Every finding on record at Falls City Nursing and Rehabilitation Center

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5)Based on record reviews and interviews, the facility failed to notify the resident's physician of a change in condition, failed to report a fall that delayed in the resident medical care for one sampled resident and failed to follow standards of practice after an injury to the head for one sampled resident (Resident 1). The facility census was 42.Findings are:A record review of the admission Record with a printed date of 5/6/26 revealed that Resident 1 was admitted to the facility on [DATE] with the diagnosis of Dementia - severe with anxiety and Behavioral Disturbance behaviors, which included agitation, aggression, and wandering, often caused by fear, overstimulation, or unmet needs, Depression (characterized by persistent sadness, loss of interest in activities, and low energy), Cognitive communication Deficit (a communication impairment stemming from underlying cognitive issues-such as memory, attention, or executive function deficits-rather than primary language or speech disorders), Absolute Glaucoma Bilateral (characterized by total, irreversible blindness, severe eye pain, and a stony hard eye, with no pupillary light reflex). A record review of the care plan dated 12/16/25 for Resident 1 revealed the following: Safety:-4/23/26-Per Physician, obtain CT scan (a quick, painless, and noninvasive imaging procedure that uses X-rays to create detailed, cross-sectional, or 3D images of bones, organs, and tissues). Resident transported to the hospital for CT after scheduled appointment with the Physician.-4/25/26 ice to hematoma to head, neurological checks (noninvasive, rapid evaluation of a person's nervous system, assessing brain, spinal cord, and nerve function, typically performed after injuries or to monitor conditions like strokes) started.-4/25/26 move recliner out of room to area by the nurses' station for increase supervision.-5/2/26 Dycem (Nonslip Matting) in recliner. A record review of Resident 1's progress notes revealed the following entries:-4/21/26 at 5:30 PM Resident 1 had been complaining of head pain. Called Physician and waiting for a response.-4/23/26 at 9:43 AM Vital signs taken. Resident 1 agitated, complained of pain in the back of (genders) head. Appointment scheduled with Resident 1 Physician at 11:00 AM this day.-4/23/26 at 2:54 PM A nurse from the hospital called and stated Resident 1 was being transported to the hospital.-4/24/26 at 1:00 PM A nurse from the hospital called and stated Resident 1 had a fall that morning at 2 AM. -4/24/26 at 4:30 PM A nurse from the hospital notified the facility that Resident 1 had a C1 fracture and that Resident 1 would be transferred back to the facility this day.A record review of Resident 1 progress notes revealed that on 4/21/26 and 4/22/26 there was no assessments for Resident 1 fall. A record review of the facility investigation of a interview with staff dated 4/23/26 revealed:-A therapist had seen Resident 1 on the floor in Resident 1 room. The therapist had told an CNA (Certified nursing assistant). The therapist did see the Licensed Practical Nurse (LPN) -A and CNA- B go into the room-An interview with CNA-B revealed that (gender) and LPN-A had assisted Resident 1 off the floor and into Resident 1's recliner.-An interview with the LPN-A revealed per phone call that (gender) did not witness a fall and that no one had told (gender) of a fall. LPN-A did know the steps to complete, when asked what do to if a resident has a fall. A record Review of the Fall Management System policy and procedure with the date of 6/18 revealed:-When a resident sustains a fall, a physical assessment will be completed by a license nurse, with results documented in the medical record.-The attending Physician and Resident's Representative shall be notified of the fall and the resident's status. Follow up documentation will be completed for a least every shift x 72 hours following incident. A Fall Risk Evaluation will be completed post fall incident. A record review of Policy/Procedure dated 7/19 Notification, Physician, or Responsible Party revealed:-It is the policy of the facility to promptly notify the resident, his/her attending physician, and or family/responsible party of changes in the resident's condition and or status-The nurse will notify the resident's attending physician when: A resident is involved in any accident or incident which results in an injury including injuries of an unknown source and There is a significant change in residents physical, mental, or psychosocial status. An interview on 5/6/26 at 2:00 PM with CNA-B confirmed that (gender) did not report the fall for Resident 1 because the LPN (LPN-A) was in the room with Resident 1 and that is who (gender) would of reported the fall to. An interview with the Director of Nursing (DON) confirmed that when (gender) got the information regarding the CT scan for Resident 1, (gender) did start interviewing staff. The DON confirmed that the first time (gender) had called LPN-A, LPN-A denied that Resident 1 had fallen. The DON confirmed that in the second interview with LPN-A, LPN-A did admit that Resident 1 had been on the floor and LPN-A and CNA-B assisted Resident 1 off the floor and into the recliner, LPN-A did not asses the resident and didn't document or report the fall and should have. The DON confirmed that LPN-A was terminated from the building and did report LPN- A to LPN-A's agency. DON further confirmed that the facility started their own investigation, generated their own plan of correction which included a systematic changes with fall investigation, post fall monitoring, notification of resident, physician and family member, all staff education on fall prevention, fall monitoring, and fall reporting. The facility's plan of correction that put the facility back into compliance on 4/24/26 revealed:Resident Specific: Name, date and time Interventions implemented by the facility: Interventions to prevent future fallsSystem Changes: education to staff, post fall check list with questions asked, an area for witness statements and a neurological form to be filled out with falls or injuries.Monitoring: The Administrator or designee will interview 3 staff member weekly x 4 to verify understanding of post fall protocols, a completion of the post fall check list x 3 weeks x 4 weeks and will bring audits to the Quality Assurance Committee for review.A record review indicates the auditing was started on 4/26/2026 and had audits through 5/2/2026.

Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, interview, and record review, the facility failed to ensure the chemical low-temperature (temp) dish machine reached a minimum temp of 120 degrees Fahrenheit (F)(a temperature scale) during all wash and rinse cycles and failed to ensure spoiled vegetables from the garden were disposed of to prevent foodborne illness. This had the potential to affect 38 residents that consumed food from the kitchen. The total facility census was 39. Findings are:A.A record review of the facility's undated Dish Machine Temperature Log policy revealed the Dietary Manager (DM) would train dishwashing staff to monitor dish machine temperatures throughout the dishwashing process. Dishwashing staff would be trained to report any problem with the dish machine to the dietary supervisor as soon as they occur. A record review of the National Sanitation Foundation (NSF) Machine Operational Requirements sticker on the facility's dish machine revealed wash temperature was a minimum of 120 degrees F, and the minimum rinse temperature was 120 degrees F. A record review of the facility's Low Temperature Dish Machine Log dated July 2025 revealed the wash temp should have been greater than (>) 120 degrees, and the rinse temperature should have been > 75 degrees. An observation on 07/29/2025 at 11:38 AM revealed the facility's DM, took the Robot Coupe (a blender) supplies to dish room, loaded and ran the facility's chemical low-temp dish machine. The dish machine's temperature reached 88 degrees F during the wash cycle, 100 degrees F during the rinse cycle. The DM left the dishwashing area after starting the dish machine and returned to the prep area. The DM then returned to the dishwashing area, gathered the supplies, returned to the prep area and pureed the pasta dish with the washed Robot Coupe's supplies. An observation on 07/29/2025 at 12:29 PM revealed the facility's Regional Certified Dietary Manager (RCDM) revealed the RCDM ran a cookie sheet through the facility's dish machine. The wash temp reached 88 degrees F and the rinse temp reached 100 degrees F. The RCDM continued spraying off dishes while the dish machine ran its cycles. An observation on 07/29/2025 at 12:40 PM the RCDM removed the cookie sheet from the dish machine. The RCDM then loaded the dish machine with pots and kitchen utensils. The was temp reached 100 degrees F and the rinse temp reached 112 degrees F. In an interview on 07/29/2025 at 12:45 PM, Dietary Aide (DA)-F confirmed that the staff had to run the sanitizer 3-4 loads before it reaches 120 degrees F. In an interview on 07/31/2025 at 12:53 PM, the facility's Assistant Director of Nursing (ADON) confirmed 38 of the 39 residents in the facility consume food from the kitchen. In an interview on 07/29/2025 at 12:54 PM, the RCDM confirmed the dish machine did not reach 120 degrees F during the wash and rinse cycles until the last load the RCDM ran, and it should have. The contract company the facility's used to service the dish machine provided the Low Temperature Dish Machine Log sheet. In an interview on 07/30/2025 at 11:42 AM, a representative (Rep) from the facility's contracted dish machine service company confirmed the wash and rinse temperatures of the dish machine should have been a minimum of 120 degrees F to properly sanitize the dishes. B.A record review of the facility's Resident Consumption of Facility-Grown Produce policy dated 4/2025 revealed residents may consume the food from the garden provided all safety protocols are followed to mitigate (prevent) the risk of foodborne illness. An observation on 07/28/2025 at 9:15 AM revealed a box on the 3-compartment sink in the kitchen that contained 1 cucumber with a gray fuzzy coating on it and 2 soft tomatoes with brown holes in them and a gnat (a small flying insect) inside 1 of them that flew out. An observation on 07/28/2025 at 9:58 AM with the facility's Activities Director (AD), that was the active DM while the DM was out that morning, revealed a box on the 3-compartment sink in the kitchen that contained 1 cucumber with a gray fuzzy coating on it and 2 soft tomatoes with brown holes in them. In an interview on 07/28/2025 at 9:58 AM with the facility's AD, that was the active DM while the DM was out that morning, confirmed there was a box on the 3-compartment sink in the kitchen that contained 1 cucumber with a gray fuzzy coating on it and 2 soft tomatoes with brown holes in them, and should not have been. The AD confirmed they were from the facility's garden and threw the box of vegetables in the trash can.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.13 Based on record reviews, observations, and interviews, the facility staff failed to implement speech therapy (ST, a type of therapy focused on improving or restoring a person's ability to swallow safely and effectively) orders for 1 (Resident 3) of 1 sampled resident. The facility staff identified a census of 40. Findings are:A record review of an admission Record printed on 07/29/2025 indicated Resident 3 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease (a brain condition that causes problems with movement, mental health and other issues) and dementia (a usually progressive condition marked by the development of multiple cognitive deficits such as memory impairment, aphasia, and the inability to plan and initiate complex behavior). A record review of Resident 3's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 05/28/2025 revealed in Section K, Swallowing/Nutritional Status a check mark was placed under the question signs and symptoms of a swallowing disorder. The check mark was placed next to the option C. Coughing or choking during meals or when swallowing medications. The MDS also revealed Resident 3's Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 9, indicating the resident was moderately impaired. A record review of Resident 3'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 an intervention to monitor for signs and symptoms of dysphagia (difficulty in swallowing) related to the Parkinson's disease diagnosis. No information regarding intervention on how to respond to symptoms of dysphagia was noted. A record review of a fax communication sent to Resident 3's provider dated 12/27/2024 revealed a request for speech therapy (ST) to eval/tx (evaluate and treat) with a handwritten response of yes please. The order was signed by MDS-licensed practical nurse (LPN, a nurse who provide basic medical care under the supervision of a registered nurse or physician) on 01/02/2025. A record review of Resident 3's Medication Review Report dated 01/14/2025 revealed an order for ST to eval/tx with an order date of 1/02/2025 signed by the provider on 01/14/2025.A record review of Resident 3's Speech Therapy Discharge Summary dated 03/21/2024 to 4/10/2024 revealed a discharge summary completed date of 4/29/2024. The facility was unable to provide more recent documentation related to speech therapy. An observation of Resident 3 on 07/29/2025 at 7:55 AM revealed the resident coughing and choking after drinking a thin liquid from a coffee cup during breakfast. An observation of Resident 3 on 07/29/2025 at 8:18 AM revealed coughing heard from the resident while resident was sitting in the recliner. An observation of Resident 3 on 07/29/2025 at 11:26 AM revealed the resident drinking a clear, thin liquid from a straw after receiving medication in apple sauce. The resident began coughing and choking immediately after. An interview with Nursing Assistant (NA, a healthcare professional who provides basic care and support to the residents) NA-C on 07/30/2025 at 1:02 PM revealed that the NA had noticed Resident 3 coughing sometimes when drinking and stayed with Resident 3 until the resident was finished coughing and then reported to the nurse on duty. An interview on 07/30/2025 at 12:56 PM with Resident 3's family member reported that the resident did choke on both food and liquid. The family member felt it was related to the progression of the resident's Parkinson's disease. An interview with Occupational Therapist (OT, a healthcare professional who specializes in helping people improve their ability to perform everyday activities) OT-D on 07/30/2025 at 2:11 PM reported that the facility had not had an ST since December of 2024 and that some residents were going offsite for their therapy. An interview with Physical Therapist (PT, a healthcare professional who specializes in helping people improve physical movement) PT-E on 07/30/2025 at 2:11 PM reported that the facility has not had an ST since December of 2024 and that some residents were going offsite for their therapy. An interview on 07/31/2025 at 9:20 AM with Director of Nursing (DON), confirmed the last time the resident had received ST was in 2024.

Licensure Reference Number 175 NAC 12-006.18(B) Based on observation, interview, and record review, the facility failed to ensure that 1 (Resident 4) of 2 sampled residents' oxygen concentrator filters were clean, the positive airway pressure (PAP) device (a machine used to treat sleep apnea) contained a filter, the tubing was replaced, and ensure that the nasal cannulas and PAP masks for 2 (Residents 4 and 13) of 2 sampled residents were clean and stored off the floor to prevent the potential for cross contamination. The facility census was 39. Findings are:A. A record review of the facility’s undated “Respiratory Equipment Policy“ revealed PAP masks, tubing, and filters must be cleaned and disinfected per manufacturer instructions and replaced as needed (at least every 3–6 months or sooner if damaged or contaminated). A record review of the undated “ResMed AirSense 10 Users Guide” revealed the air filter should be replaced at least every 6 months and more often if needed. https://document.resmed.com/documents/products/machine/airsense-series/user-guide/airsense-10-device-with-humidifier_user-guide_amer_eng.pdf A record review of the undated “Mirage™ FX NASAL MASK User Guide” revealed that the mask and headgear should only be gently handwashed. Daily or after each use, disassemble the mask components according to the disassembly instructions. Thoroughly clean the separated mask components, excluding the headgear, by gently rubbing them in warm water (approximately 86°F/30°C) using mild soap and rinse all components well with drinking-quality water and allow them to air dry out of direct sunlight. Once completely dry, reassemble the mask components following the reassembly instructions. https://document.resmed.com/documents/products/mask/mirage-series/user-guide/mirage-fx_user-guide_amer_por.pdf A record review of Resident 4’s “Order Summary Report” dated 07/29/2025 revealed the resident had an order for PAP set at 7 centimeters of water pressure. The order stated to clean the CPAP mask and equipment with soapy water daily. An observation on 07/28/2025 at 11:14 AM revealed that Resident 4’s ResMed AirSense 10 PAP device had no filter in place, the PAP mask (Mirage FX) was not cleaned, and the tubing was discolored, bent, and visibly worn. An observation on 07/29/2025 at 3:30 PM revealed that Resident 4’s ResMed AirSense 10 PAP machine was on the resident’s bedside table. The filter housing was opened, and no filter was found to be installed in the designated compartment. No replacement or spare filters were available in the immediate vicinity. The PAP tubing was cloudy, coated with visible interior film, and displayed signs of wear including kinking and reduced flexibility. The PAP mask appeared to have accumulated residue, indicating it had not been cleaned. In an interview on 07/29/2025 at 4:49 PM, Registered Nurse (RN)-A, confirmed that Resident 4’s PAP should have had a filter, the tubing was visibly worn and coated, and the mask had not been cleaned and should have been. B. A record review of the facility’s undated “Oxygen Policy” revealed that tubing must be kept off the floor and equipment must be cleaned regularly. Oxygen cannulas or masks should be changed when soiled or dirty. A record review of Resident 4’s “Order Summary Report” dated 07/29/2025 revealed the resident had an order for Oxygen at 2 liters continuously via nasal cannula every shift for shortness of breath. An observation on 07/28/2025 at 11:14 AM revealed that Resident 4’s nasal cannula was connected to the oxygen tank on the rear of the wheelchair, with nasal prongs resting directly on the floor. The oxygen concentrator had a dense buildup of dark gray, fuzzy sediment on both side filters. An observation on 07/29/2025 at 3:30 PM revealed that Resident 4’s nasal cannula was connected to an oxygen tank secured to the back of the resident’s wheelchair. The tubing was draped across the frame with the prongs resting on the floor. No device was observed to elevate or contain the tubing. An oxygen concentrator was positioned on the floor. Both air intake filters were covered in a dense, gray, fuzzy layer, spanning the full filter surface and obscuring the mesh beneath. In an interview on 07/29/2025 at 4:49 PM, RN-A, confirmed that Resident 4’s nasal cannula should not have been on the floor and the oxygen concentrator filters were gray, fuzzy, and should have been clean. RN-A confirmed that these conditions were not acceptable and should not have occurred. C. A record review of Resident 13’s admission record revealed Resident 13 was admitted to the facility on [DATE]. A record review of Resident 13’s diagnosis revealed gender had Sleep Apnea (Breathing stops and starts while sleeping), Lung nodules (small mass in lungs), Emphysema (a condition in which the air sacs of the lungs are damaged and enlarged causing breathlessness.) Chronic Obstructive Pulmonary Disease (COPD) a pulmonary disease that is characterized by chronic typically irreversible airway obstruction resulting in a slowed rate of exhalation. A record review of Resident 13’s Care plan dated 03/28/2021 revealed to give oxygen therapy as ordered by the physician. It also stated to clean the PAP (positive airway pressure device used to treat respiratory conditions) mask and equipment with soapy water daily and rinse well. When clean hang the tubing to dry. A record review of Resident 13’s Care Plan dated 03/28/2021 revealed gender had altered respiratory status with difficulty breathing related to Sleep Apnea and COPD. A record review of Resident 13’s physician order dated 4/21/2025 revealed that the staff are to ensure the oxygen tubing is on Resident 13 properly related to it slipping off Resident 13’s face every 2 hours for monitoring. An observation on 07/28/2025 at 2:18 PM revealed that Resident 13 had the PAP device face mask lying on the bedside dresser with area on the inside of mask having brown and black flecks. An observation on 07/29/2025 at 7:45 AM revealed that Resident 13’s PAP device face mask was sitting on top of used clothing protector and had scattered brown and black flecks on the inside of mask. An observation on 7/30/25 at 2:30 PM revealed that Resident 13’s PAP device face mask lying in gender's recliner chair. An observation on 07/31/2025 at 8:01 AM of Resident 13’s room revealed PAP device mask was lying on top of the gender's hat which was on top of the bedside table. There were scattered black and brown flecks on the inside surface of the mask. An observation on 07/31/2025 at 10:10 AM of Resident 13's room revealed that the PAP mask was lying on top of a blanket in gender's recliner chair. The PAP face mask had flecks of brown and black on the inside of the mask. The nasal cannula portion of the resident's oxygen tubing was on the floor. An observation on 07/31/2025 at 10:10 AM of Resident 13's room revealed the nasal cannula of the oxygen tubing was lying on the floor. An interview on 07/28/2025 at 2:05 PM revealed Resident 13 stated gender had a respiratory infection a two weeks ago and that is why gender was on oxygen and used a PAP machine at night. An interview on 07/30/2025 at 10:06 AM with Resident 13 revealed gender had oxygen tubing on with physician setting for amount of oxygen delivered. Resident 13 stated that the oxygen keeps them from having difficulty breathing. An interview on 07/31/2025 at 10:19 AM with Medication Aide B (MA-B) revealed that the PAP device facemask and tubing in Resident 13's room was sitting on top of a blanket in recliner chair and that Resident 13's oxygen tubing had the nasal cannula lying on the floor. MA- B clarified that the PAP device mask should be cleaned and put on top of a paper towel after each use and that there were a few specks of brown and black on the inside of the mask. MA-B clarified that when the oxygen tubing was off the resident, it was supposed to be put in the bag that holds it on the oxygen concentrator. An interview on 07/31/2025 at 11:12 AM with the Director of Nursing (DON) revealed that when the PAP device was taken off in the morning it should have been cleaned with soap and water and put on a paper towel and tubing hung up to air dry. The DON stated that if the oxygen tubing was removed by Resident 13 it was supposed to be put in the bag on the concentrator machine.

Licensure Reference Number 175 NAC 12.006.12(D)(i) Based on observations, interviews and record review, the facility failed to secure all medications in a locked storage area and to limit access to authorized personnel. The facility identified a census of 41. Findings are: Record review of facility's undated Drug Storage Policy revealed: It is the policy of this facility to ensure the proper and safe storage of drugs and biologicals. Drugs and/or biologicals should not be left unsecured/unattended. Medication and treatment carts will be kept locked when unattended. Observation on 3/25/25 at 9:00 AM revealed a medication cart containing resident's medications, located near the nurse's station, was unlocked and unattended by staff. Interview with Director of Nursing (DON) on 3/25/25 at 9:01 AM confirmed the medication cart was unlocked and should have been locked. Observation on 3/25/25 at 4:16 PM revealed a medication cart containing resident's medications, located near the nurse's station, was unlocked and unattended by staff. Interview on 3/25/25 at 4:17 PM with DON confirmed that the medication cart was unlocked and should have been locked.

Licensure Reference Number 175 NAC 12-006.09B Based on record review and interview; the facility failed to code the Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) assessment to reflect the resident's status for 4 (Residents 9, 11, 19 and 34) of 12 sampled residents. The facility census was 39. Findings are: A. Review of Resident 9's May 2024 Medication Administration Record (MAR) revealed Resident 9 received Seroquel (an antipsychotic medication used to treat certain mental/mood disorders) 50 milligrams (mg) at bedtime. Review of Resident 9's Note to Attending Physician/Provider, dated 5/8/24, revealed Resident 9's physician marked no, that a Gradual Dose Reduction (GDR) is contraindicated because previous GDRs had failed. Review of Resident 9's MDS, dated [DATE], revealed the following: -Yes coded to the question: Did the resident receive antipsychotic medications since admission/entry? -Yes coded to the question: Has a GDR been attempted with 5/18/24 entered as the date of the last attempted GDR -No coded to the question: Physician documented GDR as clinically contraindicated Review of the MDS 3.0 Resident Assessment Instrument (RAI) User's Manual v1.18.11, dated October 2023 revealed the following: -Code no if a GDR has not been attempted -Code yes if a GDR has been documented by a physician as clinically contraindicated and enter the date the physician documented GDR attempts as clinically contraindicated. In an interview on 7/10/24 at 10:49 AM, the MDS nurse confirmed that a GDR had not been attempted and should have been coded No and that a GDR had been documented as contraindicated by Resident 9's physician should have been coded Yes with a date of 5/8/24 entered. B. Review of Resident 11's April MAR revealed Resident 11 received Seroquel 12.5mg at bedtime. Review of Resident 11's Note to Attending Physician/Provider, dated 11/17/23, revealed Resident 11's physician marked ok when asked if [gender] would consider decreasing Resident 11's Seroquel from 25mg to 12.5mg at bedtime due to staff reporting Resident 11 had not displayed any behaviors and felt as though [gender] could trial a reduction at this time. Review of Resident 11's MDS, dated [DATE], revealed the following: -Yes coded to the question: Did the resident receive antipsychotic medications since admission/entry? -Yes coded to the question: Has a GDR been attempted with 7/24/23 entered as the date of the last attempted GDR -Yes coded to the question: Physician documented GDR as clinically contraindicated with 7/24/23 entered as the date of the last attempted GDR Review of the MDS 3.0 RAI User's Manual v1.18.11, dated October 2023 revealed the following: -Code yes if a GDR had been attempted and enter the date of the last attempted GDR -Code no if a GDR had not been documented by a physician as clinically contraindicated In an interview on 7/10/24 at 11:00 AM, the MDS nurse confirmed the date of the last attempted GDR for Resident 11 was 11/17/24, not 7/24/23 and that 11/17/24 should have been entered instead of 7/24/23. The MDS nurse further confirmed a GDR had not been documented as clinically contraindicated for Resident 11 and that question should have been coded no. C. Review of Resident 19's May MAR revealed Resident 19 did not have an order for an anticoagulant (blood thinner) or a diuretic (medication that increases the production of urine). The MAR did reveal that Resident 19 had taken Aspirin (antiplatelet used to prevent blood from forming a clot) DR (delayed release) 81mg twice a day. Review of Resident 19's MDS, dated [DATE], revealed that Resident 19 had taken an anticoagulant and diuretic. The MDS further revealed that Resident 19 had not taken an antiplatelet medication. Review of the MDS 3.0 RAI User's Manual v1.18.11, dated October 2023, revealed the following: -Anticoagulant: check if an anticoagulant medication was taken by the resident at anytime during the 7-day look-back period -Diuretic: check if a diuretic medication was taken by the resident at any time during the 7-day look-back period -Antiplatelet: check if an antiplatelet medication (e.g. aspirin/extended release) was taken by the resident at any time during the 7-day observation period -Do not code antiplatelet medications such as aspirin/extended release as an anticoagulant. In an interview on 7/10/24 at 10:54 AM, the MDS nurse confirmed that Resident 19 did not have an order for an anticoagulant or diuretic and did have an order for an antiplatelet medication. The MDS nurse further confirmed that anticoagulant and diuretic should not have been marked as taken and that antiplatelet should have been marked as taken on the MDS. D. Review of Resident 34's April and May 2024 MARs revealed Resident 34 did not have an order for an anticoagulant. The MARs did reveal that Resident 34 had taken Clopidogrel (antiplatelet used to prevent blood from forming a clot) 75mg once every three days. Review of Resident 34's MDS, dated [DATE], revealed that Resident 34 had taken an anticoagulant and had not taken an antiplatelet. Review of the MDS 3.0 RAI User's Manual v1.18.11, dated October 2023, revealed the following: -Anticoagulant: check if an anticoagulant medication was taken by the resident at anytime during the 7-day look-back period -Antiplatelet: check if an antiplatelet medication (e.g. clopidogrel) was taken by the resident at any time during the 7-day observation period -Do not code antiplatelet medications such as clopidogrel release as an anticoagulant. In an interview on 7/10/24 at 10:47 AM, the MDS nurse confirmed that Resident 34 did not have an order for an anticoagulant and did have an order for an antiplatelet during the 7-day look-back period in April and May. The MDS nurse further confirmed that anticoagulant should not have been marked as taken and that antiplatelet should have been marked as taken on the MDS. E. Review of Resident 34's hospice plan of care, dated 5/2/24, revealed the following: -admitted to hospice on 5/2/24 with a diagnosis of vascular dementia (caused by decreased blood flow to brain tissue causing memory problems, problems with movement, urinary problems, and tremors -A verbal certification was given on 5/2/24 from Resident 34s physician that [gender] certified that Resident 34s prognosis is 6 months or less if the disease runs its normal course Review of Resident 34's MDS, dated [DATE], revealed the following: -No coded on the question: Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? Review of the MDS 3.0 RAI User's Manual v1.18.11, dated October 2023, revealed the following: -Code yes if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services In an interview on 7/10/24 at 10:47 AM, the MDS nurse confirmed that Resident 34 had physician documentation that [gender] is terminally ill and was receiving hospice services. The MDS nurse further confirmed that yes should have been coded for the question: Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months.

Licensure Reference Number 175 NAC 12-006.09C Based on interview and record review, the facility failed to develop and implement a resident-centered comprehensive care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) that accurately reflected the needs for 1 (Resident 34) of 12 sampled residents. The facility census was 39. Findings are: Review of Resident 34's Significant Change Minimum Data Set (MDS- a comprehensive assessment completed when a resident has a major decline or improvement in their status), dated 5/3/24, revealed that Resident 34 was receiving hospice services while a resident. Review of Resident 34's comprehensive care plan, dated 7/9/24, revealed no resident-centered care plan related to hospice. Review of the facility's Care Plan policy, undated, revealed the following: -1. Care plans are modified between care plan conference when appropriate to meet the resident's current needs, problems, and goals. -3. The care plan will be updated and/or revised for the following reasons: a significant change in the resident's condition. In an interview on 7/10/24 at 10:47 AM, the MDS nurse confirmed that there was no hospice care plan for Resident 34 and that one should have been developed and implemented after Resident 34 had been admitted to hospice and a significant change MDS had been completed.

Licensure Reference Number 175 NAC 12-006.17A(2) Licensure Reference Number 175 NAC 12-006.17A(4) Licensure Reference Number 175 NAC 12-006.17B Licensure Reference Number 175 NAC 12-006.17D Based on observation, interview, and record review, the facility failed to ensure staff and visitors' COVID-19 screening was completed and evaluated prior to entrance into facility, failed to ensure signage was posted indicating what Personal Protective Equipment (PPE) staff and visitors were to be use for a Modified Yellow Isolation Zone and a Gray Zone isolation room, failed to ensure staff and visitors donned (put on) the correct PPE for specific Isolation Zones, failed to ensure staff performed hand hygiene between residents during medication delivery, and failed to ensure staff wore a surgical mask above the nose while eating in a resident care area to prevent the potential spread of COVID-19. This had the potential to affect all residents in the facility. Total census was 25. Findings are: A. An observation on 06/21/2022 at 09:21 AM of signs as a visitor entered the building and completed the screening process revealed a Staff Screening Log Book, a Visitor COVID-19 Screening Log book, and 3 signs: - All staff must wear mask while in the building. Temperature first and then mask. - Visitor - Please ensure you are checking in at the front table and filling out the questionnaire as well as taking your temperature. Thank you. - Welcome!! Please complete wellness check form by front door. Masks are required when in public areas. A record review on 06/21/2022 at 09:21 AM of the Staff Screening Log Book from dates 05/19/2022 - 06/22/2022 revealed 9 entries without the employee having completed a Fever Check, and 26 entries without the employee having completed the questions for symptoms of COVID-19. A record review on 06/21/2022 at 09:21 AM of the Visitor COVID-19 Screening Log Book from dates 04/24/2022 - 06/22/2022 revealed 12 entries without the visitor having completed a Fever Check, and 17 entries without the visitor having completed the questions for symptoms of COVID-19. An observation on 06/22/2022 at 10:14 AM revealed 2 visitors were allowed entrance into the facility through the main entrance and completed the Visitor COVID-19 Screening Log before the 2 visitors proceeded down the 100 hall and into Resident 4's room. The staff did not review the Visitor COVID-19 Screening Log for the 2 visitors. Record Review of the Visitor COVID-19 Screening Log dated 06/21/2022 - 06/22/2022 revealed the 2 visitors from the 06/22/2022 at 10:14 AM observation that went to Resident 4's room both marked yes to the question: Have you traveled internationally or taken a cruise in the last 14 days? An observation on 06/22/2022 at 09:53 AM revealed a Physician (DR.)-F walking down the 100 hallway and then standing at the medication cart with a surgical mask on. Record review with the facility Administrator revealed DR.-F did not complete a Visitor COVID-19 Screening Log or a Staff Screening Log for the facility visit on 06/22/2022. In an interview on 06/22/2022 at 10:09 AM, the Administrator confirmed that DR.-F was allowed to enter the building without having completed a Visitor COVID-19 Screening Log or a Staff Screening Log for the facility visit on 06/22/2022. An observation on 06/22/2022 at 11:33 AM revealed a Contract Delivery Driver (DD)-G exited the break room and walked through the dining room with no PPE on. DD-G then exited the building through the employee entrance. Record review of the Staff Screening Log Book at the employee entrance, and Visitor COVID-19 Screening Log book and Staff Screening Log book at the front door did not reveal DD-G completed a screening questionnaire. In an interview on 06/22/2022 at 11:37 AM, the Director of Nursing (DON) confirmed that DD-G should have been wearing PPE and should have completed a screening questionnaire but did not. In an interview on 06/22/2022 at 11:45 AM, the Administrator confirmed the facility checked the screening logbooks twice a week and prior to visitors and staff being allowed entrance to the facility, the staff did not review the screening log for abnormal answers to the questions and should be. B. Record review of an email dated 06/21/2022 at 05:49 PM from the Director of Nursing (DON) to Infection Control Assessment and Promotion Program (ICAP) revealed the facility continued to follow Modified Yellow Zone precautions and recommended the staff should have been wearing a N95 mask (a mask designed to achieve a very close fit and very efficient filtration) and eye protection. In an interview on 07/05/2022 at 02:58 PM, the DON confirmed that it is the facility's policy that they follow Infection Control Assessment and Promotion Program (ICAP) recommendations for isolation room zoning. Record review of the unnamed, undated ICAP recommendation sheet for Isolation Room Zoning revealed the staff was to wear COVID-19 Full PPE (N95, eye protection, isolation gown, and gloves) in a Gray Zone Isolation room and the resident's door was to remain closed. An observation on 06/21/2022 at 09:21 AM of the facility did not reveal signs posted alerting visitors and staff that the resident care areas were a Modified Yellow isolation zone. An observation of room [ROOM NUMBER]/21/2022 at 12:03 PM revealed room [ROOM NUMBER]'s door was 1/3 open. The room had an isolation cart, a trashcan containing clean reusable gowns outside of the door to the room, and a sign that had instructions on how to Doff (remove) Personal Protective Equipment (PPE) on the wall. No signage was observed to notify the staff or visitors if this was an isolation room or what level of isolation Resident 29 was in. In an interview on 06/21/2022 at 09:21 AM the Administrator confirmed that Resident 29 was in room [ROOM NUMBER], was a new admission from the hospital, and was in a Gray Zone isolation room. In an interview on 07/05/2022 at 08:47 AM, the DON confirmed the entire facility was in a Modified Yellow Isolation Zone and there was not a Modified Yellow Zone sign posted and should have been to alert Contract Staff for the need of donning (put on) specific PPE. C. Record review of an email dated 06/21/2022 at 05:49 PM from the Director of Nursing (DON) to Infection Control Assessment and Promotion Program (ICAP) revealed the facility continued to follow Modified Yellow Zone precautions and staff should have been wearing a N95 mask and eye protection. An observation on 06/21/2022 at 12:03 PM revealed Medication Aide (MA)-I donned (put on) an N-95 mask, face shield, gown, and gloves to Resident 29, Gray Zone room and delivered a tray of food to the resident. MA-I then removed all Personal Protective Equipment (PPE) inside the room and exited the room. MA-I then stood in the doorway talking to the resident without a mask on. MA-I walked from room [ROOM NUMBER] to the nurse's station and back to room [ROOM NUMBER] without a mask on. An observation on 06/22/2022 at 09:53 AM revealed a visitor walk down the 100 hallway with a cloth mask on. An observation on 06/22/2022 at 09:53 AM revealed a Physician (DR.)-F walking down the 100 hallway and then standing at the medication cart with a surgical mask on. In an interview on 06/22/2022 at 10:02 AM, the DON confirmed that direct care providers should have been wearing an N-95, and DR.-F was not. An observation on 06/22/2022 at 11:33 AM revealed a Contract Delivery Driver (DD)-G exited the break room and walked through the dining room with no PPE on. DD-G then exited the building through the employee entrance. In an interview on 06/22/2022 at 11:37 AM, the Director of Nursing (DON) confirmed that DD-G should have been wearing PPE D. Record review of the facility's Infection Prevention and Control Program Policy with a revised date of 04/2022 revealed the hand hygiene (cleaning) procedures will be followed by ay staff involved in direct resident contact. Record review of the facility's Infection Control Policy revised 11/2012 revealed handwashing before and after resident contact is the most effective infection control measure to prevent transmission of microorganisms (a microscopic organism especially a bacteria, virus, or fungus). An observation on 06/21/2022 at 11:54 AM revealed a Medication Aide (MA)-H entered the facility's dining room sat in Resident 4's wheeled walker, touched the table in front on the resident, and touched the resident shoulder while giving Resident 4 medications. MA-H then returned to the medication cart, and placed medications for Resident 2. MA-H returned to the dining room and touched Resident 2's shoulder while dumping the medication into Resident 2's mouth. MA-H returned to the medication cart and placed medication in a cup for Resident 29. MA-H walked down the 100 hall and put a gown and gloves on to enter a Gray Zone isolation room. No hand hygiene was performed throughout the observation. In an interview on 07/05/2022 at 07:08 AM, the Administrator confirmed that MA-H should have performed hand hygiene between each resident during medication administration on 06/21/2022 at 11:54 AM. E. An observation on 06/22/22 at 07:45 AM revealed MA (Medication Aide)-H had prepared medications and administered medications with no hand hygiene before or after. An observation on 06/22/22 at 08:02 AM revealed MA-H had prepared medications and administered medications for Resident 25 with no hand hygiene before or after. An observation on 07/05/22 at 2:09 PM revealed NA (Nursing Assistant)-L, standing at the medication cart with a surgical mask below (gender) chin and eating popcorn.

Based on interview and record review, the facility failed to ensure unvaccinated staff had COVID-19 testing completed according to the community transmission rates. This had the potential to affect all residents in the facility. Total census was 25. Findings are: Record review of Nursing Assistant (NA)-J's Religious Exemption Request - Vaccination Form dated 06/10/2022 revealed NA-J had requested and was granted a Religious Exemption for the COVID-19 vaccine. NA-J's Religious Exemption Request - Vaccination Form dated 06/10/2022 revealed NA-J agreed to be tested at least weekly for COVID-19 unless a state or local health agency required more frequent testing. Record review of the Centers for Disease Control and Prevention's COVID Data Tracker Community Transmission rates for [NAME] County Nebraska revealed [NAME] County, Nebraska's Community Transmission rates for 06/13/2022 was Substantial and 06/23/2022 was High. Record review of an email dated 06/09/2022 at 03:26 PM from the Infection Control Assessment and Promotion Program (ICAP) to the Director of Nursing (DON) revealed all unvaccinated or not up to date staff should have been tested twice a week if the community transmission rate for [NAME] County, Nebraska is Substantial or High. Record review with the DON, of the Falls City Nursing and Rehab Nursing Schedule dated June 2022 and the facility's un-named COVID-19 testing logs dated 04/07/2022 - 06/17/2022 revealed NA-J worked a 12-hour day shift on 06/13/2022 and the only COVID-19 test that was performed on NA-J was on 06/15/2022. Record review with the DON, of the Falls City Nursing and Rehab Nursing Schedule dated June 2022 and the facility's testing logs titled BD Veritor COVID dated 06/17/2022 - 07/05/2022 revealed NA-J worked a 12-hour day shift on 06/23/2022 but had not been tested for COVID-19 since 06/15/2022. In an interview on 07/05/2022 at 02:30 PM, the DON confirmed NA-J worked on 06/13/2022 and 06/23/2022 and did not get tested prior to NA-J scheduled shifts. The DON confirmed the [NAME] County Community Transmission was Substantial on 06/13/2022 and High on 06/23/2022 and NA-J should have tested twice per week or at least prior to working those dates.

Licensure Reference Number 175 NAC 12-006.18A(1) Based on observation, interview, and record review, the facility failed to ensure the exhaust fans (negative ventilation system) were working and in good repair. This affected 20 of 39 resident rooms. Total census was 25. Findings are: An observation of resident room 119 on 06/21/2022 at 12:34 PM revealed the Exhaust Fans in the resident's restroom was not functioning. An observation of resident room 120 on 06/21/2022 at 12:56 PM revealed the Exhaust Fans in the resident's restroom was not functioning. An observation of resident room 107 on 06/21/2022 at 01:35 PM revealed the Exhaust Fans in the resident's restroom was not functioning. An observation of resident room 118 on 06/21/2022 at 02:01 PM revealed the Exhaust Fans in the resident's restroom was not functioning. An observation of resident room 114 on 06/21/2022 at 02:42 PM revealed the Exhaust Fans in the resident's restroom was not functioning. An observation on 06/22/22 at 01:50 PM revealed resident rooms 105, 112, 117, 120, 201, 209, and 211 Exhaust Fans in the resident's restrooms were not functioning. An observation on 06/22/22 at 02:22 PM with Maintenance Supervisor (MS)-E revealed the exhaust fans were not functioning in the following rooms: Room 205, 207, 209, 211, 210, 212, 214, 216, 217, 218, 219, 103, 105, 107, 110, 112, 111, 109, 115, and 113. An interview on 06/22/22 at 02:22 PM with MS-E confirmed the exhaust fans were not functioning in the following resident restrooms: Room 205, 207, 209, 211, 210, 212, 214, 216, 217, 218, 219, 103, 105, 107, 110, 112, 111, 109, 115, and 113. Record review of the Work History Report for the Exhaust Fans dated 06/28/2022 did not reveal a work order to repair the Exhaust Fans. An interview on 07/05/2022 at 06:57 AM with MS-E confirmed that 4 of 4 Exhaust Fan motors were defective.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B Based on interview and record review, the facility failed to ensure the MDS (Minimum Data Set, a comprehensive assessment of each resident's physical and mental functional capabilities) reflected the resident's current status at the time of the assessment related to Level II PASARR's (Preadmission Screening and Resident Review that is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. Level II screening is triggered by evidence of a serious mental illness (MI), Intellectual or Developmental Disabilities (ID/DD) or condition related to Intellectual or Developmental Disabilities (RC)as defined by state and federal) for Resident 5, 18 and 19. The sample size was 4. The facility census was 25. FINDINGS ARE: A. A record review of the Admission Record dated 08/13/2021 revealed Resident 5 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the Order Summary Report dated 6/22/22 revealed Resident 5 was taking the following medications that affect mood and behaviors: -[MEDICATION(S)] (a medication used to treat anxiety) Tablet 10 MG Give 10 mg by mouth at bedtime for anxiety. -[MEDICATION(S)] Tablet 15 MG Give 15 mg by mouth one time a day for anxiety. -[MEDICATION(S)] HCl (a medication used to treat depression and anxiety) Capsule Delayed Release Sprinkle 40 MG Give 40 mg by mouth one time a day for Major depression, recurrent. -[MEDICATION(S)] (a medication used to treat mental/mood conditions) Tablet 25 MG Give 25 mg by mouth at bedtime related to [CONDITION(S)] DISORDER, DEPRESSIVE TYPE. A record review of the PASARR dated 9/6/21 for Resident 5 revealed it was a Level II and did contain the MI/ID/DD diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the MDS dated [DATE], section A 1500 had the following question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition with an answer of NO. An interview on 06/22/22 at 10:40 AM with LPN (Licensed Practical Nurse)-C after review of the MDS dated [DATE], section A 1500 for Resident 5 confirmed the MDS didn't reflect the current status of the resident and should not indicate no level II PASARR. B. A record review of the Admission Record dated 12/22/2020 revealed Resident 18 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the Order Summary Report dated 6/22/22 revealed Resident 18 taking the following medications that affect mood and behaviors: -[MEDICATION(S)] (a medicationused to treat depression and anxiety) HCl Capsule Delayed Release Sprinkle 60 MG Give 60 mg by mouth one time a day for depression. -[MEDICATION(S)] Tablet 50 MG Give 25 mg by mouth at bedtime for behavior related to [CONDITION(S)] DISORDER, CURRENT EPISODE DEPRESSED, MILD OR MODERATE SEVERITY. -[MEDICATION(S)] HCl (an antidepressant medication) Tablet 100 MG Give 100 mg by mouth at bedtime. A record review of the PASARR dated 03/10/2021 for Resident 18 revealed it was a Level II and did contain the MI/ID/DD diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the MDS dated [DATE], section A 1500 had the following question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition with an answer of NO. An interview on 06/22/22 at 10:40 AM with LPN-C, after review of the MDS dated [DATE], section A 1500 for Resident 18 confirmed the MDS didn't reflect the current status of the resident and should not indicate no level II PASARR. C. Record review of Resident 19's Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 19's Level II PASARR dated 08/05/2021 revealed Resident 19 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Section A1500 of Resident 19's Annual MDS dated [DATE] did not reveal that Resident 19 had a Level II PASARR. In an interview on 06/22/22 at 11:21 AM, Licensed Practical Nurse (LPN)-C confirmed Resident 19 had a Level II PASARR that confirmed the resident had a serious mental illness and that the MDS did not reflect the resident's Level II PASARR.

Licensure Reference Number 175 NAC 12-007.03I(5) Based on observation and interview, the facility failed to ensure each resident in a semiprivate (a room shared by 2 people) room had individualized closet space. This had the potential to affect 4 (Residents 3, 6 ,15, and 25) of 25 residents in the facility. Total census was 25. Findings are: Observation on 06/22/22 at 07:53 AM revealed resident rooms 102 and 205 were semi-private rooms with 2 residents in each room and 1 closet with no dividers or separate space. In an interview on 06/22/2022 at 08:02 AM, the DON (Director of Nursing) confirmed that all resident rooms except 4 on the south end are all set up the same and only have 1 closet with no dividers. In an interview on 06/22/2022 at 08:40 AM the Administrator confirmed that 29 resident rooms in the facility are considered semi-private. Observation on 06/22/2022 at 02:22 PM of rooms 102 and 205 with the Maintenance Supervisor (MS)-E revealed rooms 102 and 205 were semi-private rooms with 2 residents in each room and 1 closet with no dividers or separate space for each resident and the shelf was too high for a resident in a wheelchair to reach. In an interview on 06/22/2022 at 02:22 PM, MS-E confirmed rooms 102 and 205 were semi-private rooms with 2 residents in each room and 1 closet with no dividers or separate space for each resident and the shelf was too high for a resident in a wheelchair to reach.

Licensure Reference Number 175 NAC ,d+[DATE].05(4) Based on interview and record review, the facility failed to ensure the most recent Advanced Directive (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) was documented per the resident's wishes in the resident's electronic medical record (EMR). This affected 1 (Resident 2) of 2 sampled residents. Total census was 25. Record review of Resident 2's Directives to Define Scope of Medical Care dated [DATE] revealed Resident 2 chose full cardiopulmonary resuscitation (CPR)(emergency lifesaving procedures performed when a persons heart stops beating or a person stops breathing) in the event it was indicated. Record review of Resident 2's EMR Clinical Census dated [DATE] revealed the resident's code status was listed as do not resuscitate (DNR). In an interview on [DATE] at 01:02 PM Social Services Supervisor (SS)-D confirmed Resident 2's Directives to Define Scope of Medical Care dated [DATE] was marked by the resident as full CPR and the EMR indicated that the resident was a DNR.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.04A3d Based on record review and interview, the facility failed to ensure background checks were completed for all new employees. The sample size was 3. The facility census was 25. FINDINGS ARE: A record review of a new employee file for NA (Nursing Assistant)-J revealed a background form titled Nebraska Central Registry which read as follows: Your request is being returned and will not be processed for the following reason: Minors must have guardian consent. A record review of the facility policy titled Pre-Employment Investigations, Nebraska dated January 2022, revealed the following: IV. Pre-employment Offer Procedures: 5. Licensing and Certification Verification: For any individual applying for a potion that requires a state-issued license or certification, the hiring manager or designee should verify that the applicant's license(s) and certification(s) are current and in good standing. 6. Conditional Offer of Employment: If an applicant's reference checks and license/certification verifications are satisfactory, the company may give the applicant a conditional offer of employment. The conditional offer may be verbal or written, but in either case the applicant should be advised that the offer of employment is contingent on the outcome of the pre-employment screening processes set forth below An interview with Administrator-A on 07/05/22 at 12:38 PM after review of the new employee file for NA-J, confirmed that no guardian consent had been obtained and no follow up regarding a background check had been completed for NA-J.

Licensure Reference Number 175 NAC 12-006.09B1(2) Based on interview and record review, the facility staff failed to complete a Significant Change in Status Assessment (SCSA) MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) when Resident 11 was discharged from Hospice (a program designed to give supportive care to people in the final phase of a terminal illness). This affected 1 (Resident 11) of 1 sampled resident. Total census was 25. Findings are: In an interview on 06/22/2022 at 10:32 AM, Resident 11's representative revealed the resident had recently been discharged from Hospice. Record review of the Discharge-Transfer Summary Report [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review did not reveal a SCSA MDS had been completed when Resident 11 was discharged from Hospice on 05/26/2022. In an interview with the MDS nurse, LPN-C (Licensed Practical Nurse) on 06/22/2022 at 12:34 PM, LPN-C confirmed a SCSA MDS had not been completed when Resident 11 was discharged from Hospice on 05/26/2022.

Based on record review and interview, the facility failed to ensure a level 2 PASARR (Preadmission Screening and Resident Review - a screening tool used to detect mental disorder or intellectual disability prior to admission) was completed after receiving a new MI (Mental Illness) diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 25. Findings are: A record review revealed Level 1 PASARR was completed on 4/1/2021 for Resident 25. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the list of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A record review of orders for Resident 15 listed [MEDICATION(S)] Tablet 100 MG (antipsychotic medication) give 1.5 tablet by mouth at bedtime for [CONDITION(S)] DISORDER/[CONDITION(S)] (post traumatic stress disorder) give 1.5 tabs of 100mg to equal 150mg, dated 8/20/2021. A record review of the list of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident 15's annual MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for careplanning) dated 4/5/2022 revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Question I6100 reads Post Traumatic Stress Disorder was not marked. The MDS also revealed in question N0410, the resident was on an antipsychotic medication for 7 days and had not had a level 2 PASARR completed in question A1500. A record review of Resident 15's comprehensive careplan (written instructions needed to provide effective and person centered care of the resident that meet progessional standards of quality care) date initiated 4/8/2021, revealed [MEDICATION(S)], [CONDITION(S)] medication use for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview with the DON (Director of Nursing) on 07/05/22 at 12:03 PM confirmed that 4/1/2021 was the most recently completed PASARR for Resident 15 and a new PASARR was not done after the [CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview with the DON on 07/05/2022 at 04:05 PM confirmed there was no facility policy for updating and completing PASARR evaluations.

LICENSURE REFERENCE NUMBER 12-006.09D8b Based on observation, interview and record review; the facility failed to ensure thickened liquids were available between meals to maintain hydration status for Resident 26. The sample size was 3. The facility census was 25. FINDINGS ARE: A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's physical and mental functional capabilities) for Resident 26, section C 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 13. A record review of the admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 06/21/22 at 01:53 PM with Resident 26 confirmed (gender) was to receive thickened liquids. Observation on 6/21/22 at 1:53PM in the resident's room revealed the resident had coffee thin liquids noted at their bedside on the beside table. An observation on 07/05/22 at 01:55 PM revealed an empty water pitcher at Resident 26's bedside. During the observation, Resident 26 voiced not having any hydration available or offered outside of meals thus far today. An interview with the facility Administrator on 07/05/22 at 02:25 PM confirmed that the facility expectation was that water is passed every shift and expected that it would be passed/provided prior to 2 PM. A record review of the facility policy titled Hydration and dated 6/2022 revealed the following: Purpose: To ensure that each resident is encouraged to consume adequate fluids in order to maintain proper hydration for optimum functioning of various body systems. Procedure: 2. Each resident will be offered fluids of choice at least three times daily at times other than meals or snacks.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D6 Based on observation, interview and record review; the facility failed to ensure storage of respiratory equipment, when not in use, in a manner to prevent the potential for cross contamination for Resident 3 and 5. The sample size was 5. The facility census was 25. FINDINGS ARE: A. An observation on 06/21/22 at 12:14 PM revealed Resident 5 had oxygen tubing that was rolled up and tucked under the handle of the concentrator and was not being stored in the zip-lock baggie taped onto machine specifically to place oxygen tubing into when not in use An observation on 06/22/22 at 09:48 AM in Resident 5's room revealed that the oxygen tubing attached to the portable oxygen tank for Resident 5 was not in use and the nasal cannula was resting against the wheel of the wheelchair. A record review of the undated facility policy titled Oxygen, Use of did not address care and storage of oxygen equipment when not in use. An interview with the DON (Director of Nursing) on 06/22/22 at 10:15 AM confirmed that the facility expectation was that any oxygen tubing was to be stored inside a zip lock bag when not in use. B. An observation on 06/21/22 at 12:12 PM in Resident 3's room revealed oxygen tubing, which was not in use, had been draped across the bed with the cannula touching the aqua-k pad An observation on 06/22/22 on 09:48 AM revealed that the oxygen tubing attached to the portable oxygen tank for Resident 3 was not in use and the cannula was resting on the wheel of the wheelchair.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.12A Based on observation, interview and record review; the facility failed to ensure that the task of medication administration, including oxygen, was completed only by licensed or credentialed personnel. This affected 1 of 5 sampled residents (Resident 3). The facility census was 25. FINDINGS ARE: An observation on 06/22/22 at 09:08 AM revealed Resident 3 being assisted out of the bathroom with no oxygen on and into bed by NA (Nursing Assistant)-K. The observation then revealed that NA-K had placed the oxygen cannula back into Resident 3's nose. The observation on 06/22/22 at 09:08 AM revealed Resident 3 to be coughing with labored breathing once in bed after using the restroom with no oxygen on. A record review of the undated facility policy titled Oxygen, Use of revealed it did not address which personnel were allowed to administer or provide oxygen. An interview on 06/22/22 at 10:15 AM with the DON (Director of Nursing) confirmed that the facility expectation was that only nurses or Medication Aides were to administer oxygen, and that NAs (Nursing Assistant's) were not licensed, credentialed, or trained to do so.

Licensure reference: 175 NAC 12-006.09D2b Based on record review and interview, the facility failed to identify and evaluate a pressure sore for 1 [Resident 3] of 4 sampled residents with pressure sores. The facility had a total census of 32 residents. Findings are: A review of Resident 3's Admission assessment dated [DATE] revealed a 1.2 x 1.2 cm [centimeter] reddened area to the resident's left heel. A review of Resident 3's Care Plan included a goal initiated on 10/4/21 to have the left heel wound heal without complications prior to the next review. Interventions included: -encourage resident to float heels -monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -needs pressure reducing mattress, pillow, to protect the skin while in bed A review of Resident 3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -paint heel with [MEDICATION(S)] daily -needs to float heel -apply bilateral Prevalon boots [a boot designed to decrease pressure on the heel] when in bed or chair A review of Resident 3's 11/2021 Treatment Administration Record revealed orders to paint the heel with [MEDICATION(S)] daily and loosely wrap, to float heels and use Prevalon boots when bed or chair were initiated on 11/22/21. A review of Resident 3's Skin Pressure Weekly assessment dated [DATE] revealed Resident 3 had a Suspected Deep Tissue Injury to right heel measuring 4.5 cm length x 5 cm width with a black/brown (Eschar) wound bed. The pressure sore had an onset date of 11/22/21. A review of Resident 3's Skin Pressure Weekly assessment dated [DATE] revealed Resident 3 had a Suspected Deep Tissue Injury to right heel measuring 4.8 cm length x 4 cm width with a black/brown (Eschar) wound bed. A review of Resident 3's Skin Pressure Weekly assessment dated [DATE] revealed Resident 3 had a Suspected Deep Tissue Injury to right heel measuring 4.5 cm length x 4 cm width with a black/brown (Eschar) wound bed. A review of Resident 3's Skin Pressure Weekly assessment dated [DATE] revealed Resident 3 had a Suspected Deep Tissue Injury to left heel measuring 3.5 cm length x 4 cm width with a black/brown (Eschar) wound bed. A review of Resident 3's Skin Pressure Weekly assessment dated [DATE] revealed Resident 3 had a Suspected Deep Tissue Injury to left heel measuring 3.7 cm length x 4 cm width with a black/brown (Eschar) wound bed. A review of Resident 3's Skin Pressure Weekly assessment dated [DATE] revealed Resident 3 had a Suspected Deep Tissue Injury to left heel measuring 3.2 cm length x 2.5 cm width with a black/brown (Eschar) wound bed. A review of Resident 3's Skin Pressure Weekly assessment dated [DATE] revealed Resident 3 had a Suspected Deep Tissue Injury to left heel measuring 2.8 cm length x 3.2 cm width with a black/brown (Eschar) wound bed. A review of Resident 3's Skin Pressure Weekly assessment dated [DATE] revealed Resident 3 had a Suspected Deep Tissue Injury to left heel measuring 3.5 cm length x 3 cm width with a black/brown (Eschar) wound bed. A review of Resident 3's Progress Note dated 1/29/22 revealed Resident 3 discharged from the facility on that date. In interviews on 2/16/22 between 2:45 PM-3:16 PM, the Acting Director of Nursing reported that Resident 3 only had a pressure sore on the left heel. The Acting Director of Nursing reported the first documentation regardingthe left heel were physician treatment orders dated 11/18/21. The Acting Director of Nursing confirmed weekly skin evaluations completed on Resident 3 did not identify pressure sore on the left heel. The Acting Director of Nursing confirmed no assessment of the left heel pressure sore could be found between 11/22/21 when treatments were started and 12/8/21. The Acting Director of Nursing confirmed weekly assessments should have been started when a red area was noted on the left heel during the admission assessment. A review of the facility procedure dated 11/2021 titled Skin Assessments & Wound Documentation revealed the following: -The nurse completing weekly wound rounds will utilize the Pressure/Non-Pressure Assessment. -All new or worsened skin concerns must be addressed immediately. -Wounds-Present On Admission 1. Complete Skin assessment section on Initial Admission Assessment (UDA). You must include wound measurements and complete wound assessment. 2. Treatment-All wounds must have treatment orders. If no orders on admission, CALL to get order of treatment. Notify pharmacy of order (fax and call). 3. Notify DON [Director of Nursing] and Wound Nurse in PCC [Point Click Care] via PCC messaging System. 4. Update 24 hour care plan, as applicable (Problem, intervention, goal).