Every finding on record at Good Samaritan Society - Auburn

Licensure Reference: 175 NAC 12-006.11 (A) Based on observation, interview, and record review, the facility failed to ensure portion sizes identified on the menu were being followed when serving foods to residents. This has the potential to affect all 58 residents of the facility. Findings are: A. Observations of steam table on 2/10/25 at 12:14 PM revealed the following serving sizes were being used to serve food to residents:-Rice #10 scoop [3/8 cup]-Pureed pork cutlet #10 [3/8 cup]-Minced and moist pork 3 ounces B. In an interview on 2/10/25 at 12:14 PM, [NAME] F confirmed the following serving sizes were being used to serve food to residents:-Rice #10 scoop [3/8 cup]-Pureed pork cutlet #10 [3/8 cup]-Minced and moist pork 3 ounces C. A review of facility menu for lunch meal on 2/10/26 revealed the following serving sizes were identified:-Rice #8 scoop [1/2 cup]-Pureed pork cutlet #8 scoop [1/2 cup]-Minced and moist pork #8 [1/2 cup] D. In an interview on 2/10/26 at 1:16 PM, Dietary Department Director and Consultant Registered Dietitian confirmed the correct serving sizes had not been used. E. In further interview on 2/10/26 at 2:50 PM, Consultant Registered Dietitian reported that facility did not have a policy related to serving sizes but that the menu serving sizes are to be followed.

Licensure Reference: 175 NAC 12-006.11(E) Based on observation and interview, the facility failed to ensure test strips were available to check the sanitizer concentration level in the 3-compartment sink and failed to ensure pasteurized eggs were used for preparation of soft, cooked eggs. This could affect all 58 residents of the facility. Findings are:A. Observations on 2/10/26 between 9:36-10:10 AM revealed the label on the box of whole eggs located in the walk-in refrigerator revealed no documentation that stated the eggs were pasteurized. In an interview on 2/10/26 at 1:16 PM, Dietary Department Director and Consultant Registered Dietitian confirmed the whole eggs were not pasteurized and that the wrong eggs had been ordered. The Dietary Department Director and Consultant Registered Dietitian confirmed that that it is facility policy to use pasteurized eggs. Dietary Department Director and Consultant Registered Dietitian confirmed that residents' eggs are cooked to order and can be ordered over easy. A review of facility policy revised 6/27/25 titled Food Handling revealed the following:- If residents are served soft eggs, ensure that pasteurized shell eggs have been used and cooked to 145 degrees Fahrenheit for 15 seconds. B. Observations on 2/10/26 between 9:36-10:10 AM revealed 3 compartment sink used quaternary sanitizer for sanitizing pots and pans washed in the 3-compartment sink. During the observation, the Dietary Department Director was unable to locate test strip to evaluate the concentration of the sanitizer. Further observation revealed a log for sanitizer concentration documentation on the wall by the 3-compartment sink was not for the current month and was not complete. In an interview on 2/10/26 between 9:36-10:10 AM, the Dietary Department Director confirmed that test strips for evaluating concentration of the quat sanitizer could not be found and that a sanitizer log for the 3-compartment sink was not being completed. A review of facility policy revised 3/27/25 titled Warewashing-Mechanical and Manual revealed the following under temperature and chemical concentration:- Proper test strips and thermometers are available. Temperatures and/or chemical concentration will be recorded on either Chemical Sanitizing Log (GSS#454) or Pot/Pan Hot Water Sanitizing Log (GSS#465). A review of the 2022 Food and Drug Administration Food Code revealed the following:- Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device.

Licensure Reference Number 175 NAC 12-006.18(B & D) Based on observation, record review and interview the facility failed to complete hand hygiene while simultaneously providing dining assistance between 3 residents (Residents 4, 7, and 16) and the facility failed to store oxygen tubing in a manner to prevent the potential for cross contamination for 2 (Residents 5 and 7) of 2 sampled residents. The facility census was 58. Findings are:A. Record review of the facility's Hand Hygiene- Enterprise policy with a revision date of 11/13/2025 revealed the following: -All employees are responsible for maintaining adequate hand hygiene by adhering to specific infection control practices. -All employees in patient care areas (unless otherwise noted in their policy) will adhere to the 4 moments of hand hygiene and 2 zones of hand hygiene. 1. Entering Room 2. Before clean task 3. After bodily fluid/glove removal 4. Exiting room 5. Zones: Patient zone and health-care zones A record review of the facility's Hand Hygiene Clinical Skill Checklist dated 10/2023 revealed the following: -Hand hygiene is performed before touching anything in healthcare zone and when leaving a patient zone. An observation on 02/09/2026 at 12:11 PM revealed Nursing Assistant (NA)-C feeding Resident 16. NA-C rolled to the opposite end of the table, grabbed the handles on Resident 4's wheelchair, did not complete hand hygiene and began feeding Resident 4. NA-C attempted to place silverware in Resident 4's hand and then wiped Resident 4's mouth with a napkin. NA-C did not complete hand hygiene, grabbed Resident 7's silverware and gave Resident 7 a bite of food. NA-C did not complete hand hygiene and went back to assist feeding Resident 4. NA-C did not complete hand hygiene, went back to Resident 7 and assisted Resident 7 to take a bite of food. NA-C rolled back to the end of the table with Resident 16, did not complete hand hygiene and began to assist feeding Resident 16. In an interview on 02/09/2026 at 12:11 PM NA-C confirmed that hand hygiene was not completed while switching between residents and should have been. B. Record review of facility policy titled Oxygen Administration, Safety, Mask Types dated revised 07/30/2025 revealed the following: -Purpose: -To keep oxygen equipment clean and maintained in good condition. -Guidelines: -9. All oxygen equipment will be clean, safe and functional. -Oxygen Cylinder -14. When oxygen is not in use, store cannula, face mask or face tent and tubing in zip-lock bag/plastic bag secured to oxygen cylinder or concentrator. -Oxygen Concentrator -12. Attach a bag to the concentrator to allow storage of oxygen cannula or mask when not in use. Record review of Resident 5's Transfer/Discharge Report (TDR) printed 02/09/2026 showed the facility admitted Resident 5 on 04/18/2025. Further review of the TDR identified Resident 5 had diagnoses which included COVID-19, morbid obesity, and wheezing. Record review of Resident 5's Order Summary Report revealed an order dated 01/31/2026 for oxygen (O2) 1-4 liters (L) via nasal cannula as needed (PRN) for maintaining O2 above 90%. An observation on 02/10/2026 at 7:28 AM revealed Resident 5's O2 concentrator up against the wall with the oxygen tube wrapped around the concentrator. The O2 tube was not protected or secured. An observation on 02/10/2026 at 3:03 PM with Registered Nurse (RN)-I revealed Resident 5's O2 concentrator up against the wall with the oxygen tubing wrapped around the concentrator. The O2 tube was not protected. During an interview on 02/10/2026 at 3:05 PM, RN-I reported that the facility staff would keep O2 supplies available in the room, even if the residents' O2 orders were only PRN. RN-I confirmed Resident 5's O2 tubing was not stored in a bag and should have been. RN-I further confirmed improper storage of the O2 tubing created the potential for cross-contamination. C. Record review of Resident 7's TDR printed 02/09/2026 revealed the facility admitted the resident on 03/24/2025. Further reviews of the TDR identified Resident 7 have diagnoses which included personal history of COVID-19, Pneumonia, and personal history of pulmonary embolism. Record review of Resident 7's Order Summary Report revealed an order dated 04/18/2025 for Oxygen via nasal cannula 1-4 L per minute as needed for dyspnea (trouble breathing), hypoxia (O2 saturation less than 88%) or acute angina (chest pain). An observation on 02/09/2026 at 10:25 AM revealed Resident 7 had an O2 cylinder on the back of the wheelchair. The O2 tube and nasal cannula were draped over the wheelchair and not stored in a bag. An observation on 02/09/2026 at 12:00 PM revealed Resident 7 was in the dining room. The O2 cylinder was in use, and the nasal cannula was worn. An observation on 02/10/2026 at 3:00 PM with RN-I revealed the tubing connected to the cylinder on the back of Resident 7's wheelchair was draped over the handles and wheels of the wheelchair and was not secured in a bag. An interview on 02/10/2026 at 3:01 PM with RN-I confirmed the O2 tubing was to be stored in a bag and was not. RN-I further confirmed the potential for cross-contamination.

Based on observation, interview and record review, the facility failed to ensure that a staff member did not leave medications at the bedside for Resident 53. The facility had a census of 58.A record review of the facility's Medication Administration Including Scheduling and Medication Aides Policy, reviewed on 04/08/2025 revealed the following:Procedure:9. Do not leave medications at the bedside or at the table unless there is a specific physician order to do so, and the resident has been evaluated for self-administration. An observation on 2/8/2026 at 10:25 AM revealed a medication cup with pills in it on the bedside table of Resident 53.An interview on 2/8/2026 at 10:25 AM with Resident 53 revealed they could not remember when the pills were put on the table.An interview on 2/8/2025 at 10:25 AM with Medication Aide H (MA) confirmed they had not given Resident 53 the medications that were in the medication cup. MA H confirmed they did not know what medications were in the medication cup. MA H confirmed the medications should not have been left at Resident 53's bedside.An interview at 10:30 AM with Licensed Practical Nurse D (LPN) confirmed LPN D had administered medications to Resident 53 and had not witnessed the resident take all of their medication. LPN D confirmed they should have remained in the room until Resident 53 had taken all of their medications.

Licensure Reference: 175 NA 12-006.09(H)(v) Based on interview and record review, the facility failed to ensure restorative services were provided for 1 [Resident 31] of 2 sampled residents. The facility had a total census of 58 residents. Findings are: A review of Resident 31's Transfer/Discharge Report revealed Resident 31 was admitted on [DATE] with diagnoses of hemiplegia [paralysis] and hemiparesis [partial motor weakness or inability] following cerebral infarction [stroke] affecting right dominant side. A review of Resident 31's quarterly MDS [Minimum Data Set; a comprehensive assessment used for care planning] with assessment reference date of 12/30/25 revealed the following: -Resident 31's Brief Interview for Mental Status score of 5. A review of the MDS manual revealed a score of 0-7 means severe cognitive impairment. -No information on mobility-Impairment of range of motion on one side for upper and lower extremities A review of Resident 31's Care plan revealed a focus area dated 10/22/24 that stated Resident 31 needed restorative interventions due to limited physical mobility related to cerebrovascular accident with the following interventions listed:-Nursing rehabilitation 1: Transfers: Sit to stand for 5 reps with Hemi-walker, CGA [Care Giver Assistance] of one and a gait belt 2 times a week. Stand/pivot for 5 reps with Hemi-walker and CGA and gait belt 2 times per week.-Nursing Rehab #1: Walking Ambulate with Hemi-walker up to 90 feet with CGA of one and a gait belt, wheelchair to follow 2 times per week. A review of Resident 31's restorative documentation from 1/11/26 to 2/9/26 for restorative program of transfers sit to stand for 5 reps with Hemi-walker and stand/pivot reps with Hemi-walker 2 times per week revealed Resident 31 received restorative services one time on 1/18/26. A review of Resident 31's restorative documentation from 1/11/26 to 2/9/26 for restorative program of ambulate with Hemi-walker up to 90 feet 2 times per week revealed Resident 31 did not receive restorative services for ambulation on any days. In an interview on 2/10/26 at 3:06-3:12 PM, LPN A reported restorative orders come from therapy and are entered into resident's plan of care. LPN A confirmed that the restorative program is not being done. In an interview on 2/10/26 at 9:31 AM, Restorative Aide B confirmed Restorative Aide B had only provided Resident 31 with restorative services one time between 1/11/26-2/9/26. Restorative Aide B reported that Restorative Aide B had been working the floor as an aide or medication aide in place of working as the restorative aide. In an interview on 2/11/26 at 11:05 AM, the Administrator confirmed that the facility did not have adequate staffing to provide restorative services for the number of days indicated. A review of facility policy dated 12/8/25 titled Restorative-Nursing Care Implementation and Screening revealed the following policy: - Each resident will receive restorative nursing care to the extent possible, based on individual strengths, needs and problems as defined in nursing assessments. This restorative care will be outlined in the resident's nursing care plan.

Licensure Reference Number 175 NAC 12-006.09(H)(iv)(5)Based on record review and interview, the facility failed to implement physician's orders for bowel management for 2 (Residents 7 & 2) of 5 sampled residents. The facility staff identified a census of 58.Findings are: A. A record review of Resident 2's Minimum Data Set (MDS – a federally mandated assessment tool used to assess a resident's functional, medical and psychological status in Medicare or Medicaid certified nursing homes), dated 01/06/2026 revealed Resident 2 was admitted to the facility on [DATE]. Resident 2's Brief Interview for Mental Status (BIMS - a federally mandated tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) revealed a BIMS of 3, indicating the resident was severely cognitively impaired. Resident 2 was found to have no known allergies and had the following diagnoses: Type 2 Diabetes, Seizure disorder, Legal Blindness (a definition used by government agencies to determine eligibility for services), Atrial Fibrillation (rapid and irregular heartbeat), Coronary Artery Disease (a serious heart condition caused by plaque build up in the arteries), Hypotension (low blood pressure), Peripheral Vascular Disease (a progressive circulation disorder, characterized by narrowed, blocked or spasm-prone blood vessels outside the heart), Depression, Chronic Kidney Disease (long term, progressive loss of kidney function), high cholesterol, and osteoarthritis. A record review of Resident 2's order summary revealed the following orders for bowel management; Dulcolax Suppository (Bisacodyl) 10 MG (milligram) Insert 10 mg rectally as needed for constipation Give daily as needed. Contact provider/practitioner if there are three days without a significant BM (bowel movement). Prescriber Written Active 10/13/2021 Milk of Magnesia Suspension 400 MG/5ML (Magnesium Hydroxide) Give 30 ml (milliliter) by mouth as needed for constipation Give daily as needed. Contact provider/practitioner if there are three days without a significant BM. Contraindicated for resident with renal impairment. Prescriber Written Active 10/13/2021 A record review of the facility's undated Bowel Management Protocol revealed the following: A standard bowel evacuation protocol is crucial to prevent complications such as constipation, fecal impaction, or incontinence. Evidence-based protocols help ensure consistent, safe, and effective care. Below is Good Samaritan- [NAME] comprehensive bowel management protocol based on current best practices, including recommendations from sources such as: National Institute for Health and Care Excellence (NICE) The American Medical Directors Association (AMDA) Initial Resident Assessment Conduct upon admission and regularly (e.g., quarterly or with any change in condition). Include: Usual bowel pattern and frequency Diet and fluid intake Mobility level Current medications (opioids, anticholinergics) Cognitive status History of constipation, impaction, incontinence Prevention of Constipation Hydration Fiber intake Toileting schedule if appropriate Medication review as needed Constipation No BM for 24 hour: MOM 30 CC No BM 48 hours: Bisacodyl or glycerin suppository No BM for 72 hours or more: Assess for fecal impaction (abdominal status, abdominal distention, overflow incontinence, nausea, hard mass palpated rectally. Contact medical provider Fecal Impaction Protocol Signs: Abdominal distension, overflow incontinence, nausea, hard mass palpated rectally Notify physician if no BM 3 days Monitoring and Documentation Daily bowel record: Stool frequency, consistency (Bristol scale), ease of passage Monitor effectiveness of interventions Notify provider if: No BM in 3 days Signs of impaction or bowel obstruction Change in bowel habits Regular care plan updates as needed A record review of Resident 2's bowel movements for January 2026 revealed Resident 2 did not have a bowel movement on January 19, 20, 21, 22 and 23. A record review of Resident 2's bowel movements for February between 2/1/26 and 2/10/26 revealed resident did not have a bowel movement on the 4, 5, 6 and 7. A record review of Resident 2's Dulcolax Suppository order revealed the provider should have been contacted if the resident had 3 days without a significant bowel movement. A record review of Resident 2's Milk of Magnesia order revealed the provider should have been contacted if the resident had 3 days without a significant bowel movement. An interview on 02/10/2026 at 1:15 PM with Licensed Practical Nurse (LPN) D confirmed Resident 2 did not have a bowel movement on January 19, 20, 21, 22, 23 and February 4, 5, 6, and 7. LPN D confirmed Resident 2's order stated the provider should have been notified after 3 days without a bowel movement. LPN D said (gender) did not know why the provider had not been notified. LPN D confirmed the following process: the night shift nurse prepared a report for the day shift of which residents are at day 3 without a bowel movement. LPN D confirmed that the day shift nurse's responsibility is to notify the Medication Aide (MA) of which residents require bowel movement medication. The MA is responsible for informing the nurse if a resident refuses the bowel movement medication. LPN D confirmed that the Director of Nursing (DON) is responsible for notifying the family or family representative of changes in condition of a resident. An interview on 2/10/26 at 2:40 PM with LPN E confirmed if a resident is 3 days without a bowel movement an alert is supposed to appear on their chart and the Medication Aide is to give the medication. LPN E confirmed if it is more than 3 days without a bowel movement the nurse is supposed to notify the primary care provider. LPN E confirmed the DON is supposed to notify the family of changes in condition of the resident. B. Record review of Resident 7's Transfer/Discharge Report (TDR) printed 02/09/2026 revealed the facility admitted the resident on 03/24/2025. Further review of the TDR identified Resident 7 had diagnoses that included constipation, muscle weakness, need for assistance with personal care, and other reduced mobility. Record review of Resident 7's comprehensive Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) revealed the facility staff identified the following about the resident: -Resident 7 was dependent upon staff for toileting hygiene, lower body dressing, and transfers. -Resident 7 was always incontinent of bowel, was not on a toileting program, and had constipation present. Record review of Resident 7's Order Summary Report printed 02/09/2026 revealed the following orders: -Dulcolax (laxative medication) suppository 10 milligram (mg) insert 1 suppository rectally, daily as needed (PRN). Contact provider/practitioner if there are three days without a significant bowel movement dated 05/14/2025. -Milk of Magnesia (laxative medication) suspension 400 mg per (/) 5 milliliters (mL) give 30 mL by mouth PRN constipation. Give daily as needed. Contact provider/practitioner if there are three days without a significant BM dated 10/19/2025. Record review of Resident 7's Bowel Records from 01/12/2026 through 2/10/2026 revealed Resident 7 did not have a bowel movement on 02/04/2026, 02/05/2026, 02/06/2026, 02/07/2026, and 02/08/2026. Record review of Resident 7's Medication Administration Record (MAR) for February 2026 revealed there was no use of PRN bowel medications. Record review of Resident 7's Progress Notes dated 02/04/2026 through 02/09/2026 revealed no evidence the facility notified Resident 7's provider/practitioner of no significant bowel movement in three days. An interview on 02/10/2026 at 10:55 AM with Licensed Practical Nurse (LPN)-G revealed the facility's night nurse is responsible for running a no-bowel movement list. The night nurse would be responsible for notifying the oncoming day nurse of those residents who had not had a bowel movement in three days. LPN-G further revealed that LPN-G would notify the Medication Aide (MA) if a resident was on the no bowel movement list and required the administration of PRN medications. LPN-G reported [gender] would assess the abdomen on day four of no bowel movement. During a follow-up interview on 02/10/2026 at 11:55 AM, LPN-G confirmed Resident 7 had no bowel movement on 02/04/2026, 02/05/2026, 02/06/2026, 02/07/2026, and 02/08/2026. LPN-G further confirmed there was no evidence PRN bowel medications were administered, nor that Resident 7's provider/practitioner had been notified of no bowel movement in three days. LPN-G reported the bowel medications should have been utilized and the provider notified per orders.

Licensure Reference Number 175 NAC 12.006.11(E) Nebraska Food Code 2017 Section 4-602.13 Based on observation, interview, and record review; the facility failed to maintain the cleanliness of a fan and the walls inside the walk in cooler and 2 ventilation covers above a food preparation area in a manner to prevent the potential for food borne illness. The facility also failed to ensure that a plastic scoop handle was not in contact with flour inside a flour bin. This had the potential to affect 62 residents that ate foods prepared in the facility kitchen. The facility census was 62. Findings are: Record review of the Nebraska Food Code dated 2017 Section 4-602.13 revealed that non-food contact surfaces of equipment shall be cleaned at a frequency necessary to prevent the accumulation of soil residues. Observations on 9/30/24 between 8:20 AM and 8:35 AM, and on 9/30/24 between 9:15 AM and 10:15 AM revealed the following environmental concerns in the facility kitchen: - A condenser fan in the walk in cooler was turned on and was functional. It was coated with a dark gray/black substance. There was also a coating of a dark grey fuzzy substance on the interior walls and ceiling of the walk in cooler. - Two large air conditioner covers in the ceiling above the food preparation table were coated with a dark grey/black substance. - A plastic scoop was present in the flour bin on top of the flour with the handle of the scoop in contact with the flour product. Observation on 9/30/24 between 11:00 AM and 11:30 AM with the Dietary Manager (DM) confirmed the following environmental concerns: - A condenser fan in the walk in cooler was turned on and was functional. It was coated with a dark gray/black substance. There was also a coating of a dark grey fuzzy substance on the interior walls and ceiling of the walk in cooler. - Two large air conditioner covers in the ceiling above the food preparation table were coated with dark grey/black substance. - A plastic scoop was present in the flour bin on top of the flour with the handle of the scoop in contact with the flour product. Interview on 9/30/24 at 11:35 AM with the DM confirmed the presence of dust on the 2 air conditioner covers, dust on the condenser fan in the walk in cooler, dust on the walls and ceiling of the walk in cooler and a scoop present in the flour bin. The DM confirmed the scoop should have been stored outside of the bin and should not have been in contact with the flour. The DM confirmed that the air conditioner covers (2) were directly over a food preparation area which could have the potential to cause food borne illness if the dust dropped down into the foods. The DM confirmed that the fan in the cooler was not on a cleaning schedule and was unsure of the last time it had been cleaned. The DM confirmed that the air conditioner covers were not on the dietary cleaning schedule and was unsure of the last time they had been cleaned. Record review of undated dietary cleaning schedules revealed that the cleaning schedules did not identify the condenser fan in the walk in cooler or the air conditioner covers on the cleaning schedules. Interview on 10/01/24 at 10:36 AM with the facility Registered Dietician confirmed that all 62 residents that resided in the facility ate foods that had been prepared in the facility kitchen.

Licensure Reference Number 175 NAC 12-006.19 Based on observations and interview, the facility failed to maintain the cleanliness of the bathroom ceiling ventilation covers and the condition of the base of the toilets in 15 (Rooms 207, 211, 302, 311, 314, 315, 402, 403, 404, 405, 406, 411, 504, 505 and 506) of 62 occupied resident rooms in the facility. The facility census was 62. Findings are: Observation on 9/30/24 between 3:00 PM and 4:00 PM revealed the following: - Ventilation covers were coated with a collection of a dark fuzzy substance resembling dust in resident bathrooms in rooms 207, 211, 314, 315, 402, 403, 404, 405, 406, 411, 504, and 506. - There was corrosion surrounding the base of the toilet with a dark brown substance present and cracked caulking around the base of the toilet in resident bathrooms in rooms 207, 211, 302, 311, 314, 402, 403, 404, 405, 406, 411, 504, 505, and 506. Observation on 10/02/24 between 7:53 AM and 8:55 AM with the facility Maintenance Director (MD) and the facility Administrator confirmed the following observations during the environmental tour of the facility: - Ventilation covers were coated with a collection of a dark fuzzy substance resembling dust in resident bathrooms in rooms 207, 211, 314, 315, 402, 403, 404, 405, 406, 411, 504, and 506. - There was corrosion surrounding the base of the toilet with a dark brown substance present and cracked caulking around the base of the toilet in resident bathrooms in rooms 207, 211, 302, 311, 314, 402, 403, 404, 405, 406, 411, 504, 505, and 506. Interview on 10/02/24 at 8:56 AM with the facility MD confirmed the dust coated ventilation covers in resident bathrooms in rooms 207, 211, 314, 315, 402, 403, 404, 405, 406, 411, 504, and 506. The MD confirmed that there was corrosion surrounding the base of the toilet with dark brown substances present and cracked caulking around the base of the toilets in resident bathrooms in rooms 207, 211, 302, 311, 314, 402, 403, 404, 405, 406, 411, 504, 505, and 506. The MD confirmed those areas needed to be cleaned and recaulked around the toilet base. The MD confirmed that there were no active work orders for the concerns identified during the environmental tour.

Licensure Reference Number 175 NAC 12.006.18(B) & 1-005.06 Based on observation, interview, and record review; the facility failed to secure a urinary catheter bag to prevent the potential for cross contamination for 1 (Resident 14) of 2 residents sampled. The facility census was 62. The Findings Are: Record review of Resident 14's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 9-17-2024 revealed the facility staff assessed the following about the resident: -Diagnoses of Diabetes Mellitus Type 2, heart failure and obstructive uropathy (structural or functional hindrance of normal urine flow). -Required partial assistance with personal hygiene and rolling right and left. -Required total assistance with lower body dressing, transfers and toileting. -Has an indwelling urinary catheter (a thin, hollow tube that's inserted into the bladder to drain urine). An observation on 9-30-2024 at 9:05 AM revealed Resident 14 sitting in a recliner with a urinary catheter bag hanging from the trash can with the bottom of the bag touching the floor. An observation on 10-3-2024 at 8:52 AM revealed Resident 14 sitting in a recliner with a urinary catheter bag hanging from the trash can with the bottom of the bag touching the floor. An interview with Nursing Assistant (NA)-A on 10-03-2024 at 9:30 AM confirmed Resident 14's catheter drainage bag was touching the floor. An interview with Licensed Practical Nurse (LPN)-B on 10/3/24 at 9:40 AM confirmed catheter drainage bags should not touch the floor. An interview with the Director of Nursing (DON) on 10-03-2024 at 11:57 AM confirmed catheter bags should not touch the floor or be hung on a trash can. Record review of the facility's policy Catheter Care dated 7-30-2024 revealed: -catheters are always properly secured, connected and maintained using a sterile closed drainage system.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18A Based on observation and interview, the facility failed to ensure light fixtures in the dining area by the kitchen, were free of pests. This affected 12 of 24 sampled residents. The facility census was 55. Findings are: On 03/03/22 at 0842 AM, observation of the light fixtures in the dining room nearest to the kitchen had dead insects in multiple light fixtures. On 03/08/22 at 8:35 AM, observation of the dining room revealed multiple pests in each light fixture. On 03/08/22 at 9:51 AM, an interview with the Administrator revealed the expectation of cleaning the light fixtures in the dining room had been for maintenance to clean these each month. The Administrator confirmed that the cleaning of the light fixtures from pests had not been completed by the maintenance personnel.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, record review, and interview; the facility failed to serve food and fluids in a manner to prevent food borne illness. This affected 14 of 20 residents in the 100 dining room. The facility census was 55. Finding are: Observation on 03/07/22 at 1230 PM in the 100 dining room refrigerator revealed juices were outdated with a date of 2-11-22. 03/07/22 at 2:40 PM an interview with the Dietary Manager confirmed that the outdated juice was in the refrigerator and should have been discarded by the 11th of February, 2022. Record Review of the 7/21/2016 version of the Food Code based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service practices revealed that outdated food and fluids should be discarded by the expiration date.

Based on record review and interview, the facility failed to ensure a new PASRR (Pre-Admission Screening and Resident Review) review had been completed after a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 55. Findings are: A. Review of Resident 16's Admission PASRR was completed on 1/27/14 as a level 1. The rationale documented on the level 1 screen determined that Resident 16 exhibited no evidence to suggest presence or known conditions of mental illness, intellectual disability, or a condition related to intellectual disability. As such, no further level 1 screening was required unless the individual was later suspected or found to have a mental illness or intellectual disability condition. Record review of Resident 16's Admission Face Sheet printed on 3/7/22 revealed that Resident 16 was admitted to the facility on [DATE] and a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 16's annual Minimum Data Set [ MDS-a comprehensive assessment tool used to develop a resident's care plan) dated 12/29/21 section A1500 for PASRR revealed that Resident 16 was not considered by the State level 2 PASRR process to have a serious mental illness or intellectual disability or a related condition. The MDS further identified Resident 16 to have a current Psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 16's Psychiatric Note dated 1/7/22 indicated that Resident 16 had exhibited a behavioral change with increased agitation and yelling out. The note indicated that Resident 16 had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident 16's Electronic Medical Record revealed that a new PASRR had not been completed since 9/7/18 while the resident did have a new mental illness diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 03/07/22 at 12:39 PM with the Social Services Assistant [SSA] B confirmed that Resident 16 had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . B. Record review of Resident 47's PASSAR level 1 dated 12-01-2016 revealed The PASSAR level 1 did not identify Resident 47 had any Serious Mental Illness (SMI). Record review of a Orders Summary Sheet dated 3-07-2022 revealed on 11-10-2016 revealed Resident 47 had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 47's medical record revealed a new PASSAR had not been completed. On 3-07-2022 at 12:36 PM an interview was conducted with the Social Services Assistant (SSA) B. During the interview SSA B confirmed a new PASSAR had not been completed and should have been.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on record review and interview the facility staff failed to monitor for side effect for the use of anti-psychotic medications for 2 (Resident 11 and 47) of 5 reviewed. The facility staff identified a census of 55. Findings are; A. Record review of Resident 11's Order Summary Sheet dated 3-07-2022 revealed Resident 11's practitioner order medications that included [MEDICATION(S)] (an anti-psychotic medication) 5 milligrams (mg) to be given daily. Review of Resident 11 medical record that included Progress Notes, Medication Administration Records (MAR) for March 2022 and Practitioners order revealed there was not indications the facility staff were monitoring Resident 11 for side effect related to the use of the [MEDICATION(S)] medication. On 3-07-2022 at 2:50 PM an interview was conducted with Licensed Practical Nurse(LPN) C. During the interview LPN C confirmed side effects were not being monitored for Resident 11. B. Record review of Resident 47's MAR for March 2022 revealed Resident 47 had medications ordered that included [MEDICATION(S)] (anti-psychotic medication) 0.25 mg every morning. Review of Resident 47's medical record that included Progress Notes, MAR for March 2022 and Practitioners order revealed there was not indications the facility staff were monitoring Resident 47 for side effect related to the use of the [MEDICATION(S)] medication. On 3-07-2022 at 2:50 PM an interview was conducted with LPN C During the interview LPN C confirmed side effects were not being monitored for Resident 47. On 3-07-2022 at 2:50 PM an interview was conducted with Registered Nurse (RN) D. During the interview RN D confirmed the side effect of using the [MEDICATION(S)] were not being monitored for Resident 47. Record review of the facility policy for [CONDITION(S)] Medicationsd revised on 12-01-2021 revealed the following information: - Procedure: -D. Monitor for effectiveness and potential adverse consequences.

Licensure Reference Number 175 NAC 12-006.17 Based on observation, record review and interview; the facility failed to maintain a 6 foot distance between 8 residents during meals in the main dining area for residents that required assist with eating. This created the potential for exposure to COVID - 19 due to the reduced physical distancing between residents. The facility census was 58. Findings are: Record review of a Center for Medicare and Medicaid (CMS) Memo QSO-20-28-NH dated 4/24/20 revealed the following: 14. Communal Dining: Nursing homes should adhere to social distancing, such as being at separate tables at least 6 feet apart. Social distancing should be practiced at all times. Record review of a facility policy entitled Food and Nutrition Services Considerations for Pandemic / Epidemic Outbreaks COVID-19 dated March 19 2020 revealed that residents with choking / swallowing risk were to be assisted in a dining location. The policy called for 1 resident per table, 6 feet apart. Observation on 6/22/20 between 11:40 AM and 12:55 revealed a total of 9 tables set up for meal service. Four of the tables were set for 2 residents to be seated at a table. At 12:00 PM, 12 residents that required assist with eating were seated in the main dining room. Four of the tables had 2 residents at each table as they were assisted with eating for a total of 8 residents. The residents were seated across form each other at the tables while eating. Observation on 6/22/20 at 12:50 PM with the facility Administrator confirmed that at 4 of the tables, the residents were seated 2 to a table across from each other. The facility administrator measured the width of the tables with a tape measurer. The width of the table measured 3 feet 5 inches. The Administrator then measured the width from wheelchair arm to wheelchair arm across the table. This measurement equally 4 feet and 5 inches. In an interview on 6/22/20 at 12:50 PM, the facility Administrator confirmed that 4 of the tables had 2 residents per table and that the residents seated across from each other at the tables were not 6 feet apart.

Licensure Reference Number 175 NAC 12-006.11C Based on observation, record review and interview, the facility failed to ensure hand washing in the kitchen was completed between dirty and clean tasks to prevent the potential for food borne illness. This had the potential to affect 59 of 61 residents that ate food prepared in the facility kitchen. The facility census was 61. Findings are: Observation on 02/10/20 at 10:15 AM revealed Dietary Staff D was preparing ground meat for lunch. After completing the ground meat mixture, Dietary Staff D handled the inside of the beater and walked to the dishwasher put the beater in the rack and proceed to run a cycle in the dishwasher. Dietary Staff D came back and did not wash hands prior to finishing the puree mixture. Record review of Facility Policy and Procedure dated 2/2013 and revised on 7/2018 revealed, dietary staff are to wash hands between dirty and clean handing. Interview on 02/10/20 at 1:10 PM with Dietary Staff D confirmed that hands were not washed when going from a dirty task to a clean task. Interview on 02/10/20 at 1:15 PM with Dietary Manager confirmed the expectation when going from a dirty task to a clean task hand washing is to be completed. Nebraska Food Code dated (MONTH) (YEAR), section 2-301.14 revealed: -When to wash. (E) After handling soiled Equipment or utensils. (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks.

Licensure Reference Number 175 NAC 12-006.05(4) Based on record review and interview, the facility failed to ensure a signed copy of the resident's code status (the level of medical interventions a person wishes to have started if their heart or breathing stops) was obtained for 14 residents, (Residents 49, 20, 23, 51, 11, 40, 54, 12, 7, 43, 57, 8, 3 and 56) of 15 residents sampled. The facility census was 61. Findings are: [NAME] Record review of Resident 20's Progress Notes dated 10/23/18 at 11:14 AM revealed that Resident 20's wishes are to be a DNR (No Not Resuscitate-revive someone if their heart stops or breathing ceases). Record review of Resident 20's medical record revealed no signed copy of Resident 20's wishes to be a DNR. Interview with Administrator on 02/11/20 at 09:16 AM confirmed that Resident 20's preference for DNR was not obtained in writing. B. Record review of Resident 11's Progress Notes dated 06/07/16 at 2:09 PM revealed that Resident 11's wishes are to be a DNR. Record review of Resident 11's medical record revealed no signed copy of Resident 11's wishes to be a DNR. Interview with Administrator on 02/11/20 at 09:16 AM confirmed that Resident 11's preference for DNR was not obtained in writing. C. Record review of Resident 57's Progress Notes dated 08/18/15 at 3:48 PM revealed that Resident 57's wishes are to be a DNR. Record review of Resident 57's medical record revealed no signed copy of Resident 57's wishes to be a DNR. Interview with Administrator on 02/11/20 at 09:16 AM confirmed that Resident 57's preference for DNR was not obtained in writing. D. Record review of Resident 56's Progress Notes dated 07/05/19 at 07:40 AM revealed that Resident 56's wishes are to be a DNR. Record review of Resident 56's medical record revealed no signed copy of Resident 56's wishes to be a DNR. Interview with Administrator on 02/11/20 at 09:16 AM confirmed that Resident 56's preference for DNR was not obtained in writing. E) Review of Resident 43's Face Sheet dated 2/6/20 revealed the resident's Advance Directive was Do Not Resuscitate (DNR - indicates a resident does not want to receive cardiopulmonary resuscitation if the heart stops beating or the resident stops breathing). Review of Resident 43's Electronic Health Record (EHR) revealed an absence of the documentation related to the resident or resident representative's choice of code status. Review of Resident 43's undated Care Plan revealed an absence of documentation related to advance directives or code status. F) Review of Resident 51's Face Sheet dated 2/6/20 revealed the resident's Advance Directive was DNR. Review of Resident 51's EHR revealed an absence of the documentation related to the resident or resident representative's choice of code status. Review of Resident 51's undated Care Plan revealed an absence of documentation related to advance directives or code status. Review of the Advance Care Planning and Advance Directives Policy revised 4/2016 revealed if a resident had formulated an advance directive, a copy will be scanned into the EHR. Interview on 02/06/20 with the Administrator (ADM) revealed a resident's code status was noted on the face sheet and on the name tag on the resident's door. The ADM revealed on admission a staff member would discuss code status with the resident and the resident representative and document the discussion in the resident's progress notes. The ADM revealed the resident/resident representative's code status decision is sent to the physician, who would give the order for the DNR. G Record review of Resident 40's Care Conference Note dated 01/09/19 revealed that Resident 40 continued to be a Do Not Resuscitate (DNR) Advanced Directive per their request. Record review of Resident 40 electronic Medical Record that there was not any Resident or Family signed Advanced Directive in the electronic record. Interview on 02/10/20 at 3:35 PM with Social Services Director (SSD) revealed that they do not keep a signed copy of the resident's Advanced Directive in the Medical Record. H Record review of Resident 49's Progress Note dated 10/24/18 revealed that Resident 49 and Resident's 49 Mother POA (Power of Attorney) met with Social Service Director (SSD) to change to Do Not Resuscitate (DNR) code status Advanced Directive per Resident 49's request. Record review of Resident 49 electronic Medical Record revealed that there was not any Resident or Family signed Advanced Directive in the electronic record. Interview on 02/10/20 at 3:35 PM with Social Services Director (SSD) revealed that they do not keep a signed copy of the resident's Advanced Directive in the Medical Record. I) Record review on 02/10/20 of Resident 7's Progress Notes dated 6/25/2019 at 3:07 PM revealed that Resident 7's wishes are to be a DNR. Record review on 2/10/20 of Resident 7's medical record revealed no signed copy of Resident 7's request to be a DNR. Interview with Social Service Director on 02/11/20 at 09:22 AM confirmed that the facility does not have a signed copy in writing of Resident 7's request to be a DNR. J) Record review on 02/11/20 of Resident 12's Progress Notes dated 11/28/2018 at 5:03 PM revealed that Resident 12's wishes are to be a DNR. Record review on 2/11/20 of Resident 7's medical record revealed no signed copy of Resident 12's request to be a DNR. Interview on 2/11/20 with Social Service Director at 9:10 AM confirmed that the facility does not have a copy in writing of Resident 12's request to be a DNR. K) Record review on 2/11/20 of Resident 23's Progress Notes dated 8/28/2019 at 2:28 PM revealed that Resident 23's wishes are to be a Full Code (interventions needed to get a heart started, when stopped). Record review on 2/11/20 of medical record revealed no signed copy of Resident 23's request to be a Full Code. Interview on 2/11/20 at 9:15 PM confirmed that the facility does not have a signed copy in writing of Resident 23's request to be a Full Code. L. Record review of Progress Note dated 12/15/17 and most recent, undated Care Plan revealed that on 12/15/17 the Social Service Designee discussed Resident 54's wishes in regards to Advanced Directives however, the facility failed to establish and maintain documentation of Advanced directives on Resident 54's chart. Interview conducted on 02/11/20 at 11:15 with Administrator revealed no actual form is signed or maintained on Resident's chart M. Record review of Progress Note dated 10/15/19 and most recent, undated Care Plan revealed that on 10/15/19 the Social Service Designee discussed Resident 08's wishes in regards to Advanced Directives however, the facility failed to establish and maintain documentation of Advanced directives on Resident 08's chart. Interview conducted on 02/11/20 at 11:15 with Administrator revealed no actual form is signed or maintained on Resident's chart N. Record review of Progress Note dated 01/29/16 and most recent, undated Care Plan revealed that on 01/29/16 the Social Service Designee discussed Resident 03's wishes in regards to Advanced Directives however, the facility failed to establish and maintain documentation of Advanced directives on Resident 03's chart. Interview conducted on 02/11/20 at 11:15 with Administrator revealed no actual form is signed or maintained on Resident's chart

Licensure Reference Number 175 NAC 12-006.11D Based on observation and interview, the facility failed to prepare the roast pork puree as directed by the recipe for 2 residents (Residents 49, 5) of 2 residents reviewed. The facility census was 61. Findings are: Observation on 02/10/20 at 10:15 AM revealed Dietary Staff D prepared 2 roast pork purees for 2 (Residents 49, 5) in the facility kitchen. Dietary Staff D added ¼ cup of water to the roast pork puree times 2. Dietary staff D stopped the blender and poured more water into the roast pork puree without measuring the water. Record review of Roast Pork recipe dated 10/3/16 revealed: for puree, place portions of roast pork and broth into blender and process until smooth. For every 5 portions, combine ¾ teaspoon soup base with ¾ sup hot water to form broth. Interview on 02/10/20 at 1:10 PM with Dietary Staff D confirmed the puree recipe for the roast pork was not followed. Interview with Dietary Manager on 02/10/20 at 1:15 PM confirmed the expectation is to follow puree recipe.

Licensure Reference Number NAC 175 12-006.09D2 Based on observation, record review and interview; the facility failed to document and monitor bruising for one resident (Resident 43) of three residents reviewed. The facility census was 61. Findings are: Observation on 02/05/20 at 11:18 AM revealed Resident 43 had 3 small purple bruises to right arm. Record review of Resident 43's Electronic Health Records (EHR) assessments revealed no skin observations were completed from 9/30/19 to 2/11/2020. Interview on 02/10/20 at 03:18 PM with Director of Nursing (DON) revealed the facility would not do resident skin checks until a skin issue was identified. Interview on 02/11/20 at 07:52 AM with Licensed Practical Nurse (LPN) A revealed skin issues would be documented in the progress notes under Health Status or under the Skin User-Defined Assessments (UDA). LPN A also revealed that a skin assessment should be completed every week on the resident's bath day. LPN A also verbalized that if there was a skin tear or bruise that is of unknown origin the facility would do a risk management or incident report. Interview on 02/11/20 at 07:58 AM with Nurse Aide (NA) B revealed the residents should get a skin check weekly during the first bath of the week. If a resident would have a second bath and the nurse aide would notice a skin issue, the nurse aide would call the nurse to come look at it. NA B also verbalized that the nurse aides did not document on the residents skin condition. Review of Resident 43's care plan revealed the nurse should be notified of new areas of skin breakdown including bruises that were noted during bath or daily care. Record review of Resident 43's P[NAME] bathing documentation revealed the resident had a bath on 2/7/20 and refused a bath on 2/10/20. Review of progress notes in Resident 43's EHR revealed no documentation related to bruising from 2/5/20 to 2/11/2020. Review of Skin Assessment, Pressure Ulcer Prevention and Documentation Requirements Policy, revised 3/2019, revealed if a bruise was observed on a resident it should be reported to the nurse immediately, and should be monitored weekly and the progress towards healing should be documented on the skin observation UDA and on the resident's care plan. Interview on 02/11/20 08:57 AM with Physical Therapy (PT) C revealed therapy discharged Resident 43 1-2 weeks ago, and the resident was independent with a walker. Interview on 02/11/20 at 09:24 AM with the DON revealed that an NA would report a bruise, skin tear or any skin concern to the nurse during a resident bath. The nurse would get orders if a treatment was needed and skin monitoring would be added to the Treatment Administration Record (TAR) until the area healed. The DON also verbalized that when a skin area was initially found there would be a progress note and if the area was suspicious there would be an incident report. The DON revealed that once the area was healed it would be discontinued off the TAR with a note as to why it was discontinued. The DON revealed that the nurse aides could document in the Point of Care (P[NAME]) charting under skin checks, but is not required daily charting. DON confirmed independent residents would only have skin checks completed with bathing, if the resident would report a concern, or if the staff would see a skin issue. The DON confirmed that Resident 43 did not have any documentation related to monitoring bruises in the EHR. The DON also confirmed Resident 43 did not have any skin assessments scheduled. Resident 43 did have initial skin assessments upon admission and continued on daily skilled nurses notes which included skin assessments but the resident no longer received skilled care after 12/28/19 so did not had a full body skin assessment since 12/27/19. The DON revealed skin concerns would be noticed during a bath. DON was unable to provide answer when asked how skin concerns would be identified on an independent resident who refused baths. Observation on 02/11/20 at 09:56 AM of Resident 43 revealed the resident had fading brown bruises to bilateral arms and purple bruises to right arm. Record review of Resident 43's TAR revealed an absence of documentation regarding monitoring of bruises.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10A1 Based on observation, record review, and interview; the facility failed to ensure 1 resident (Resident 43) was assessed for safe self-administration of medication on 1 residents reviewed. Facility census was 61. Findings are: Observation on 2/5/20 at 11:15 AM revealed Resident 43 had a package of Xylimelt mints (oral-adhering discs that stick to the teeth or gums to relieve persistent dry mouth) in a small basket kept on the resident's bedside table. Interview on 2/5/20 at 11:15 AM with Resident 43 revealed the mints are used to treat dry mouth through the night. Observation on 2/10/20 at 11:47 AM revealed Resident 43 had the Xylimelt mints and a container of TUMS (Calcium [MEDICATION NAME] Antacid - a medication used to treat symptoms caused by too much stomach acid, such as heartburn, upset stomach, or indigestion) in the small basket kept on the resident's bedside table. Review of Resident 43's Order Summary dated 2/10/20 revealed an order for [REDACTED].>Review of Resident 43's undated Care Plan revealed an absence of documentation related to self-administration of medication. Review of the Resident Self-Administration of Medication policy revised 10/2017 revealed that a physician's orders [REDACTED]. The policy also revealed medication cannot be left within reach of another resident and must be under the control of the resident who is self-administering at all times. Interview on 02/10/20 at 02:34 PM with the DON (Director of Nursing) confirmed Resident 43 did not have a self-administration of medication assessment completed. The DON also confirmed self-administration of medication was not on Resident 43's care plan and the resident should not have any medications kept at the bedside. The DON revealed the resident's family probably brought the TUMS and Xylimelt mints into the facility for Resident 43.

Licensure Reference Number 175 NAC 12-006.17 Based on observation and interview, the facility failed to ensure oxygen tubing was not in contact with the floor for 2 residents (Residents 7, 20) of 2 residents reviewed. The facility census was 61. Findings are: [NAME] Observation on 2/5/20 at 4:19 PM, 2/6/20 at 8:23 AM, and 2/10/20 at 9:05 AM revealed Resident 7's oxygen tubing lying on the floor across room connected to an oxygen concentrator (a medical device that delivers supplemental oxygen). The nasal cannula (a device used to deliver supplemental oxygen, which are placed in the nostrils) was touching the floor. Observation on 2/11/20 at 9:28 AM revealed Resident 7's oxygen tubing lying on floor with nasal cannula under Resident 7's wheelchair wheel. Interview on 02/11/20 at 9:54 AM with Director of Nursing confirmed the facility expectation is not to have oxygen tubing on the floor for infection control issues. B. Observation on 02/06/20 at 03:26 PM revealed that Resident 20 was in the bathroom and the oxygen tubing was strung all the way from the oxygen concentrator (a medical device used to deliver oxygen) by the recliner to the wheelchair right outside the bathroom door. The nasal prongs and the tubing were touching the floor. Observation on 02/10/20 at 09:10 AM revealed that Resident 20 was lying in bed. Resident 20's oxygen tubing was coiled on the floor from the oxygen concentrator to the bed. Observation on 02/11/20 at 08:39 AM revealed that Resident 20 was out of their room, the oxygen concentrator was turned off and the oxygen tubing was lying on the floor from the bed to the oxygen concentrator. Interview on 02/11/20 at 08:37 AM with DON confirmed that oxygen tubing should not be on the floor.

Licensure Reference Number: 175 NAC 12-006.05(9) Based on interviews and record reviews, the facility failed to ensure 1 resident (Resident 22) of 35 residents sampled was free from abuse. The facility staff identified the census at 64. A review of Resident 22's Admission Record dated 9-27-17 revealed that Resident 22 was admitted to the facility on [DATE]. A review of Resident 22's Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning) dated 8-29-17 revealed a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact). An interview conducted on 9-25-17 at 2:14 PM with Resident 22 revealed that Resident 22 was involved in an altercation one morning with Resident 31 where Resident 22 was hit by Resident 31. Resident 22 reported that Resident 31 also threatened to kill Resident 22 and that Resident 31 attempted to hit Resident 22 again that evening. Resident 22 reported that they did not feel safe around Resident 31 and that the resident had a lock put on their door until Resident 31 was discharged in order to ensure Resident 31 did not get in the room. An interview conducted on 9-28-17 at 9:01 AM with Resident 22 revealed that Resident 22 felt the facility staff handled resident concerns well except for the way the facility handled Resident 31. Resident 22 reported it took the facility months to do anything about Resident 31. A review of the facility's Resident to Resident investigation dated 4-25-17 revealed that Resident 31 at 7:27 AM slapped Resident 22 across the face and rammed their electric wheelchair into Resident 22's electric wheelchair. The facility staff intervened and removed Resident 31 from the area and that multiple staff heard Resident 31 say they wanted to kill Resident 22. Resident 31 was documented to have told the Social Services Director that they would beat Resident 22 down. Resident 22 and Resident 31 resided in different parts of the facility and ate in separate dining rooms. A review of a witness statements dated 4-25-17 revealed that Resident 31 was overheard saying they would kill Resident 22 or beat Resident 22 to death. An interview conducted on 9-27-17 at 9:33 AM with Licensed Practical Nurse (LPN) A revealed that Resident 22 had come to Resident 31's room and yelled at Resident 31 while LPN A was doing Resident 31's leg treatments. LPN A reported that Resident 31 attempted to stand up and go after Resident 22, but that Resident 31 ended up falling due to their feet being slippery as their dressing change was in process. LPN A reported that they spoke with Resident 31 about their temper and told Resident 31 to let it go and not go after Resident 22. LPN A reported that they asked a staff member from another hallway to follow Resident 31 to make sure Resident 31 to not go after Resident 22. LPN A reported that the staff person followed Resident 31 to Resident 22's room but the resident was not there. Resident 31 then went to the main dining with the staff person following, but the staff person was too far behind Resident 31 to keep them from hitting Resident 22. LPN A reports that Resident 31 did not eat meals in the main dining room and did not have a reason to go into the main dining room that day. LPN A reported that they did not call 911 or send Resident 31 to the emergency room . An interview conducted on 9-27-17 at 9:44 AM with the Social Services Director (SSD) revealed that both Residents 31 and 22 were placed on 15 minute checks and encouraged to stay out of each other's hallways. The SSD called the State Ombudsman and a 30 day discharge notice was issued to Resident 31. The SSD reported that they did call the local sheriff's office by non-emergency line and they said they would come to the facility if they had time. Resident 31 was not sent to the emergency room . The SSD reported that they called Resident 31's psychiatric nurse practitioner who spoke with the resident on the phone. The nurse practitioner told the SSD that Resident 31 knew what they were doing when they hit Resident 22 and was cognitively aware of his actions and his threats. The SSD reported that Resident 31 continued to verbalize threats towards Resident 22 that day. The SSD reported that a 30 day notice of discharge had been issued to Resident 31 in the past due to the resident having physical and verbal altercations with other residents, but it was not followed up. Resident remained in the facility until July because the facility struggled to find the resident a safe discharge location because the resident refused to be transferred to another skilled nursing facility. A review of Resident 31's Admission Record dated 9-27-17 revealed Resident 31 was admitted to the facility on [DATE] and was discharged from the facility on 7-14-17. A review of Resident 31's 15 minute checks revealed no documentation that resident was checked on 4-25-17 from 1:00 PM to 2:00 PM and on 4/28/17 from 5:15 AM to 6:00 AM. A review of Resident 31's progress note date 2-10-17 at 4:45 PM revealed that Resident 31 reported to the nurse that they had hit another resident in the face because the other resident had said the wrong thing to the wrong person. The nurse checked with the other resident that confirmed they were hit in the left cheek by Resident 31. A review of Resident 31's progress note dated 2-10-17 at 7:27 PM revealed that Resident 31 approached another resident from a previous altercation and told the other resident You better shut your mouth or I'm going to shut it for you. A review of Resident 31's progress note dated 3-4-17 revealed that Resident 31 was upset related to another residents clothing and was making accusations and threats toward the other resident. A review of Resident 31's progress noted dated 3-8-17 revealed that Resident 31 met with the SSD to discuss increased behaviors toward other residents and how the behaviors were affecting other resident's safety and endangering them. The resident verbalized to the SSD that they would stop bullying and belittling other residents. The resident was issued a 30 day notice of discharge at the meeting and the State Ombudsman was notified. A review of Resident 31's progress note dated 4-26-17 revealed that the SSD spoke with the State Ombudsman regarding the incident on 4-25-17 and that an 30 day notice of discharge had been issued to the resident on 3-8-17. The Ombudsman reported that per regulation, discharge can be as soon as practical if the safety of other residents and staff are a concern. A review of Resident 31's psychiatric progress note dated 4-20-17 revealed that facility staff had called the nurse practitioner several times due to increased behaviors. Resident 31 was having outbursts, rude to staff, threatening, and had been making scenes in front of other residents. The resident stated to the nurse practitioner that When I get in a corner, I don't back down. I never have and never will. The progress note instructed the facility staff to call 911 or send the resident to the emergency department in case of an emergency. A review of Resident 31's psychiatric progress note dated 4-25-17 revealed that Resident 31 visited on the phone with the psychiatric nurse practitioner. Resident 31 admitted to hitting Resident 22 and verbalized that if Resident 22 ever came near the resident's room again the resident would kill Resident 22. Resident 31 told the nurse practitioner that they were liable to hit Resident 22 again because they do not take lip from anybody, that is just who they are and they will never let people talk to them that way. The resident refused medication changes. Resident 31 expressed understanding that assaulting and threatening other residents was unacceptable and would not be tolerated in nursing facilities. The nurse practitioner made plans to see the resident in the facility the following month. A review of Resident 31's care plan revealed an intervention dated 4-13-17 for facility staff to intervene as necessary to protect the rights and safety of others. If an increase in aggression was noted or the resident had violent or threatening behaviors, the charge nurse was to call 911 and notify the DON. An interview conducted on 9-27-17 at 9:58 AM with the Director of Nursing (DON) revealed that Resident 31 and Resident 22 were placed on 15 minute checks. The police were called, but they did not do anything. The resident was not sent to the emergency room because the management staff felt the emergency room would not have done anything for the resident. An interview conducted on 9-28-17 at 8:11 AM with the Administrator revealed that Resident 31 threatening to kill Resident 22 would have been an emergency situation and the emergency room would have been a safe place for discharge for Resident 31. An interview conducted on 9-28-17 at 10:34 AM with the DON revealed that Resident 31 was not seen again by the psychiatric nurse practitioner after the incident on 4-25-17 due to the nurse practitioner going on medical leave and no one was assigned to see their patients during the medical leave. An interview conducted on 9-28-17 at 10:54 AM with the psychiatric nurse practitioner revealed that Resident 31 had been a patient of theirs for approximately 2 years. Resident 31 acted out aggressively in order to get attention. Resident 31 had the cognitive function to know what they did was wrong. The nurse practitioner reported that they felt Resident 31 would not act out violently again, but could not say for certain that the resident would not have acted out again had a resident said something that upset Resident 31. Resident 31 was cognitively aware of their actions.