Every finding on record at Eventide Williamsburg

Licensure Reference Number 175 NAC 12-006.09Based on record reviews and interviews, the facility failed to ensure professional standards of practice were followed when administering a transdermal (a way to administer medication through the skin) patch containing a narcotic for 1 of 1 resident reviewed (Resident 1). The facility census was 26. Findings are: Record review of Resident 1's admission Record revealed that Resident 1 was admitted to the facility on [DATE] after a fall that resulted in a fracture of the right upper arm, a fracture of the sacrum (the bone between the bottom of the spine and the tailbone), and a fracture of the right pubis bone (the front part of the pelvis). Record review of Resident 1's progress notes from the hospital revealed that Resident 1 had surgery to repair the fracture to the right upper arm. Record review of the hospital progress notes revealed that an order for a Buprenorphine patch (an opioid-medicated pain patch used to treat severe, constant pain over a 7-day period) was initiated during the hospital stay. Record review of the facility's Order Summary dated 02/13/2026 for Resident 1 revealed an order for 1-7.5/HR Buprenorphine patch to be placed on the skin every 7 days on Fridays. The order also revealed to remove the old patch and rotate the placement of the new patch each week. Record review of Resident 1's medication administration revealed that the pain patch was applied on 02/20/2026 and 02/27/2026. Record review of the facility's incident report dated 03/10/2026 revealed that the old Buprenorphine pain patch was not removed by the Medication Aides (MAs) on 02/27/2026 and 03/06/2026. Record review of Resident 1's progress notes revealed that Resident 1 and the family requested that the pain patch be held until 03/09/2026 as the resident reported minimal pain. Record review of Resident 1's administration record for the month of March 2026 revealed that the Buprenorphine patch was held on 03/06/2026 and not administered on 03/09/2026. Interview on 04/01/2026 at 2:48 PM with the Director of Nursing (DON) revealed that the incident was brought to (gender) attention on 03/10/2026 and that prior to this time the facility did not have a system in place to ensure that the old patch was removed before applying a new patch to prevent more than one patch on the skin at a time. Record review of the facility's policy titled Policy and Procedure: Medication-Administration and Storage with a revised date of 03/2025 revealed that all narcotic medicated patches will be checked for placement 3 times a day: during the day shift, the afternoon shift, and the night shift. Interview on 04/02/2026 at 12:45 PM with the DON confirmed that it is the facility's expectation that the MAs/Nurses remove the old narcotic patch prior to placing a new one.

Licensure Reference 175 NAC 1-005.06(D)Based on record review, observation and interviews, the facility failed to ensure infection control standards of practice were followed during wound care for Resident 27. This affected 1 of 1 resident observed for wound care. The facility census was 26.Findings are:A record review of the facility's Hand Hygiene policy revised 11/24 revealed that hand hygiene should be performed before and after resident contact including before leaving the room, before every clean procedure, after every dirty procedure, and as needed. Further review revealed that handwashing should take at least 20 seconds.A record review of the facility's Guidelines for Wearing Gloves policy revised 4/23 revealed that gloves should be changed between dirty and clean procedures on the same resident, and that hand hygiene should be performed before putting gloves on and after removing gloves.A record review of Resident 27's admission Record printed 12/03/20205 revealed the resident was admitted on [DATE] and had a diagnosis of cellulitis (a bacterial infection of the skin and deeper tissue underneath the skin) of the left arm.A record review of Resident 27's Order Summary printed 12/03/2025 revealed a current order for a daily dressing change to the wound on Resident 27's left arm as follows: DRESSING CHANGE TO LEFT ARM daily cleanse wound with Vashe [a brand of wound cleanser] wound cleanser moisten 4x4 gauze with Vashe cleanser and apply to wound bed leave on the wound bed for 3-5minutes apply Vaseline gauze to skin tear and cover with Mepilex [an absorbent foam dressing] every day shift for skin with a start date of 11/25/2025.An observation on 12/02/2025 from 10:58 AM to 11:10 AM revealed that Registered Nurse (RN) A entered Resident 27's room, used hand sanitizer and put gloves on, and opened a cupboard door to retrieve wound care supplies. Wearing the same gloves, RN A took the wound care supplies to the overbed table next to the table and put them directly on the surface of the table. RN A then pushed Resident 27's sleeve up to access the left elbow. Without performing hand hygiene or changing gloves, RN A opened the Vashe wash, applied it to a gauze sponge, used it to wipe the surface of the wound, then left the gauze to sit on the wound. After two minutes, the RN stated they had not measured the wound, removed the gauze, measured the wound, and replaced the gauze. Wearing the same gloves, RN A opened the Vaseline gauze and foam dressing packages. The RN then patted their uniform and reached into their pockets, then walked across the hall into the nurse's station and reached into a black bag, then pulled scissors out of a front pocket of their scrubs. RN A then removed their gloves, went to the sink and washed their hands with soap and water for 12 seconds. As the RN reached for paper towels, their hand brushed against a pile of coats under the paper towel dispenser. RN A then went back across the hall to Resident 27's room, put gloves on, then reached into their pockets to retrieve an alcohol wipe and cleaned the scissors. Wearing the same gloves, RN A used the scissors to cut a piece of the Vaseline gauze, then removed the gauze with Vashe on it from the left elbow wound and applied the Vaseline gauze. RN A then applied the foam dressing, then reached into their pockets, retrieved a pen and put the date and their initials on the dressing. Wearing the same gloves, RN A then opened the cupboard door, put wound care supplies away, and locked the cupboard door with a key on a key ring with multiple other keys.An interview on 12/02/2025 at 11:15 AM with RN A confirmed that the overbed table had not been clean, and that there should have been a barrier placed between the table and the wound care supplies. The RN further confirmed that they should have performed hand hygiene and changed their gloves between touching objects such as a cupboard door, keys, clothing or a bag and touching the resident or the wound care supplies, and between removing the old dressing, cleaning the wound, and applying the new dressing. RN A confirmed they should not have been in the hall with the gloves on, and that handwashing should take at least 20 seconds.An interview on 12/03/2025 at 2:45 PM with the Administrator (ADM) confirmed the facility did not have a policy for wound care.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on record review and interviews; the facility failed to notify Resident 1's representative of being denied Hospice admission and a large bruise of unknown origin for 1 (Resident 1) of 5 sampled residents. The facility census was 15. Findings are: A record review of Resident 1's Progress Notes on 6/23/2025 at 6:00 PM revealed that a call was placed to Resident 1's Advanced Practice Registered Nurse (APRN) related to Resident 1 having a large, bruised area on (genders) left side that radiates into (genders) waist area & under left breast. It was 1st noticed by the Medication Aide-A on Thursday 6/19/2025 but has gotten larger and Resident 1 is now complains of it hurting. No recorded falls have been documented, and Resident 1 does have a chair alarm on. No SBAR (Situation, Background, Assessment, Recommendation) was written, and this Registered Nurse (RN) didn't have the APRN look at the bruise today when APRN arrived at the facility. A record review of the progress notes revealed there is no documentation for the bruise on the left side of Resident 1 before 6/23/25. Further review of the progress notes revealed there is no skin assessment on Resident 1's bruise to (gender) left side. An interview on 6/30/25 at 10:30 AM with the RN revealed that (gender) does not remember if the family was notified and there are no notes in the progress notes indicating the family was updated. The RN confirmed that the facility charts in the progress notes weekly for skin assessments. The RN confirmed that (gender) did not fill out an incident report and should have. An interview on 6/30/25 at 1:00 PM with Resident 1's Representative confirmed that the family was not notified of the bruise. The Representative confirmed that (gender) is in the facility 3-4 times a day. The Representative further confirmed that (gender) had requested a hospice consultation and was not notified that Resident 1 was denied hospice until (gender) called hospice. An interview on 6/30/25 at 11:30 AM with Social Services confirmed that hospice did not admit Resident 1 and (gender) thought that Resident 1's representative was aware. An interview on 6/30/25 at 2:13 PM with the Director of Nursing (DON) confirmed that Resident 1's representatives had not been notified of hospice denying admission for Resident 1. DON confirmed that (gender) though hospice would update the family on being denied hospice services and family was not updated when bruise was noted on Resident 1 and representatives should have been updated on the bruise and hospice denying admission.

Licensure Reference Number 175 NAC 12-006.02(H) Based on observation, record review, and interviews, the facility failed to investigate an incident of injury of unknown origin for 1 (Resident 1) of 5 sampled residents. The facility census was 15. Findings are: A record review of [NAME] Health Care Services policy and procedures Manual: Abuse Identification and Prevention (Identifying and Reporting Incidents) revealed that in section Investigation Injuries of Unknown or suspicious origin: -When an injury of unknown or suspicious origin is discovered, a QAR (Quality Assurance Report/Incident Report) must be initiated by the responsible professional. -Injuries that are indicators of physical abuse may include but are not limited to the following: -Bruises on bilateral arms, bilateral on soft parts of body not over a bony prominence (not knees or elbows), Clustered on trunk, on top of head, old and new bruised present at the same time, not resembling the explanation given for the cause, -Any injury of unknown source, -Fracture of unknown origin. A record review of the admission record revealed that Resident 1 was admitted to the facility on [DATE] with the diagnosis of Dementia (a decline in mental ability severe enough to interfere with daily life), Neurocognitive disorders with [NAME] Bodies (a neurodegenerative disorder characterized by a decline in thinking abilities, particularly attention, visual perception and executive function, along with the presence of [NAME] bodies (protein deposit) in the brain. A record review of Resident 1's quarterly Minimum Data Set (MDS, a standardized assessment tool used to evaluate the health and functional status of residents) dated 5/9/25 revealed that Section C -Cognitive Patterns with a Brief Interview for Mental Status (BIMS, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function), score of 7 indicating severely impaired. An observation on 6/30/25 at 9:45 AM revealed a bruise that was dark purple/red in color on the left hip side of Resident 1. The bruise was on the left hip going up the left side of Resident 1. A record review of Resident 1's Progress Notes on 6/23/2025 at 6:00 PM revealed that a call was placed to Resident 1's Advanced Practice Registered Nurse (APRN) related to Resident 1 having a large, bruised area on (genders) left side that radiates into (genders) waist area & under left breast. It was 1st noticed by the Medication Aide (MA)-A on 6/19/2025 but has gotten larger and Resident 1 was now complains of it hurting. No recorded falls have been documented, and Resident 1 does have a chair alarm on. No Situation Background Assessment Recommendation (SBAR) was written, and this Registered Nusrse (RN) didn't have APRN look at the bruise today when APRN arrives at the facility. An interview on 6/30/25 at 10:20 AM with MA-B confirmed that Resident 1 has a chair alarm and when Resident 1 stands up Resident 1 will sit back down when the alarm goes off. MA-B confirmed that Resident 1 does not walk around on (gender) own anymore. MA-B confirmed that sometimes Resident 1 is a one assist and other times Resident is a 2 assist with ambulation and transfers. An interview on 6/30/25 at 11:30 AM with the Director of Nursing (DON) confirmed that (gender) was aware of the bruise on Resident 1 after the fact on the 6/24/25. The (MA-A) did not report it until 6/23/25. The DON confirmed that no incident report was completed and no investigation was completed. The DON confirmed that Resident 1 gets bruises from walking around and running into things. The DON confirmed that (gender) didn't feel the need to report Resident 1 bruise since Resident 1 gets bruises all the time. The DON confirmed that (gender) saw no need to investigate complete an incident form. The DON confirmed that (gender) should of done a incident report and should have done an investigation.

Licensure Reference Number 174 NAC 12-006.02(H)St 28-372 Based on record review and interviews; the facilty failed to report and submit a completed investigation of injury of unknown origin for 1 (Resident 1) of 5 sampled residents to the State Agency within the 5 working days. The facilty census was 15. Findings are: A record review of [NAME] Health Care Services policy and procedures Manual: Abuse Identification and Prevention (Identifying and Reporting Incidents)dated 10/17/22 revealed that in section Investigation Injuries of Unknown or suspicious origin: -When an injury of unknown or suspicious origin is discovered, a QAR (Quality Assurance Report/Incident Report) must be initiated by the responsible professional. -Injuries that are indicators of physical abuse may include but are not limited to the following: -Bruises on bilateral arms, bilateral on soft parts of body not over bony prominence (not knees or elbows), Clustered on trunk, on top of head, old and new bruised present at the same time, not resembling the explanation given for the cause, -Any injury of unknown source, -Fracture of unknown origin. A record review of Resident 1's Progress Notes on 6/23/2025 at 6:00 PM revealed that a call was placed to Resident 1's Advanced Practice Registered Nurse (APRN) related to Resident 1 having a large, bruised area on (genders) left side that radiates into (genders) waist area & under left breast. It was 1st noticed by the Medication Aide (MA)-A on Thursday 6/19/2025 but has gotten larger and (gender) now complains of it hurting. No recorded falls have been documented, and (gender) does have chair alarm on. There was no SBAR (Situation, Background, Assessment, and Recommendation) was written, and this Registered Nurse (RN) didn't have APRN look at the bruise today when APRN arrives at the facility. An observation on 6/30/25 at 9:45 AM revealed a bruise that was dark purple/red in color on the left hip side of Resident 1. The bruise was on the left hip going up the left side of Resident 1. An interview on 6/30/25 at 10:20 AM with MA-B confirmed that Resident 1 has a chair alarm and when Resident 1 stands up Resident 1 will sit back down when the alarm goes off. MA-B confirmed that Resident 1 does not walk around on (gender) own anymore. MA-B confirmed that sometimes Resident 1 is a one assist and other times Resident is a 2 assist with ambulation and transfers. An interview on 6/30/25 at 11:30 AM with the Director of Nursing (DON) was aware of bruise on Resident 1 after the fact on the 6/24/25. The MA-A did not report it until 6/23/25. The DON confirmed that no incident report was completed, and no investigation was completed. The DON revealed that Resident 1 gets bruises from walking around and running into things. The DON revealed that (gender) didn't feel the need to report Resident 1's bruise since Resident 1 gets bruises all the time. The DON confirmed that (gender) did not investigate or report the bruise. The DON confirmed that (gender) should of done a incident report and should have done an investigation and submitted it to the State Agency in the required timeframe.

Licensure Reference Number NAC 175 12-006.11c Based on observations, record review, and interviews, the facility failed to store food in a manner that would prevent food born illness to the residents, and failed to ensure hair was secured under a hairnet during meal service. This had the potential to affect all 30 residents. The facility identified a resident census of 30. Findings are: A. A review of the facility policy, Food storage, preparation, and handling, last reviewed on 12/23, revealed: The purpose of the policy is to protect the health of all individuals eating food prepared by the food and nutrition services department. To ensure that the period of food storage is consistent with the retention of food quality. Specific procedures are available for the storage, preparation, and service of food. Compliance with these procedures shall be included by reverence in all job descriptions developed after this date. Compliance with these procedures shall be a condition of employment for food service employees as per the related [NAME] policy. -All food which are removed from their original container are to be identified by their common name and the date on which the item was placed in storage. -Each employee shall review the storage area specific to their position on a daily basis and discard all foods which have reached the end of their storage period. Foods which have improperly stored will also be discarded. -Any prepared item will be discarded after three (3) days of refrigeration or three (3) months in the freezer. A Review of the facility policy, Policy for food brought into facility, (no effective date) revealed: The purpose of the policy is food safety. The policy is intended for food provided to residents from outside of the facility must be handled with appropriate food safety procedures. -Staff that receive food for storage must label with patient name and date the food arrived as it is placed in the resident refrigerator. (40 degrees or less) - Food will be disposed of if it is three days old or in a deteriorating state. An observation in the Harbor House refrigerator on 11/18/24 at 7:25 A.M., one Pantry ridge meat and cheese tray dated 11/13/2024 without and expiration date and one saucer plate of mixed cheese dated 11/13/24 without an expiration date. An observation in the Cove house on 11/18/24 at 7:43 A.M., one opened bag of sandwich style sliced turkey 32 ounce, with and expiration date of 12/24, and open date of 11/11/24. An interview on 11/19/2024 at 9:02 A.M. with Chef Manager confirmed the food items are to be removed 3 days after opening as per the policy. B. Review of the Nebraska Food Code 2-402.11, dated 2017 revealed that hair restraints are to be worn to keep hair from coming in contact with food, equipment, or utensils. An observation on 11/20/24 at 10:14 AM LPN - B went into the kitchen and put a hairnet on the top of (gender) head leaving the ponytail exposed and hanging down. In an interview on 11/20/24 at 10:15 AM LPN - B confirmed that all hair should have been contained under the hairnet. In an interview on 11/20/24 at 10:16 AM the Director of Nursing (DON) confirmed that all hair should be contained under a hairnet. In an interview on 11/20/24 at 02:59 PM the Certified Dietician (CD) confirmed that a hairnet must contain all hair. It was further confirmed there was no hairnet policy, and they follow the Nebraska Food Code regarding hair being covered.

Licensure Reference Number 175 NAC 12-006.18 Based on observation, interview, and record review, the facility failed to ensure hand hygiene was completed during catheter cares for Resident 18. The sample size was 1. The census was 30 at the time of survey. Findings are: Review of facility policy dated last reviewed 10/26/24, titled Hand Hygiene and Gloving, revealed alcohol based hand rub is recommended in all situations except when hands are visibly soiled. Review of the Centers for Disease Control and Preventions (CDC) website dated 2/27/2024 recommendation revealed that washing hands before and after using gloves helps prevent the spread of germs. Review of Resident 18's admission Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 10/27/24 revealed an admission to the facility on [DATE] and a Brief Interview for Mental Status (BIMS - a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 11 which indicated moderate cognitive impairment. Review of Resident 18's Comprehensive Care Plan (CCP - written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) revealed an indwelling foley catheter in place and catheter cares are to be performed per the physician orders initiated on 11/1/24. An observation during catheter cares on 11/20/24 at 10:57 AM for Resident 18, the Nursing Assistant (NA) - A changed gloves and did not perform any hand hygiene. In an interview on 11/20/24 at 11:01 AM NA - A confirmed that no hand hygiene was performed when changing gloves, and there was no hand sanitizer within reach. In an interview on 11/21/24 at 1:19 PM Licensed Practical Nurse (LPN) - B confirmed that hand hygiene is required when changing gloves.

Licensure Reference 175 NAC 12-006.18C1 Based on observation, interviews, and record review, the facility failed to transport clean linens in a manner to prevent cross contamination. This had the potential to affect all residents. The facility census was 32. Findings are: A review of the facility's undated policy Laundry Procedures revealed the following: Linens are handled, stored, processed and transported in such a manner as to prevent the spread of infection (away from the body). An observation on 12/12/2023 at 1:52 PM revealed, Nurse Aide (NA) C carried clean towels and washcloths out of the laundry room, and carried them up against their body, with the linens touching NA C's uniform shirt. An interview on 12/12/2023 at 1:54 PM with NA C revealed, that the towels and washcloths were clean, that they delivered them from the laundry room to the bath house, and that they should not carry linens against their body or touching their clothing. An interview on 12/12/2023 at 1:58 PM with Licensed Practical Nurse (LPN) B revealed, that when transporting linens, staff should be holding them away from their bodies. LPN B further revealed, that NA C carried clean linens against their body. An interview on 12/12/2023 at 2:43 PM with LPN B revealed., that the facility's policy specified to handle linens away from the body.

Licensure Reference Number 175 NAC 12-006.11E Based on observation and interview, the facility failed to store food and equipment in a manner to prevent contamination and failed to date food in 2 of 2 kitchens. This had the potential to affect 31 residents that ate food prepared in the facility kitchens. The facility census was 31. Findings are: An observation on 10/24/22 from 7:51 AM to 8:02 AM revealed the following in the initial kitchen tour of Harbor House: -area between wall and ice machine on floor with debris present -microwave with dried debris on walls and inside door -grease build up around stove and front of oven -dried liquid running down wall next to oven -pans above stove with cooking side facing ceiling -no dates on lettuce salads in refrigerator in kitchen area -boxes on the floor, in pantry, with potatoes, tomato juice, and Shasta pop cans -Plunkett's pest control box in pantry -undated opened quarter bag of extra wide noodles -measuring scoop in container labeled flour with lid not secure -container of parsley flakes undated and no expiration date on container -unlabeled and undated shaker with white powder in it with greasy, grime buildup on top -undated shaker labeled salt with greasy, grime buildup on top An observation 10/24/22 from 8:04 AM to 08:14 AM revealed the following in the initial kitchen tour of Cove House: -Plunkett's pest control box next to stove -large pan on bottom shelf with cooking side facing up -no dates on tea, lemonade or pink juice in refrigerator in kitchen area -2 undated bags with sandwich in each bag -unlabeled and undated to go container with a hamburger and french fries in it -juice spilled in door of refrigerator in kitchen area -undated opened cookie dough package in freezer in kitchen area -Dairy Queen cup with ice cream in freezer, with no date or name -Dairy Queen cup with date of 6/10/22 and no name -undated opened bag frozen waffles -undated opened box of bacon -Plunkett's pest control box under shelving with canned items -dirty trash can and cart with food debris and other disposable items on top -labeled container of rice with measuring scoop in it -opened and undated brown sugar bag -opened brownie mix box with no date -opened and undated bag of sourdough bread -opened and undated bag of Sara [NAME] bread -opened and undated bag of [NAME] buns -container with tomato soup expiration date of 10/21/22 -plastic bag of roast beef expiration date of 10/23/22 -plastic bag of honey ham expiration date of 10/23/22 -pan of coffee cake expiration date of 10/23/22 -pan of ham expiration date of 10/17/22 -sugar cookie dough with no date -tator tots with no date -fish fillets with no date -breadsticks with no date -wontons with no date -sausage with no date -italian sausage with no date -white rolled up food with no date In an interview on 10/25/22 at 1:00 PM, the Dietary Manager (DM) confirmed that items should be in a closed storage bag, dated with an open date and there should be no scoops in containers. In an interview on 10/27/22 at 2:00 PM, the DM confirmed that all residents in both houses receive meals from the kitchens.

Based on interview and record review, the facility failed to ensure pneumococcal immunizations were offered to 2 (Residents 16 and 24) of 5 residents reviewed. The facility had a total census of 31 residents. The findings are: A. A review of an undated policy titled Flu, Pneumonia, and COVID-19 Vaccines revealed the following: -Purpose: To ensure that each client is up-to-date with influenza, pneumonia, and COVID-19 vaccinations as recommended by the CDC (Centers for Disease Control and Prevention). -Policy: Each client will be assessed for the need of Influenza, COVID-19, and pneumonia vaccinations upon admission, annually or as needed. -4. If pneumonia immunization is not recorded after age of 65, inquire about this history with client, their family, or the primary care medical office. If documentation is not confirmed then vaccinate client after verbal consent. If client was vaccinated for pneumonia before age 65, a booster of [MEDICATION(S)] is recommended. Refer to CDC Website for [MEDICATION(S)] and Prevnar vaccination grids. (Pneumococcal vaccine timing for adults) www.cdc.gov -13. Vaccination is to be strongly encouraged for all residents without contraindications to the vaccine. All residents who decline the vaccination, will need a declination form in their medical record. This needs to be signed by the resident or their representative, if applicable. B. A review of Resident 24's electronic medical record revealed an admitted [DATE]. A review of Resident 24's immunization records did not reveal documentation of any pneumococcal immunizations. In an interview on 10/27/22 at 1:00 PM, the IP (Infection Preventionist) confirmed no documentation of pneumococcal immunization could be located for Resident 24. The IP further confirmed the facility did not follow their policy for pneumonia vaccination. C. A review of Resident 16's medical record revealed an admitted [DATE]. A review of Resident 16's immunization records revealed Resident 16 received a pneumococcal vaccine (Prevnar 13) on 9/25/2015. No other pneumococcal immunizations were documented in the record. In an interview on 10/27/22 at 1:00 PM, the IP reported Resident 16 received a [MEDICATION(S)] immunization on 9/25/2015, not Prevnar 13. The IP confirmed there was no documentation Resident 16 had been offered any further pneumococcal immunizations. The IP further confirmed the facility did not follow their policy for pneumonia vaccination.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C3a Based on record review and interview, the facility failed to ensure a recapitulation of stay for 2 (Residents 19 and 32) of 2 residents reviewed was completed after discharge from the facility. The facility census was 31. FINDINGS ARE: A. A record review of the Progress Notes dated 7/29/22 revealed no documentation of the location that Resident 32 had been discharged to. A record review of discharge paperwork for Resident 32 revealed it did not contain a recapitulation of stay for the timeframe of 4/1/22 to 7/31/22. An interview on 10/27/22 at 01:11 PM with the DON (Director of Nursing) confirmed no recapitulation of Resident 32's stay existed. B. A review of Resident 19's electronic medical record revealed an admitted [DATE] and a discharge date of [DATE]. A review of Resident 19's progress notes revealed they were discharged to another facility on 10/18/22. A review of Resident 19's medical record did not reveal a documented discharge summary for Resident 19. In an interview on 10/27/22 at 1:12 PM, the DON (Director of Nursing) confirmed a discharge summary, including a recapitulation of stay, was not completed for Resident 19. The DON stated the facility did not currently have a process for doing discharge summary documentation.

Licensure Reference Number 175 NAC 12-006.09D1c Based on observation, record review and interview, the facility failed to provide incontinence care or ask the resident to be changed for 2 (Resident 6 and 11) of 3 sampled residents. The facility census was 31. Findings are: A. A review of the Admission Record revealed Resident 6 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 6's, undated, elimination care plan revealed Resident 6 had an actual decline in continence related to falls with lumbar 4 (L4) fracture, dementia, depression and [CONDITION(S)] as evidenced by (AEB) frequently incontinent of bladder and bowel. The interventions that were included on Resident 6's incontinence care plan include: to change Resident 6's adult disposable brief frequently and as needed (PRN) and to check Resident 6 frequently and as required for incontinence. A record review of the MDS (Minimum Data Set) dated 7/22/22 revealed that Resident 6 required extensive assistance by two staff members for toileting use. A review of the Brief Interview for Mental Status (BIMS) for Resident 6, dated 7/22/22, revealed severe cognitive impairment. An observation on 10/24/22 at 9:28 AM revealed Resident 6 was sitting in their wheelchair in the dining room at the table. An observation on 10/24/22 at 11:16 AM revealed Resident 6 was sitting in their wheelchair in their room with a noticeable smell of urine. An observation on 10/24/22 at 1:43 PM revealed Resident 6 was sitting in their wheelchair in their room with a noticeable smell of urine. An observation on 10/24/22 at 2:58 PM revealed Resident 6 lying in bed with their eyes closed. Continuous observations on 10/25/22 from 7:48 AM until 12:49 PM revealed Resident 6 was in their wheelchair in the dining room or living room participating in activities and no staff asking the resident to be changed. An observation on 10/25/22 at 12:49 PM revealed Resident 6 being assisted back to their room by staff. An observation on 10/25/22 at 2:04 PM revealed Resident 6 to be in their wheelchair in their room and preferred to not lay down at that time, when asked by NA F (Nurse Aide). NA F asked Resident 6 if staff could check them and Resident 6 refused. Resident 6 remained in their wheelchair in their room at that time. In an interview on 10/25/22 at 2:28 PM, NA F confirmed staff are expected to check residents for incontinence and change them if needed every two to three hours. In an interview on 10/25/22 at 4:45 PM, the Corporate Registered Nurse (RN) confirmed that staff are expected to check and change residents every 2 hours if they are care planned for check and change. In an interview on 10/25/22 at 4:45 PM, the DON (Director of Nursing) confirmed that a resident would be care planned for check and change every 2 hours while awake and at night staff would just check the resident for incontinence. The DON further confirmed that residents would be care planned for check and change if the resident was on diuretic (medication that increases urinary output) and before or after staff give certain medications. In an interview on 10/25/22 at 4:45 PM, the Corporate RN confirmed that a resident would be care planned for check and change if the resident was experiencing skin breakdown and that it is individualized by the resident due to diagnosis, if the resident is able to articulate that they had been incontinent, if the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 10/26/22 at 9:21 AM, the DON confirmed that a resident should not be up in their wheelchair from before breakfast until after lunch without being checked or changed. B. A record review of Resident 11's, undated, elimination care plan revealed that Resident 11 had an actual decline in incontinence related to diuretic use, Alzheimer's, dementia, and muscle weakness AEB incontinent of bladder and bowel. Resident 11's had an actual deficit in ADLs related to Alzheimer's, dementia, muscle weakness, diuretic and anti-depressant use. Resident 11's ADL care plan revealed that Resident 11 required check and change for toilet use by one to two staff. A review of the MDS dated [DATE] revealed that toilet use, which includes how a resident cleanses self after elimination; changes pad; and adjusts clothes, did not occur and that Resident 11 was always incontinent of bowel and bladder. A review of Resident 11's BIMS assessment, dated 10/9/22, revealed the interview was not attempted with Resident 11 because Resident 11 is rarely/never understood. A staff interview was completed that revealed Resident 11 is severely impaired when making decisions regarding tasks of daily life. A record review of Resident 11's, undated, communication care plan reveals an actual communication problem related to Alzheimer's and dementia AEB is rarely/never understood. An intervention listed for the communication care plan is to anticipate and meet needs. In an interview on 10/24/22 at 11:30 AM, Resident 11's family member confirmed Resident 11 is not able to identify their continence. An observation on 10/25/22 at 7:48 AM revealed Resident 11 was in the dining room at the table eating breakfast. An observation on 10/25/22 at 8:23 AM revealed Social Worker (SW) assisted Resident 11 to their room. Continuous observation of Resident 11 on 10/25/22 from 7:48 AM to 10:59 AM revealed no staff members entering Resident 11's room or asking to change the resident. Resident 11 remained up in their wheelchair. In an interview on 10/25/22 at 2:28 PM, NA F confirmed that staff are expected to check residents for incontinence and change residents if needed every two to three hours. NA F confirmed that Resident 11 is not taken to the toilet due to requiring a hoyer lift for transfers and that staff just change Resident 11. In an interview on 10/25/22 at 2:30 PM, RN E reported that Resident 11 used an EZ Stand (a mechanical device used to transfer residents that are able to bear some weight) four years ago and would ask to go to the bathroom, Resident 11 then stopped asking to go or would say no if they needed to go and staff began to check and change Resident 11. In an interview on 10/25/22 at 4:45 PM, the Corporate Registered Nurse (RN) confirmed that staff are expected to check and change residents every 2 hours if they are care planned for check and change. In an interview on 10/25/22 at 4:45 PM, the DON confirmed that a resident would be care planned for check and change every 2 hours while awake and at night staff would just check the resident for incontinence. The DON further confirmed that residents would be care planned for check and change if the resident was on diuretic (medication that increases urinary output) and before or after staff give certain medications (did not provide specific examples). In an interview on 10/25/22 at 4:45 PM, the Corporate RN confirmed that a resident would be care planned for check and change if the resident was experiencing skin breakdown and that it is individualized by the resident due to diagnosis, if the resident is able to articulate that they had been incontinent, if the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 10/26/22 at 9:21 AM, the DON confirmed that a resident should not be up in their wheelchair from before breakfast until after lunch without being checked or changed.

Based on record review and interview, the facility failed to ensure staff competency for 2 of 5 newly hired employees related to Abuse and Neglect training and Dementia care training prior to providing direct patient cares. The facility census was 31. FINDINGS ARE: A record review conducted on 10/26/22 at 11:07 AM of the education and training for 5 new employees, revealed 2 of 5 had not received Abuse and Neglect training or Dementia care training prior to providing direct patient cares. An interview on 10/26/22 at 4:55 PM with the facility Administrator confirmed that 2 of 5 reviewed new employees had not received Abuse and Neglect training or dementia care training prior to providing direct patient cares and should have.

Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to ensure non-pharmacological interventions were provided prior to an as needed (PRN) [CONDITION(S)] (a medication that affects a person's mental state) medication given and documentation of clinical rationale for increase in anti-psychotic (medications used to treat psychotic disorders) medication for 1 resident (Resident 6) of 2 residents sampled. The facility census was 31. Findings are: A. A review of Resident 6's Admission Record, dated 10/26/22, revealed Resident 6 was admitted to the facility on [DATE]. Diagnoses included lumbar fracture, dementia with behavioral disturbance, depression, and other mixed anxiety disorders. A review of the facility's Pharmacy Services policy, dated August 2016, revealed the following: -Psychoactive Drug Monitoring -C.: Non-pharmacological interventions such as behavior modification or social services and their effects are documented as a part of the care planning process, and are utilized by the prescriber in assessing continued need for psychoactive medication. A record review of Resident 6's physician orders revealed the following: [MEDICATION(S)] (an anti-psychotic medication that is used to treat certain mental/mood conditions) and [MEDICATION(S)] (an anti-anxiety medication given to treat anxiety and panic disorders): [MEDICATION(S)] 12.5 milligram (mg) by mouth (po) 1 tablet (tab) po in AM PRN, and [MEDICATION(S)] (an anti-anxiety medication given to treat anxiety and panic disorder) .25mg TID PRN A record review of Resident 6's Medication Administration Record (MAR) from 7/15/22 to 10/27/22 revealed that PRN [MEDICATION(S)] was given 51 times with no documentation of non-pharmacological interventions 29 times. PRN [MEDICATION(S)] was given 21 times with no documentation of non-pharmacological interventions 20 times. In an interview on 10/27/22 at 12:28 PM with the Director of Nursing (DON), confirmed that documentation was not present for non-pharmacological interventions prior to PRN [MEDICATION(S)] or [MEDICATION(S)] use. B. A review of the facility's Pharmacy Services policy, dated August 2016, revealed the following: -Psychoactive drug monitoring guidelines include bujt may not be limited to: -Antipsychotics -2. Residents receive antipsychotic medication only for behaviors that are quantitatively and objectively documented through the use of behavior monitoring charts or a similar mechanism. A record review of Resident 6's physician orders revealed the following: [MEDICATION(S)] (an anti-psychotic medication that is used to treat certain mental/mood conditions) medication changes: 7/27/22- [MEDICATION(S)] 12.5 milligram (mg) by mouth (po) bedtime (HS) 1 tablet (tab) po in AM PRN, 8/4/22 [MEDICATION(S)] 12.5mg three times a day (TID) 8/30/22 [MEDICATION(S)] 25mg TID, 9/12/22 [MEDICATION(S)] 37.5mg TID A review of Resident 6's behavior monitoring log from 7/15/22 (admitted ) thru 9/12/22 (date of last dose increase) indicated the following targeted behaviors for Resident 6's [MEDICATION(S)] use: delusions, social isolation, disorganized behavior/speech, decreased participation in activities and repetitive movements. A review on the behavior TAR (treatment administration record) from 7/15/22 (admitted ) thru 9/12/22 (date of last dose increase) revealed Resident 6 was without behaviors 25 of 34 times in July, in August 51 of 62 times and in September 21 of 24 times. In an interview on 10/27/22 12:28 PM, the Director of Nursing (DON), confirmed that documentation was not present to explain the multiple increased dose of [MEDICATION(S)].

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on record review and interview, the facility failed to ensure residents were free from significant medication errors related to insulin being given outside of parameters for one resident (Resident 1) of two sampled. The facility census was 31. FINDINGS ARE: A record review of the Active Orders Summary dated 10/25/22 revealed Resident 1 had the following orders: -[MEDICATION(S)] (a rapid-acting insulin that helps lower mealtime blood sugar spikes) INJ [MEDICATION(S)] INJECT 2 UNITS SUBCUTANEOUSLY AT BEDTIME FOR BLOOD GLUCOSE GREATER THAN 200 -[MEDICATION(S)] INJ [MEDICATION(S)] INJECT 'SQ' PER SLIDING SCALE AT BEDTIME: LESS THAN 200=0U; 200-251=1U; 251-300=2U; 301-350=3U; 351-400=4U; GREATER THEN 400=6U & CALL MD; IF GREATER THAN 500, RECHECK BLOOD GLUCOSE IN 3 HOURS -[MEDICATION(S)] INJ [MEDICATION(S)] INJECT 'SQ' PER SLIDING SCALE THREE TIMES DAILY WITH MEALS: LESS THAN 151=0U; 151-200=1U; 201-250=2U; 251-300=3U; 301-350=4U; 351-400=5U; GREATER THAN 400=6U & CALL MD *GIVE 15 MIN BEFORE A MEAL -[MEDICATION(S)] INJ [MEDICATION(S)] INJECT 7 UNITS SUBCUTANEOUSL Y DAILY WITH SUPPER [MEDICATION(S)] FLEX INJ 100UNIT INJECT 10 UNITS SUBCUTANEOUSLY AT BEDTIME A record review of the MAR (Medication Administration Record)/TAR (Treatment Administration Record) dated October 2022 and September 2022, revealed Resident 1 had received a scheduled dose of [MEDICATION(S)] insulin when the blood sugar was below parameters on 9/1/22, 9/25/22, and 10/21/22 although the blood glucose was outside of the prescribed parameters. A record review of the MAR/TAR dated [DATE] and [DATE] revealed Resident 1's blood glucose result on 9/1/22 was 146, on 9/25/22 was 185 and on 10/21/22 was 133. An interview on 10/26/22 at 03:44 PM with the DON (Director of Nursing), after review of the blood sugars and insulin for October and September 2022 for Resident 1, confirmed that the insulin was given on 9/1/22, 9/25/22, and 10/21/22 and should not have been given.

Based on record review and interview, the facility failed to ensure staff were tested for Covid-19 (a mild to severe respiratory illness that is caused by a coronavirus) according to CMS (Centers for Medicare & Medicaid Services) gudelines related to incomplete or blank testing logs on 5 occasions. The sample size was 8. The facility census was 34. FINDINGS ARE: A record review of the Covid-19 staff testing logs dated 4/1/22 through 5/31/22 revealed 5 staff test logs which did not contain final results and this area was found to be blank. An interview on 6/6/22 at 11:23 AM with the Director of Nursing (DON) after review of the staff Covid-19 testing logs confirmed that 5 logs did not contain results and the blank areas should contain results. Continued interview on 6/6/22 at 11:23 AM with the DON, after review of the 5 incomplete staff Covid-19 testing logs confirmed that one log was for OT-D (Occupational Therapist), who was the most recent staff member who contacted Covid-19. A record review of the facility policy titled Communicable Diseases dated 3/12/20 did not contain information related to Covid-19 testing results. A record review of the facility policy titled Covid-19 Testing dated 11/4/21 revealed no reference regarding documentation of testing results. An observation on 6/6/22 revealed a sign dated 5/18/22, posted near the Covid-19 screening table for staff related to Covid-19 testing which read as follows: 4. Make sure you complete the informed Consent and Test Info every time you complete a test. Per CDC (Center for Disease Control) guidelines, we have totrack and report weekly ALL staff and residents when have been tested .

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on interviews and record reviews, the facility failed to ensure interventions were in place to prevent accidents for Resident 4, 8, 11 and 22. The sample size was 12. The facility identified a census of 39. FINDINGS ARE: A. An interview on 07/07/21 at 10:31 AM with Resident 4 revealed a history of falls including a fall with a [CONDITION(S)] resulting in admission to the facility for rehabilitation. A record review conducted on 07/07/21 at 03:34 PM of the incident log titled Incidents by Incident Types for a date range of 07/07/20 - 07/07/21 revealed falls for Resident 4 on 07/15/20, 07/30/20, 09/20/20, 10/28/20, and 3/26/21. A record review of the post fall reports for Resident 4, titled Post Fall Huddle Team revealed new interventions had been indicated after each fall. A record review of the Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) for Resident 4 did include a fall problem, goal and interventions initiated on 07/13/20 and did currently contain all fall dates since admission. The review of the interventions listed for fall prevention for Resident 4 did not include post fall interventions that had been indicated as put in place after each fall except the fall on 7/30/20. The record review of the CCP revealed a transfer ability for Resident 4 to be independent in room with a stand by assist outside of the room. A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) revealed a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 14 for Resident 4. A record review of the Admission Record for Resident 4 revealed an admitted [DATE] with a primary diagnosis of left femur fracture post fall on same level. B. An interview on 07/07/21 at 09:17 AM with Resident 11 revealed a history of falls resulting in a hospitalization prior to admission to the facility. A record review conducted on 07/12/21 at 01:02 PM of the facility incident log revealed falls for Resident 11 had occurred on 2/8/21, 3/24/21, 4/21/21, and 6/20/21 which resulted in [CONDITION(S)] and hospitalization . A record review of the Post Fall Huddle Team reports for Resident 11 revealed new interventions had been recommended after each fall. A record review of the CCP for Resident 11 revealed these new post fall interventions for falls on 2/8/21, 3/24/21, 4/21/21, and 6/20/21 had not been placed on Resident 11's CCP. C. 07/12/21 at 01:02 PM A record review of the facility incident log revealed falls for Resident 22 had occurred on 7/6/20, 8/27/20, 1/30/21, 5/20/21. A record review of the documents titled Post Fall Huddle Team reports for those fall dates revealed new interventions had been documented on the Huddle report sheet. A record review of the CCP for Resident 22 revealed these new post fall interventions for falls on 7/6/20, 8/27/20, 1/30/21, and 5/20/21 had not been placed on Resident 22's CCP. The record review revealed one intervention which had already been in place prior. An interview with the DON (Director of Nursing) on 7/12/21 at 07:20 AM, after review of the Huddle reports and the CCP's for Residents 4,11, and 22 revealed that past interventions were resolved and off the CCP's. During the interview on 7/12/21 at 07:20 AM it was stated that the DON would check the previous CCP's for the post fall huddle team recommendations and provide copies which did not occur. D. Record review revealed Resident 8 had fall on 3/23/21 at 1:45 PM in room, resident had no injury and the staff did fall huddle at that time, a new intervention was on the fall huddle but not placed on the care plan. Interview on 7/12/21 at 11:46 AM with the Director of Nursing, revealed fall from 3/22/21 that a fall huddle was completed but the information not placed on the care plan for nursing staff to see.

LICENSURE REFERENCE NUMBER 175 NAC 12-006 Based on observation, interview and record review, the facility failed to ensure care and treatments were provided as per professional standards and facility policy related to bowel care medications for Resident 4. The sample size was 12. The facility identified a census of 39. FINDINGS ARE: An interview conducted on 07/07/21 at 10:31 AM with Resident 4 revealed complaints of severe constipation. During the interview, Resident 4 voiced being on bowel medications currently. An interview conducted on 07/07/21 at 04:20 PM with the facility DON (Director of Nursing) revealed Resident 4 to be very concerned with bowel habits to the extent of causing anxiety. The interview revealed that Resident 4 had been admitted due to over use of bowel medications. A record review of the documents presented as an H&P for Resident 4 did not indicate any concerns related to bowel habits. A record review conducted on 07/08/21 of the MAR (Medication Administration Record) dated 7/1/21-7/31/21 revealed Resident 4 received routine bowel medications to include the following; [MEDICATION(S)] Sod 100mg, take one capsule by mouth twice daily for constipation Senna 8.6mg 2 tablets by mouth twice daily for constipation A record review conducted on 07/08/21 at 08:42 AM of the document titled Bowel Documentation' dated 5/6/21 through 7/7/21 in comparison to the MAR (Medication Administration Record) dated June 2021 and July 2021, revealed Resident 4 had no BM documented from 6/30/21 through 7/2/21 with no PRN (as needed) bowel meds given, 7/4/21 through 7/7/21 with no PRN bowel meds given, 6/19/21 through 6/21/21 with no PRN bowel meds given, 6/5/21 through 6/7/21 with no PRN bowel meds given, and 5/28/21 through 5/30/21 with no PRN bowel meds given. 07/08/21 09:03 AM A record review of the facility policy titled Bowel Care Program and dated 12/12/14 revealed the following steps; a. On day three of no bowel movement -- Milk of Magnesia 07/08/21 09:05 AM (Magnesium Hydroxide) 30 ml orally x1. b. On day four of no bowel movement -- [MEDICATION(S)] ([MEDICATION(S)]) 10mg Suppository Rectally x1 c. If no stool within 4 hours of having a [MEDICATION(S)], re-evaluate to rule out impaction and administer one of the following: i. [MEDICATION(S)] (Fleets) enema R x1, if no stool within 4 hours of having [MEDICATION(S)]. ii. Magnesium [MEDICATION(S)] 4 ounces by mouth x1, if no stool within 4 hours of having [MEDICATION(S)] if no results, contact physician to update on client's bowel status, may request routine bowel medication. 07/08/21 09:11 AM A Record review of the Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) for Resident 4 revealed no problem, goal or interventions related to constipation or bowel history. An interview with the DON (Director of Nursing) conducted on 07/08/21 at 09:35 AM, after review of the Bowel Documentation records for Resident 4, confirmed facility bowel protocol had not been followed. During the interview, the DON had been able to produce documentation that on 2 occasions, Resident 4 had been offered PRN bowel medications and decline the need for them.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on observation, interview and record review, the facility failed to review and revise the CCP (Comprehensive Care Plan) for Resident 14 related to the use of the Trilogy and the [NAME] (a virtual assistant that listens to, and responds to voice commands, giving you answers, reminders and offering other useful information when you need it), fall interventions for Resident 4 and 11, and related to bowel care concerns for Resident 4. The sample size was 12. The facility identified a census of 39. FINDINGS ARE: An interview conducted on 7/07/21 at 10:51 AM with Resident 14 revealed voice weakness which worsened the longer (gender) spoke. The interview revealed Resident 14 used an [NAME] activate the call light at times. A record review of the Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) for Resident 14 revealed no problem, goal or intervention that included the use of the Trilogy or the [NAME]. A record Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the CCP for Resident 4 did include a fall problem, goal and interventions initiated on 07/13/20 and did currently contain all fall dates since admission. The review of the interventions listed for fall prevention for Resident 4 did not include post fall interventions that had been indicated as put in place after each fall except 7/30/20. The record review of the CCP indicated a transfer ability for Resident 4 to be independent in room with a SBA (stand by assist) outside of the room. A record review of the facility incident log revealed falls for Resident 11 had occurred on 2/8/21, 3/24/21, 4/21/21 which resulted in [CONDITION(S)] and hospitalization and 6/20/21. A record Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the CCP for Resident 11 revealed these new post fall interventions had not been placed on CCP. An interview on 7/8/21 at 04:36 PM with the DON after review of the CCP for Resident 14, confirmed that it did not contain interventions to include the Trilogy and the [NAME] use. An interview with the DON on 7/12/21 at 07:20 AM, after review of the Huddle reports and the CCP's for Residents 4 and 11, revealed that past interventions were resolved and off the CCP's. During the interview, it was stated that DON would check the previous CCP's for the post fall huddle team recommendations and provide copies which did not occur.

LINCENSURE REFERRENCE NUMBER 175 NAC 12-006.09B Based on observation, record review and interview, the facility failed to ensure the accuracy of the Resident Assessment related to anticoagulant use for Resident 14. The sample size was 12. The facility identified a census of 39. FINDINGS ARE: An observation of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) indicators for Resident 14 included anticoagulant use. A record review conducted on 07/12/21 12:08 PM of the Active Orders list for Resident 14 revealed no order for an anticoagulant. A record review on 07/12/21 at 12:08 PM of the MAR (Medication Administration Record) dated July 2021 for Resident 14 did not indicate anticoagulant use. A record review of Section N of the MDS dated [DATE] revealed that Resident 14 had taken an anticoagulant x 7 days during the observation period. An interview with the facility MDS nurse on 07/12/21 at 01:08 PM confirmed that the MDS, section N, that indicated anticoagulant use had been incorrect and entered in error. The interview confirmed that an adjusted statement to correct the error had already been initiated.