hygiene Changing briefs or assisting with toileting Device care or use: Central line, urinary catheter, feeding tube tracheostomy Wound Care: any skin opening requiring a dressing Do not wear the same gown and gloves for care of more than one person. A record review of Resident 4's admission Record dated 3/11/2026 revealed the following diagnosis:Extended Spectrum Beta Lactamase (ESBL) Resistance and Personal History of Methicillin Resistant Staphylococcus Aureus Infection (Germs that are difficult to treat). An observation on 3/12/2026 at 5:36 AM of Resident 4's room door frame revealed that there is an EBP magnet on the top left side. An observation on 3/12/2026 between 6:58 AM and 8:10 AM revealed LPN-E entered Resident 4's room with the treatment cart (a mobile storage that contains supplies for treatments of skin issues and/or wounds). LPN-E did not put on a gown. LPN-E removed wound care supplies from the treatment cart and placed the supplies on the residents' uncleaned bedside table without disenfecting the table or putting a protective barrier down. There were scissors on the bedside table upon entering Resident 4's room. LPN-E used the scissors to cut the xeroform gauze to size and did not disenfect the scissors prior to using them on the wound care supplies. In an interview on 3/12/2026 between 6:58 AM and 8:10 AM LPN-E confirmed that the treatment cart should not have entered the room and did. LPN-E confirmed that LPN-E should have had EBP on while doing the dressing change and did not. LPN-E confirmed that the table should have been disinfected prior to placing wound care supplies on table and was not. LPN-E confirmed that the scissors should have been disinfected prior to cutting the wound care supplies and they were not. In an interview on 3/12/2026 at 11:55AM DON confirmed that the process in the EBP signage is the expectation for all staff to follow while providing high contact cares for anyone on EBP, including the residents with the EBP magnets in the top of the door frames.

Licensure Reference Number 175 NAC 12.006.11(E)Licensure Reference Number 175 NAC 12.006.18(D) Based on observation, interview, and record review, the facility failed to ensure all kitchen staff performed hand washing for at least 20 seconds when preparing food, entering or re-entering the food service area, and before applying and when removing gloves. This had the potential to affect all 62 residents that consumed food from the kitchen. The total facility census was 62. Findings are:A record review of the facility's undated Handwashing Policy: Food Preparation Areas revealed that employees must wash their hands whenever entering or re-entering food preparation areas, before handling food, clean equipment, utensils, or serving items, after touching hair, face, body, or clothing, and before putting on gloves and after removing gloves. Hand washing should be performed for at least 20 seconds with soap and water. An observation on 01/20/2026 at 10:22 AM - 12:30 PM revealed Dietary Aide (DA)-N put hand in sleeve (hot pad) and got a pot off the stove, went to the dish room, came back to the food preparation (prep) area, got aluminum foil, gloved, touched DA-N's glasses on DA-N's face with the right hand, took out 1 frank (hot dog) from the pot with tongs and wrapped it, grabbed a bun with the right hand and placed a frank in the bun and wrapped it. DA-N completed the process of placing the franks in the bun with the right hand 3 more times then removed gloves without performing hand washing. DA-N then took the pot to the dish room, went to the dry storage and got cans of chicken noodle soup, got a steam pan, opened the cans and dumped the chicken noodle soup in the steam pan and put on the stove without performing hand washing. At 12:05 PM DA-N exited the kitchen, returned to the kitchen, discarded soup cans, washed hands for 14 seconds, left the kitchen and re-entered, gloved, got a chicken leg and placed in on a plate with the gloved hand, placed it in the microwave, removed it, checked the temperature of the chicken leg, placed it back in the microwave, removed it, checked the temperature again, and then exited the kitchen. DA-N returned to the kitchen, got a clean frying pan, got 8 pieces of bread out of the wrapper with DA-N's bare right hand, put the bread on the ledge of the stove and then placed bread in the frying pan. DA-N then went to the reach-in refrigerator, got a package of cheese slices, gloved, placed the cheese slices between the bread slices with the gloved hands, removed gloves and threw away the cheese package, all without hand washing. DA-N then opened a steam pan of butter on the shelf above the stove, grabbed a piece of bread with a bare left hand and brushed butter on the bread with the right hand and repeated the process for 3 more slices of bread in the frying pan. DA-N then removed the 4 grilled cheese sandwiches and wrapped with foil while touching the sandwiches with bare hands, no hand washing. DA-N opened 2 large cans of pineapple and dumped into a large bowl, exited the kitchen, returned to the kitchen and went to dry storage, got Styrofoam bowls and lids and put the bowls on a serving tray while another kitchen staff member scooped the pineapple into them while touching the inside of the bowls with DA-N's ungloved thumbs, and did not perform hand washing. In an interview on 01/20/2026 at 2:03 PM, the facility's Dietary Manager (DM) confirmed DA-N should have washed hands for at least 20 seconds when DA-N entered the food prep area, before putting gloves on and after removing gloves, and should not have touched food or utensils without hand washing.

Licensure Reference Number 175 NAC 12-006.18 Based on observation and interview, the facility failed to maintain ventilation covers, water systems, fixtures, ceilings, doors, outlet covers and call systems in clean, good and working condition in 11 (rooms 204, 301, 304, 305, 306, 310, 502, 505, 511, 512, 514) of 42 occupied resident rooms. The facility census was 64.Findings are: Observation on 01/20/26 between11:35 AM and 12:13 PM with the facility Maintenance Supervisor and the facility Administrator, during the environmental tour of the facility , revealed the following environmental concerns: - There was no call string attached to the wall in the bathroom of room [ROOM NUMBER]. - The water pressure was very light in the sink in rooms [ROOM NUMBERS]. - Cobwebs were present along the walls and ceiling in room [ROOM NUMBER]. - The ventilation system covers were coated with a grey fuzzy substance that resembled dust in rooms 301, 304, 305, 306, 316, 502, 505, 511, 512, 514. - The bathroom light was out (not functioning) in room [ROOM NUMBER]. - There were reddish brown stains on the ceiling and light cover and dark stains on the floor in the bathroom in room [ROOM NUMBER]. - There were scratches and a deep gouge in the bathroom door in room [ROOM NUMBER]. - The call light outlet was cracked and broken on the wall in room [ROOM NUMBER]. - The phone outlet cover was broken on the wall in room [ROOM NUMBER]. Interview on 01/20/2026 at 12:15 PM with the Maintenance Supervisor [MS] confirmed the issues observed during the environmental tour and confirmed that they needed to be cleaned and / or repaired. The MS confirmed that there were no active work orders for the concerns identified during the environmental tour and that staff were inconsistent with submitting work orders.

Licensure Reference Number 175 NAC 12-006.05(G) Based on record review and interview, the facility failed to ensure that behavior monitoring was completed for the continued use of psychotropic medications for 2 (Resident 39 and Resident 31) of 7 residents reviewed for behavior management and unnecessary medications. The facility census was 64.Findings are: Record review of a facility policy titled Behavior monitoring dated January 2024 revealed the objective of the mood and behavior policy and procedure is to provide a plan of care that is individualized to the residents needs based upon the comprehensive assessment by the interdisciplinary team. Number 5.a. on the policy and procedure revealed mood and behavior tracking: Mood and behavior tracking documentation will be completed by front line staff, based upon comprehensive outcomes, to identify mood or behavior patterns, interventions attempted and outcomes of approaches. A. A record review of Resident 39's Clinical Census dated 01/15/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 39's Medical Diagnosis dated 01/15/2026 reveled the resident had diagnoses of Personal History Of Traumatic Brain Injury (TBI), Unspecified Mood (effective) Disorder, and History Of Falling. A record review of Resident 39's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 10/21/2025 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 13, which indicated the resident was cognitively aware. The resident required supervision/touching assistance with eating, oral hygiene, and footwear and required partial/moderate assistance with toileting, dressing, and personal hygiene. The resident required supervision or touching assistance with all mobility. The resident did have inattention, disorganized thinking, and was depressed. The resident did have verbal behavioral symptoms directed toward others that significantly interfered with resident care. And put others at significant risk for physical injury. The resident exhibited wandering behaviors (walking around aimlessly) and (gender) behaviors were worse. The resident had not fallen. The resident was on antidepressant medications and anticonvulsants, but hypnotics were not marked. A record review of Resident 39's Care Plan with an admission date of 10/15/2025 revealed the resident had a focus area of behavioral problems, for being verbal and physically aggressive, of mood problems related to mental health, a diagnosis of TBI and was on 2 medications for a mood disorder. Target moods included agitation, isolation, and verbally and physically aggressive. There was an intervention on the care plan which identified that the resident was very impulsive, not very redirectable, and does not like education, gets irritable when reminded of safety. A record review of Resident 39's Clinical Physician Orders dated 01/15/2026 revealed the resident had orders for Amitriptyline (medication to treat depression), Mirtazapine (a medication to treat depression and improves sleep and appetite), and Trazadone (and antidepressant that can treat Insomnia). A record review of Resident 39's Progress Notes dated 01/10/2026 revealed the resident left the facility 2 times on 01/10/2026 without signing out and letting staff know. A record review of Resident 39's Documentation Survey Report v2 for monitoring behavior symptoms dated 11/2025 revealed behavior monitoring was not completed on: -11/01/2025 the 10:00 PM – 6:00 AM shift -11/02/2025 the 2:00 PM – 10:00 PM shift -11/02/2025 the 10:00 PM – 6:00 AM shift -11/03/2025 the 6:00 AM - 2:00 PM shift -11/03/2025 the 10:00 PM – 6:00 AM shift -11/04/2025 the 6:00 AM - 2:00 PM shift -11/04/2025 the 2:00 PM – 10:00 PM shift -11/08/2025 the 2:00 PM – 10:00 PM shift -11/08/2025 the 10:00 PM – 6:00 AM shift -11/09/2025 the 10:00 PM – 6:00 AM shift -11/11/2025 the 10:00 PM – 6:00 AM shift -11/14/2025 the 2:00 PM – 10:00 PM shift -11/14/2025 the 10:00 PM – 6:00 AM shift -11/17/2025 the 2:00 PM – 10:00 PM shift -11/19/2025 the 2:00 PM – 10:00 PM shift -11/22/2025 the 2:00 PM – 10:00 PM shift -11/23/2025 the 2:00 PM – 10:00 PM shift -11/24/2025 the 10:00 PM – 6:00 AM shift -11/25/2025 the 2:00 PM – 10:00 PM shift -11/25/2025 the 10:00 PM – 6:00 AM shift -11/26/2025 the 10:00 PM – 6:00 AM shift -11/27/2025 the 10:00 PM – 6:00 AM shift -11/28/2025 the 2:00 PM – 10:00 PM shift -11/29/2025 the 10:00 PM – 6:00 AM shift -11/30/2025 the 10:00 PM – 6:00 AM shift A record review of Resident 39's Documentation Survey Report v2 for monitoring behavior symptoms dated 12/2025 revealed behavior monitoring was not completed on: -12/01/2025 the 10:00 PM – 6:00 AM shift -12/02/2025 the 2:00 PM – 10:00 PM shift -12/03/2025 the 10:00 PM – 6:00 AM shift -12/06/2025 the 2:00 PM – 10:00 PM shift -12/06/2025 the 10:00 PM – 6:00 AM shift -12/07/2025 the 10:00 PM – 6:00 AM shift -12/09/2025 the 2:00 PM – 10:00 PM shift -12/09/2025 the 10:00 PM – 6:00 AM shift -12/10/2025 the 10:00 PM – 6:00 AM shift -12/11/2025 the 2:00 PM – 10:00 PM shift -12/13/2025 the 6:00 AM - 2:00 PM shift -12/15/2025 the 10:00 PM – 6:00 AM shift -12/17/2025 the 10:00 PM – 6:00 AM shift -12/19/2025 the 10:00 PM – 6:00 AM shift -12/27/2025 the 10:00 PM – 6:00 AM shift -12/28/2025 the 10:00 PM – 6:00 AM shift -12/31/2025 the 2:00 PM – 10:00 PM shift -12/31/2025 the 10:00 PM – 6:00 AM shift A record review of Resident 39's Documentation Survey Report v2 for monitoring behavior symptoms dated 01/2026 did not reveal the resident had behaviors on 01/10/2026 when the resident left the facility while refusing to sign out. In an interview on 01/21/2026 at 8:46 AM, Clinical Consultant (CC)-L confirmed there were a lot of shifts the Nursing Assistants should have completed the behavior monitoring on Resident 39 but did not. B. Record review of Resident 31's admission Face Sheet revealed that Resident 31 was admitted to the facility on [DATE] and included diagnoses of major depressive disorder, recurrent, severe with psychotic symptoms, suicidal ideations, schizoaffective disorder, personality disorder, and anxiety disorder. Record review of Resident 31's quarterly MDS dated [DATE] revealed that Resident 31 had a BIMS score of 13, which indicated the resident was cognitively intact, had a total mood score of 2 which indicated minimal depression, exhibited behavioral symptoms not directed toward others 1 - 3 days per week, rejected cares 1 - 3 days per week, exhibited no wandering behaviors, was independent with activities of daily living, was independent with ambulation, used antidepressant and antianxiety meds daily and wore an elopement alarm daily. Record review of Resident 31's Physician Orders revealed that Resident 31 took the following medications with indications for their use: - Buspirone [an antianxiety medication] 10 milligrams [mg] tab 3 times daily for major depressive disorder recurrent with psychotic symptoms started on 10/20/25. Indications for use [Target behaviors] included: suicidal ideations, auditory hallucinations and nightmares. - Escitalopram [an antidepressant medication] 20 mg 1 time daily for major depressive disorder recurrent with psychotic symptoms started on 8/14/25. Indications for use [Target behaviors] included: sadness, isolation and suicidal ideations. - Trazadone [an antidepressant medication] 50 mg 1 tab daily at bedtime started on 7/29/25. Indications for use [Target behaviors] included: suicidal ideations, auditory hallucinations and nightmares. Record review of Resident 31's Care Plan dated 12/3/25 revealed that Resident 31 was at risk for elopement [leaving the building without staff knowledge] related to exit seeking behavior, impaired cognition and impulsiveness. The care plan identified that Resident 31 wore a wander guard device [a device that alerts staff when a resident is trying to leave the building]. The care plan identified that Resident 31 used antianxiety and antidepressant medications daily with an intervention to observe the resident for safety and adverse reactions to the medications such as hostility, rage, aggressive or impulsive behaviors and hallucinations. Observation on 1/14/25 at 12:21 PM revealed Resident 31 dressed and stood in the doorway of [gender] room in the facility. The resident wore a wander guard on the left wrist. Record review of Resident 31's Behavior Monitoring task documented by the nursing assistants for November and December 2025 and January 2026 revealed no behavior monitoring had been completed on the following dates: November 2025: - day shift 11/3, 11/4, 11/21, 11/22 - evening shift: 11/2, 11/4, 11/8, 11/12, 11/22, 11/23, 11/25, 11/28 - night shift 11/1, 11/2, 11/8, 11/17, 11/19, 11/24, 11/25, 11/26, 11/29, 11/30/25 December 2025 - day shift 12/6, 12/16, 12/20/25 - evening shift: 12/6, 12/9, 12/11, 12/16, 12/21/25 - night shift: 12/1, 12/3, 12/6, 12/7, 12/9, 12/10, 12/16, 12/17, 12/23, 12/24, 12/26, 12/29, 12/31 January 2026: - day shift 1/5/26 - night shift 1/1, 1/4 , 1/5, 1/6, 1/7, 1/11, 1/12/26 Interview on 01/21/2026 at 9:06 AM Clinical Coordinator [CC] - L confirmed that behavior monitoring for Resident 31 had not been consistently documented for November 2025, December 2025 and January 2026. CC-L confirmed the nurse aides should document behavior monitoring on each shift and this was not done consistently and should have been.

Licensure Reference Number 175 NAC 12-006.09(H) (iii)Based on observation, interview and record review the facility failed to ensure that an air mattress was working and calibrated correctly for 1 resident (Resident 24). The facility reported a census of 64.A record review of Resident 24's undated care plan revealed Resident 24 had an admission date of 05/31/2025 and had the following diagnoses: Spastic Hemiplegia (brain damage disorder affecting one side of the body, causing stiffness, weakness and poor motor control in the affected arm and leg), quadriplegia (paralysis affecting all four limbs and the torso), cramps and spasms of muscle, amputation of left foot, amputation of right leg above the knee, and a history of wounds. A record review of Resident 24's Skin Observation Sheet, dated 1/13/2026 revealed Resident had a Stage III pressure ulcer (a deep crater where fat tissue is visible) to the sacrum (tailbone). Resident 24 also had a venous ulcer to the left lateral leg, a venous ulcer to the left anterior lower leg, a venous ulcer to the left lateral lower stump and a surgical wound to the right lower stump. A record review of Resident 24's undated care plan revealed a focus area for potential and actual impairment of skin integrity (possibility of/or actual skin damage) and an intervention dated 11/8/2023 for a low air loss mattress (an inflatable medical mattress designed to reduce pressure, enhance circulation and manage moisture). A record review of Resident 24's order summary did not reveal an order for an inflatable mattress or parameters for its use. A record review of Residents 24's weight summary note dated 11/5/2025 revealed the most recent recorded weight of 190.4lbs. A record review of the instruction manual for the Med Aire Plus 8 Alternating Pressure and Low Air Loss Mattress Replacement System revealed the following information:Operation: Mode Selection. It is recommended to always keep the control unit in the alternating pressure mode when the patient is in a lying position for more efficient pressure ulcer prevention and treatment.Weight setting selection.The pressure of the mattress can be adjusted by choosing the patients corresponding weight setting using the weight setting buttons (+) (-). Use the weight setting buttons to select the desired level. Pressure levels will range from 10-50 mmHg. An observation on 01/15/2026 at 10:00 AM, accompanied by Licensed Practical Nurse M (LPN), revealed Resident 24's inflatable mattress had a beeping (alarm) noise. An observation on 01/15/2026 at 2:10 PM revealed Resident 24's inflatable mattress had a beeping noise. An observation on 01/20/2026 at 8:16 AM revealed Resident 24's mattress was not beeping, and the mattress controls revealed the mattress was set at the highest setting [PHONE NUMBER]lbs. An interview on 01/15/2026 at 10:02 AM with LPN M confirmed Resident 24's inflatable air mattress was alarm beeping, which indicated it was not working correctly. LPN M confirmed they did not know how to correct it. LPN M revealed they had called the medical equipment people to fix it 2 weeks ago but was unable to provide evidence of the call. LPN M confirmed over or under inflation of an air mattress for a resident with pressure injuries could make the injuries worse or cause new skin issues. LPN M confirmed they were not familiar with the air mattress and did not know how to calibrate it or adjust it to the resident. An interview on 01/15/2026 at 10:05 AM with Resident 24 confirmed the mattress had been beeping for weeks and no one knew how to fix it. An interview on 01/15/2026 at 2:10 PM with Medication Aide I (MA) confirmed Resident 24's mattress had been beeping for several weeks. An interview on 01/15/2026 with the Interim Director of Nursing (IDON), confirmed they were unaware Resident 24's mattress had been beeping and had been beeping all day. The IDON confirmed they had not been notified of the malfunction. The IDON confirmed a malfunctioning air mattress could cause further injury to Resident 24's wounds. An interview on 01/15/2026 at 3:51 PM with the Maintenance Director (MD) confirmed they had not been informed of the issue with Resident 24's mattress until 1/15/2025. The MD revealed Resident 24 did not wish to change to another bed. The MD confirmed they would be able to attach a new motor to Resident 24's mattress and would not have to move the resident. The MD revealed the air mattress would be calibrated to the manufacturer's instructions. An interview on 01/15/2026 at 3:51 PM with the IDON confirmed they did not want to cause Resident 24 further discomfort by moving them and agreed attaching a replacement motor to the existing mattress would be a suitable repair. An interview on 01/20/2026 at 8:31 AM with the MD revealed they calibrated the air mattress by inflating it completely and then reducing air pressure until Resident 24 stated they were comfortable. An interview on 01/20/2026 at 9:23 AM with the IDON confirmed they did not know how to calibrate an air loss mattress. The IDON confirmed it was unknown how long the air mattress had been malfunctioning. The IDON confirmed they thought it was appropriate to inflate the bed according to the residents comfort level. The IDON reviewed Resident 24's last recorded weight of 190.4lbs. The IDON confirmed the mattress should have been calibrated according to Resident 24's weight as the resident has active wounds.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)Based on record review and interviews, the facility failed to provide surgical wound care as ordered by the physician for 1 (Resident 46) of 1 sampled resident. The facility staff identified a census of 64. Findings are:A record review of the facility's New/re-admission Process to be completed by the Licensed Nurse undated procedure revealed the following: 6. Licensed Nurse then to review admission orders. b. Wound orders to be inputted by the License Nurse (medication would be inputted by the Pharmacy, but the Licensed Nurse needs to input the order for the treatment. A record review Resident 46's Face Sheet revealed that the resident was admitted on [DATE] with a diagnosis of Encounter for surgical aftercare following surgery on the circulatory system. A record review of the hospitals after visit summary (AVS) for Resident 46 dated 12/19/2025 revealed the following: Wound care Location: Toe, fourth; Location orientation: Left; Wash area: soap and water, rinse and pat dry; Topicals (to wound bed): Povidone (Betadine) liquid/swabs; Primary dressing: Gauze square; Secondary dressing: Gauze, rolled; Wash foot with soap and water daily; rinse and pat dry with a clean towel. Betadine paintleft fourth toe and place gauze floss between each toe space and allow to dry completely before applying socks and/or Rooke boot (a vascular boot that provides redistribution of pressure to help treat and/or prevent skin breakdown). Ensure that dry gauze is in the crease of the 5th pinky toe. Frequency: twice a day. A record review of Resident 46's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated [DATE] revealed that the wound care order was not activated on the TAR until 12/23/2025. Wound care was not charted on the TAR from 12/19/2025 until 12/23/2025. In an interview on 01/15/2026 at 2:51 PM Interim Director of Nursing (IDON) confirmed that the facility staff should have utilized the wound care orders on the AVS. IDON confirmed that the wound care order was not initiated on 12/19/2025. In an interview on 01/21/2026 at 12:28 PM Director of Nursing (DON) confirmed that wound care was not completed from 12/19/2025 until 12/23/2025.

Based on record review and interview the facility failed to provide a bed hold information and a written reason for transfer at the time of hospitalization for Resident 1 on 5 occasions. The facility staff identified a census of 64.Findings are: A. A record review of a policy titled Bed Hold and Return to Facility Policy and Procedure created 5/17 and revised 1/2024 revealed the following information: Policy It is the policy of the facility that residents who are transferred to the hospital or go on a therapeutic leave are provided with written information about the State's bed hold duration and payment amount before and the transfer. Additionally, this facility permits residents to return to the facility after hospitalization or therapeutic leave if their needs can be met by the facility, they require the services provided by the facility and they are eligible for Medicaid or Medicare covered services or services covered by another payor. Residents and their representative will be provided with bed hold and return information at admission and before a hospital transfer or therapeutic leave. The facility will maintain in contact with the resident and representative while the resident is absent from the facility and arrange for their return if appropriate.Nursing and social work staff are educated. B. A record review of Resident 1's Clinical Census revealed Resident 1 was admitted to the facility on [DATE] and listed on a hospital leave 12/01/2025, 12/09/2025, 12/18/2025 and 01/02/2026. A record review of Resident 1's Progress Notes dated 11/30/25 at 2:12 AM revealed the doctors office was notified and Resident 1 was sent out to the Emergency Room. A Record review of Resident 1's medical records including progress notes and miscellaneous documents revealed no bed hold information or reason for transfer for Resident 1 for 11/30/25, 12/01/25, 12/09/25, 12/18/25, and on 01/02/26. An interview with Social Service Director on 1/20/2026 at 9:50 AM confirmed the facility had no bed hold forms or reason for transfer forms completed for Resident 1 and should have completed one with each transfer out to the hospital.

Licensure Reference Number 12-006.02(H) Based on record review and interview the facility failed to initiate and complete a thorough investigation related to a fall with a significant injury for Resident 1. The facility staff identified a census of 64. Findings are:A. Record review of facility policy titled Abuse, Neglect and Exploitation created 11-17 [no year] revealed the following information: Policy: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the residents' medical symptoms. Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. 7. Investigation of Alleged Abuse, Neglect and Exploitation- When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include: a. Interview the involved resident, if possible, and document all responses. If the resident is cognitively impaired, interview the resident several times to compare responses. b. If there is no discernable response from the resident, or if the residents' response is incongruent with that of a reasonable person, interview the residents family, responsible parties, or other individuals involved in the residents life to gather how he/she believes the resident would react to the incident. c. Interview all witnesses separately. Include roommates, residents and adjoining rooms, staff members in the area, and visitors in the area. Obtain witness statements, according to appropriate policies. All statements should be signed and dated by the person making the statement. d. Document the entire investigation chronologically. B. A record review of Resident 1's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing homes identify health problems) dated 12/4/25 revealed Resident 1 required substantial assist with upper body dressing, lower body dressing, putting on and taking off footwear, and was dependent for transfers. A record review of a Brief Interview for Mental Status (BIM's, used to measure cognitive impairment in nursing home residents categorized as 0-7 as severely impaired, 8-12 as moderately impaired and 13-15 as cognitively intact) dated 12/9/2025 revealed a score of 13/15. A record review of Resident 1's Progress note dated 1/2/2026 at 10:00 AM revealed Resident 1 had a ground level fall that resulted in a right facial laceration and required transport to the hospital. A record review of the Hospital Discharge summary dated [DATE] revealed that Resident 1 had right upper eye lid laceration with sutures. Interview with Clinical Consultant A on 01/15/25 at 3:41 PM confirmed the facility did not complete a written investigation for Resident 1's fall with the significant injury to the State Agency.

Licensure Reference Number 175 NAC 12-006.02(A) Based on interview and record review, the facility failed to ensure the state agency was notified of Resident 39's elopement on 01/10/2026 and Resident 1's fall with major injury. This affected 2 (Resident 39 and 1) of 4 sampled residents. The facility census was 62. Findings are: A record review of the facility's Abuse, Neglect, and Exploitation policy last dated 1/2024 revealed the facility staff should have reported all allegations of Abuse, Neglect, and Exploitation including injuries of unknown source within 2 hours for serious bodily injury and 24 hours if no injury. The report of the investigation results should have been sent to the State Survey Agency within 5 working days of the incident. A. A record review of the facility's Elopement / Exit Seeking policy dated 09/02/2019 revealed: Elopement is defined as a resident leaving the physical structure of the facility without the knowledge of the facility staff. A record review of Resident 39's Clinical Census dated 01/15/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 39's Medical Diagnosis dated 01/15/2026 revealed the resident had diagnoses of Personal History Of Traumatic Brain Injury (TBI), Unspecified Mood (effective) Disorder, and History Of Falling. A record review of Resident 39's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 10/21/2025 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 13, which indicated the resident was cognitively aware. The resident required supervision/touching assistance with eating, oral hygiene, and footwear and required partial/moderate assistance with toileting, dressing, and personal hygiene. The resident required supervision or touching assistance with all mobility. The resident did have inattention, disorganized thinking, and was depressed. The resident did have verbal behavioral symptoms directed toward others that significantly interfered with resident care. And put others at significant risk for physical injury. The resident exhibited wandering behaviors (walking around aimlessly) and his behaviors were worse. The resident had not fallen. The resident was on antidepressant medications and anticonvulsants (medications used to treat convulsions), but hypnotics were not marked. A record review of Resident 39's Care Plan with an admission date of 10/15/2025 revealed the resident had a focus area of the resident was independent with activity participation and an intervention included the resident's preferred activities were walking outside. There was a focus area that the resident had a functional deficit (deficiency) with the current activities of daily living and there were interventions on the care plan of the resident would walk independently, was independent with a wheelchair, was very impulsive, not very redirectable, and does not like education, gets irritable when reminded of safety. The care plan did not reveal interventions related to the resident's wandering behaviors. A record review of Resident 39's Progress Notes dated 01/10/2026 revealed the resident left the facility 2 times on 01/10/2026 without signing out and letting staff know the resident was leaving. On 01/10/2026 at 10:07 AM the resident was educated on the use of the resident sign out book and if the resident wanted to leave the premises, the resident had to sign out and in. On 01/10/2026 at 1:37 PM the resident was trying to leave the facility without signing out and continued to exit seek. The police offered to take the resident to the hospital, but (gender) refused and 911 was called to take the resident to the emergency room. On 01/10/2026 at 7:35 PM it was documented the resident arrived back from the hospital at 6:25 PM by stretcher. A Nursing Assistant (NA) alerted the nurse that the resident's wheelchair was near the drive-up area and the resident did not notify staff or sign out the book of leaving the facility. The elopement drill was completed. The Administrator was notified at 6:41 PM, the resident's power of attorney (person designated to make decisions for a person) was notified at 6:55 PM, and 911 was notified at 7:03 PM. The surrounding area was searched, and the Omaha Police Department and staff were searching for the resident. On 01/10/2026 at 10:00 PM it was documented that the resident returned to the facility escorted by the police and the Administrator. The resident was assessed and sent to the hospital for evaluation of hypothermia (excessively low body temperature) and injuries from a fall. The resident had abrasions to the left side of the head, base of hand, knuckles, and complained of left shoulder pain. In an interview on 01/20/2026 at 8:18 AM, the Administrator confirmed the second time the resident left the facility without signing out on 01/10/2026, nobody knew where the resident was going. The Administrator confirmed the incident was not reported to the State Agency. B. Record review of Resident 1's Progress Note dated 1/2/2026 at 10:00 AM revealed Resident 1 had a ground level fall that resulted in a right facial laceration and required transport to the hospital. Record review of the Hospital Discharge summary dated [DATE] revealed that Resident 1 had a right upper eye lid laceration with sutures. Interview with Clinical Consultant A on 01/15/25 at 3:41 PM confirmed the facility did not report Resident 1's fall with the significant injury to the State Agency and should have.

Based on record review and interview, the facility failed to ensure that 1 [Resident 1] of 7 sampled residents was permitted to readmit following hospitalization. The facility had a total census of 71 residents. Findings are: A. A review of Resident 1's admission Record revealed Resident 1 was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease [a progressive neurodegenerative disorder] with dyskinesia [involuntary uncontrolled movements]. A review of Resident 1's Progress Note dated 1/14/25 revealed Resident 1 was leaving facility for a peg tube [a feeding tube insert through the skin and stomach wall] insertion that morning. A review of Progress Notes from 1/14/25-1/31/25 revealed Resident 1 remained in the hospital. A review of Resident 1 census in electronic medical record revealed Resident 1 was identified as being in the hospital on 1/14/25 and billing was stopped on 1/31/25. Further review of Resident 1's electronic medical record revealed Resident 1's primary payer had been Medicaid until 2/1/24 at which time Resident 1 payer was identified as private pay. A review of undated Nursing facility Transfer or Discharge Notice revealed Resident 1 was being discharged for failure to pay for a stay at the facility after reasonable and appropriate notice. The notice also stated that Non-payment applies if the resident does not submit the necessary paperwork for third-party payment or after the third party including Medicare or Medicaid, denies the claim and the resident revises to pay for his or her stay. The Nursing Facility Transfer or Discharge Notice did not identify a date of transfer/discharge or identify a place that Resident 1 would be transferred or discharged to. In an interview on 2/6/25 at 9:19 AM, Resident 1's family member reported Resident 1 had been set to be released from the hospital back to the facility on Friday, 1/31/25. Resident 1's family member reported being notified on Friday that Resident 1 would not be allowed to return to the facility and was sent a notice of discharge by email. Family Member of Resident 1 reported that Resident 1 remained in the hospital. In interviews on 2/6/25 at 10:24 AM and 1:33 PM, Business Manager C reported Resident 1 is not being readmitted and Business Manager C was directed to issue a 30-day notice. Business Manager C confirmed Resident 1's Medicaid payment stopped on 2/1/24. Business Manager C reported that Medicaid applications have been filed for Resident 1 on 5/13/24, 10/23/24, 10/31/24 and 1/28/25. In an interview on 2/6/25 at 2:19 PM, Hospital Laison D confirmed Resident 1 has been denied readmit due to financial reasons. Hospital Laison D reported an understanding that Resident 1 would be readmitted when Resident 1 had a payer source. In interviews on 2/26/25 at 12:23 PM and 1:42 PM, the Administrator reported that Resident 1's Medicaid application has been denied 4 times. The Administrator confirmed that Resident 1 had a new Medicaid application completed on 1/28/25 and Resident 1 would be allowed to return when Resident 1's has a payor source. B. A review of facility policy titled Transfer and Discharge updated 1/2024 revealed policy did not address readmission following transfer/discharge to the hospital.

Licensure Reference Number 175 NAC 12.006.09(H)(iii)(3) Based on observation, interview and record review the facility failed to provide treatment for a skin breakdown for 1 (Resident 56) of 3 residents sampled residents. The facility census was 68. The findings are: Record review of Resident 56's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 08-16-2024 revealed the facility staff assessed the following about the resident: -Diagnosis of Diabetes Mellitus Type 2, Severe Protein Calorie Malnutrition, Cirrhosis of the liver, and Clostridium Difficile Enterocolitis (a condition that causes diarrhea and inflammation of the colon, or colitis, that can be life-threatening). -Brief Interview of Mental Status (BIMS, an assessment that aids in detecting cognitive impairment. A score of 0-7 equals severe impairment, 8-12 indicates moderate impairment and 13-15 indicates cognitively intact) score of 12 indicating moderate cognitive impairment. -required extensive assistance with oral hygiene and bed mobility. -required total assistance with dressing, toileting and bathing. -was always incontinent of bowel and bladder. Record review of Resident 56's Skin/Wound Weekly Observation Form (SWOF) dated 09-02-2024 revealed the were no skin issues identified. Record review of Resident 56's SWOF dated 09-09-2024 revealed a new skin issue was identified and described as Moisture Associated Skin Damage (MASD, is a general term for skin problems that occur due to prolonged exposure to moisture from bodily fluids such as urine or feces.) without measurements, to the groin and scrotum. The SWOF revealed Resident 56's physician was updated and response from the physician was pending. Record Review of Resident 56's Electronic Health Record (EHR) that included progress notes, orders and administration records revealed no follow up from the physician or Nurse Practitioner (NP). Record review of Resident 56's Treatment Administration Record (TAR) for September 2024 printed on 09-19-2024 revealed no treatment had been administered for MASD. Record review of Resident 56's progress note dated 09-15-2024 revealed the facility staff had noted that Resident 56 had an increase in redness to the groin, peri area, inner thighs and scrotal area that was foul smelling and Resident 56 had a new open area measuring 4 centimeters (cm) by 2 cm to the right buttock. Record review of Resident 56's SWOF dated 09-15-2024 revealed a new skin issue was identified and described as MASD to groin without measurements and a new skin issue identified as an open area to the right buttock measuring 4 cm by 2 cm. Furthermore, the SWOF indicated Resident 56's physician was notified and response from physician was will see on Monday (09-16-2024). Record Review of Resident 56's EHR such as progress notes, physician orders, and care plan revealed Resident 56 was not seen by the physician or NP on 09-16-2024 and did not contain information facility staff followed up to obtain a treatment for the skin breakdown. Record review of Resident 56's progress note dated 09-18-2024 revealed a Nurse Practitioner (NP) for Resident 56's physician was at the facility and gave treatment orders for MASD areas. Record review of Resident 56's TAR printed 09-23-2024 revealed an order dated 09-18-2024 to wash perineal area, groin, inner thighs and scrotal area with soap and water, pat dry, apply Desitin (a zinc oxide cream), cover with antifungal powder twice daily. The TAR revealed where staff are to sign that this treatment was administered was left blank until 09-21-2024, 2 days later. Observation on 09-23-2024 at 1:00 PM of Nursing Assistant (NA) E providing incontinence care for Resident 56 revealed Resident 56's pants were wet with urine and the incontinence brief that was in use was saturated. Further observation of Resident 56's skin revealed a dark red and swollen penis and scrotum, dark red skin to bilateral groins, inner thighs, gluteal cleft and bilateral buttocks. During the observation an open area was observed to Resident 56's right buttock that had a tear drop appearance that measured approximately 3 cm by 1 cm with dark red wound edges and a pale pink wound bed. Record Review of Resident 56's progress note dated 09-23-2024 revealed the NP had seen Resident 56 for MASD to scrotum, inner thighs, and groin with redness and swelling. New orders received for Prednisone (oral steroid) 10 milligrams daily for 7 days due to no improvement in redness or swelling. An interview with Licensed Practical Nurse (LPN) G on 09-24-2024 at 1:25 PM revealed on 09-23-2024 after observing the wound at 1:00 PM, LPN G notified the NP because the swelling to the penis and scrotum had worsened. An interview with the Director of Nursing (DON) on 09-24-2024 at 10:39 AM confirmed Resident 56 was not seen on Monday 09-16-2024 and was not seen by the NP until Wednesday 09-18-2024. An interview with the DON on 09-24-2024 at 1:33 PM revealed on 09-22-2024 the DON had observed the area and there wasn't any swelling and confirmed treatment of Resident 56's MASD was not received until 09-18-2024 and not implemented until 09-21-2024. Record Review of the Facility Skin and Wound Management-Prevention of Pressure dated 01/2024 revealed on page 4 under alterations in skin integrity for perineal denudation revealed directions to cleanse skin, gently dry. Apply a zinc oxide paste twice a day and as needed due to incontinence or excessive drainage. According to Allnurses.com a denuded wound is an injury that occurs when the protective top layer of the skin is gone, leaving the underlying tissue exposed and common causes of denuded wounds include trauma, burns, surgical procedures, and wound debridement. Trauma can include lacerations, abrasions, and puncture wounds. In addition, medical practices can cause denuded wounds if they involve scraping away the skin, such as in wound debridement. Other causes of denuded wounds include chronic diseases, such as diabetes and vascular disease, which can lead to ulcerations. Additionally, the skin can become denuded by prolonged contact with waste body fluids such as urine, wound exudate, and stool.

Licensure Reference 175 NAC 12-006.09D7 Based on observation, record review, and interview, the facility failed to ensure each resident received supervision to prevent accidents for 1 (Resident #65) of 4 residents reviewed for supervision. Specifically, the facility failed to monitor and supervise a severely cognitively impaired resident with known wandering and exit seeking behaviors to prevent elopement. Resident #65 eloped and was found across the street from the facility on 01/10/2023 and 07/13/2023. The first elopement occurred on 01/10/2023 with further attempts and/or actual elopements occurring on 02/01/2023, 02/11/2023, 03/01/2023, 05/26/2023, 07/13/2023, and 07/19/2023. The facility also failed to ensure hot water temperatures in residents' hand sinks were within range to prevent burn/scald injuries. This affected 8 (Rooms 305, 306, 307, 308, 309, 310, 314, and 316) of 14 rooms on Hall 300. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 01/10/2023 when the Director of Nursing (DON) observed Resident #65 outside the facility and across the street. The Administrator was notified of the IJ on 08/10/2023 at 10:54 AM and provided the IJ Template at 10:57 AM. An abatment plan was requested. The abatement plan was accepted by the State Survey Agency on 08/10/2023 at 7:43 PM. The IJ was removed on 08/11/2023 at 2:05 PM, after the survey team performed onsite verification that the abatement plan had been implemented. Noncompliance for F689 remained at the lower scope and severity of no actual harm with an isolated potential for more than minimal harm that was not immediate jeopardy. Findings are: 1. A facility policy titled, Elopement/Exit Seeking, reviewed and revised on 09/02/2019, indicated, Cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the physical structure of the facility without the knowledge of facility staff. 1. Upon admission, residents will be assessed for elopement risk. 2. Residents shall be reassessed at least quarterly related to elopement risk. 3. Cognitively impaired residents with the physical ability to leave the facility without assistance, and who have demonstrated or vocalized a desire to leave the facility will be placed on a unit with an electronic monitoring system. If a facility does not have an operational electronic monitoring system, the resident will be evaluated for transfer to a more appropriate facility that offers electronic monitoring. Interim safety monitoring measures shall be implemented pending transfer. The policy further indicated, 6. Electronic monitoring devices shall be checked for function at least once every 24 hours. In the event of an electronic monitoring system failure, alternate security measures will be implemented to include temporary use of manual door alarms, visual monitoring of exit doors, increased staffing levels, and/or increased observation of at-risk residents. A policy titled Resident Elopement Follow-Up Procedure, reviewed and revised on 09/02/2019, indicated, It is the policy of this facility to provide a safe and secure environment for our residents and to be proactive in preventing resident elopement. The policy further indicated, 3. Plan of Care will be modified to incorporate an increased elopement risk and increased monitoring as needed based on behaviors. Review of an Admission Record revealed Resident #65 was admitted to the facility on [DATE] with diabetes, osteoarthritis, Alzheimer's disease, chronic pain, cerebral infarction, and hypertension. Review of the annual Minimum Data Set (MDS), with an Assessment Reference Date of 06/24/2023, revealed Resident #65 had a Brief Interview for Mental Status (BIMS) score of 6, meaning the resident had severe cognitive impairment. The MDS indicated Resident #65 experienced continuous disorganized thinking. The resident was independent with locomotion on and off the unit and with walking in their room and the corridor. The MDS indicated the resident did not wander in the past seven days. Review of the care plan, initiated 06/01/2023, revealed Resident #65 was at risk for elopement related to exit seeking behaviors. The care plan indicated that on 07/13/2023, Resident #65 removed the wander monitoring bracelet and eloped. The care plan did not provide direction to staff regarding interventions to reduce the risk of or prevent the elopement of Resident #65. Review of Progress Notes, dated 01/10/2023 at 6:49 PM and completed by the Director of Nursing (DON), indicated Resident #65 was outside of the building across the street, talking to workers that were working on a house. The resident was asking them to use a phone. The resident willingly returned to the facility with staff. The resident was educated on letting staff know they wished to leave the facility and signing themselves out. Review of Progress Notes, dated 02/01/2023 at 1:58 PM and completed by Licensed Practical Nurse (LPN) B, revealed at 10:30 AM Resident #65 attempted to go outside by the kitchen door. The note indicated during nice weather, the resident liked to go out the door onto the patio and tend to plants. Review of Progress Notes, dated 02/11/2023 at 1:19 PM and completed by LPN Q, revealed at 12:30 PM, Resident #65 left the building with a walker, and a staff member saw the resident walking in the parking area. The note indicated the resident was escorted back into the facility and was provided education on signing a book to let staff know the resident was going outside and the proper way to leave the building. Review of Progress Notes, dated 02/14/2023 at 12:04 PM and completed by LPN B, revealed Resident #65 had a wander monitoring bracelet applied to the left side of their walker. Review of Progress Notes, dated 03/01/2023 at 1:26 PM and completed by the DON, revealed Resident #65 was exit seeking and the resident stated they wanted to go to the hospital due to back pain. The note indicated Resident #65 exited the building to go to the courtyard and started walking towards the street and was resistive to coming back inside the facility. The note indicated the nurse practitioner (NP) was notified, and the resident was sent to the hospital. Review of Progress Notes, dated 03/01/2023 at 1:36 PM and completed by LPN B, indicated around 12:30 (PM) Resident #65 went out the back door and out the back gate before staff were able to get to them. The note indicated the resident stated they were going to go to a house down the road because no one would listen to them about their back pain. The resident requested to go to the hospital. Review of a Nursing Quarterly Data Collection form, dated 03/27/2023 and completed by the MDS Coordinator, revealed Resident #65 did not have a history of exit seeking, wandering, or getting lost. The form indicated Resident #65 did not have a diagnosis of Alzheimer's disease and was not a potential elopement risk. Review of Progress Notes, dated 03/27/2023 at 3:19 PM and completed by the MDS Coordinator, indicated Resident #65 did not have a potential for elopement. During an interview on 08/10/2023 at 8:24 AM, LPN I indicated the wandering/elopement assessment dated [DATE], which indicated Resident #65 was not an elopement risk, was coded incorrectly. LPN I stated the resident absolutely would have been at risk at that time. Review of Progress Notes, dated 05/22/2023 at 4:13 AM and completed by LPN S, revealed Resident #65 was outside sitting at the gazebo. The resident was encouraged to come inside, and the resident came back into the facility without difficulty. During an interview on 08/10/2023 at 2:14 PM, LPN S stated on 5/22/2023 at 4:13 AM they could not find Resident #65. They found the resident outside sleeping in the gazebo. LPN S indicated it was about 2:00 AM, 3:00 AM, or 4:00 AM. LPN S indicated none of the staff knew the resident was outside. LPN S stated the resident did wear a wander monitoring bracelet, but the resident frequently took it off. Review of Progress Notes, dated 05/26/2023 at 11:18 AM and completed by the MDS Coordinator, revealed Resident #65 was observed outside by staff, attempting to walk down the sidewalk with the intention of leaving the facility grounds. The note indicated the resident was unsteady and almost fell three times. The note indicated the resident refused any alternative activities and returned to the facility after approximately 45 minutes of encouragement by staff. The note indicated Resident #65 had a history of dementia, behaviors, and attempting to leave facility grounds. A review of Progress Notes, dated 06/22/2023 and completed by LPN B, indicated Resident #65 was a potential elopement risk. Review of Progress Notes, dated 07/13/2023 at 11:56 AM and completed by LPN C, revealed Resident #65 was walking outside and was assisted from the grass to the cement for safety. The note indicated the resident was not easily redirected and the nurse was unable to get the resident to return to the building. The note indicated an interpreter helped with translation and management was called to assist with redirection. Review of Progress Notes, dated 07/13/2023 at 7:09 PM and completed by Registered Nurse (RN) D, indicated Resident #65 was found outside by a nursing assistant (NA). They noted the resident refused to come back inside the facility and the NA stayed with the resident for a couple hours before the resident returned to the facility. Review of Progress Notes, dated 07/13/2023 at 7:11 PM and completed by the DON, revealed Resident #65 and their family were informed that staff needed to be notified before the resident went outside. The note indicated the resident needed to be accompanied by family or staff when going outside. Review of an Elopement Risk Assessment, dated 07/13/2023, revealed Resident #65 had intermittent confusion, purposeful exit seeking, and was a score of 10, meaning the resident is at high risk for elopement. Review of the weather for 07/13/2023, obtained from the weatherunderground.com website, revealed the temperature for that date was 80 degrees Fahrenheit. Review of an Abuse, Neglect or Misappropriation document, dated 07/20/2023, revealed the date of the incident to be 07/13/2023 at 11:30 AM. The document indicated Resident #65 was observed ambulating with their walker through the gate of the fence in the back yard of the facility heading toward a neighboring house across the street. The document indicated staff responded immediately but were unable to redirect the resident back to the facility. The resident indicated they wanted to live under a bridge. The document indicated management called law enforcement for assistance. The document indicated Resident #65 returned to the facility after approximately two hours and remained in the gazebo until their family arrived. The document indicated Resident #65 had a wander monitoring bracelet on their walker due to cutting it off their wrist on multiple occasions. The document indicated the facility monitored the placement and function of the wander monitoring bracelet every shift and staff were educated to be aware of the resident's location. The document indicated a lock was applied to the gate in the backyard and had contacted facilities with dementia units in the area. Review of an Order Summary Report for the timeframe from 01/01/2023 through 08/31/2023 revealed an order, dated 07/13/2023, which indicated, Check placement and function of wander guard [wander monitoring bracelet] q [every] shift. There was no order for a wander monitoring bracelet prior to 07/13/2023. Review of Progress Notes, dated 07/14/2023 at 10:30 AM and completed by RN E, revealed Resident #65 was angry due to a wander monitoring bracelet being on the walker. The nurse documented there were slices in the band of the wander monitoring bracelet. Review of Progress Notes, dated 07/15/2023 at 11:05 AM, indicated Resident #65 cut the wander monitoring bracelet off with a plastic knife from the kitchen. Review of Progress Notes, dated 07/15/2023 at 2:25 PM, indicated Resident #65 cut the wander monitoring bracelet off their walker and the nurse planned to replace the wander monitoring bracelet when the resident was asleep. Review of Progress Notes, dated 07/16/2023 at 4:53 AM and completed by RN E, indicated on 07/15/2023 at 10:20 PM Resident #65 was outside in the gazebo and wanted to sleep there. The note indicated the resident came inside and staff initiated every 10-minute checks on the resident until the resident fell asleep and a new wander monitoring bracelet could be placed. The note indicated the resident slept in their bed all night. Review of Progress Notes, dated 07/17/2023 at 3:05 AM, indicated the wander monitoring bracelet band was noted to be damaged. Review of Progress Notes, dated 07/18/2023 at 8:33 PM and completed by RN D, revealed Resident #65 was outside lying on a bench and refused to come inside. Review of Progress Notes, dated 07/19/2023 at 9:36 AM and completed by LPN B, revealed Resident #65 was outside in a fenced area lying under a tree. The resident indicated they cut the wander monitoring bracelet off with a butter knife. The note indicated the resident remained outside under the tree with staff monitoring. The wander monitoring bracelet was found on the resident's overbed table, and the strap had been cut. Review of Progress Notes, dated 07/19/2023 at 4:00 PM and completed by the Administrator, indicated law enforcement and emergency medical personnel were at the facility to take Resident #65 for a mental health evaluation. The note indicated the resident was not cooperative and kicked and punched while being assisted to a gurney with wrists cuffed. The resident was transported to a medical facility for a psychiatric evaluation. During an interview on 08/09/2023 at 2:35 PM, the DON provided a Staff In-Service sheet dated 07/20/2023. The Staff In-Service sheet revealed 12 staff members were in-serviced related to alarms, staff answering the alarms, and who was at risk for elopement. The DON stated it was a regularly scheduled in-service and confirmed no education was given to staff on 07/13/2023, the day of Resident #65's elopement. During an observation on 08/08/2023 at 9:20 AM, the exterior door on the south side of the building, leading to the fenced gazebo area, was unsecure. The surveyor was able to push the door open and exit the building without a keypad or an alarm sounding. Further observations on 08/08/2023 at 9:47 AM, 11:39 AM, 1:45 PM, 2:39 PM, and 4:40 PM revealed the northwest gate that included the gazebo area, where residents went outside, was wide open. Signage on the gate indicated, Gate is to remain locked at all times. THIS IS NOT AN OPTION. The wooden gate outside the conference room was unlocked and open, leaving both areas unsecure for residents. During an observation on 08/08/2023 at 2:39 PM, LPN I went outside with the surveyor. LPN I confirmed the northwest gate was open and stated the gate should be closed. During an observation on 08/08/2023 at 4:40 PM, the Chief Operating Officer, the DON, and the Corporate Nurse Consultant observed the gate on the patio outside was unlocked and residents could elope through the conference room. The Chief Operating Officer acknowledged the sign that indicated, Gate is to remain locked at all times. TRIS IS NOT AN OPTION. The DON and Corporate Nurse Consultant confirmed the patio door was unlocked and they both stood at the door until the Maintenance Director could put a keypad code on the exit door from the conference room. During an interview on 08/08/2023 at 9:33 AM, Resident #18 stated they were going outside on 07/13/2023 to see the garden with Certified Medication Assistant (CMA) A. Resident #18 stated when they exited the door, they saw Resident #65 outside. Resident #18 stated, Look, [Resident #65] is across the street over by the brown house. Resident #18 stated CMA A ran back into the building to get help. Resident #18 stated they were hollering at Resident #65. Resident #65 turned around once but kept standing by the house. Resident #18 stated five or six staff members ran over there, and Resident #65 would not come back. Resident #18 stated Resident #65 was saying that was their house and they thought they lived there. Resident #18 stated the police had to get the resident and bring them back. Resident #18 stated Resident #65 was allowed to go outside by themselves, but they did not think the resident would go out the gate. During a telephone interview on 08/08/2023 at 2:51 PM, CMA A stated Resident #65 was confused, and when CMA A and Resident #18 went outside to the garden on 07/13/2023, Resident #65 was already out there and on the outside of the gate. CMA A told Resident #18 to keep calling for Resident #65 and the CMA went inside to get help. CMA A stated Resident #65 crossed the street. CMA A stated there was not any staff outside with the resident. During an interview on 08/08/2023 at 1:59 PM, LPN I stated they were the charge nurse on 07/13/2023 when Resident #65 eloped. LPN I said Resident #65 was alert and oriented to situations and confused at times. LPN I stated Resident #65 was allowed to go outside by themselves. LPN I stated Resident #65 had exit-seeking behaviors prior to the elopement on 07/13/2023. The LPN stated the resident had a wander monitoring bracelet placed three to six months before the elopement but could not find the order for it. LPN I stated Resident #65 had a wander monitoring bracelet prior to July 2023, because they knew the resident had cut it off. LPN I confirmed Resident #65's care plan was initiated on 06/01/2023 and stated the care plan for wandering and exit-seeking behavior should have been assessed prior to that date. LPN I indicated Resident #65 should have been assessed for other interventions and that they needed supervision outside. LPN I stated the current lock on the south gate was applied after the elopement with Resident #65 and the LPN stated the south gate should be locked at all times. LPN I stated there was not any direct education provided to staff after the elopement. During an interview on 08/08/2023 at 12:05 PM, LPN C stated Resident #65 was confused. LPN C stated they were the nurse for Resident #65 on 07/13/2023 when the resident eloped. LPN C stated Resident #65 went outside a lot and had a wander monitoring bracelet that the resident cut off all the time. LPN C stated Resident #65 would sneak out of the facility and go outside. LPN C stated when Resident #65 refused the wander monitoring bracelet, staff would do frequent checks and rounds but sometimes [the resident] gets out. During an interview on 08/08/2023 at 12:30 PM, NA J stated they were Resident #65's NA on 07/13/2023. NA J stated it was their understanding that Resident #65 was to wear a wander monitoring bracelet. NA J stated the resident took it off frequently. NA J stated the south gate did not have a lock on it prior to Resident #65 eloping on 07/13/2023. NA J said the facility added the lock after the resident eloped. The NA said they did not receive any in-services related to elopement/wandering residents on 07/13/2023. NA J stated Resident #65's behavior was not new and spoke of a Memorial Day incident when Resident #65 started walking down the street but did not make it and was not allowed outside after that for a while. NA J stated they were not aware they should be checking for wander monitoring bracelets. During an interview on 08/09/2023 at 9:22 AM, Housekeeper (HSK) F stated that one of the NAs came to get them to translate for Resident #65 on 07/13/2023. HSK F stated when they went outside, Resident #65 was already across the road, in front of a house. HSK F stated Resident #65 was very angry and wanted to get out of the facility. HSK F stated Resident #65 refused to go back into the facility. Resident #65 was told they would have to call the police to help, and Resident #65 told them to call the police and sat on the curb and waited for the police to come. HSK F stated they saw Resident #65 outside the facility without staff present prior to the elopement on 07/13/2023. HSK F stated they felt the facility needed to be more aware of residents. During an interview on 08/09/2023 at 9:55 AM, LPN B stated Resident #65 wandered frequently and sometimes would be in the courtyard alone. LPN B stated Resident #65 had a wander monitoring bracelet. LPN B indicated it was not safe for Resident #65 to go outside alone. LPN B stated the resident liked to take the wander monitoring bracelet off and because of this, a wander monitoring bracelet was not an appropriate intervention for Resident #65. LPN B reported that on 03/01/2023, Resident #65 got out of the building and was on the other side of the gate and would not come back in until they sent the resident to the hospital. During an interview on 08/08/2023 at 11:08 AM, Certified Medication Assistant (CMA) G stated Resident #65's wander monitoring bracelet was always on their walker, but the resident would cut them off. CMA G stated they were aware of Resident #65 cutting the wander monitoring bracelet on three separate occasions; sometimes the resident would hand the wander monitoring bracelet to staff. They stated staff would try to replace it but sometimes Resident #65 would not allow it. CMA G stated Resident #65 was confused and was allowed to go outside by themselves on 07/13/2024. CMA G said staff were not required to be outside with the resident. CMA G stated Resident #65 tried to leave the facility before 07/13/2023, and that was not Resident #65's first attempt. During an interview on 08/09/2023 at 7:25 AM, the Corporate Nurse Consultant stated they were not aware of any other elopements by Resident #65 besides the elopement on 07/13/2023. During an interview on 08/09/2023 at 11:26 AM, the DON stated on 07/19/2023 Resident #65 was hospitalized and evaluated for treatment. The DON stated Resident #65 was harmful to themselves and needed a locked dementia unit. The resident was not allowed to come back to the facility because they did not feel they could meet their needs. The DON indicated that after looking back at the progress notes, medical chart, and assessments, they did not feel staff were coding/assessing the resident appropriately. The DON said Resident #65 had Alzheimer's disease and two documented instances of leaving the premises. The DON stated Resident #65 went outside often, and staff would not always be supervising them. The DON stated it was not appropriate for a resident with cognitive impairment to go outside by themselves at 4:00 AM. The DON stated their expectation for a resident that was cognitively impaired and a fall risk, was staff would monitor them when they went outside. The DON stated after reading the progress notes from 01/10/2023 and 02/11/2023, they would consider those incidents to be elopements. The DON stated the progress note from 03/01/2023 indicated Resident #65 had exit seeking behavior and the resident should have been coded as an elopement risk. The DON read the elopement assessment for 03/27/2023, and stated, No, this assessment is not accurate. The DON indicated the physician order for the wander monitoring bracelet was placed on 07/13/2023 and confirmed Resident #65 had worn a wander monitoring bracelet prior to that date. The DON indicated the resident had a history of taking the wander monitoring bracelet off. The DON stated they kept the resident safe outside with intermittent monitoring. The DON stated when a resident removed their wander monitoring bracelet the staff would implement every 15-minute checks or provide one-on-one for the resident. The DON stated Resident #65 was not being assessed appropriately so those interventions were not implemented. The DON indicated that since Resident #65's wandering behavior began in January of 2023, Resident #65's care plan should have been updated sooner. The DON confirmed the care plan was initiated on 06/01/2023 and could not find anything before that date. During an interview on 08/09/2023 at 1:54 PM, the Administrator stated they filed to have Resident #65 taken for a mental health review on 07/19/2023. The Administrator indicated the resident needed an inpatient locked unit. The resident would not keep a wander monitoring bracelet on and cut it off. The Administrator indicated the resident needed more care than the facility could provide. The resident was a danger to themselves and others. The Administrator indicated they did not know about the elopement or exit seeking behaviors of Resident #65 on 01/10/2023, 02/11/2023, and 05/26/2023. The Administrator stated they should have been notified and stated the resident should have had a wander monitoring bracelet and gone to the hospital sooner. The Administrator indicated Resident #65's exit seeking behavior should have been on the care plan and the care plan should have been updated the first time the resident eloped or tried to leave the facility. The Administrator indicated the cause for Resident #65's exit seeking behavior should have been assessed and addressed. During an interview on 08/10/2023 at 8:47 AM, the MDS Coordinator confirmed she completed the elopement assessment on 03/27/2023. The MDS Coordinator reported they marked that Resident #65 was not a wandering/exit seeking resident. After reading the progress note from 01/10/2023, the MDS Coordinator stated they thought the resident was not making sound decisions. After reading the progress note for 02/01/2023, the MDS Coordinator did not think the resident was exit seeking. The resident liked to go outside and was allowed to go by themselves. The MDS Coordinator also did not think the incident on 02/11/2023 was exit seeking; the resident was doing something outside. After reading the progress note for 03/01/2023, the MDS Coordinator stated the resident was exit seeking at that time. After reading the progress notes, the MDS Coordinator stated Resident #65 was not coded correctly on the elopement assessment on 03/27/2023. The MDS Coordinator stated the resident should have been assessed as a wanderer. The MDS Coordinator stated if they would have coded the resident correctly, the resident would have triggered as being at risk for elopement and would have been reviewed by the interdisciplinary team. The MDS Coordinator confirmed Resident #65 wore a wander monitoring bracelet but cut it off frequently. The MDS Coordinator indicated the wander monitoring bracelet was not an appropriate intervention since they could take it off. The MDS Coordinator indicated another intervention should have been put in place on the second removal. The MDS Coordinator confirmed that the care plan should have been initiated prior to 06/01/2023. During an interview on 08/11/2023 at 9:32 AM, the Nurse Practitioner (NP) was asked if they were notified of Resident #65's elopements. The NP stated they were notified of the elopement in July 2023 but did not recall the others. The NP indicated Resident #65 was having increasing behaviors, being physically aggressive, and was exit seeking. The resident always wandered, but in July 2023 it got worse. The NP indicated the resident needed a locked unit and the resident should have been placed in one sooner than they were. The NP indicated they mentioned it to the DON several times. The NP confirmed Resident #65 was allowed to go outside unattended and stated the resident should have been supervised. The resident was wandering/exit seeking and should not have been outside by themselves. The NP stated that for Resident #65, an appropriate intervention would have been one-on-one supervision. The NP indicated the care plan should have been updated when the behavior was first identified. 18639 2. On 08/09/2023 at 2:50 PM, the Maintenance Supervisor provided documentation of the facility's water temperature testing logs and stated what was provided was all they had. The Logbook Report, generated on 08/09/2023, indicated hot water temperatures had been tested on the following nine dates in the previous 12 months: 07/14/2023, 06/16/2023, 05/10/2023, 04/05/2023, 03/15/2023, 02/06/2023, 02/02/2023, 01/02/2023, and 10/17/2022. During an interview on 08/10/2023 at 10:31 AM, the Maintenance Supervisor stated they had just taken hot water temperatures of the hand sinks in the residents' rooms on Hall 300 and provided a copy of the temperatures just taken. The hand sink hot water temperatures were as follows: - room [ROOM NUMBER], occupied by 2 residents, was 126.1 degrees Fahrenheit (F). - room [ROOM NUMBER], occupied by 2 residents, was 122.5 degrees F. - room [ROOM NUMBER], occupied by 2 residents, was 127 degrees F. - room [ROOM NUMBER], occupied by 2 residents, was 126.2 degrees F. - room [ROOM NUMBER], occupied by 2 residents, was 125.9 degrees F. - room [ROOM NUMBER], occupied by 1 resident, was 124.9 degrees F. - room [ROOM NUMBER], occupied by 2 residents, was 122.7 degrees F. - room [ROOM NUMBER], occupied by 1 resident, was 123.2 degrees F. Review of the facility's Incidents By Incident Type log, dated 01/01/2023 through 08/10/2023, revealed there had been no incidents related to water being too hot. During an interview on 08/11/2023 at 8:16 AM, Resident #2 stated the hot water did not get too hot in their sink and they usually used cold water. During an interview on 08/11/2023 at 8:21 AM, Resident #33 stated the water was not too hot because they mixed cold water with hot water. During an interview on 08/11/2023 at 8:23 AM, Licensed Practical Nurse (LPN) B stated no resident on Hall 300 had complained of the hot water being too hot. The LPN stated Resident #21, who had severe cognitive impairment, could not use the hand sink by themselves. During an interview on 08/11/2023 at 8:28 AM, Certified Medication Assistant (CMA) A stated no resident on Hall 300 had complained of the water being too hot. The CMA stated Resident #21 could not use the sink by themselves. During an interview on 08/11/2023 at 9:38 AM, the Maintenance Supervisor stated they were responsible for testing the hot water in the residents' hand sinks and the bathing areas. They stated they tested the hot water weekly and tested random rooms, one at each end of the resident halls. The Maintenance Supervisor stated they had not completed weekly hot water testing since 10/2022. They stated no resident had complained of water being too hot. They stated not testing the hot water temperatures could result in a resident getting scalded or burned. During an interview on 08/11/2023 at 9:44 AM, the Director of Nursing (DON) stated they were not aware of any resident who had been burned because the hot water was too hot. They stated not testing the hot water could result in a resident being burned. During an interview on 08/11/2023 at 11:29 AM, the Administrator stated maintenance personnel were responsible for testing hot water temperatures. They stated the hot water was tested weekly, and the hot water temperature was supposed to be less than 120 degrees F. The Administrator stated they periodically reviewed the hot water testing logs, and no resident had complained that the hot water in their hand sink was too hot. The Administrator stated there was a possibility for injury by scalding if hot water temperatures were not monitored. The Administrator stated they were not aware hot water temperatures had been tested on ly nine times since 10/2022. The Administrator stated testing hot water temperatures weekly was not regulatory. They stated the facility did not have a hot water testing policy and procedure. Abatement Plan: Resident [#65] discharged from the facility on 07/19/2023. 1. All residents were assessed to identify impaired cognitive status by social services by 8/10/2023 at 14:00 pm[TRUNCATED]

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on record review, observation, and interview; the facility failed to evaluate pressure ulcer healing and implement interventions to prevent the development of pressure ulcers for 2 (Resident 1 and 5) of 4 sampled residents. The facility staff identified a census of 76. Findings are: A. Record review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tools used for care planning) dated 2-05-2023 revealed the facility staff assessed the following about the resident; -Brief Interview of Mental Status (BIMS) was a 12. According to the MDS manual a score of 8 to 12 indicated moderately impaired cognition. -Required extensive assistance with bed mobility, toilet use and personal hygiene. -Required limited assistance with transfers and dressing. -Was at risk for pressure ulcer development. -Currently had 2 stage 3 pressure ulcers (Stage 3 Pressure Ulcer: Full-thickness skin loss in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar (dead tissue) may be visible but does not obscure the depth of tissue loss). Record review of a Physician's Orders sheet dated 10-28-2022 revealed Resident 1 was diagnosed with a stage 3 pressure ulcer to the right buttocks that measured 4.1 centimeters (cm) by 4.0 cm by 0.1 cm and a left buttock stage 3 pressure ulcer that measured 0.6 cm by 2.0 cm by 0.1 cm. Record review of an appointment sheet with the practitioner progress note dated 2-24-2023 revealed the right buttock region measured 7.2 by 3.0 by 0.1 cm and the left region measured 6.4 cm by 3.50 cm by 0.1 cm. The practitioner directed the current treatment be continued and to return to the clinic in 2 months. Record review of Resident 1's Skin/Wound Weekly Observation sheet dated 3-16-2023 revealed Resident 1 had a pressure ulcer identified as a stage 3 to the right buttocks that measured 7.2 cm by 3.0 and a stage 3 pressure ulcer to the left buttock that measured 6.4 cm by 3.5 cm. Record review of Resident 1's medical record that included practitioners orders, Comprehensive Care Plan and progress notes did not contain information on ongoing evaluation of Resident 1's pressure ulcer to the left and right buttocks. Record review of a facility Wound and Skin Log sheet dated 4-03-2023 revealed Resident 1's right buttocks pressure ulcer measured 7.2 cm by 3.0 cm by 0.1 cm and the left buttocks pressure ulcer measured 6.4 cm by 3.50 cm by 0.10 cm. Observation on 4-12-2023 at 9:47 AM of Resident 1's treatment to the pressure ulcers on the left and right buttocks with Licensed Practical Nurse (LPN) B revealed Resident 1 had 2 areas on the right buttocks that measured approximately 3.2 cm by 2.3 wide and the second measured approximately 2.1 roundish. Further observation revealed Resident 1 had 2 open area to the left buttock with both areas measuring approximately the size of a nickel. On 4-12-2023 at 11:55 AM an interview with LPN B revealed that LPN B was the facility wound nurse. LPN B revealed skin checks were to be completed on all residents weekly and residents with identified wounds were to have an assessment completed weekly. LPN B revealed Resident 1 had 4 open areas to the buttocks that were pressure ulcers. LPN B revealed Resident 1 did not have weekly assessments completed. LPN B revealed the measurements documented on the Wound and Skin Log dated 4-03-2023 were taken from the appointment sheet dated 2-24-2023 and no actual measurement had been completed for the Wound and Skin Log dated 4-03-2023. Record review of the facility Clinical Management for Wound care Documentation dated 5-2017 revealed the following information; -The purpose of this guideline is to provide a consistent process for accurate and complete wound treatment documentation. -Policy explanation and Compliance guideline -The facility must maintain clinical record on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible and organize. The clinical record must contain enough information to show that the facility knows the status of the individual, has adequate plans of care, and provides sufficient evidence of the effects of care provided. Documentation should provide a picture of the residents progress, including response to treatment, change in condition, and changes in treatment. -Treatment and Documentation Guidelines: -Type of wound such as pressure, surgical, etc. -Stage of pressure injury. -Measurements with height, width, depth undermining or tunneling. -Description of the wound such as drainage, odor, type of tissue and color of the wound bed. -Current treatment. -Weekly progress towards healing and effectiveness of current interventions. Record review of an undated policy on Skin Integrity Guideline provided on 4-12-2023 by Nurse Consultant C revealed the following information: -Purpose: -To provide a comprehensive approach for monitoring skin condition. To promote healing of wounds of any etiology. - Documentation of weekly Skin Evaluations/Observations. -Licensed nurses will be responsible for performing a skin evaluation/observation weekly, utilizing the weekly Skin Review Form. -Licensed nurses to document weekly on identified wounds using the Wound Evaluation Flow Sheet. 40338 B. Record review of the physician orders dated 1-30-2023 for Resident 5 revealed an order for a Prevalon boot (a boot that floats the heel off the surface of the mattress) to the right foot when in bed for every shift for wound care. Review of the Tissue Analytics wound evaluation dated 2-27-23 revealed an order for Prevalon boots. Record review of the April 2023 Treatment Administration Record revealed documentation on every shift that Prevalon boot was on Resident 5. There was no documentation in the medical record indicating that Resident 5 refused the Prevalon boots. Observation on 4-12-23 at 6:19 AM revealed Resident 5 was lying in bed. The Prevalon boot was sitting on the floor next to the dresser. Observation on 4-12-23 at 7:24 AM revealed Resident 5 remained in bed. The Prevalon boot was sitting on the floor next to the dresser. On 4-12-23 at 7:16 AM an interview was conducted with LPN-A which revealed the Prevalon boot was ordered for right foot while in bed for Resident 5. LPN-A confirmed the boot was not on Resident 5.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observation, record review and interview; the facility staff failed to re-evaluate and implement interventions to manage pain for 1 (Resident 42) of 2 sampled residents. The facility staff identified a census of 63. Findings are: Record review of Resident 42's Minimum Date Set (MDS: a federally mandated assessment tool used for care planning) dated 6-02-2022 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was a 8. According to the MDS Manuel, a score of 8 to 12 indicates moderately impaired cognition. -Required extensive assistance with bed mobility and eating. -Required extensive assistance with transfers, dressing, toilet use and personal hygiene. Record review of a Quarterly Pain Assessment (QPA) dated 5-31-2022 revealed the facility staff assessed Resident 42 with having a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the QPA dated 5-31-2022 revealed the facility staff indicated Resident 42 was not in pain or at risk for pain. Record review of a Resident 42's Occupational Therapy Evaluation and Plan of Treatment (OTEPT) note dated 5-18-2022 revealed the referral was due to decreased in range of motion indicating the need for Occupational Therapy (OT) to decrease painful condition of upper extremities. Further review of Resident 42's OTEPT note dated 5-18-2022 revealed Resident 42 had skin breakdown to the left hand with moderate to severe flexion contractures. The reason for services was to decrease the painful condition of the upper extremity and improve motor control/tone. According to the National Cancer Institute found at www.cancer.gov a contracture is a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff. This prevents normal movement of a joint or other body parts. Record review of Resident 42's Comprehensive Care Plan (CCP) revised on 2-04-2019 revealed Resident 42 needed pain management. A goal revised on 5-27-2022 was Resident 42 would maintain adequate level of comfort as evidenced by no signs or symptoms of unrelieved pain or distress. Interventions to meet this goal included administering pain medication, evaluate characteristics and frequency of pain and to evaluate the need to provide medications prior to treatment or therapy. Observation on 7-11-2022 at 1:10 PM revealed Resident 42 was in bed with a splinting device to the right hand and a rolled gauze to the left hand. The left hand fingers were pressing into the palm of the left hand. On 7-11-2022 at 1:10 PM an interview was conducted with Resident 42. When asked if the left hand was painful, Resident 42 responded yes. Record review of an Order Summary Report sheet printed on 7-13-2022 revealed Resident 42's practitioner ordered a treatment to the left hand that directed staff to use soap and water daily to clean the entire hand including the palm and fingers. In addition, staff were to place a rolled wash cloth into the palm of the hand to assist in keeping the area dry. Observation on 7-13-2022 at 2:05 PM of Resident 42's left hand treatment revealed Licensed Practical nurse (LPN) U explained to Resident 42 of the plan to complete the treatment. LPN U obtained a wash cloth with soap and water and stated to open Resident 42's left hand. Resident 42 stated my hand hurts. LPN U continued to open Resident 42's left hand in a prying like manner, Resident 42's face become reddens, brows furrowed and yells out, stop, stop. LPN U continues to pry open the left hand and started to wash the palm when Resident 42 started to hit out at LPN U. LPN U stated to Resident 42 we need to get this done. Resident 42's face reddened, brow was furrowed and started to cry out. LPN U stopped the treatment as Resident 42 hit out. On 7-13-2022 at 2:15 PM an interview was completed with LPN U. During the interview LPN U reported Resident 42 is always painful due to the contractures. When asked if Resident 42 had been pre-medicated prior to the left hand treatment, LPN U stated no. LPN U confirmed the treatment should have been stopped and Resident 42 given some medication for pain. Record review of The facility Policy on 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-center care plan and the residents goal. -Policy Explanation and Compliance Guidelines: -2. Behavioral signs and symptoms that my suggest the presence of pain include but are not limited to : -d. Resisting care, striking out. -g. Facial expressions, grimacing, frowning, fear, grinding of teeth. -k. Sighing, groaning, crying and 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 12-006.05(9) Based on record review and interview; the facility staff failed to ensure 1 (Resident 133) of 1 resident reviewed were free from involuntary seclusion. The facility staff identified a census of 85. Findings are: Record review of an Admission Record sheet printed on 6-15-2017 revealed Resident 133 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 133's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) dated 5-10-17 revealed the facility staff had assessed Resident 133 with a Brief Interview of Mental Status (BIMS) of 15. According to the MDS Manuel, a BIMS of 13 to 15 indicates a person is cognitively intact. Record review of Resident 133's Comprehensive Care Plan (CCP) dated 4-28-2017 revealed Resident 133 was placed into a private room for isolation related to poor hygiene, touching private parts and touching everything else. Record review of Resident 133's medical record revealed there was no evidence that the facility had completed observations with Resident 133 to determine what additional education Resident 133 would need for hand hygiene including demonstrating for nursing staff Resident 133's understanding of hand hygiene. Record review of Resident 133's Progress Notes (PN) dated 4-27-2017 revealed Resident 133 was assessed as having no open areas. Record review of a physician review sheet dated 4-28-17 revealed Resident 133's physician had seen Resident 133 for a review of the hospital discharge and review of medications. Further review of the physician review sheet revealed the plan was for the resident to be admitted to the facility with the same medications and treatments. There was no indications or orders for Resident 133 to be placed into isolation. Review of Resident 133's PN dated 5-09-2017 revealed Resident 133 was in contact isolation. Review of Resident 133's PN dated 5-18-2017 revealed Resident 133 was eating meals in (gender) room as Resident 133 was in isolation. On 6-26-2017 at 7:42 AM an interview was conducted with Resident 133. During the interview, Resident 133 reported no understanding what the reason for isolation was or how isolation procedures were to be implemented. Resident 133 reported during the interview that Resident 133 was in isolation for almost 2 months. Resident 133 reported I was very bored, nothing to do. On 6-27-2017 at 4:25 PM a follow up interview was completed with Resident 133 related to Resident 133's isolation in room. Resident 133 reported during the interview the facility staff had reported Resident 133 had [MEDICAL CONDITION], Resident 133 stated I don't have [MEDICAL CONDITION]. Resident 133 reported not being able to come out of the room. Resident 133 stated when I would open my door, they would yell at me, you can't come out, you can't come out. Resident 133 stated it made me feel very very badly. Resident 133 reported during the interview about being very upset about not being able to leave the room and stated I cried a lot. It bothered me. On 6-27-2017 at 7:49 AM an interview was conducted with the Director of Nursing (DON). During the interview, the DON reported there was no education provided to Resident 133 for the isolation and further reported that the DON was not sure why Resident 133 was in isolation. On 6-28-2017 at 6:30 AM an interview was conducted with Licensed Practical Nurse (LPN) H and LPN I who both worked on the unit Resident 133 resided on. During the interview when asked why Resident 133 had been in isolation, LPN H and LPN I reported being told Resident 133 had [MEDICAL CONDITION]. LPN H stated I wasn't sure about that. LPN I reported after a while the [MEDICAL CONDITION] issue was dropped. When asked if LPN H and LPN I knew why Resident 133 was in isolation, Both LPN H and LPN I stated not really, we don't make that decision. LPN I reported LPN I's understanding was that Resident 133 had poor handwashing and did scratching of self in peri area. LPN I reported not being aware of anyone teaching Resident 133 about hand hygiene.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a Based on record review and interview; the facility staff failed evaluate causal factors for the development of pressure ulcers and failed to implement addition interventions to prevent addition pressure ulcer development for 1(Resident 1) of 3 residents. The facility staff identified a census of 79. Findings are: Record review of an Admission Record sheet dated 2-02-2017 revealed Resident 1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 1's Comprehensive Care Plan (CCP) dated 6-01-2016 revealed Resident 1 was at risk or had actual pressure ulcer development. The goal that was identified on Resident 1's CCP was to have intact skin. Interventions listed on the CCP included weekly skin inspection, pressure reducing cushion to wheelchair, pressure reducing mattress. Further review of Resident 1's CCP revealed had written entries dated 1-7-2017 revealed Resident 1 had open areas to the left buttocks and on 12-5-2016 had an open area to the penis. Review of a Fax sheet dated 1-07-2017 revealed the facility had notified the practitioner that Resident 1 had skin breakdown to the scrotum, buttocks and coccyx areas and request a treatment. Record review of Resident 1's Weekly Skin Check sheet dated 1-03-2017 revealed the skin breakdown that had been identified was the wound to the penis. Record review of a Weekly Wound Assessment sheet (WWA) dated 1-19-2017 revealed on 1-07-2017, Resident 1 was assessed with [REDACTED]. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) to the Right Ischium that measured 2.3 centimeter (cm) by 2.3 cm by 2.9 cm. The Stage IV pressure ulcer was acquired at the facility. Record review of a WWA sheet dated 1-19-2017 revealed Resident 1 was assessed as having a stage 1 (Stage I - An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: - Skin temperature (warmth or coolness); - Tissue consistency (firm or boggy); - Sensation (pain, itching); and/or - A defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.) The pressure ulcer measured 1.0 cm by 1.0 cm. Record review of a WWA sheet dated 1-19-2017 revealed Resident 1 was assessed as having a Stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) to the right buttocks that measured 0.6 cm by 0.3 cm by 0.1 cm that was identified on 1-07-2017. Record review of Resident 1's medical record revealed there was no evidence of the facility staff evaluation of casual factors as to why Resident 1 developed the Stage IV pressure ulcer. Record review of a WWA sheet dated 1-13-2017 revealed Resident 1 was assessed as having a pressure ulcer to the right heel. The staging of the pressure ulcer was identified as suspected Deep Tissue Injury. According to the information on the WWA sheet, a suspected deep tissue injury is a localized area of discolored intact skin due to pressure or shearing. Record review of a WWA sheet dated 1-19-2017 revealed on 1-17-2017 Resident 1 was assessed as having a Stage 3 (Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) to the left lower leg that measured 3.3 cm by 1.8 cm. Further review of Resident 1's medical record revealed there was no evidence the facility staff had implemented intervention and evaluated casual factors for the development of the additional pressure ulcers . On 2-02-2017 at 12:59 PM an interview was conducted with the facility Assistant Director of Nursing (ADON). During the interview, the WWA sheets were reviewed. The ADON confirmed, during the interview, that Resident 1 had developed the pressure ulcers at the facility. The ADON confirmed the casual factors for the development of pressure ulcers had not been completed for Resident 1.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and interview; the facility staff failed to ensure residents were supervised when receiving hot liquids for 2 (Resident 3 and 4) of 3 residents reviewed. The facility staff identified a census of 79. Findings are: Record review of an Admission record sheet printed on 1-11-2017 revealed Resident 3 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of an Injury of Unknown Origin (IOUO) sheet dated 1-11-2017 revealed on 1-7-2017 Resident 3 was assessed as having a 9 centimeters (cm) by 3 cm red area with 4 blisters that measured individually as 3 cm by 3 cm, 2 cm by 1 cm, 2 cm by 0.2 cm, and 2 cm by 1.0 cm. According to the information on the IOUO sheet, Resident 3 was in the dining room and yelled for help. \ Dietary Assistant (DA) A was the first to respond with a nurse coming into the dining room. According to the IOUO, both the DA and the nurse saw Resident 3 dropped the coffee Resident 3 was drinking into the lap area. Record review of an undated, handwritten statement revealed DA A reported hearing another resident yell for help and the resident reported Resident 3 dropped hot coffee into (gender) lap. According to the written statement, DA A obtained towels and assisted the resident to clean up the coffee. DA A documented that medication assistant walked into the dining room and assisted Resident 3 to the nurse. Record review of Resident 3's Comprehensive Care Plan (CCP) dated 12-15-2016 revealed the facility staff identified Resident 3 was at risk for injury related to hot liquid burns. Interventions identified on the CCP dated 12-15-2016 revealed staff were to complete a hot liquid assessment on admission and place a lid on all hot liquid containers. If spills occurred, staff were to notify the physician, family and Director of Nursing (DON ). On 2-01-2017 at 1:43 PM, an interview was conducted with DA A. During the interview, DA A reported that another resident saw Resident 3 drop hot coffee into the lap area. DA A reported there was not a lid on the hot liquid container. In addition, DA A reported there was no one in the dining supervising the residents. On 1-31-2017 at 5:19 PM an interview was conducted with Resident 3. During the interview, Resident 3 reported that staff had provided the hot coffee. Resident 3 reported spilling the hot coffee and stated boy did that hurt. Observation on 1-17-2017 at 9:57 AM with the Assistant Director of Nursing (ADON) of Resident 3 inner thigh area revealed a redden area that measured approximately 5 centimeters (CM) long and 2 cm wide. No blistering was observed at this time. Record review of an educational form dated by staff on 1-09-2016 revealed staff were educated on ensuring residents who triggered the hot liquid protocol were to have lids on their hot beverages. Further review of the educational form dated 1-09-2017 revealed there was no education on ensuring residents were supervised to prevent hot liquid spills. B. Record review of an Admission Record sheet dated 1-30-2017 revealed Resident 4 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 4's Care Plan (CP) dated 12-15-2016 revealed the facility staff had identified Resident 4 was at risk for hot liquid spills. Further review of Resident 4's CP dated 12-15-16 revealed a hand written update, dated 1-29-2017, that Resident 4 had sustained a burn to the right inner thigh and, on 10-17-2016, Resident 4 was to be on a 1 to 1 assistance in the dining area . Record review of an Accident/Unusual Occurrence (AUO) from dated 2-03-2017 revealed that, on 1-29-2017, Resident 4 was evaluated as having burns to both inner thigh area. The right thigh measured 17 cm by 10 cm and the left thigh measured 2 cm by 1 cm. According to the information in the AUO report, there were no witness. Further review of the AUO dated 2-03-2017 revealed Licensed Practical Nurse (LPN) B had reported to the DON that Resident 4 had obtained burns to the thigh area at supper time. Review of a written statement signed by Nursing Assistant (NA) C on 1-29-2017 revealed NA C reported assisting residents to the dining room. According to the written statement, NA C transported Resident 4 to the dining room and left Resident 4 there to transport other residents to the dining room. NA C documented, upon return to the dining room, Resident 4 had a drink. NA C documented seeing a spill on the table and onto the resident's pants. NA C reported cleaning the table, wiped Resident 4's pants off, and then assisted Resident 4 with supper. Review of a statement written by the DON on 2-2-2017 of a follow up interview with NA C revealed NA C reported assisting residents to the dining room for supper, According to the written statement, NA C was the only nursing person in the dining room at 5:40 PM. Observation on 2-01-2017 at 9:09 AM of the burn area with the ADON revealed LPN D removed the soiled dressing revealing a red and blistered area that measured approximately 12 cm by 5 cm's on the right thigh and the left thigh area burn measured approximately 2 cm round open area. An interview was conducted on 2-1-2017 at 2:07 PM with DA E. During the interview, DA E reported making and giving the coffee to Resident 4. According to DA E, the coffee temperature was a 150 degrees. DA E further reported that a staff member was with Resident 4. On 2-2-2017 at 5:22 AM, an interview was conducted with Certified Medication Assistant (CMA) F. During the interview, CMA F reported serving Resident 4 supper as NA C was sitting with Resident 4. When asked if a nurse was in the dining room to supervise, CMA F stated no. On 2-2-2017 at 8:15 AM, an interview was conducted with LPN G. During the interview, LPN G reported there was to be a nurse in the dining room at meal times. On 2-2-2017 at 8:38 AM, an interview was conducted with Resident 4. During the interview, Resident 4 reported spilling the coffee into the lap area. When asked if a lid was on the cup being used for coffee, Resident 4 stated yes. When asked if there was any staff in the dining room when the spilled occurred, Resident 4 stated No. Record review of the facility education to staff dated 1-30-17 revealed the topic was spilled hot liquids. Further review of the education sheet revealed requiring supervision in the dining room was not part of the education. On 2-2-2017 at 10:30 AM, an interview was conducted with the DON. During the interview, the DON confirmed a nurse was to be in the dining room at meal times. The DON reported no when asked if they had evaluated if a nurse was in the dining room at the time of the burns for Resident 3 and Resident 4. The DON further confirmed staff education had not been completed after Resident 4 sustained a burn from hot liquids.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on observation, record review and interview; the facility staff failed to evaluate and implement interventions to manage pain for 1 (Resident 3) of 1 residents reviewed for pain. The facility staff identified a census of 88. Findings are: Record review of a Admission Record sheet dated 12-12-2016 revealed Resident 3 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 3's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) signed on 12-13-2016 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) was assessed as a 10. According to the MDS Manuel, a score of 8 to 12 indicate moderately impaired cognition. -Required supervision with bed mobility, transfers, ambulation, eating and toilet use. -Required extensive assistance with dressing and personal hygiene. -No indicators of pain. Record review of an Accidents/Unusual Occurrence sheet revealed Resident 3 fell on [DATE]. Record review of a Radiology Report sheet dated 12-14-2016 revealed Resident was evaluated with having an Acute distal end right clavicle fracture. Record review of Resident 3's progress notes revealed Resident 3 discharged from the facility on 12-22-2016. Record review of a Clinical Health Status sheet dated 12-26-2016 revealed Resident 3 was readmitted to the facility with a fracture to the right hip. Further review of the Resident Assessment sheet revealed that, on a scale of 0 to 10, Resident 3 ' s acceptable level of pain was a 4. Record review of Resident 3's care plan dated 12-28-2016 revealed Resident 3 had pain to the right shoulder and right hip. Interventions identified on the care plan for control of pain included the following: -Assess and establish a level of pain on the numeric assessment tool. -Monitor response on numeric pain scale related to medication and procedures. -Evaluate the need to provide medications prior to a treatment or therapy. -Don't wait for the resident to request pain medication, but offer to the resident at frequency indicated in the physician ' s orders. Observation on 1-03-2017 at 8:14 AM with the Director of Staff Development (DSD) revealed Nursing Assistant (NA) E, NA F and NA G transferring the resident NA E informed Resident 3 of the process of a transfer from bed to Resident 3's wheelchair. NA E applied a gait belt to Resident 3 while Resident 3 was in bed. NA E turned Resident 3 from side to side to apply the gait belt which resulted in Resident 3 moaning and crying out. Resident 3's eyes were clinched shut with a deeply furrowed face. NA E, NA F and NA G them slid Resident 3 to the right edge of the bed. Observations at this time revealed Resident 3 had a deeply furrowed brow, was holding (gender) breath and moaned out loud. The NA's did not stop the transfer and inform the nurse of Resident 3's pain. NA E, NA F and NA G, on the count of three, lifted Resident 3 from the bed into the wheelchair. Observations during the transfer from bed to the wheelchair revealed Resident 3 eye were tightly closed The resident initially held (gender's) breath and moaned out loud. NA E, NA F and NA G then positioned Resident 3 in the wheelchair causing Resident 3's face to turn reddish and the resident again moaned out loud. On 1-03-2017 at 8:24 AM, an interview was conducted with NA E. During the interview when asked if Resident 3 was in pain, NA E reported Resident 3 was always painful. An interview with Resident 3 was conducted on 1-03-2017 at 8:26. During the interview when Resident 3 was asked to rate pain on a scale of 0 to 10 with 10 being the worst, Resident 3 reported the pain level as being a 9. On 1-03-2017 at 8:30 AM, an interview was conducted with Licensed Practical Nurse (LPN) H. During the interview when asked when the last time Resident 3 had pain medication, LPN reported pain medications was last administered on 1-02-2017 at 9:03 PM. Record review of Resident 3's Medication Administration Record [REDACTED]. An interview was conducted on 1-03-2017 at 8:40 AM with the DSD. During the interview, the DSD confirmed Resident 3 was having pain and should have been pre-medicated. An interview on 1-03-2017 at 2:48 PM was conducted with the Director of Nursing (DON). When asked if the NA's should have stopped the transfer and informed the nurse of Resident 3's pain, the DON stated yes. Record review of the facility policy on Pain Management dated 9-2013 revealed the following information: -Policy: -The facility is committed to reducing physical and psychosocial symptoms associated with pain to assist the resident in achieving their highest practicable level of functioning. -Procedure: -#3. Complete a pain evaluation with increase of pain. -#5. Identify potential causes for the resident's pain. Evaluate alleviating and/or exacerbating factors. -#6. Determine appropriate interventions to manage pain and side effects. Appropriate interventions may include pharmacological as well as non-pharmacological interventions. -#8. Communicate interventions to staff. -#13. Re-assess the resident ' s status as indicated including, but not limited to, level of pain relief, side effect management and effectiveness of interventions.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observation, record review and interview; the facility staff failed to implement assessed interventions and failed to evaluate casual factors to prevent falls for 1 resident (Resident 1) and failed to implement additional interventions after a fall for 1 resident (Resident 2). The facility staff identified a census of 89. Findings are: A. Record review of an Admission Record sheet dated 7-22-2016 revealed Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 1's Comprehensive Care Plan (CCP) dated 5-03-2016 revealed Resident 1 was at risk of falling. The goal was that Resident 1 would not have fall related injuries. The interventions listed on the CCP dated 5-03-2016 included for staff to keep environment well lit and free of clutter, call light and personal items in reach and assess the resident for pain. Further review of Resident 1's CCP revealed Resident 1 required 2 staff to assist with transfers. Record review of a Verification of Investigation (VOI) dated 5-28-2016 revealed Resident 1 had fallen in (gender) room. According to the VOI dated 5-28-2016, interventions implemented were non-skid socks, bed in low position, mat at bed side, commode at bed side and alarm box moved out of the resident's reach. Record review of a Post Fall Analysis/Plan sheet (PFAPS) dated 6-07-2016 revealed Resident 1 had fallen. According to the PFAPS dated 6-07-2016 the resident had a history of [REDACTED]. The new intervention was to apply wireless alarms to the bed as Resident 1 was able to turn of the previous type of alarms. Record review of a VOI dated 6-12-2016 revealed Resident 1 had fallen onto the floor. According to the VIO dated 6-12-2016 Resident 1 was transferring from a wheelchair to the bedside commode. Record review of the PFAPS dated 6-12-2016 revealed the facility staff identified that Resident 1 had impaired safety awareness/judgement. According to the PFAPS dated 6-12-2016, therapy was working with Resident 1 to use a walker. The PFAPS did not have information on how the facility staff were implementing interventions to prevent falls when Resident 1 was not working with therapy. Record review of an Interdisciplinary Progress Note (IPN) dated 6-14-2016 revealed Resident 1 was found on the floor with a wheelchair partially on top of Resident 1. According to the IPN dated 6-14-2016, Resident 1 was going to the bathroom. Record review of a PFAPS dated 6-15-2016 revealed the intervention was to assess the environment. The PFAPS did not contain information on how the environment was to be assessed or what interventions were implemented in an attempt to prevent falls while the environment was assessed. Further review of the PFAPS dated 6-15-2016 revealed there was no evidence on how the facility staff were assisting Resident 1 with toileting needs. Record review of a VOI dated 7-05-2016 revealed the resident was found sitting on the floor. According to the information on the VOI dated 7-05-2016 Resident 1 would often get up without using the call light. Record review of a VOI dated 7-7-2016 revealed Resident 1 had fallen when attempting to go to the bathroom. The VOI dated 7-7-2016 identified that Resident 1 had removed the alarms. The intervention identified on the VOI dated 7-7-2016 was to get Resident 1 up in the wheelchair and have staff sit with Resident 1 if Resident 1 continually set off the alarm of bed and commode. The VOI dated 7-7-2016 identified the CCP had not been revised with the intervention. Record review of Resident 1's CCP dated 5-03-2016 revealed the intervention for staff to get Resident 1 up in the wheelchair and have staff sit with Resident 1 if Resident 1 continually set off the alarm of bed and commode was not on the CCP. Record review of the PFAPS dated 7-7-2016 did not have any additional interventions to prevent falls for Resident 1. Record review of a VOI dated 7-17-2016 revealed the resident had fallen in the dinning room. According to the VOI dated 7-17-2016, Resident 1 had a possible fracture and was sent to the Hospital. No new interventions were identified on the VOI to prevent falls when Resident 1 would return to the facility. Record review of a Progress Note dated 7-20-2016 revealed Resident 1 was readmitted to the facility with a fractured right elbow. Record review of a Resident Cardex Information sheet (a basic information sheet for nursing assistant on how to take care of residents) printed on 8-4-2016 revealed it did not identify staff were to sit with the resident, the resident was to have a low bed or that a fall mat was to be in place. Observation on 8-03-2016 at 9:52 AM revealed Resident 1 was seated in a wheelchair in (gender) room. The call light was out of reach and Resident 1's bed was in the medium height. Observation on 8-03-2016 at 11:03 AM with Licensed Practical Nurse (LPN) A revealed Nursing Assistant (NA) B using a gait belt transferred Resident 1 from the bed to the wheelchair without an additional staff assisting. An interview was conducted with LPN A on 8-04-2016 at 7:02 AM. During the interview, LPN A confirmed Resident 1's bed was not in the low position during the observation on 8-03-2016 at 9:52 AM and further confirmed Resident 1 was transferred with one staff member. LPN A further reported that Resident 1 was impulsive and needed more monitoring. An interview was conducted with the Director of Nursing (DON) on 8-04-2016 at 7:30 AM. During the interview, the DON reported that there was not any trending of Resident 1's falls. Review of Resident 1's CCP also was conducted with the DON. When asked to offer Resident 1 to use the bathroom on rounds was an intervention, the DON stated no, they should have been doing that. The DON further confirmed that new interventions to prevent falls had not been implemented when Resident 1 returned from the hospital. On 8-04-2016 at 8:52 AM an interview was conducted with the Assistant Director of Nursing (ADON). Review of the VOI dated 7-17-16 was conducted with the ADON. The ADON reported that Resident 1 was impulsive and needed more supervision. The ADON confirmed Resident 1 had been left alone in the dining room when Resident 1 fell . B. Record review of an Admission Record sheet printed on 8-02-2016 revealed Resident 2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 2's CCP dated 2-25-2016 revealed the facility staff had identified Resident 2 was at risk for falls. The goal for Resident 2 was not to have any fall related injuries. Interventions to prevent falls included call light or personal items in reach, use gait belt with transfers, keep environment clutter free and provide foot wear to prevent slipping. Record review of Resident 2's Progress notes identified the resident was alert and oriented. Record review of an Abuse, Neglect or Misappropriation sheet dated 8-2-2016 revealed Resident 2 had fallen on 7-27-2016 with a resulting fracture. Review of the resident's medical record that included progress notes, CCP and physician orders [REDACTED]. An interview was conducted with the DON on 8-03-2016 at 5:05 PM. During the interview, the DON confirmed there were no new interventions to prevent falls. Record review of the facility undated Falls Management Guideline revealed the following: -Process: -Following a residents fall appropriate interventions are implemented. -Care plan updated. -Residents with Multiple Falls: -Trending of falls for the individual-time of day, reason for fall, location of fall etc. Cross reference to F315 for failure to implement a toileting program for Resident 1.