Every finding on record at Good Samaritan Society - Hastings Village

Licensure Reference Number 175 NAC 12-006.11(E) Based on record reviews, observations, and interviews, the facility failed to follow the 2022 Food and Drug Administration (FDA) food code. This had the potential to affect all residents eating food out of the kitchen. The facility census was 52. Findings are: A record review of a policy titled, Date Marking- Food and Nutrition dated 4/3/24. The policy revealed:Policy:Time Temperature Control for Safety Foods (TCS) items are date-marked when received, when manufacturer package is opened and when removed from freezer into refrigeration. Dates are monitored to ensure food safety and quality for all foods at the location, including TCS snacks stored outside the preparation kitchen.Procedure:When TCS food is received, employees:Observe for vendors date of delivery and if not available, date mark the item with the delivery date.Observe for USE by date or USE or Freeze by date. This is an expiration date.As much as possible, food items should remain in their original containers/packaging if that package has a receiving date clearly marked.If the items are removed from the original container/package, individual items are labeled and dated with date of receiving.When TCS food has been opened but remains in storage, employees:Ensure that ready-to-eat TCS foods opened at the location are clearly date marked for:1. The date time the original container is opened2. The date or day by which the food shall be consumed on the premises, sold or discarded.3. Ready-to-eat foods TCS foods prepared at the location and held in refrigeration for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded.4. A food item is discarded when:The container does not bear a date or day.The TCS item is beyond the USE by date. On 7/14/26 at 9:00 AM, the facility kitchen was observed. The following items were found to be present in the kitchen.Several stand-up refrigerator/freezers labeled 100, 400, and cook fridge contained prepared and opened food items with an open date, no use by date. All use by dates were found to be blank.In the walk-in refrigerator a tub of chicken salad was found with a posted open date of 7/3/26.In the walk-in freezer an uncovered dished-up bowl of ice cream was found with no date or label.The stove and ovens are found to be on caster wheels. When moved, food debris was found to be on the floor between the wall and stoves.A tall food warmer was currently in use with lunch holding warm food trays. In the crease between the door and the seal of the door food debris and dust was thick and coated. An observation on 7/14/26 at 2:05 PM revealed a Dietary Aide (DA)-L was preparing foods and drinks for dinner service. DA-L was found to have artificial fingernails nails. An interview on 7/14/26 at 4:00 PM with the Dietary Manager (DM) revealed not knowing that DA-L had artificial fingernails nails. An interview on 7/14/26 at 4:00 PM with the Registered Dietician (RD) confirmed that dietary employees may not wear artificial fingernails when working with exposed food.

Licensure Reference Number 175 NAC 12-006.04(A)(ii)Licensure Reference Number 175 NAC 12-006.18Licensure Reference Number 175 NAC 12-006.09 (H)(vi)(3)(g)Based on record review and interview the facility failed to ensure that pre-employment health screens were completed for 5 of 6 sampled staff to prevent the potential for communicable disease for all facility residents; failed to ensure that reusable medical care equipment was cleansed and/or changed at a frequency to ensure it was maintained in a sanitary and usable condition for 2 residents (Resident 6 and 15); failed to ensure that staff providing direct resident cares did not have artificial nails that prevented proper hand sanitization during care for 2 residents (Resident 6 and 15); failed to ensure that all reusable oxygen equipment was thoroughly cleaned after use; and failed to ensure that disposable oxygen equipment was properly labeled and discarded for the prevention of infection for 1 resident (Resident 67). The facility census was 52.Findings are: A. Record review of the facility policy titled Hiring and Screening dated [DATE] revealed that the facility complies with existing federal regulations. The section titled Health Assessment and Drug Screen revealed that a pre-employment health screen will be conducted on all job applicants who have accepted offers of employment. The health assessment is required prior to the first day of employment. Record review of the untitled and undated list of facility staff with hire dates revealed that Housekeeping Supervisor (HS) had a hire date of [DATE]. Record review of the employee file for HS revealed that it did not contain a Communicable Disease Screening form (a pre-employment health screen was not conducted). Record review of the untitled and undated list of facility staff with hire dates revealed that Nurse Aide-C (NA-C) had a hire date of [DATE]. Record review of the employee file for NA-C revealed a Communicable Disease Screening form dated 5/2004 for NA-C. The form was signed by NA-C on [DATE]. The section titled Completed by Location revealed boxes to document completion of Communicable Disease Review and Immunization Review. The boxes were not marked as completed. The line for the Form completed by and Date were not completed and contained no reviewer signature as required. Record review of the untitled and undated list of facility staff with hire dates revealed that Nurse Aide-D (NA-D) had a hire date of [DATE]. Record review of the employee file for NA-D revealed a Communicable Disease Screening form dated 5/2004 for NA-D. The form was signed by NA-D on [DATE]. The section titled Completed by Location revealed boxes to document completion of Communicable Disease Review and Immunization Review. The boxes were not marked as completed. The line for the Form completed by and Date were not completed and contained no reviewer signature as required. Record review of the untitled and undated list of facility staff with hire dates revealed that Registered Nurse-E (RN-E) had a hire date of [DATE]. Record review of the employee file for RN-E revealed a Communicable Disease Screening form dated 5/2004 for RN-E. The form was signed by RN-E on [DATE]. The section titled Completed by Location revealed boxes to document completion of Communicable Disease Review and Immunization Review. The boxes were not marked as completed. The line for the Form completed by and Date were not completed and contained no reviewer signature as required. Record review of the untitled and undated list of facility staff with hire dates revealed that Dietary Aide-F (DA-F) had a hire date of [DATE]. Record review of the employee file for DA-F revealed a Communicable Disease Screening form dated 5/2004 for DA-F. The form was signed by DA-F on [DATE]. The section titled Completed by Location revealed boxes to document completion of Communicable Disease Review and Immunization Review. The boxes were not marked as completed. The line for the Form completed by and Date were not completed and contained no reviewer signature as required. Interview on [DATE] at 2:46 PM with the Facility Administrator (FA) confirmed that the facility did not complete the required Communicable Disease Screening for HS. The FA confirmed that the Communicable Disease Screening forms for NA-C, NA-D, RN-E, and DA-F were not reviewed as required and were incomplete. B. In an observation completed on [DATE] at 1:27 PM of Resident 6's bathroom it was observed that a bed pan was placed into a clear plastic bag hanging off a bar attached to the wall. There was visible brown particles debris in the bottom of the bed pan and an odor of vinegar and urine. In an observation completed on [DATE] at 9:45 AM Nurse Aide I (NA-I) and Nurse Aide N (NA-N) assisted Resident 6 to utilize the bed pan while lying in bed. When the resident had completed use of the bed pan NA-I took the bed pan into the resident's bathroom and then returned to the resident's bedside. In an observation completed on [DATE] at 9:55 AM of Resident 6's bathroom it was observed that the residents' bed pan was placed into a clear plastic bag hanging off a bar attached to the wall. There were visible brown and yellow particles to the inside of the residents' bed pan. In an interview completed on [DATE] at 10:00 AM with NA-I, NA-I stated that after a bed pan is utilized, they take it into the residents' bathroom and squirt a vinegar and water solution into it and then empty it into the toilet. They complete this a couple of times but sometime all the soiling does not come out. The NA stated that they are not sure how often the residents' bed pans are replaced. In an interview completed on [DATE] at 1:45 PM with the facility Director of Nursing (DON), the DON stated that they were unsure of the frequency that residents bed pans were changed and the method used by facility staff to cleanse them between uses. DON observed Resident 6's bed pan that is hanging in a clear plastic bag on a bar in the residents' restroom. The DON confirmed that the residents bed pan was unclean and should be thoroughly cleaned between uses until changed. The DON confirmed that the use of the vinegar and water solution for rinsing the bed pan did not properly cleanse the bed pan between uses. C. In an observation completed on [DATE] at 11:52 AM NA-I and NA-K assisted Resident 15 to utilize the bed pan while lying in bed. When the resident had completed using the bed pan NA-I took the bed pan into the resident's bathroom. The NA used a spray bottle to spray a solution into the bed pan and then swished it around and emptied the contents into the toilet. The NA then repeated the process and then placed the bed pan into a clear plastic bag hanging of a bar in the resident's bathroom. There is visible light brown thick substance present to the back edge and lip of the bed pan. In an interview completed on [DATE] at 1:45 PM with the facility Director of Nursing (DON), the DON stated that they were unsure of the frequency that residents bed pans were changed and the method used by facility staff to cleanse them between uses. DON observed Resident 6's bed pan that is hanging in a clear plastic bag on a bar in the residents' restroom. The DON confirmed that the residents bed pan was unclean and should be thoroughly cleaned between uses until changed. The DON confirmed that the use of the vinegar and water solution for rinsing the bed pan did not properly cleanse the bed pan between uses. D. In an observation completed on [DATE] at 9:45 AM Nurse Aide I (NA-I) assisted Resident 6 to utilize the bed pan while lying in bed. When the resident had completed use of the bed pan NA-I took the bed pan into the resident's bathroom and then returned to the resident's bedside. NA-I was observed to have long pointed bright pink fingernails to all fingers of both hands. In an observation completed on [DATE] at 11:52 AM NA-I assisted Resident 15 to utilize the bed pan while lying in bed. When the resident had completed using the bed pan NA-I took the bed pan into the resident's bathroom. When the NA returned to the resident bed side it was observed that the NA had long pointed bright pink fingernails to all fingers of both hands. In an interview completed on [DATE] at 1:35 PM with the facility Infection Preventionist (IP), the IP confirmed that the facility discouraged direct care staff from having long false fingernails. In an interview completed on [DATE] at 1:36 PM with NA-I, NA-I confirmed that they had long false fingernails and this was discouraged while working in the facility and providing care to residents. The NA confirmed that they should not have false nails on. E. Record review of the facility policy dated [DATE] Oxygen Administration, Safety, Mask types – R/S, LTC, Therapy and Rehab revealed that the purpose of the policy was to administer oxygen and store oxygen in a safe manner, to keep oxygen equipment clean and maintained in good condition, and to administer carious levels of oxygen concentration and/or humidity in a safe manner. Equipment included oxygen concentrators, oxygen cylinders, and oxygen tubing among others. Oxygen was to administered with a medical provider's orders. Continuing education would be provided annually of safety, handling and usage requirements for employees that handle oxygen. Guidelines revealed that 9.) all oxygen therapy equipment will be clean, sage and functional. 10.) All oxygen cylinders and concentrators will be stored in a clean, controlled area. 13.) Employees should be trained in proper cleaning and storage of all oxygen cylinders, concentrators and liquid oxygen. Record review of the Resident Clinical Census data from the electronic medical record (EMR) revealed Resident 67 was admitted on [DATE]. Record review of the Medical Diagnoses dated [DATE] revealed Resident 67 had the following diagnoses: malignant neoplasm (cancer) of the right bronchus or lung, secondary malignant neoplasm (cancer) of the brain, chronic obstructive pulmonary disease (COPD) (a progressive lung disease that makes it hard to breathe), chronic respiratory failure (a long-term condition where the respiratory system cannot adequately supply oxygen to the blood or remove carbon dioxide), shortness of breath, and generalized weakness among other diagnoses. Oxygen Concentrators were assigned to an individual resident and should not be shared without proper cleaning between residents. Best practice was to label each concentrator with the resident's name. Cleaning of the concentrator and filter and inspections revealed that disposable equipment should be changed weekly or according to the manufacturer's instructions and marked with a date and initials. Filters were to be changed between residents. Observation on [DATE] at 4:21 PM in the room of Resident 67 who has an oxygen concentrator at bedside revealed: The oxygen tubing is not labeled. Blue bag used for oxygen supplies when not in use was dated [DATE] and room [ROOM NUMBER] and had another resident's initials on the bag. There is also a portable oxygen cannister with oxygen tubing attached that is not labeled or dated. Observation on [DATE] at 9:25 AM revealed oxygen tubing was dated and labeled. Oxygen concentrator was at bedside and the blue bag for extra supplies or supply storage remained on the concentrator and was dated [DATE] with the wrong room number. Observation on [DATE] at 9:50 AM revealed the oxygen cylinder remained in the room but the tubing had been discarded. The blue bag on the oxygen concentrator remained on the concentrator dated [DATE], with the wrong room number and another resident's initials. The oxygen tubing was now dated and labeled. Interview on [DATE] at 1:20 PM with Medication Aide (MA) M revealed that the night shift staff are the ones that change the oxygen tubing. I am not sure how often it is done but I think it is completed once a week. The tubing is supposed to be dated and labeled. The blue bags were also supposed to be changed but wasn't sure how often. The bag on the oxygen concentrator does not belong to this resident. I think that the resident whose initials are on that blue bag passed away. Interview on [DATE] at 1:23 PM with the Director of Nursing (DON) revealed the DON did not know how often the oxygen tubing was to be changed for each resident. I will need to check the facility policy. I will also need to check the policy for how often the blue bags that hold supplies are changed. I am not sure about how often they change out the oxygen concentrators or if we leave them here. DON confirmed that the blue bag on the oxygen concentrator for Resident 67 is labeled [DATE] and has the initials of another resident in room [ROOM NUMBER] on the label. That can't belong to Resident 67 because Resident 67 wasn't admitted until [DATE]. Interview on [DATE] at 1:26 PM with the Quality Assurance Coordinator (QAC) revealed that the oxygen concentrators come to the facility from a medical supply company. They are switched out every once in a while, by the company that supplies them for us, otherwise the facility keep them in house in storage. QAC further stated that the oxygen concentrators are cleaned and stored somewhere but wasn't sure where and stated that Infection Preventionist (IP) would know more about where the facility staff store them. Interview on [DATE] at 1:30 PM with the Infection Preventionist (IP) who revealed that oxygen tubing is supposed to be changed out weekly and labeled and dated. The little blue bags that are used for oxygen storage supplies is supposed to be changed every month. The IP confirmed that the blue bag in the room of Resident 67 was not supposed to be in that room and had not been changed from the last resident who must have used that oxygen concentrator. The IP confirmed that the last person who had that bag had expired and that the bag should have been thrown away. The IP stated that the concentrators are cleaned thoroughly, or supposed to be, then stored in the closet. Observation on [DATE] at 1:37 PM of the oxygen concentrators stored in a storage room where there were 4 concentrators not in use with the IP nurse revealed that 3 of the 4 stored concentrators that were cleaned had a used blue bag on them. The Infection Control Nurse immediately removed these and said (gender) had some work to do and some training to do with staff. The IP confirmed that the blue bags should have been removed from the concentrators if the concentrators were thoroughly cleaned.

Licensure Reference Number 175 NAC 12-007.03(K). Based on observations and interviews, the facility failed to affix handrails securely to the walls in resident corridors, this had the potential to affect all residents residing in the facility. The facility census was 52. Findings are: An observation and walkthrough at 3:30 PM on 7/14/26 with the Maintenance Director (MD) and Housekeeping Supervisor (HS) revealed a several foot long rounded handrail in the front corridor area of the building entrance loose. The MD and HS observed drywall falling from around the edges of the handrails, screws and attachments that were affixed to the wall. An observation and walkthrough at 3:30 PM on 7/14/26 with MD and HS revealed loose handrailing beside the bathing room on 100 hall. MD revealed they were aware of this railing being loose. An observation and walkthrough at 3:30 PM on 7/14/26 with MD and HS revealed loose handrailing beside and across from the activity room in an open corridor area where people gather. MD revealed they were unaware of this railing being loose. An observation and walkthrough at 3:35 PM on 7/14/26 with MD and HS revealed loose handrailing across from the smaller dining room that is occupied by residents who reside in the 400 halls. MD revealed they were unaware of this railing being loose. An observation and walkthrough at 3:35 PM on 7/14/26 with MD and HS revealed loose handrailing outside of Resident 47's room. MD revealed they were unaware of this railing being loose. An observation and walkthrough at 3:35 PM on 7/14/26 with MD and HS revealed loose handrailing outside of Resident 50's room. MD revealed they were unaware of this railing being loose. A record review of documentation titled Logbook Documentation dated 7/1/26 revealed:1.Safety inspections shall be completed so that the entire operational location is inspected quarterly by the safe practices and inspections task group of the safety committee.2. The person assigned the responsibility for the safe practices and inspections task group, as outlined by the safety committee, should perform the safety inspections.3. The safety inspections shall be conducted on a scheduled basis.5. Immediately schedule and/or repair required repair.Instructions: Complete the inspection other interior areas checklist.Railings/grab bars in good condition: checkmark yes/no/non-applicable(NA)Lobby/Entrance - blankHallways - blankComments: No informationInspection summary for safety committee (include plan of correction): No informationPerform task for building: 100 handrail pulled out of wall again. An interview at 3:30 PM on 7/14/26 with MD revealed knowing the handrails in the front corridor area were loose and drywall was falling out of the wall. MD agreed this was considered a hazard and was aware of the concern. An interview at 3:30 PM on 7/14/26 with MD revealed knowing the handrails beside the bathing room on 100 hall were loose and not affixed to the wall securely. An interview at 3:30 PM on 7/14/26 with MD revealed not knowing the handrails beside and across from the activity room in an open corridor area were loose and not affixed to the wall securely. An interview at 3:35 PMon 7/14/26 with MD revealed not knowing the handrailing outside of Resident 47's room were loose and not affixed to the wall securely. An interview at 3:35 PM on 7/14/26 with MD revealed not knowing the handrailing outside of Resident 50's room were loose and not affixed to the wall securely.

Licensure Reference Number 175 NAC 12-006.12(D)(iii)Based on observation, record review, and interview the facility failed to ensure that medications and medical supplies were not expired. The facility census was 52.Findings are:Record review of the facility policy titled Medications: Acquisition, Receiving, Dispensing, and Storage dated 3/30/26 revealed that the location will routinely check for expired medications and necessary disposal will be done in accordance with state/pharmacy regulations. Observation on 7/13/26 at 10:11 AM in the 100 medication storage room revealed that a box of Vacuette Drawing Needles expired on 5/19/26 (sterile, single-use stainless steel needles used by medical professionals to collect venous blood samples). An unopened box of Accucheck SafeT-Pro Plus lancets expired on 2/28/25 (a sterile single-use medical device with a blade that pricks the skin to draw small drops of blood for checking blood sugar). Alginate dressings with some expired on 9/1/24 and some on 7/1/25 (a natural wound dressing that covers and absorbs wound fluid). Tubes of Remedy Cream with some expired on 1/2025, some expired on 7/2025, and some on 11/2025 (an antifungal medication applied onto the skin). Observation on 7/14/26 at 2:56 PM in the 400 medication room revealed that an opened package of purple top specimen tubes expired on 3/1/25 (vacuum blood collection tubes containing an additive that prevents blood from clotting for laboratory blood tests) . A bag with two Bisacodyl suppositories in the refrigerator that expired on 1/2025 (a medication inserted into the rectum for stimulating a bowel movement to treat constipation). Observation on 7/14/26 in the 100 medication room with the facility Director of Nursing (DON) confirmed that the Vacuette drawing needles expired on 5/19/26. The DON confirmed that the unopened box of Accucheck Safe T-Pro Plus lancets expired on 2/28/25. The DON confirmed that the container of Alginate dressings had packages that expired on 9/1/24 and some on 7/1/25. The DON confirmed that the tubes of Remedy Cream were all expired. The DON confirmed that some tubes expired on 1/2025, some on 7/2025, and some on 11/2025. Observation on 7/14/26 at 3:47 PM in the 400 medication room with the DON confirmed that the opened package of purple specimen tubes expired on 3/1/25. The DON confirmed that the two Bisacodyl suppositories were expired with an expiration date of 1/2025. Interview on 7/14/26 at 3:47 PM with the DON confirmed that the facility is required to monitor medications and medical supplies to ensure that they are not outdated. The DON confirmed that the outdated medications and supplies should not be used and would be disposed of.

Licensure Reference Number 175 NAC 12-006.04(H) Based on record reviews, interviews and observations, the facility failed to serve meals in a timely manner based on the facility's posted time for meals. This had the potential to affect all residents who ate meals in the dining rooms. The facility census was 52. Findings are:A record review of posted mealtimes and locations reveal:Breakfast-7:30 AMLunch-11:30 AMEvening Meal-5:30 PMDining room locations:100 Avenue-Central Hub of Building400 Avenue-Between 400 Nurse Station and room [ROOM NUMBER] An observation in 100 Avenue dining room on 7/13/26 at 11:57 AM, meal service had not yet started. An observation in 100 Avenue dining room on 7/13/26 at 12:45 PM, last person was served their meal for lunch. An observation in 100 Avenue dining room on 7/14/26 at 8:00 AM, meal service had not yet started. An observation in 400 Avenue dining room on 7/14/26 at 8:10 AM, meal service had not yet started. An observation in 400 Avenue dining room on 7/14/26 at 8:55 AM, last person was served their meal for breakfast. An interview with Medication Aide (MA)-J on 7/14/26 at 8:58 AM revealed they are responsible for delivering the meals but are unable to care for the residents and deliver meals, therefore kitchen staff typically do this and takes longer than anticipated. An observation in 400 Avenue dining room on 7/14/26 at 11:50 AM, meal service had not yet started. An observation in 400 Avenue dining room on 7/14/26 at 12:48 PM, last person was served their meal for lunch. An observation in 400 Avenue dining room on 7/15/26 at 8:35 AM, last person was served their meal for breakfast. An observation in 100 Avenue dining room on 7/15/26 at 8:37 AM, last person was served their meal for breakfast. The Dietary Manager (DM) was interviewed on 7/14/26 at 2:45 PM revealing that the dietary aides that serve the meal are also responsible for serving the residents and confirmed the above listed meals were late being served.

Licensure Reference Number 175 NAC 12-006.19 Based on record reviews and interviews, the facility failed to provide daily housekeeping per the Resident Agreement for 2 residents (Resident 18 and Resident 25) of 13 residents sampled. The facility census was 52. Findings are:A record review of a facility policy titled Housing with Services: Rehab/Skilled & Long-Term Care: Housekeeping Resource Packet dated 8/21/25Standard or Light Cleaning-Rehabilitation/Skilled Care & Long Term Care:Purpose: To provide procedures for the proper, daily cleaning of resident roomsBackground: Rehabilitation/skilled care setting provide care and services to residents who are often vulnerable to infections and the effects of infections due to weakened immune systems. As such, thorough, routine, and high quality cleaning procedures are necessary to minimize the prevalence of infection.Procedure:1. Standard or light cleaning should occur on a daily basis in occupied rooms. If standard or light cleaning is not scheduled daily, the scheduled should be adjusted for daily cleaning in rooms where residents are under transmission precautions or other conditions that may require more frequent cleaning. A record review of a housekeeping calendar for July reveals that only Monday through Friday is scheduled for 1 housekeeper and 1 housekeeping supervisor both from 6:00 AM through 2:30 PM. The schedules states: 100-hall is scheduled for daily cleanings on Mondays, Wednesdays and Fridays. 400-hall is scheduled for daily cleanings on Tuesdays and Thursdays. Friday's state trash and toilets. A record review of a schedule outline for housekeeping titled, 100 rooms Monday, Wednesday, Friday 400 Tuesday and Thursday undated reveal:Dust all surfaces including vents, wipe high touch surfaces, clean bedrails, bedside tables top to bottom, call lights, bed remotes, clean mirrors, soap and sanitizer drip trays, sink, toilets inside and out, check/restock supplies, spray all fabric surfaces with airlift, take trash out, vacuum and mop.Monday through Friday-run floor machineMonday through Friday-clean bath house and shower houseMonday through Friday-clean all public bathrooms and breakroomMonday through Friday-vacuum all carpet areasMonday and Friday-and as needed, clean all entryway windows (100) Tuesday and Thursday (400)Monday-high dusting in hallways and common areas(100) Thursdays (400)Wednesday-low dusting in hallways and common areas (100) Thursdays (400)Monday and Friday-Dust furniture in common areasClean hopper rooms and carts on Wednesdays (100) Thursdays (400)Monday-(100) Tuesday (400) and as needed clean drip trays on sanitizer dispensers in hallwaysMonday through Friday-handrails at the end of the dayFriday's-change out laundry carts A record review of a Resident Handbook, dated 6/21 revealed Housekeeping Services:Your room will be cleaned daily and replenished with paper supplies by the housekeeping staff. Wet Floor signs are placed in areas where the floors are wet. Please be careful when you see these signs in the halls. An interview with Housekeeping Supervisor (HS) and Housekeeper (HSK)-H on 7/14/26 at 9:55 AM revealed that no housekeeping services are done on weekends because there is no additional housekeepers hired at this time to fill the position. HS further revealed that it had been this way since coming to work at the facility. Additionally, HS revealed that an ad has been placed to hire someone to fill the position. A record review of an employee listing revealed a hire date for HS on 3/3/26. An interview on 7/12/26 at 3:47 PM with Resident 25 reveals soiling on the window makes it difficult to view nature outside, not sure if or when the window will be cleaned. An observation on 3/14/26 at 3:30 PM with HS and Maintenance Director (MD) revealed Resident 25's outdoor window contains buildup of soiling and scaling from outdoors. An interview with MD and HS on 3/14/26 at 3:30 PM reveals windows are cleaned outdoors in springtime. Windows were not scheduled to be cleaned however MD reveals a plan will be set to get them cleaned in the future. An observation on 7/12/26 at 3:35 PM with Resident 18 revealed strong urine odors in room and bathroom. An interview on 3/14/26 at 3:35 PM with HS revealed some residents need additional cleaning in bathrooms as necessary to prevent lingering odors.

The facility failed to ensure that the Ombudsman was notified of transfers and discharges; and failed to ensure that a written copy of the reason for transfer to the hospital was given to the resident or the resident representative. This affected one of one sampled residents, Resident 14. Based on record review and interview, the facility failed to ensure that the State Ombudsman was notified of all transfers and discharges; and failed to ensure that a written copy of the reason for transfer to the hospital was given to the resident or the resident representative. This affected 1 of 1 sampled residents, Resident 14. The facility Census was 52. Findings were:Record review of the facility's Admission, Transfer and Discharge Team policy dated 9/8/2025 revealed the purpose was to discuss potential admissions, transfers, and discharges and implications for the operation of the entire facility and to make decisions on admissions, transfers, or discharges balancing the needs of the resident and the facility's ability to meet those needs. Furthermore the policy procedure stated that admissions, transfers, and discharges will be conducted according to state and federal guidelines. Record review of Resident 14's Clinical Census revealed Resident 14 transferred to the hospital on 7/5/26 and returned to the facility on7/8/2026.Record review of the Ombudsman notifications for the past 6 months revealed that there were no notifications sent to the Ombudsman in the past 6 months.Interview with the Social Services Director (SSD) on 7/13/2026 at 1:37 PM confirmed that no information had been sent to the Ombudsman since SSD's hire date in May 2026. After searching through records, the SSD was unable to locate any other information sent to the State Ombudsman since the year 2022. The SSD also revealed not knowing this was a requirement of the facility as the SSD was not trained to send these notifications and would contact the specified State Ombudsman immediately to find out what was required from the facility. When asked if any notifications had been sent to residents or to the resident representatives, the SSD stated, I have not given any written notifications at the time of the transfers or discharges. I do call the families and let them know we are transferring, or that we transferred a resident. I did contact the family of Resident 14 prior at the time of the transfer to the hospital.Interview on 7/13/26 at 1:40 PM with the Facility Administrator (FA) revealed that SSD is new to the facility as of May 2026 and did not know that one needed to inform the Ombudsman about any transfers, or discharges of residents in the facility at any time. The FA joined the facility on 6/8/26 and will start an immediate review of those individuals that need to be reported to the State Ombudsman's office and assist the SSD with documents that have not been completed. The FA will discuss with the SSD what needs to be reported, to whom information needs to be reported, and what needs to be reported. Interview with the FA on 7/13/26 at 1:55 PM who is seated in the administration office with the SSD training the SSD about the interventions that must be taken when a resident leaves the facility. FA confirmed that no documentation related to Ombudsman notification was sent to the Ombudsman and that the Ombudsman is going to be contacted to find out how and when the Ombudsman wants to be notified about discharges and transfers. FA stated I did not know that we needed to send the resident or the representative a written copy of the reason for transfer. We will look into this too. FA confirmed that no written reason for transfer was given to either Resident 14 or the resident representative at the time of transfer and that the Ombudsman was not notified that Resident 14 transferred to the hospital on 7/5/2026.

Licensure Reference Number 175 NAC 12-006.09(F)Based on record review and interview the facility failed to ensure that care conferences (meetings) (essential team conferences held quarterly at nursing homes with multiple medical professionals in one room to update the resident's care plan, address problems and answer resident/resident representative's questions) were provided to the resident/resident representative as required for 1 resident (Resident 5) of 3 sampled residents. The facility census was 52.Findings are:Record review of the facility policy titled Comprehensive Care Plan and Care Conferences dated 12/29/25 revealed that the purpose is to develop a person-centered care plan for each resident and to provide an ongoing method of assessing, implementing, evaluating, and updating the resident's care plan to help maintain the resident's highest practicable level of function. The social worker or designated employee will establish the time and place to hold the care conference. Invite residents and their representative at least two weeks in advance of the care conference. Invitations may be sent to the resident representative using the Care Plan Invitation Letter. If the resident and/or representative is not invited to the care conference, an explanation must be included in the medical record. Support the care conference by orienting residents and/or their representatives to the care planning process. Inform residents and representatives of the right to request meetings, request revisions to the care plan, and to be informed in advance of changes to the care plan. During the care conference, review the resident's advance directive orders to ensure the orders still reflect the resident's preferences and there are no changes needed. Document this discussion in the Progress Note-Care Conference Note. During or after the care conference, the Progress Note-Care Conference Note will be completed by a member of the interdisciplinary team. Include in this note that the resident was informed of their right to sign the care plan. Care plans are to be reviewed with each Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) completed. Interview on 7/12/26 at 11:39 AM with Resident 5 revealed that Resident 5 does not get care plan meetings every 3 months. Resident 5 revealed that they can't remember when their last care plan meeting was.Interview on 7/14/26 at 3:50 PM with the facility Social Services Director (SSD) revealed that residents are notified of upcoming care plan meetings and a notice is placed in the resident's room with the date, time, and location of the care plan meeting. The SSD revealed that the resident family/representative is notified of the upcoming care plan meeting by phone call. The SSD revealed that notes from the care plan meeting are documented in a progress note under care conference in the resident's medical record.Record review of the MDS resident assessment dated [DATE] for Resident 5 revealed that it was a quarterly assessment. The assessment revealed that Resident 5 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 15. (BIMS scoring: 13-15: Cognitively intact; 8-12: Moderately impaired; 0-7: Severely impaired). The assessment revealed that Resident 5 required moderate assistance with lower body dressing.Record review of the medical record for Resident 5 revealed no progress note for any care conference following the 10/14/25 MDS assessment. Record review of the MDS resident assessment dated [DATE] for Resident 5 revealed that it was an annual assessment. The assessment revealed that Resident 5 had a BIMS score of 14 (a change with a lower score than the score of 15 on 10/14/25). The assessment revealed that Resident 5 was now independent with lower body dressing. Record review of the medical record for Resident 5 revealed no progress note for any care conference following the 1/12/26 MDS assessment. Interview on 7/15/26 at 2:40 PM with the SSD confirmed that the facility had no documentation that a care conference was completed for Resident 5's MDS assessments on 10/14/25 and 1/12/26 as required. The SSD confirmed that the care conferences did not occur. The SSD confirmed that care conferences are required to be provided at least quarterly.

Licensure Reference Number 175 NAC. 12-006.09(H)(i)(2)Based on interviews, observations, and record reviews, the facility failed to provide the necessary care and services to assist in maintaining a resident's level of function for 1 resident (Resident 6) of 1 sampled resident, and complete routine bathing for 1 resident (Resident 6) of 2 sampled residents. The facility census was 52.Findings are:A.Record review of a Resident Handbook on 07/15/2026 revealed Restorative Nursing care focuses on restoring and or maintaining physical function. Restorative Nursing focuses on rehabilitation and restorative interventions to maintain the resident's abilities.In an interview completed on 07/13/2026 at 10:26 AM with Resident 6, Resident 6 stated that they felt that their level of function had declined since admission from the facility. The resident stated that they had received therapy services and were able to use the sit to stand lift for transfers at the end of therapy services. The resident stated that staff were able to utilize the sit to stand lift to assist the resident into the bathroom to use the toilet and they felt like they had less episodes of incontinence at that time. The resident stated that at this time staff had to use the full body lift to transfer the resident and due to this the resident now utilizes the bed pan for elimination vs being able to be transferred on to the toilet. The resident stated that they feel like they have more incontinence episodes due to this factor. The resident stated that once they completed therapy services the facility provided no exercises or programs to assist the resident in not having a decline in the ability to transfer or incontinence episodes.Record review Resident 6's comprehensive 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 12/15/2025 revealed Resident 6 voiced no symptoms or alterations in their mood during the mood interview. The resident required set up or clean up assistance with personal hygiene, was able to independently propel themselves in their wheelchair 150 feet, was occasionally incontinent of bladder and continent of bowel.Record review of Resident 6's Quarterly MDS dated [DATE] revealed the resident expressed mood symptoms of little interest or pleasure in doing things, and feeling down depressed or hopeless 2-6 or several days in the prior 7 days, required partial to moderate assistance with personal hygiene, partial to moderate assistance to wheel them selves in their wheel chair 150 feet, and was frequently incontinent of bladder and bowel.In an interview completed on 07/14/2026 at 9:58 AM with the Physical Therapy Assistant (PTA) the PTA confirmed that when Resident 6 was discharged from therapy services the resident was able to transfer using the sit to stand lift. The PTA stated that when a resident is discharged from therapy services the therapy department does not make recommendations for Restorative Nursing Services to maintain the residents level of function as long as possible due to the facility not having a Restorative Nursing program at this time.In an interview completed on 07/14/2026 at 10:18 AM with Nurse Aide I (NA-I), NA-I stated that the facility did not have a restorative nursing program at this time. The NA stated that Resident 6 was able to transfer using the sit to stand lift and use the toilet to void into but their legs got weak and they could not stand as long at this time so staff used the full body lift to transfer the resident and now the resident had to use the bed pan to toilet. The NA confirmed that this was a decline in the residents' abilities.In an interview completed on 07/14/2026 at 2:45 PM with the facility Director of Nursing, DON, the DON confirmed that the facility did not have a Restorative Nursing Program or any program to assist residents with health maintenance activities to assist in the prevention of the decline in function/abilities and should. The DON confirmed that Resident 6 had a decline in mood, ability to perform personal hygiene activities, ability to self-propel their wheelchair, and level in continence. The DON confirmed that a Restorative Nursing program could have helped in preventing the decline in Resident 6's condition.B.In an interview completed on 07/13/2026 at 10:26 AM with Resident 6, Resident 6 stated that they wished to have 2 baths a week but often only received 1 bath a week. The resident stated that some weeks they did not receive a bath all week.Record review of Resident 6's Progress Notes revealed documentation by the Social Services Director (SSD) on 06/11/2026 at 11:00 AM that the resident expressed during a care conference meeting that they were only getting one bath a week and were supposed to be scheduled for two baths a week. The note also documented that the resident's care plan was changed to better fit the residents needs and wants.Record review of Resident 6's Care Plan on 07/14/2026 revealed an intervention that the resident only wished to have one whirlpool bath a week during the day dated 01/03/2026 with a revision dated listed as 04/14/2026. There was not documentation present on the residents care plan reflecting the residents wishes for two baths a week voiced during the care conference held on 06/11/2026 as stated in the progress note.Record review of Resident 6's Point of Care documentation on 07/15/2026 revealed that Resident 6 received a whirlpool bath on 06/16, 06/23, 06/30, and 07/07. There was no documentation present that the resident received bathing twice weekly as preferred and no documentation present that the resident received a bath since 07/07.In an interview completed on 07/15/2026 at 1:20 PM with Nurse Aide K, (NA-K) stated that they were scheduled to give baths on this day. The NA stated that they got re-assigned to work the floor and there was not a bath aide assigned this day due to staffing issues.In an interview completed on 07/15/2026 at 3:45 PM with the facility DON, the DON stated that the afternoon shift would work to get the bathing done that was not completed this day due to the staffing issue.In an interview completed on 07/16/2026 at 9:20 AM with Resident 6, Resident 6 stated they did not get a bath yet this week. The resident stated they were not aware of a plan in place to ensure that the resident received a bath.In an interview completed on 07/16/2026 at 10:15 AM with NA-K, NA-K stated that they were scheduled to give baths this day. The NA stated that they were unaware if all of the residents from the previous day received a bath or not that they were just informed to complete their baths as scheduled for this day.In an interview completed on 07/16/2026 at 11:10 AM with the DON, the DON confirmed that Resident 6 had not had a bath since 07/07/2026, is scheduled to have a weekly bath, and had not been bathed in over a week.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(2)Based on observations, record review, and interviews, the facility failed to provide care in a manner to promote healing of a pressure related skin injury for 1 resident, (Resident 15), of 1 sampled resident. The facility census was 52. Findings are:A.Record review of a document titled Top tips for Best Wound Cleansing Practices and dated 06/30/2017 revealed Potable drinkable tap water can be used if there is no other alternative.In an observation completed on 07/14/2026 at 2:19 PM of wound care being provided to Resident 15 by Licensed Practical Nurse-A (LPN-A). LPN-A entered the residents' bathroom and obtained a washcloth that was hanging on the bar of the residents bathroom wall under the faucet in the bathroom and moistened the washcloth with water from the tap. The LPN rang the excess water from the cloth and then with the resident placed on their left side placed the tap water moistened wash cloth to the resident's sacrum. The LPN then allowed the resident to roll back onto their back with the washcloth present over their sacrum. The LPN then awaited additional staff assistance with completing cares for Resident 15. Once the additional staff member was present the LPN then had the resident roll to their left side, removed the tap water moistened wash cloth from the resident's sacral area, and covered the resident's sacral area with a 4 inch by 4 inch foam bordered dressing. Both staff members completed cares for the resident and then exited the resident's room.In an interview completed on 07/14/2026 at 2:38 PM with LPN-A, LPN-A stated that the order for Resident 15's pressure-related skin injury stated to pat the area with water and then apply the 4 inch by 4 inch bordered foam dressing to the sacral area. The LPN stated that is what was written in the order for treatment of the area, so they were just following the orders when caring for the area.Record review of Resident 15's Order Summary Report on 07/14/2026 revealed the resident had an order stating Stage 1 pressure ulcer cleanse with water and pat dry with gauze cover with foam dressing every other day.In an interview completed on 07/14/2026 at 2:45 PM with the facility Director of Nursing (DON), the DON confirmed that wounds should be cleansed with a wound cleanser or soap and water. The DON confirmed that the directions for cleansing the wound should have been clarified with the residents provider ensuring that it was up to current clinical standards of practice.B.In an observation of Resident 15 completed on 07/13/2026 at 3:48 PM the resident was observed to be lying on their back in their bed with the head of their bed elevated greater than 35 degrees. The resident had a specialty mattress visible to their bed. The control box attached to the foot of the residents' bed had a white dial with weight setting written on it. The dial was set at the 275 mark.In an observation of Resident 15 completed on 07/14/2026 at 9:36 AM the resident was observed to be lying on their left side with the head of their bed elevated at approximately 35 degrees. The resident had a specialty mattress visible to their bed. The control box attached to the foot of the residents' bed had a white dial with weight setting written on it. The dial was set at the 225 mark.In an observation of Resident 15 completed on 07/14/2026 at 2:19 PM wound care was observed to be provided to the resident. The resident had a specialty mattress visible to their bed. The control box attached to the foot of the residents' bed had a white dial with weight setting written on it. The dial was set between the 225 and 275 mark.In an interview completed on 07/14/2026 at 2:38 PM with LPN-A, LPN-A confirmed that Resident 15 had an air exchange mattress present to their bed. The LPN stated that they were not sure of what the control box for the mattress was to be set at or how often it was checked to ensure that the setting was correct, and the mattress was functioning properly. The LPN stated that the resident should have an order for the mattress, and the order should state what the setting should be at and how often the mattress should be checked for the proper setting and function.Record review of Resident 15's Electronic Medical Health Record (EMHR) on 07/14/2026 at 3:10 PM revealed no provider orders instructing what the specialty mattress was to be set at or the frequency the mattress was checked for the proper setting and function.In an interview completed on 07/14/2026 at 2:45 PM with the facility DON, the DON stated that they were unsure of the specifications for the specialty mattress on Resident 15's bed. The DON stated that they would contact the supplier and implement safety measures for the use of the mattress once obtained from the supplier. The DON confirmed that there should be directions in Resident 15's orders indicating what the mattress should be set on and frequency of checking the setting and the function of the mattress and there was not.

Licensure Reference Number 175 NAC 12-006.09(H)(iv)(1)Based on record review, observation, and interview, the facility failed to provide perineal care (the cleansing in the genital and anal areas to prevent infection and skin breakdown) per professional standards of practice for 2 residents (Resident 6 and Resident 15) of 2 sampled residents. The facility census was 52.Findings are:Record review of a document titled Nebraska ICAP UTI Perineal Care Procedure https://icap.nebraskamed.com/ and dated 0209/2017 revealed for female residents separate the labia and wash from front to back on each side of the labia and in the center over the urethra and vaginal opening, using a clean area of the washcloth for each stroke.Record review of a facility policy titled Perineal Care and dated 07/30/2025 revealed to separate the labia with one hand and using a disposable wipe, using downward strokes from the front to the back.A.In an observation completed on 07/14/2026 at 9:45 AM of perineal care being provided to Resident 6 by Nurse Aide N(NA-N) and Nurse Aide I(NA-I) the following was observed:-NA-I applied TENA cleansing cream to a moistened cloth wash cloth. The NA used the cloth to first wipe down the residents left front upper inner thigh, folded over a section of the moistened cloth then wiped down the right front upper inner thigh, folded over another section of the moistened cloth and wiped down the center of the residents' upper inner thighs. The NA did not separate the residents' legs, use one hand to separate the labia and cleanse the inner labia over the urethra and vaginal opening.In an interview completed on 07/14/2026 at 10:15 AM with NA-I, NA-I confirmed that they did not separate the residents' inner labia and cleanse the urethra and vaginal opening and should have.In an interview completed on 07/14/2026 at 3:45 PM with the facility Director of Nursing, the DON stated that it was the facility expectation to utilize disposable cloths for peri cares. The DON stated that each wipe was only to be used for one wipe then the cloth should be thrown away. The DON confirmed that NA-I should have separated the residents' inner labia and used a disposable cloth to wipe in a downward motion over the resident's meatus and vaginal opening during perineal cares.B.In an observation completed on 07/14/2026 at 11:52 AM of perineal care being provided to Resident 15 by NA-K the following was observed:-With Resident 15 lying on their right-side NA-K used a gloved hand to obtain a premoistened disposable wipe from its blue plastic rectangular container. The NA then used the wipe to wipe between the residents' legs going from front to back. The NA then folded the wipe and used the same wipe to repeat the motion wiping between the residents' legs going from front to back. The NA then threw the wipe in the trash can and placed the clean incontinence product under the residents' bottom and allowed the resident to roll back onto their back and then to their left side. The NA then pulled up the incontinence product between the residents' legs and fastened the closure of the product located over each hip. The NA did not cleanse the front of the resident's perineal area separating the labia and cleansing the meatus and over the vaginal opening.In an interview completed on 07/14/2026 at 12:10 PM with NA-K, NA-K confirmed that they did not cleanse the front of Resident 15's perineal area separating the labia and cleansing the meatus and over the vaginal opening and should have. The NA also confirmed that they should have used a clean wipe for each wipe and did not.In an interview completed on 07/14/2026 at 3:45 PM with the DON stated that each disposable wipe was only to be used for one wipe then the cloth should be thrown away. The DON confirmed that NA-I should have separated the residents' inner labia and used a disposable cloth to wipe in a downward motion over the resident's meatus and vaginal opening during perineal cares.

Licensure Reference Number 175 NAC 12-006.09 (H)(vi)(3)(a)Licensure Reference Number 175 NAC 12-006.09 (J)(i)(1) The facility failed to ensure that admission weights were taken for all individuals in order to monitor and assess for adequate nutrition and hydration for those who receive assisted nutrition. This affected resident 67.Record review of the facility policy dated 6/2/26 admission Documentation revealed that the policy purpose was to obtain appropriate initial information regarding the resident and family and to provide the initial documentation needed on admission. The procedures included; Greet the resident and family and escort to resident's room, assist with transfer to bed or wheelchair if needed, introduce resident to roommate, explain the call light system and request return demonstration, and take the initial vital signs, weight and height and document in the weights and vitals tab in the electronic medical record. Record review of the Baseline Care Plan dated 7/8/2026 revealed that Resident 67 was at risk for altered fluid balance and skin turgor was to be evaluated, was at risk for ineffective tissue perfusion and needed to be observed for edema (excess fluid in the body tissues) and pulmonary embolism (a sudden blockage in a lung artery, typically caused by a blood clot), required enhanced barrier precautions (an infection control measure used in nursing homes and long-term care facilities) related to having a Peg Tube, (a flexible feeding tube placed directly into the stomach through the abdominal wall. It is used to deliver nutrition, fluids, and medications straight to the stomach, bypassing the mouth and esophagus) and was at risk for falls related to chronic obstructive pulmonary disease (a progressive lung disease that makes it hard to breathe), and malnutrition.Record review of the Medical Diagnoses dated 7/13/2026 revealed Resident 67 had the following diagnoses: Achalasia of the cardia (a rare swallowing disorder that affects the esophagus, making it difficult for food and liquid to move into the stomach which occurs when the lower esophageal sphincter (opening) fails to relax properly, leading to symptoms such as trouble swallowing, heartburn, and chest pain. The muscles of the esophagus do not contract effectively, which impairs the movement of food), malignant neoplasm (cancer) of the right bronchus or lung, secondary malignant neoplasm (cancer) of the brain, moderate protein calorie malnutrition, celiac disease (a chronic autoimmune disorder where eating gluten-a protein found in wheat, barley, and rye-causes your immune system to mistakenly attack your small intestine), iron deficiency anemia (lack of sufficient amount of iron in the blood stream), nausea, vomiting, and generalized weakness among other diagnoses.Record review of the Resident Clinical Census data from the electronic medical record (EMR) revealed Resident 67 was admitted on [DATE].Record review of the weights and vitals signs for the resident on 7/12/2026 revealed that there was no weight taken at the time of admission for Resident 67 and that there were no recorded weights for Resident 67 in the electronic medical record.Record review of the Resident Vitals and Weights data revealed that the first recorded weight for Resident 67 was taken on 07/13/2026 at 11:21 AM by the Director of Nursing (DON). Interview with the Director of Nursing (DON) on 07/13/2026 at 3:40 PM revealed that when new residents are admitted to the facility, that the procedure includes doing vital signs, getting height and weight, doing an initial assessment, etc. We did have a night admission, and this was my first night shift admission while working at the facility and it was also the first night shift admission for the charge nurse that was working that night. We did obtain the vital signs and got the first assessments completed for Resident 67. Unfortunately, the first weight was completed today. The resident was admitted on [DATE] and no weight was taken until today on 7/13/26 when the registered dietician found that there was no weight in Resident 67's chart. I will confirm that there as no weight taken prior to today. It was a concern for me too, as Resident 67 has a PEG tube for nutritional intake as well as a history of cancer. So, I know that having the admission weight is very important. I agree that this would make it very hard to follow whether this resident is having any weight loss or weight gain since Resident 67 was just admitted .Interview with the Facility Administrator (FA) on 7/13/2026 at 3:45 confirmed that residents are to have an admission weight when they admit to the facility. We will be working on this to fix this process too.

Licensure Reference Number 175 NAC 12-006.10(D)Based on observation, record review, and interview the facility failed to maintain a medication administration error rate of less than 5%. The facility error rate was 7.61% (27 medication administrations and 2 errors). This affected 2 of 6 residents (Residents 62 and 12). The facility census was 52.Findings are:A.Record review of the facility policy titled Insulin Administration, Insulin Pens, Insulin Pumps dated 10/31/25 revealed that the purpose of the policy is to administer insulin injections correctly and allow for safe use of insulin pens. (Insulin is a medication used to regulate blood sugar levels). The section titled Insulin Pen (a device resembling an oversized ink pen that is prefilled with insulin and used with disposable pen needles for more accurate dosing) revealed that insulin pens must be clearly labeled with the name or other identifiers to verify that the correct pen is used on the correct person. Verify the provider order, the expiration date, and the number of days the pen has been open. Follow manufacturer's instructions. Wipe the top of the pen where the needle will attach with an alcohol swab. Remove the protective pull tab from the needle and screw it onto the pen. Turn the dosage knob to 2 units to prime the pen. Holding the pen with the needle pointing upwards, press the button until at least a drop of insulin appears. Dial in the ordered dose of units. Inject the dose into the chosen site. Be sure to wait about 10 seconds to ensure that the full dose has been delivered. Record review of the manufacturer product information insert titled Novolog Injection FlexPen dated 3/2023 revealed that before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing turn the dose selector to select 2 units. Hold the Novolog Flexpen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards and press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. If you do not see a drop of insulin after 6 times, do not use the Novolog flex pen. Turn the dose selector to the number of units you need to inject. Insert the needle into the skin. Inject the dose by pressing the push-button all the way in until the 0 lines up with the pointer. Keep the needle in the skin for at least 6 seconds and keep the push-button pressed all the way in until the needle has been pulled out from the skin. This will make sure that the full dose has been given. Inject Novolog insulin subcutaneously within 5-10 minutes before a meal to prevent hypoglycemia (low blood sugar that may be life-threatening).Record review of the admission Record dated 7/15/26 for Resident 62 revealed that Resident 62 admitted into the facility on 7/8/26. Diagnoses included Diabetes and Long Term Insulin Use.Record review of the Order Summary (a listing of all physician's orders for a resident) dated 7/15/26 for Resident 62 revealed an order for 3 units of rapid acting insulin to be administered subcutaneously (injected just below the skin) 3 times daily with meals. Observation on 7/14/26 at 12:06 PM at the medication cart near the 100 hall medication room revealed that Licensed Practical Nurse-A (LPN-A) reviewed the insulin order for Resident 62. LPN-A removed the cap from the Novolog Flex insulin pen and wiped the top of the pen with an alcohol prep pad. LPN-A placed a needle on the pen and dialed 2 units and pressed the plunger with the pen held horizontal (LPN-A did not hold the pen with the needle pointing upward and observe for a drop of insulin while priming as required to ensure accurate dose of insulin). LPN-A dialed the ordered insulin dose of 3 units on the insulin pen. LPN-A carried the pen into the room of Resident 62. Observation on 7/14/26 at 12:14 PM in the room of Resident 62 revealed that LPN-A wiped an area on the left upper abdomen of Resident 62 with an alcohol prep pad. LPN-A placed the needle of the insulin pen into the resident's abdomen and injected the insulin by pushing the plunger on the insulin pen. LPN-A removed the needle immediately. (LPN-A did not hold the needle in place for at least 10 seconds to ensure the full insulin dose was delivered). LPN-A transported Resident 62 from the resident's room to the 100 dining room per wheelchair and positioned Resident 62 at a table. LPN-A exited the dining room without directing Resident 62 to drink or eat anything. Resident 62 began to visit with a tablemate.Observation of Resident 62 from 12:14 PM to 12:30 PM revealed that Resident 62 did not eat or drink anything after the administration of the insulin.Observation on 7/14/26 at 12:30 PM in the 100 dining room revealed that the Activity Director delivered a plate with mashed potatoes and gravy and minced up meat to Resident 62. Resident 62 used the fork to move some meat into gravy and took a first bite followed by a second bite of mashed potatoes with meat at 12:32 PM. (18 minutes after the rapid acting insulin was administered).Interview on 7/14/26 at 3:37 PM with LPN-A confirmed that when preparing the Novolog insulin for administration to Resident 62 the insulin pen was not held with the needle pointed upward while priming the insulin pen. LPN-A confirmed that the needle was not held into place for at least 10 seconds during administration. LPN-A confirmed that residents should eat something within 15 minutes of receiving fast acting insulin. LPN-A revealed that insulin is given before taking residents into the dining room. LPN-A revealed that the LPN does not request the resident to take a drink or eat upon getting them into the dining room. Interview on 7/15/26 at 1:53 PM with the facility Director of Nursing (DON) confirmed that an insulin pen is to be primed with 2 units before setting the physician ordered dose of insulin. The DON confirmed that the rapid acting insulins Novolog and Lispro require them to be administered within 15 minutes or less of a meal. The DON confirmed that the pen is to be held into place for 10 seconds during injection/administration. The DON confirmed that failure to prime the insulin pen correctly and failure to hold the insulin pen in place for 10 seconds during administration to ensure the correct dose of insulin is administered is a medication error. B.Record review of the manufacturer Instructions for Use Insulin Lispro Kwikpen dated July 2023 revealed that priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Turn the dose knob to 2 units to prime the pen. Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding the pen with the needle pointing up and push the dose knob in until it stops and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. You should see insulin at the tip of the needle. If you do not see insulin at the tip of the needle repeat priming no more than 4 times. If you still do not see insulin, change the needle and repeat the priming steps. Turn the dose knob to select the number of units ordered for injection after priming. Insert the needle into the skin to inject the insulin. Push the dose knob all the way in. Continue to hold the dose knob in and slowly count to 5 before removing the needle. Record review of the manufacturer product insert titled Humalog (insulin lispro) injection dated 1/2026 revealed that lispro is a rapid acting insulin. Inject within 15 minutes before a meal or immediately after a meal. Record review of the admission Record dated 7/15/26 for Resident 12 revealed that Resident 12 admitted into the facility on 6/24/26. Diagnoses included Diabetes. Record review of the Order Summary dated 7/15/26 for Resident 12 revealed an order for insulin lispro 5 units subcutaneously before lunch. Observation on 7/15/26 at 11:53 AM at the medication cart on the facility 400 hall revealed that Registered Nurse-B (RN-B) reviewed the insulin order for Resident 12. RN-B removed the cap from the Lispro insulin kwikpen and disinfected the top of the pen with an alcohol prep pad. RN-B placed a needle on the pen. RN-B dialed 2 units and pressed the dose knob in with the needle held horizontally (the needle was not held pointed upward while priming as required to ensure correct dose of insulin). RN-B turned the dose knob to 5 units. RN-B carried the pen into the room of Resident 12. RN-B cleansed an area on Resident 12's left lower abdomen and injected the insulin. RN-B held the needle in place for 3 seconds before removing the needle (RN-B did not hold the needle in place for at least 10 seconds to ensure all of the insulin was administered). The time of the administration of the insulin was 11:55 AM. RN-B assisted Resident 12 from the resident room into the 400 dining room. Resident 12 was assisted into a chair at a table with a tablemate. Observation of Resident 12 from 11:55 AM to 12:09 PM revealed that Resident 12 did not eat or drink anything after the administration of the insulin.Observation on 7/15/26 at 12:09 PM revealed that Dietary Aide-G (DA-G) delivered a plate with an egg salad sandwich to Resident 12. Resident 12 used the knife to cut the sandwich in half. Resident 12 removed the lid from cup of tea and removed the teabag. Resident 12 opened a packet of artificial sweetener and poured it into the cup of tea. Resident 12 used the spoon to stir the tea and took a sip of tea at 12:13 PM. Resident 12 then took a bite of the sandwich. (18 minutes after the rapid acting insulin was injected).Interview on 7/15/26 at 2:17 PM with RN-B confirmed that the insulin pen was not held with the needle pointed upward when priming. RN-B revealed that the needle is to be held in place during injection for 5 seconds. RN-B confirmed that the insulin lispro is a rapid acting insulin and that the resident should be provided some nourishment within 15 minutes of insulin administration to prevent low blood sugar. Interview on 7/15/26 at 1:53 PM with the facility Director of Nursing (DON) confirmed that an insulin pen is to be primed with 2 units before setting the physician ordered dose of insulin. The DON confirmed that the rapid acting insulins Novolog and Lispro require them to be administered within 15 minutes or less of a meal. The DON confirmed that the pen is to be held into place for 10 seconds during injection/administration. The DON confirmed that failure to prime the insulin pen correctly and failure to hold the insulin pen in place for 10 seconds during administration to ensure the correct dose of insulin is administered is a medication error.

Licensure Reference Number 175 NAC 12-006.10(D)Based on observation, record review, and interview the facility failed to ensure that staff administered resident insulin (a medication used to regulate blood sugar levels) in a manner to prevent significant medication administration errors (errors that jeopardize the residents health or safety) for 2 of 2 residents observed (Residents 62 and 12). The facility census was 52.Findings are:A.Record review of the facility policy titled Insulin Administration, Insulin Pens, Insulin Pumps dated 10/31/25 revealed that the purpose of the policy is to administer insulin injections correctly and allow for safe use of insulin pens. (Insulin is a medication used to regulate blood sugar levels). The section titled Insulin Pen (a device resembling an oversized ink pen that is prefilled with insulin and used with disposable pen needles for more accurate dosing) revealed that insulin pens must be clearly labeled with the name or other identifiers to verify that the correct pen is used on the correct person. Verify the provider order, the expiration date, and the number of days the pen has been open. Follow manufacturer's instructions. Wipe the top of the pen where the needle will attach with an alcohol swab. Remove the protective pull tab from the needle and screw it onto the pen. Turn the dosage knob to 2 units to prime the pen. Holding the pen with the needle pointing upwards, press the button until at least a drop of insulin appears. Dial in the ordered dose of units. Inject the dose into the chosen site. Be sure to wait about 10 seconds to ensure that the full dose has been delivered. Record review of the manufacturer product information insert titled Novolog Injection FlexPen dated 3/2023 revealed that before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing turn the dose selector to select 2 units. Hold the Novolog Flexpen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards and press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. If you do not see a drop of insulin after 6 times, do not use the Novolog flex pen. Turn the dose selector to the number of units you need to inject. Insert the needle into the skin. Inject the dose by pressing the push-button all the way in until the 0 lines up with the pointer. Keep the needle in the skin for at least 6 seconds and keep the push-button pressed all the way in until the needle has been pulled out from the skin. This will make sure that the full dose has been given. Inject Novolog insulin subcutaneously within 5-10 minutes before a meal to prevent hypoglycemia (low blood sugar that may be life-threatening).Record review of the admission Record dated 7/15/26 for Resident 62 revealed that Resident 62 admitted into the facility on 7/8/26. Diagnoses included Diabetes and Long Term Insulin Use.Record review of the Order Summary (a listing of all physician's orders for a resident) dated 7/15/26 for Resident 62 revealed an order for 3 units of rapid acting insulin to be administered subcutaneously (injected just below the skin) 3 times daily with meals. Record review of the Blood Sugar Summary dated 7/15/26 for Resident 62 blood sugars from 7/9/26 through 7/15/26 revealed that the resident's blood sugar was documented as a high of 196 on 7/11/26 at 12:13 PM. Resident 62 had a blood sugar of 94 on 7/15/26 at 7:55 AM. Observation on 7/14/26 at 12:06 PM at the medication cart near the 100 hall medication room revealed that Licensed Practical Nurse-A (LPN-A) reviewed the insulin order for Resident 62. LPN-A removed the cap from the Novolog Flex insulin pen and wiped the top of the pen with an alcohol prep pad. LPN-A placed a needle on the pen and dialed 2 units and pressed the plunger with the pen held horizontal (LPN-A did not hold the pen with the needle pointing upward and observe for a drop of insulin while priming as required to ensure accurate dose of insulin). LPN-A dialed the ordered insulin dose of 3 units on the insulin pen. LPN-A carried the pen into the room of Resident 62. Interview on 7/14/26 with Resident 62 revealed that their blood sugar levels were up and down. Observation on 7/14/26 at 12:14 PM in the room of Resident 62 revealed that LPN-A wiped an area on the left upper abdomen of Resident 62 with an alcohol prep pad. LPN-A placed the needle of the insulin pen into the resident's abdomen and injected the insulin by pushing the plunger on the insulin pen. LPN-A removed the needle immediately. (LPN-A did not hold the needle in place for at least 10 seconds to ensure the full insulin dose was delivered). LPN-A transported Resident 62 from the resident's room to the 100 dining room per wheelchair and positioned Resident 62 at a table. LPN-A exited the dining room without directing Resident 62 to drink or eat anything. Resident 62 began to visit with a tablemate.Observation of Resident 62 from 12:14 PM to 12:30 PM revealed that Resident 62 did not eat or drink anything after the administration of the insulin.Observation on 7/14/26 at 12:30 PM in the 100 dining room revealed that the Activity Director delivered a plate with mashed potatoes and gravy and minced up meat to Resident 62. Resident 62 used the fork to move some meat into gravy and took a first bite followed by a second bite of mashed potatoes with meat at 12:32 PM. (18 minutes after the rapid acting insulin was administered).Interview on 7/14/26 at 3:37 PM with LPN-A confirmed that when preparing the Novolog insulin for administration to Resident 62 the insulin pen was not held with the needle pointed upward while priming the insulin pen. LPN-A confirmed that the needle was not held into place for at least 10 seconds during administration. LPN-A confirmed that residents should eat something within 15 minutes of receiving fast acting insulin. LPN-A revealed that insulin is given before taking residents into the dining room. LPN-A revealed that the LPN does not request the resident to take a drink or eat upon getting them into the dining room. Interview on 7/15/26 at 1:53 PM with the facility Director of Nursing (DON) confirmed that an insulin pen is to be primed with 2 units before setting the physician ordered dose of insulin. The DON confirmed that the rapid acting insulins Novolog and Lispro require them to be administered within 15 minutes or less of a meal. The DON confirmed that the pen is to be held into place for 10 seconds during injection/administration. The DON confirmed that failure to prime the insulin pen correctly and failure to hold the insulin pen in place for 10 seconds during administration to ensure the correct dose of insulin is administered is a medication error. B.Record review of the manufacturer Instructions for Use Insulin Lispro Kwikpen dated July 2023 revealed that priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Turn the dose knob to 2 units to prime the pen. Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding the pen with the needle pointing up and push the dose knob in until it stops and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. You should see insulin at the tip of the needle. If you do not see insulin at the tip of the needle repeat priming no more than 4 times. If you still do not see insulin, change the needle and repeat the priming steps. Turn the dose knob to select the number of units ordered for injection after priming. Insert the needle into the skin to inject the insulin. Push the dose knob all the way in. Continue to hold the dose knob in and slowly count to 5 before removing the needle. Record review of the manufacturer product insert titled Humalog (insulin lispro) injection dated 1/2026 revealed that lispro is a rapid acting insulin. Inject within 15 minutes before a meal or immediately after a meal. Record review of the admission Record dated 7/15/26 for Resident 12 revealed that Resident 12 admitted into the facility on 6/24/26. Diagnoses included Diabetes. Record review of the Order Summary dated 7/15/26 for Resident 12 revealed an order for insulin lispro 5 units subcutaneously before lunch. Observation on 7/15/26 at 11:53 AM at the medication cart on the facility 400 hall revealed that Registered Nurse-B (RN-B) reviewed the insulin order for Resident 12. RN-B removed the cap from the Lispro insulin kwikpen and disinfected the top of the pen with an alcohol prep pad. RN-B placed a needle on the pen. RN-B dialed 2 units and pressed the dose knob in with the needle held horizontally (the needle was not held pointed upward while priming as required to ensure correct dose of insulin). RN-B turned the dose knob to 5 units. RN-B carried the pen into the room of Resident 12. RN-B cleansed an area on Resident 12's left lower abdomen and injected the insulin. RN-B held the needle in place for 3 seconds before removing the needle (RN-B did not hold the needle in place for at least 10 seconds to ensure all of the insulin was administered). The time of the administration of the insulin was 11:55 AM. RN-B assisted Resident 12 from the resident room into the 400 dining room. Resident 12 was assisted into a chair at a table with a tablemate. Observation of Resident 12 from 11:55 AM to 12:09 PM revealed that Resident 12 did not eat or drink anything after the administration of the insulin.Observation on 7/15/26 at 12:09 PM revealed that Dietary Aide-G (DA-G) delivered a plate with an egg salad sandwich to Resident 12. Resident 12 used the knife to cut the sandwich in half. Resident 12 removed the lid from cup of tea and removed the teabag. Resident 12 opened a packet of artificial sweetener and poured it into the cup of tea. Resident 12 used the spoon to stir the tea and took a sip of tea at 12:13 PM. Resident 12 then took a bite of the sandwich. (18 minutes after the rapid acting insulin was injected).Interview on 7/15/26 at 2:17 PM with RN-B confirmed that the insulin pen was not held with the needle pointed upward when priming. RN-B revealed that the needle is to be held in place during injection for 5 seconds. RN-B confirmed that the insulin lispro is a rapid acting insulin and that the resident should be provided some nourishment within 15 minutes of insulin administration to prevent low blood sugar. Interview on 7/15/26 at 1:53 PM with the facility Director of Nursing (DON) confirmed that an insulin pen is to be primed with 2 units before setting the physician ordered dose of insulin. The DON confirmed that the rapid acting insulins Novolog and Lispro require them to be administered within 15 minutes or less of a meal. The DON confirmed that the pen is to be held into place for 10 seconds during injection/administration. The DON confirmed that failure to prime the insulin pen correctly and failure to hold the insulin pen in place for 10 seconds during administration to ensure the correct dose of insulin is administered is a medication error.

Licensure Reference Number 175NAC 12-006.11(E) Based on observation, interview, and record review the facility failed to ensure sanitary conditions in the kitchen and failed to label and date leftover foods in order to prevent the potential for food borne illnesses for all residents who consumed meals prepared in the kitchen. This had to potential to affect all residents that consumed meals prepared by the facility kitchen; and the facility failed to ensure that resident room meals were served and removed in a manner to prevent the potential for foodborne illness for 2 residents (Residents 34 and 16) of 2 residents observed. The facility census was 37. Findings are: A. Record review of the undated Resident Handbook states under Food and Nutrition Services the facility serves nutritious, well-balanced meals and the registered dietician routinely reviews menus, food preparation, sanitation, and dining services. Record review of the undated policy Date Marking; Food and Nutrition revealed the purpose of the policy is to provide a guideline for proper date-marking to ensure that food is handled and stored safely. Furthermore, leftovers were defined and food items prepared for service that were not served and subsequently stored for use within 7 days per the food code. Check state regulations for more details. The definition of the best if used by dates stated that after that date the food may not taste or perform as expected but is still safe to use or consume. These, best if used by dates are not expiration dates. Staff are directed to look for the use by date, which by policy definition, is the expiration date. Observations on 03/03/2025 at 08:20 AM during the initial observation the kitchen area, the following items were found in the dietary department: -a plastic container labeled tomato soup that had a preparation date of 02/28/2025 and a use by date of 03/02/2025 in the stand-up refrigerator -3 metal unmarked containers without identification of contents, dates of preparation, or use by dates in the stand-up refrigerator. -a container labeled coleslaw with a date of preparation of 02/26/2025 and a label that revealed a use by date of 02/28/2025 in the walk-in refrigerator. -a container of potato salad with a date of preparation of 02/28/2025 and a label that revealed a use by date of 03/02/2025 in the walk-in refrigerator -a boxed cherry pie lying on the floor the of the walk-in freezer -2 individual containers of ice cream on the floor of the walk-in freezer -papers and post cards; small unidentifiable food particles that were orange/brown, black, or white in color; and food wrappers, plastic, particles that looked like sand or small pebbles all on the floor of the walk-in freezer -the inside of the stand-up refrigerator had small, grainy, unidentifiable, food particles on the bottom of the refrigerator that were tan and brownish in color -a tray of food was partially covered with saran wrap and held potato salad, cottage cheese, and macaroni salad. There was no label or date of preparation on the tray of food. One container of macaroni salad was uncovered, and the top of the macaroni salad had the appearance of being dried out. Observations on 03/03/2025 at 10:25 AM in the dietary department, the container labeled coleslaw with a date of preparation of 02/26/2025 and a use by date of 02/28/2025 in the walk-in refrigerator remained in the refrigerator. Interview on 03/03/2025 at 1:30 PM with Dietary Aide (DA-F) who stated that foods on the tray in the stand-up refrigerator needed to be thrown out. Those have been there over the weekend. At that point DA-F, noted that one of the small bowls of macaroni salad was not covered and looked dried out on top. DA-F then pulled the try to dispose of the contents. Interview on 03/04/2025 at 10:27 AM with Dietary Aide (DA-F) who stated that the coleslaw and the potato salad in the walk-in refrigerator need to be taken out and destroyed because they are past the date of the use by date on the label. Of three containers in the stand-up refrigerator that didn't have any dates or labels, two were gravies that were thrown out and one was unidentified food that was also thrown out. DA-F stated, I have no idea what that third container of food is but it is getting thrown away. Observation on 03/03/2025 at 10:40 AM. DA-F was in the walk-in freezer cleaning and sweeping up all the debris on the floor. The ice cream containers which were on the floor were swept up with the debris and discarded. The boxed cherry pie was no longer on the floor. The coleslaw and potato salad had both been removed from the walk-in refrigerator and were sitting on a counter in the preparation area ready to be destroyed. Interview on 03/04/2025 at 10:40 AM with Dietary Manager (DM) while in the kitchen. DM confirmed that the freezer needed to be cleaned and swept out and that the floors were not clean. DM confirmed that there were containers of foods that had a preparation date on them as well as a use by date on the food items that were past the use by dates marked on the containers. Confirmed that the undated gravies were thrown away because there were no labels, preparation dates or use by dates on the containers. Confirmed a third container of food that was not label was to be discarded. 41938 B. Record review of the facility policy titled Room Tray Service dated 3/12/24 revealed that the purpose is to serve meals in a timely manner to ensure safe and acceptable food temperatures. The procedure revealed that the room tray is to be delivered in a sanitary manner and plated at the proper serving temperature. Trays will be transported and delivered by employees. Remove dinnerware and utensils from the resident's room and return promptly to the kitchen. Periodically monitor room/tray service to ensure quality and timeliness of service and compliance with food temperature standards. Have the resident ready for his or her meal before room service is delivered. Monitor residents eating in their rooms as per care plan (an individualized written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) (an individualized written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) or individual needs and for problems such as choking. Record meal intakes of residents who eat in their rooms. Record review of the Nebraska Food Code dated 7/21/16 revealed that 81-2,282(2)(c) Food shall be deemed to be adulterated (unsafe) if it has been manufactured, processed, packaged, stored, or held under unsanitary conditions where it may have become unsafe for use as food. Time/temperature control for safety food means a food that requires time/temperature control for safety (TCS) to limit pathogenic microorganism growth (the ability of disease-causing germs to multiply) or toxin formation (a poisonous substance produced by germs). TCS includes meats and dairy products. Time/Temperature Control for Safety- Food that is cooked to a temperature and for a time specified under SS 3-401.11 - 3-401.13 and received hot shall be at a temperature of 135 degrees Fahrenheit (F) or above. 81-2,272.01 Time/Temperature Control for Safety Food, Hot and Cold Holding. (Replaces 2013 Food Code 3-501.16). (1) Except during preparation, cooking, or cooling or when time is used as the public health control as specified under Nebraska Pure Food Act, and except as specified under subsection (2) of this section, time/temperature control for food safety shall be maintained: (a) At one hundred thirty-five degrees Fahrenheit or above or at Forty-one degrees Fahrenheit or less. Observation on 3/3/25 at 8:56 AM in the room of Resident 34 revealed that Resident 34 was flat in bed. The breakfast meal tray sat on the over bed table beside the bed. A plate with a brown cover over it, an unopened container of fruit, and a bowl with unopened aluminum foil over it sat on the tray. A full glass of milk with plastic wrap in place over the top of the glass sat on the tray. The silverware remained wrapped inside a red cloth napkin on the tray. Observation on 3/3/25 at 10:13 AM in the room of Resident 34 revealed that the resident remained flat in the bed. The breakfast meal tray remained on the over bed table beside the bed. A plate with a brown cover over it, an unopened container of fruit, and a bowl with unopened aluminum foil over it sat on the tray. A full glass of milk with plastic wrap in place over the top of the glass sat on the tray. The silverware remained wrapped inside a red cloth napkin on the tray. Observation on 3/3/25 at 11:21 AM in the room of Resident 34 revealed that the resident continued to lay flat in the bed. The breakfast meal tray remained on the over bed table beside the bed. A plate with a brown cover over it, an unopened container of fruit, and a bowl with unopened aluminum foil over it sat on the tray. A full glass of milk with plastic wrap in place over the top of the glass sat on the tray. The silverware remained wrapped inside a red cloth napkin on the tray. Observation on 3/3/25 at 11:55 AM in the room of Resident 34 revealed that the resident continued to lay flat in the bed. The breakfast meal tray remained on the over bed table beside the bed. A plate with a brown cover over it, an unopened container of fruit, and a bowl with unopened aluminum foil over it sat on the tray. A full glass of milk with plastic wrap in place over the top of the glass sat on the tray. The silverware remained wrapped inside a red cloth napkin on the tray. Observation on 3/3/25 at 12:29 PM outside the room of Resident 34 revealed that Nurse Aide-B (NA-B) removed a meal tray from inside the enclosed tray cart and carried it into the room of Resident 34. NA-B exited the room with the resident breakfast meal tray and placed it inside the meal tray cart. NA-B re-entered the room of Resident 34. Interview on 3/3/25 at 12:34 PM with NA-B revealed that Resident 34 had not eaten any of the breakfast meal that was in the resident room all morning. NA-B revealed that staff leave the breakfast tray in the room in case the resident might want to eat something. NA-B revealed that Resident 34 is able to feed themselves. Observation on 3/3/25 at 12:43 PM in the room of Resident 34 revealed that Resident 34 sat on the edge of the bed with the meal tray on the over bed table in front of the resident. Resident 34 had eaten 3/4 of the slice of pie. The mashed potatoes and barbecue pork on the plate were untouched. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 34 dated 1/22/25 revealed that Resident 34 admitted into the facility on [DATE]. Resident 34 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 10 (a score of 10 indicates moderately impaired cognition). The MDS revealed that Resident 34 was independent with eating and able to move from lying on the back to sitting on the side of the bed with partial assistance. Record review of the care plan (an individualized written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) for Resident 34 dated 3/3/25 revealed that Resident 34 is able to feed themselves independently. C. Record review of the MDS dated [DATE] for Resident 16 revealed that Resident 16 admitted into the facility on [DATE]. Resident 16 had a Brief Interview for Mental Status (BIMS) score of 6 (a score of 6 indicates severely impaired cognition). The MDS revealed that Resident 16 requires verbal cues for eating and is able to move from lying on the back to sitting on the side of the bed with partial assistance. Record review of the care plan for Resident 16 dated 3/3/25 revealed that Resident 16 is able to feed themselves independently with supervision. Interview on 3/4/25 at 10:07 AM with Nurse Aide-B (NA-B) revealed that Resident 16 will sometimes go to the dining room for lunch, but usually won't go to the dining room for lunch and sits on the edge of the bed to eat lunch in the resident's room. Observation on 3/4/25 at 12:40 PM in the room of Resident 16 revealed that Resident 16 laid on their left side in the bed facing the wall. Nurse Aide-D (NA-D) carried the noon meal tray into the resident's room and sat it on the over bed table next to the bed. NA-D removed the cover from the plate and exited the resident room. The plate contained 3 pureed food items (cooked food that has been blended, ground, or pressed into a smooth, creamy, or liquid consistency for residents with chewing or swallowing difficulties) on it. A sealed container of applesauce, a cup of reddish liquid drink with a lid on it, and a cup of water with a lid on it sat on the meal tray. The silverware was wrapped in a dark red cloth napkin on the tray next to the drinks. Observation on 3/4/25 at 3:08 PM in the room of Resident 16 revealed that the noon meal tray remained on the over bed table. Resident 16 was flat in the bed. The food on the plate, the container of applesauce, and the drinks remained untouched. The silverware remained wrapped in the napkin. Interview on 3/4/25 at 3:16 PM with NA-D revealed that nursing staff pass the room meal trays to residents in the resident rooms. NA-D revealed that nursing staff pick up the room trays but they don't always get picked up due to staff being busy with call lights. Interview on 3/4/25 at 3:23 PM with the Dietary Manager (DM) confirmed that safe food temperatures are to be at 135 Fahrenheit (F) or above for hot foods in the steam table. The DM confirmed that cold drinks and foods are to be below 41 F for food safety. Observation on 3/4/25 at 3:25 PM in the room of Resident 16 with the Dietary Manger (DM) confirmed that the noon meal tray was still in the resident room and that no items had been consumed by Resident 16. The plate contained 3 pureed food items on it. A sealed container of applesauce, a cup of reddish liquid drink with a lid on it, and a cup of water with a lid on it sat on the meal tray. The silverware was wrapped in a dark red cloth napkin on the tray next to the drinks. The DM confirmed that the food items were accessible to the resident. Interview on 3/4/25 at 3:25 PM with the DM confirmed that the food on the meal tray still in the room of Resident 16 would not be safe to eat due to the potential for food borne illness since it was still sitting out. DM revealed that when the room trays are delivered the staff should return the tray to the kitchen if the resident is not up to eat the meal. DM revealed that the kitchen should hold the meal tray and reheat it if it will not be eaten when delivered. The DM confirmed that the facility is required to be in compliance with the food code.

Based on interviews and record reviews, the facility failed to employ a qualified social worker on a full-time basis. The facility census was 37. Findings are: A review of the Long Term Care Bed Count Record provided by the facility dated 03/03/2025 revealed the facility had a census of 37 and a licensed bed count of 175. An interview on 03/03/2025 at 12:43 PM with Resident 32's Power of Attorney (POA; a legal document that allows someone else to act on your behalf) revealed that the Social Services Department does not always provide updates on Resident 32. The POA further states the social services director is not always available when needed. An interview on 03/04/2025 at 3:28 PM with the Social Services Director (SSD) revealed that they are responsible for all duties within the department and works on a full-time basis. SSD was asked about qualifications for obtaining the role, the SSD revealed they moved into the position from the kitchen and activities department, then obtained an online certification as a social services designee in long term care. A record review of the SSD certification dated 07/11/2022 revealed a 10-hour program certificate by Career Smart Learning, modeled on the 36-hour program designed for a 120 bed and under facility. A record review of a facility job description for Social Worker, Long Term Care dated 03/05/2025 revealed that a bachelor's degree in social work is required, however, healthcare and/or mental health hospital experience is preferred. An interview on 03/05/2025 at 10:45 AM with the Facility Administrator revealed that the SSD does not have the required qualifications to hold the position for a greater than 120 bed facility and that the facility is licensed for 175 beds.

Title 175 NAC Chapter 12-006.05 (E) Based on interviews and record reviews, the facility failed to provide bathing as required for 1 resident (Resident 5). The facility census was 37. Findings are: An interview on 03/03/2025 at 10:24 AM with Resident 5 revealed that they are scheduled for weekly baths and did not get a bath last week. According to Resident 5, they were told the bath chair was not working, however told the bath aide they would like a shower and need at least one a week. Record review of Resident 5's Admission Record dated 03/03/2025 reveals an admitted on 05/18/2023. Record review of Resident 5's Care Plan Report with an initiation date of 05/18/2023, reveals: -RESIDENT ADL PREFERENCES: Resident prefers a whirlpool bath one time per week during the day. -BATHING: Prefers whirlpool. -BATHING: Resident requires bed bath 1 staff assist. Record review of Resident 5's Plan of Care (POC) Response History dated 03/04/2025 reveals 30 day look back for questions: Type of Bath reveals on 02/07/2025, 02/12/2025, 02/19/2025 a whirlpool bath was provided, and on 02/26/2025 response states not applicable. Bathing: Self Performance reveals on 02/07/2025, 02/12/2025, 02/19/2025 physical help in part of bathing activity was provided and on 02/26/2025 activities of daily living (ADL) activity itself did not occur. Bathing: Support Provided reveals on 02/07/2025, 02/12/2025, 02/19/2025 one-person physical assist was provided and on 02/26/2025, ADL activity itself did not occur. Record review of Resident 5'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 12/30/2024 reveals Section C Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14/15 which concludes the resident is cognitively intact. An interview on 03/04/2025 at 1:50 PM reveals that Medication Aide-A (MA-A) was present last week on 02/26/2025 however was not the bath aide that day. MA-A reveals that they do not know who was the bath aide that day however was aware the bath chair was not working that day. MA-A was asked what non-applicable means on the charting for type of bath given, MA-A states they do not know. An interview on 03/06/2025 at 10:19 AM with Registered Nurse-C (RN-C) reveals that scheduling floor staff on who is responsible for resident care, baths, and medication aide on the cart is determined in morning huddle and not written down. When asked what happens when a bath is missed, RN-C reveals that evening shift will assist and/or will be offered on another date. An interview on 03/06/2025 at 11:15 AM with Resident 5 reveals that the bath aide on 02/26/2025 came into the room last week stated the bath chair was broken, then stated that they did not have time to provide a shower. An interview on 03/06/2025 at 11:28 AM with Nurse Aide-B (NA-B), revealed they worked on 02/26/2025 and recalls MA-A as the bath aide that day. When asked what non-applicable means on charting for type of bath given, NA-B states they do not know.

Licensure Reference Number 175NAC 12-006.18(B) Licensure Reference Number 175NAC 1-005.06(E) Based on observation, interview, and record review the facility failed to ensure that staff wore gown and gloves as required during high contact resident care (activities with the highest risk for transfer of germs to hands and clothing) for 1 resident (Resident 33) of 2 residents observed to prevent the potential for cross contamination and infection. The facility census was 37. Findings are: Record review of the facility policy titled Standard and Transmission Based Precautions dated 4/2/24 revealed that the purpose of the policy is to prevent the spread of infection and to provide appropriate personnel with protective equipment when necessary. The section titled Enhanced Barrier Precautions (EBP) revealed that it refers to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs (Multi-Drug Resistant organisms -microorganisms (primarily bacteria) that have become resistant to one or more classes of antibiotics, making infections difficult to treat) to staff hands and clothing. Enhanced Barrier Precautions are needed for residents with chronic wounds and Residents with Indwelling Medical devices including indwelling urinary catheters. High contact resident care activities include: transfers, dressing, assisting with transfers and mobility, device care or use of urinary catheter. The facility is to incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 2/12/25 for Resident 33 revealed that Resident 33 admitted into the facility on [DATE]. The MDS revealed that Resident 33 has an indwelling urinary catheter. Resident 33 is dependent for transfer to and from a chair to bed. Resident 33 is dependent for toileting, dressing, and personal hygiene. Record review of the care plan (an individualized written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) dated 3/3/25 for Resident 33 revealed that Resident 33 requires a mechanical total body lift (a mechanical assistive device used to transfer a resident with difficulty standing up on their own) with the assistance of two staff for transfers between surfaces. The care plan revealed that Resident 33 requires Enhanced Barrier Precautions due to the indwelling urinary catheter. The care plan revealed that staff must put on gown and gloves when performing high contact care activities including dressing, bathing, transferring, providing hygiene, changing linens, repositioning, and device care. Observation on 3/4/25 at 9:07 AM outside the room of Resident 33 revealed that a sign on the doorframe revealed Enhanced Barrier Precautions. The sign revealed that providers and staff must wear gloves and a gown for the following high contact resident care activities: transferring, device care or use (urinary catheter). Observation on 3/4/25 at 9:08 AM at the room of Resident 33 revealed that Nurse Aide-E (NA-E ) and Nurse Aide-B (NA-B) entered the resident's room. NA-E and NA-B did not put on a gown or gloves. NA-E removed the call light from the resident's right hand using the bare hands. NA-E removed the blanket from the resident's lap/legs using the bare hands. The blanket was against the uniform of NA-E as NA-E placed the blanket on the resident's bed. NA-B placed a soaker pad on the seat of the recliner with the bare hands. NA-E used the bare hands to remove the urinary catheter bag from the privacy cover and handed the catheter bag to NA-B. NA-B held the catheter bag against the control bar of the mechanical total body lift using the bare hands. NA-E performed hand sanitization with Alcohol Based Hand Rub (ABHR). NA-E used the bare hands to attach the lift sling (a fabric device with straps that is placed underneath a resident when a mechanical assistive device is used to transfer a resident with difficulty or the inability to stand up on their own from a seated or lying position) to the mechanical total body lift. NA-E repositioned Resident 33's bare hands on the resident's upper abdomen using the bare hands. The urinary catheter tubing contained visible urine that was a pale tan color that was milky or cloudy in appearance. NA-B operated the mechanical total body lift and transferred Resident 33 to the recliner. NA-B held the catheter bag with the bare hands as NA-E reached over the back of the recliner. NA-E used the bare hands and repositioned the sling with the resident from behind the back of the recliner. NA-B handed the catheter bag to NA-E. NA-B picked up a pillow from the bed with the bare hands. NA-E handed the catheter bag back to NA-B. NA-B and NA-E positioned the pillow behind Resident 33 using the bare hands. NA-B and NA-E repositioned Resident 33 in the recliner using the bare hands. NA-B hung the catheter bag under the right footrest of the recliner. NA-E removed the catheter bag with the bare hands and moved it to underneath the left footrest of the recliner. NA-E picked up the blanket from the bed and placed the blanket on Resident 33. NA-E exited the room. NA-B removed the mechanical total body lift from the resident room. Interview on 3/4/25 at 9:10 AM with NA-E revealed that Resident 33 has had a urinary catheter since admission. NA-E revealed that Resident 33's urine had been cloudier recently and that the nurse was requesting a urinalysis to check for infection. Interview on 3/04/25 at 2:16 PM with NA-B revealed that the yellow carts on the halls contain Personal Protective Equipment (PPE) (protective clothing such as disposable gloves, gowns, face masks, and face shields worn to help prevent the spread of germs) for residents on Enhanced Barrier Precautions. NA-B revealed that residents with urinary catheters are on EBP. NA-B revealed that the PPE for EBP is gown and gloves. NA-B revealed that EBP for residents with catheters is for the protection of the staff and the resident. NA-B confirmed that staff are required to wear gown and gloves for residents on EBP when providing any cares to the resident on EBP. NA-B confirmed that this includes transferring residents on EBP. Interview 3/6/25 at 9:22 AM with NA-E revealed that EBP means that when staff go into a room of a resident on EBP they wear a gown and gloves. NA-E revealed that EBP is for residents with urinary catheter or open wounds. NA-E confirmed that wearing a gown and gloves are required anytime staff are going to touch a resident on EBP. NA-E revealed that the facility provided training on EBP. NA-E confirmed that NA-E did not wear gown and gloves as required with the transfer of Resident 33 on 3/4/25 observed by this surveyor. NA-E revealed that the staff were rushed that day and did not wear the gown and gloves. NA-E revealed that normally NA-E wears the gown and gloves. Interview on 3/6/25 at 10:09 AM with the facility Infection Preventionist (IP) confirmed that staff are required to wear gown and gloves during high contact resident care including resident transfers and manipulating or moving resident indwelling catheters. The IP revealed that the IP does on the spot training with staff when they do not follow EBP. The IP confirmed that the nurse aides were required to wear gown and gloves during the transfer of Resident 33 observed by this surveyor.

Licensure Reference Number 175 NAC ,d+[DATE].09 Based on record review and interview, the facility failed to follow the advance directive for Cardiopulmonary Resuscitation (CPR) (a lifesaving attempt combination of rescue breathing and chest compressions when someone's heart has stopped) or DNR (A type of advance directive in which a person states that health care providers should not perform cardiopulmonary resuscitation (restarting the heart) if his or her heart or breathing stops) for two residents (Resident 7 and 39) of 16 sampled residents. Facility census was 38. Findings are: A. Record review of the facility policy titled Advance Directive including Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) dated [DATE] revealed the purpose of the policy was to provide each resident the opportunity to make decisions related to medical care and to define a process to make resident decisions known. If cardiac arrest occurs, CPR must be initiated unless the resident has a valid DNR (Do Not Resuscitate-meaning the resident wish is that the facility staff do not perform CPR.) order on file that includes the medical order issued by a physician or other authorized non-physician practitioner; a valid Advance Direction on file that includes written instructions relating to the provision of healthcare when the individual is incapacitated. At the time of admission or re-admission, social services or designated staff member asks the resident/health care decision maker whether the resident has prepared an advance directive. The designated staff member will meet with the resident/health care decision maker to answer questions and determine if the resident/healthcare decision maker wishes to develop or amend advance directives. If an advance directive has been formulated, a copy will be scanned into OnBase (an electronic data storage for scanned documents). As necessary, physicians will be contacted for orders that reflect the resident's wishes. During the resident stay, advance directive orders are to be reviewed with the resident/healthcare decision maker at each care plan meeting to ensure no changes are needed. Document this discussion in the progress note-Care Conference Note. If a resident who has an advance directive informs a staff member that he or she has changed his or her decision, the resident's wishes for different measures will be followed and the physician will be contacted for updated orders. If the resident's medical condition or cognitive status changes, review the current advance directive orders with the resident and healthcare decision maker to determine if they wish to make changes. Physician's orders in response to resident's requests and/or advance directives regarding life-sustaining measures must be specific. Daily print a list of all advance directive orders and keep in a three-ring binder in an area easily accessible to nursing employees. When the electronic resident health record is available, the nurse may choose to access the code status on the dashboard of the resident's electronic health record. Record review of the admission record dated [DATE] revealed that under advance directive, Resident 7 was listed as a DNR. Record review of the Medication Administration Record (MAR) dated [DATE] revealed that under advance directive, Resident 7 was listed as a DNR. Record review of the Order Listing Report (which contained a list of all residents and their current code status) dated [DATE] revealed the code status listed for Resident 7 as DNR. Record review of the [NAME] Directive dated [DATE] for Resident 7 revealed Resident 7's choice to attempt resuscitation/CPR and to provide full treatment. The document was signed and dated by Resident 7 and the physician. Interview on [DATE] at 9:05 AM with the facility Director of Nursing (DON)-A revealed the process for obtaining an advance directive takes place during the admission process. DON-A revealed that Social Services (SS) is responsible for the admission process. DON-A also revealed that if SS is not available, the admissions process is completed by the facility's Business Office Director-A (BOD-A). DON-A revealed that if the advance directive is already in place, the form is discussed and verified with the resident or Power of Attorney ((POA: a legal document that allows someone else to act on your behalf if necessary). DON-A revealed that staff are aware of the current code status of each resident through the Order Listing Report printed every night shift containing a list of all residents and their current code status. Interview on [DATE] at 8:17 AM with Licensed Practical Nurse-E (LPN-E) revealed that if staff reported a non-responsive resident, LPN-E would check the resident code status on the nightly Order Listing Report and then assess the resident. Interview on [DATE] at 9:15 AM with BOD-A revealed that that SS was usually responsible for admissions and updating the code statuses during care conferences. The BOD-A revealed that the advance directive is part of the admission process and is captured on a form with an area labeled code status verification with resident or family and an area labeled advance directive note. The BOD-A revealed that when changes are made, the information is then relayed to DON-A. The BOD-A revealed that during the quarterly care conferences, the advance directive is also discussed to confirm the resident choice. Interview on [DATE] at 10:45 AM with Resident 7 revealed their Advance Directive choice is to be a full code (CPR). Interview on [DATE] at 1:11 PM with the Nursing Home Administrator (NHA) revealed DON-A interviewed Resident 7 on [DATE] in the afternoon and confirmed Resident 7's code status and choice was to be a full code. The NHA confirmed the resident choice to be full code was not documented in the resident record. The NHA confirmed that the resident record listed Resident 7 as a DNR. The Order Listing Report for all current Code Statuses revealed that Resident 7 Advance Directive order has not been revised since [DATE]. 41938 B. Record review of Resident 39's Admission Record dated [DATE] revealed Resident 39 admitted into the facility on [DATE]. Record review of Resident 39's Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated [DATE] revealed Resident 39 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 13 (a score of 13 means the resident is cognitively intact). Record review of Resident 39's Progress Note dated [DATE] at 2:28 PM titled Advance Care Planning revealed the Resident states that the resident is a full code (wants CPR performed) and wishes to continue as such. Record review of Resident 39's Electronic Health Record revealed the document Transition Orders and Information for the Continuation of Patient Care (a summary of orders from the hospital provided to the facility) for Resident 39 dated [DATE] revealed the current Code Status for Resident 39 as Full Code. Record review of the Order Recap Report (a listing of all current and previous physician orders for a resident) dated [DATE] for Resident 39 revealed that Resident 39 had a physician's order dated [DATE] for CPR. Record review of Resident 39's Progress Note dated [DATE] at 2:45 PM revealed that at approximately 2:06 PM a physical therapist working with Resident 39 and had yelled out to the hallway that they needed help. The Nursing staff ran to the resident's room to find Resident 39 sitting on the toilet. Resident 39 was disorientated, weak, and unable to verbalize clear speech. The physical therapist was holding Resident 39's head up as the resident was leaning towards the wall. When the nurse arrived, a quick assessment was completed and resident's pupils were dilated and fixed. Resident 39 was unable to hold their hands or head up at that time. The Registered Nurse (RN) on duty was standing behind this nurse at time of assessment. The RN went to nurse's station to call 911 at 2:08 PM. Resident 39 began to convulse again. Resident 39's pupils were dilated to maximum size and the resident's eyes glossed over. Resident 39 appeared to have stopped breathing after seconds of seizure like activity. The 24 hour DNR report (Order Listing Report containing the code status for CPR or DNR for all facility residents) was checked and verified that Resident 39 was a DNR. Resident 39's sternum (center chest bone) was rubbed and the resident's name repeated loudly to gather a response. No response at that time. The resident's body continued to be limp. Lung sounds and heart sounds were assessed for several minutes with no response. Resident 39 was moved to the floor. The heart and lung sounds were assessed. No heart or lung sounds were heard for 5 minutes. Time of death at 2:14 PM. RN notified family, called the primary care provider on-call weekend services, and notified administrator. This nurse notified the Director of Nursing (DON). Interview on [DATE] at 8:53 AM with the facility DON-A revealed that at admission of a resident the social worker discusses advanced directives per a verbal discussion. DON-A revealed that the social worker verifies that the advance directive code status (the resident/resident family choice for CPR or DNR) is correct by visiting with the resident/family. The social worker discusses any discrepancy with them. DON-A revealed that when the resident/resident family wants to change the resident's code status the staff document the change in the resident record and request a physician order for the change. DON-A revealed that during the resident care plan meetings the facility will review the resident choice for CPR or DNR (code status) and request a new physician order when a change of code status is expressed. Interview on [DATE] at 8:53 AM with the BOD-A revealed that the BOD initiates the resident admission process when social services is not able to be at the facility. BOD-A revealed that BOD-A has a conversation with the resident/family and asks what their wishes are for CPR or no CPR (DNR) and confirms that the orders from the doctor are the same as the resident/family wishes. BOD-A revealed that BOD-A uses the facility New Admission Checklist for the admission process. The New Admission Checklist has an advance directive line where BOD-A documents the resident/family response for their preference for CPR or DNR. BOD-A revealed if the resident/family preference does not match the physician order for CPR or DNR, BOD-A verifies with the resident/family and notifies the DON for the DON to follow-up with the physician for an order to match the resident/family wishes. BOD-A revealed that the resident code status preference is reviewed during the resident stay at each care plan meeting when resident/family are present. If the resident/family are not present at the care plan meeting social services will go to the resident room and review with the resident what the facility has as on file as their preference for CPR or no CPR. The social services will ask if this remains their preference. Record review of the facility provided Transition Orders and Information for the Continuation of Patient Care dated [DATE] revealed the current code status order as DNR/DNI. Record review of the medical record for Resident 39 revealed no documentation of a resident/resident family wish to change Resident 39's code status from CPR to DNR. Care Conference Notes (documentation of items discussed during resident care plan meetings) revealed no documentation of review of the resident code status. Interview on [DATE] at 2:12 PM with the Nursing Home Administrator confirmed that the facility had no documentation that Resident 39 or Resident 39's family had communicated that they requested to change the code status of Resident 39 from CPR to a DNR. Record review of the Abatement Statement for F678 Cardiopulmonary Resuscitation (CPR) dated [DATE] submitted by the Nursing Home Administrator on [DATE] at 4:54 PM revealed the following: -Education provided to the Health Information Manager not to scan any orders into charts unless it is noted by a Licensed Nurse. -Education to all licensed nurses, Director of Nurses, and Social Services Director by regional clinical services director Registered Nurse or Clinical Educator Registered Nurse utilizing advance directives/CPR policy to ensure resident whishes are documented in progress notes admission/re-admission and all orders are noted and placed into the electronic health record. Education will be provided to all licensed nurses currently in the building, new nurses, and all other licensed nurses prior to working their next shift. -Upon notification all residents' code status were printed from the order listing report. All resident advanced directives were produced. These two lists were compared to ensure that the code status preference for CPR choice matches. The facility is respecting the wishes of all residents and families regarding code status. -At the time of admission or re-admission, social services or designated staff member asks the resident/health care decision maker whether the resident has prepared an advance directive such as a living will, durable power of attorney for healthcare decisions. Resident wishes will be documented in the medical record progress notes. As necessary, physicians will be contacted for orders that reflect the resident's wishes. -Advance Directive orders are to be reviewed with the resident/healthcare decision maker at each care plan meeting to ensure no changes are needed. Document this decision in the Progress Note-Care Conference Note.

Licensure Reference Number 12-006.18A(3) Based on observation, record review, and interview; the facility failed to ensure interior lighting was maintained. This had a potential to affect all facility residents. The current census is 38. Findings are: Record Review of a Resident Handbook with a revision date June 2021 revealed on that the facility is responsible for the maintenance and service of the building and all equipment owned by the center. Observations at multiple times between 02/26/2024 through 02/29/2024 revealed overhead lighting in multiple areas of the facility had many light bulbs that were not functioning which included light fixtures in the hallways, dining area, and commons areas that were darkened as well as in the activities room and current therapy room. -100 Hallway between Main Entrance and Kitchen revealed two large nonfunctioning fluorescent lights. This area illuminated the wall mounted fire extinguisher box. Residents used this hallway to access the dining room three times daily. This extinguisher was located outside and between two of the kitchen doors. -Main Dining Room revealed nine large fluorescent lights functioning only on one half side, two large nonfunctioning fluorescent lights, and eight regular smaller lights nonfunctioning. Residents were in the dining room for each meal. -Central Commons area where all halls come together near Kitchen and Dining area revealed one of the large pendulum lights was not working. This was in the same area where several other hall lights were not working near the kitchen. All 400 hall residents had to access this area each time they accessed the main dining area or the main entrance/exit. Other residents who visited the 400 hallway residents had to use this area for access. -Dining Room and Activity Hallway revealed one large nonfunctioning light. This hallway leads to an exit door. -Activity Room revealed three large fluorescent lights functioning only on one half side and two large nonfunctioning fluorescent lights and eight, regular nonfunctioning lights. -Dining Room to the current Therapy Room revealed one large nonfunctioning fluorescent light. -Therapy Room revealed several smaller bulbs are not working. -Kitchen Hallway between kitchen and Dietary Manager's office revealed three of four large nonfunctioning fluorescent lights. The afternoon of 2/29/2024 at 2:30 PM one of the bulbs in the large light fixture was no longer functioning. -400 Hallway from Kitchen to the Commons Area revealed one large nonfunctioning fluorescent light. -400 Short South Hallway revealed the only fluorescent light was nonfunctioning. Leads to an exit door. -Commons area in middle of the two 400 halls revealed three large nonfunctioning fluorescent lights. Has entry/exit door. -Dining area located between the two 400 halls revealed one large nonfunctioning fluorescent light. -Short 400 Hallway Leading revealed three large nonfunctioning fluorescent lights. Leads to exit. Interview on 02/29/24 at 12:50 PM with Maintenance Supervisor (MS) revealed that maintenance replaced bulbs in the 400 Hall Therapy room, which they are currently not using because they are remodeling the room. MS had hoped to be able to replace old bulbs with new bulbs throughout the facility this week. MS hasn't had time to change all the non-functioning fluorescent bulbs or regular smaller bulbs because MS also works in laundry. MS does state that there is a process in which maintenance does a safety inspection of the interior but is not certain if that is every month or every quarter. MS will find out and return with the answer to the question. MS also stated that staff can send work orders to MS and MS tries to fix and do repairs within 24 hours or by the end of the week. Interview on 02/29/24 at 01:44 PM with MS revealed the safety inspections are done quarterly. MS is aware that there are a lot of lights out. MS clarified the maintenance department has the required T8 bulbs and smaller bulbs for replacement. MS states I am going to finish the 400 hall as soon as I can. Further discussion with MS reveals MS will concentrate on the lighting in the dining room and around the kitchen area because these areas are so dark and this will enhance patient safety.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7, 12-006.09D7a and 12-006.09D7b. Based on observation, interview, and record review; the facility failed to ensure Resident 21 was provided supervision to prevent potential accidents with injury; failed to ensure the resident environment was free of accident hazards for Resident 3; and failed to identify causal factors and implement interventions to prevent falls and potential injury for Resident 26. This affected 3 of 5 sampled residents. The facility identified a census of 34 at the time of survey. Findings are: A. Review of Resident 21's quarterly MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) dated 12/21/22 revealed an admitted [DATE]. Resident 21 had a BIMS (Brief Interview for Mental Status) score of 11 which indicated moderate cognitive impairment. Resident 21 required extensive assistance from staff for transfers and toilet use. Resident 21 had 2 or more falls since the prior assessment. Observation of Resident 21 on 2/01/2023 at 9:25 AM revealed Resident 21 was sitting in a wheelchair in their room calling out help me and rubbing their right shoulder; Resident 21's pillow and call light were on the floor in front of Resident 21's wheelchair. There were no staff in view. Continued observation revealed several staff members walked by Resident 21's room while Resident 21 was calling out for help, and no one entered the room to assist. Observation of Resident 21 on 2/02/2023 at 10:10 AM revealed Resident 21 was observed lying in bed yelling can I go to the bathroom please? NA-M (Nurse Aide) walked by the room and did not stop. Observation of Resident 21 on 2/02/2023 at 10:15 AM revealed Resident 21 was lying in bed and a family member entered the room and put the call light on shortly after entering the room. Observation of Resident 21's room on 2/2/23 at 11:30 AM revealed the call light did not have a clip on it so when it had been on the floor, the facility had failed to maintain it to make sure it stayed in place. Interview with Resident 21's family member on 2/01/23 at 10:35 AM revealed Resident 21 fell about 3 weeks ago and broke their arm. Resident 21's family member revealed Resident 21 was out in the lobby and got up unassisted and fell on to their right side. Resident 21's family member revealed they were not sure if Resident 21 was being monitored by staff when they fell or not. Residents 21's family member revealed they were not aware of what interventions the facility had put in place to prevent Resident 21 from falling again. Review of Resident 21's Progress Notes dated 11/16/21 to 2/2/23 revealed documentation Resident 21 had 17 falls since 12/6/21. There was documentation Resident 21 fell on [DATE] and was taken to the emergency room and found to have a fractured right arm; 1/5/23; 1/2/2023, 12/27/22, 12/25/22 and received a skin tear; 2 falls on 12/16/2022 at 7:28 AM and 5:30 PM; 12/13/22, 11/29/22; 8/3/2022 and was taken to the emergency room and found to have a bruised hip; 6/30/22; 5/16/2022 and was taken to the emergency room and found to have a fractured left wrist, 5/14/22; 2 falls on 5/10/2022 at 9:15 AM and 2:00 PM and was taken to the emergency room and found to have a urinary tract infection; 3/19/2022, and 12/6/2021. Review of Resident 21's Falls Tool assessments revealed the following results with the reason for the assessment listed including 18 falls: 1/17/2023 Falls Tool Return from Hospital High risk 20.0 1/15/2023 Falls Tool Fall or Found on Floor Medium risk 13.0 1/15/2023 Falls Tool Fall or Found on Floor High risk 16.0 1/5/2023 Falls Tool Fall or Found on Floor High risk 18.0 1/1/2023 Falls Tool Fall or Found on Floor High risk 18.0 12/25/2022 Falls Tool Fall or Found on Floor High risk 16.0 12/16/2022 Falls Tool Fall or Found on Floor High risk 19.0 12/16/2022 Falls Tool Fall or Found on Floor High risk 16.0 12/14/2022 Falls Tool Fall or Found on Floor High risk 20.0 12/13/2022 Falls Tool Fall or Found on Floor High risk 20.0 11/29/2022 Falls Tool Fall or Found on Floor High risk 20.0 8/3/2022 Falls Tool Fall or Found on Floor High risk 20.0 6/30/2022 Falls Tool Fall or Found on Floor High risk 20.0 5/25/2022 Falls Tool Return from Hospital High risk 20.0 5/16/2022 Falls Tool Fall or Found on Floor High risk 20.0 5/14/2022 Falls Tool Fall or Found on Floor High risk 16.0 5/10/2022 Falls Tool Fall or Found on Floor High risk 20.0 5/10/2022 Falls Tool Fall or Found on Floor High risk 20.0 3/23/2022 Falls Tool Return from Hospital High risk 16.0 3/19/2022 Falls Tool Fall or Found on Floor Medium risk 14.0 12/6/2021 Falls Tool Fall or Found on Floor Medium risk 14.0 11/16/2021 Falls Tool Admission Low risk 8.0 Review of Resident 21's Care Plan dated 12/6/2021 revealed the following about Resident 21: -12/06/21, re-educated resident to call for assistance with transfers. Educate resident not to bend over to pick up dropped items. Encourage use of grabber or to ask for assistance. -5/10/22, fall -5/10/22, lowered to floor -5/14/22, found on the floor. Educate/instruct resident and family on safe use of assistive devices. Review as indicated for significant changes in cognition, safety awareness and decision-making capacity. Educate Staff to check for cognition changes on rounds and positioning resident in bed to middle of bed. -5/16/22, found on floor. Call light bed alarm -5/19/22, resident moved to a room closer to the nurses' station for closer monitoring to help prevent further falls. -6/30/22, fall without injury -08/02/22, Staff reeducated on use and importance of sensor alarms to be plugged in and in use at all times when in bed -8/03/22, fall without injury. Immediate intervention: resident should have call light in reach at all times. Encourage resident to use call light to request assistance from staff. Resident should be encouraged to wait for staff to assist (them) with any needs to avoid further falls. Modify to maximize safety. Keep personal items such as tissues, water pitcher, cell phone, toiletries on over bed table within easy reach of resident and make sure that call light was within reach before exiting the room. Monitor resident every shift to ensure that sensor alarms to bed/wheelchair/recliner are in place and functioning properly. -11/30/22, fall without injury. Staff to ensure resident has (their) call light and anything else (they) request within reach prior to exiting room. Encourage resident to ask for assistance to reach items to help prevent further falls. Bed alarm used to alert staff to resident's movement and to assist staff in monitoring movement. Monitor resident every shift to ensure that sensor alarms to bed/wheelchair/recliner are in place and functioning properly. -12/13/22, fall without injury. Fall mat alarm was placed next to resident's bed. Concave mattress applied to bed as resident likes to sleep on the edge of the bed. Thin mattress will help prevent further falls or sliding out of bed. -12/14/22, fall without injury -12/16/22, fall without injury -12/16/22, found on floor with no injury -12/25/22, fall with skin tear to left elbow. Call light bed sensor changed. -1/01/23, found on floor in room. Remind staff to make sure resident has all (their) wants/needs beside (them) in bed with call light in reach prior to exiting (their) room after assisting (them). -1/05/23, fall in room -1/15/23, fall in lobby with MI (Major Injury). Interventions included: Audio monitor in room; to be on when in bed to alert staff to any movement. One staff member will be assigned per shift to check resident alarms. Staff will ensure the alarm was in place, turned on and functioning properly. Observation of the resident care area unit on 2/02/23 at 9:07 AM revealed Resident 21 was not located on the unit. As attempts were being made to locate Resident 21, the CB (Contract Beautician) was observed wheeling an unidentified resident down the hall of the resident care area unit. At 9:13 AM, NA-L (Nurse Aide) was inquired as to the location of Resident 21. NA-L called over their portable radio and asked if Resident 21 was in the bath house. An unidentified staff person came over the radio and said Resident 21 was in the beauty shop. At 9:15 AM Resident 21 was observed sitting in their wheelchair in the beauty shop which was located on an unoccupied and unstaffed unit. There were double fire doors at the entrance to the unit and one of them was closed. The beauty shop was observed behind the closed door. Resident 21 was observed sitting in their wheelchair in the beauty shop and no staff were present in the beauty shop or observed on the unit. Resident 21's right arm was in a cast, their back was to the door, and they were sitting by and facing the window which was across the beauty shop away from the door. There was an alarm box on their wheelchair connected to a cord that appeared to go underneath their bottom in the seat of their wheelchair. Resident 21 did not have any type of call device or call light and there was no call light observed in the beauty shop. There were 2 call boxes on the wall that had plugs in them and no cords and Resident 21's alarm box was not connected to the call box. There were no staff in the beauty shop and no staff observed on the unit. At 9:19 AM Resident 21 woke up and there were no staff in the beauty shop and no staff observed on the unit. At 9:21 AM, 14 minutes after the CB was observed on another unit with another resident, a staff person came into the beauty shop, and they identified themselves as the CB. Interview with the CB at that time revealed they were not aware and had not told by the facility Resident 21 could not be left unattended. The CB revealed the facility staff usually left the residents in the beauty shop and the CB let the residents sit by the window. The CB revealed it was a common practice for staff to bring residents to the beauty shop and leave the residents there even when the CB had more than one resident in the beauty shop. The CB revealed they had to leave the beauty shop to take another resident down to the resident care area unit and they left Resident 21 in the beauty shop unattended. The CB revealed a staff person had wheeled Resident 21 into the beauty shop and said here and left. The CB revealed they do it all the time. The CB revealed they already had another resident in the beauty shop at the time Resident 21 was brought to the beauty shop. The CB revealed they left the beauty shop to take the other resident out to the resident care area unit and they did not intend to be gone that long but they got stopped by someone and then they had to go to the office to get change. The CB revealed the facility did not train them about not leaving residents alone in the beauty shop and they had no knowledge that Resident 21 was at risk for falling. Observation of the beauty shop at that time revealed it was not visible from the dining room which was the closest area to the beauty shop and not visible from the resident care area unit. Resident 21 was also far enough away from any care areas to be heard if they yelled for help or if their alarm went off if they got up unattended. Interview with the MS (Maintenance Supervisor) on 2/02/23 at 11:10 AM revealed the alarm would have to be plugged into the box on the wall to be activated by the facility call system. The MS revealed if the alarm had a battery-operated alarm and the alarm box was on the chair, it was an audible alarm and not hooked into the call system so the resident would have to depend on staff to hear it and respond. Observation of Resident 21 on 02/02/23 at 12:00 PM revealed Resident 21 was resting in bed; there was an alarm box connected to a cable under Resident 21 and it was not connected to their call light box. Interview with the FA (Facility Administrator) on 2/02/23 at 1:40 PM revealed PT-J (Physical Therapist) and the SSD (Social Services Director) had offices on the same unit as the beauty shop and the FA believed the PT-J and the SSD would have responded if Resident 21's audible wheelchair alarm went off. The FA revealed they believed PT-J was in the therapy office charting during the time Resident 21 was unattended in the beauty shop. When the FA was notified no PT staff had been observed on the unit and the SSD door was observed closed, the FA said they tested the alarm, and it could be heard from the therapy room door 70 feet away. When the FA was inquired if PT-J and the SSD had been notified Resident 21 was in the beauty shop unattended and they needed to monitor Resident 21 and listen for their alarm the FA said no. The DON was also present and replied no to the same question. The FA revealed they felt that someone would have responded. When the FA was inquired if the unit the beauty shop was located on was staffed, the FA revealed therapy and social services was down that hall but there were no residents residing on that unit and no staff were scheduled to work on that unit and monitor it. When the FA was notified since PT-J and the SSD were not notified Resident 21 was in the beauty shop unattended and they were to stay on that unit to monitor Resident 21, they could have left the unit, could have been on the telephone, or could have been working with a resident without knowing Resident 21 was unattended in the beauty shop; the FA confirmed PT-J and the SSD did not know Resident 21 was in the beauty shop and could not have been depended upon to monitor Resident 21 or respond if Resident 21 got up unassisted and activated the alarm or called out for assistance. Observation of the unit the beauty shop was located on 2/02/23 at 1:49 PM revealed the therapy room was down the hall then around the corner down another hall and the charting office was across the therapy room. The distance from the beauty shop door (the actual distance from the location in the beauty shop was unable to be measured as the door was locked) was 135 feet 9 1/2 inches from the therapy office charting desk to the beauty shop door. The distance from the beauty shop door to the SSD door was 127 feet 11 inches. (A football field is 300 feet long from goal line to goal line). There were no staff observed in the therapy room and the SSD office door was closed. Interview with the SSD on 2/2/23 at 1:52 PM revealed they were unaware Resident 21 had been in the beauty shop on 2/2/23 and they had not been requested to monitor Resident 21. Observation of the facility therapy room on 2/06/23 at 8:44 AM revealed PT-P was in the office which was across the therapy room, and they said PT-J was not working that day. When inquired if the office was where PT-J would have been charting in on Thursday, PT-P revealed that it was. Interview with PT-J on 2/06/23 at 8:55 AM revealed the facility staff or CB did not notify them Resident 21 was in the beauty shop on 2/2/23 and that they needed to monitor Resident 21. PT-J revealed once in a while if the CB saw PT-J walking by the beauty shop they would ask them to watch, but it was not a routine thing or something they did consistently and they did not recall they had said anything to PT-J on 2/2/23 about Resident 21 being in the beauty shop and that Resident 21 required monitoring. B. Observation of Resident 21 on 2/01/2023 at 9:25 AM revealed Resident 21 was sitting in a wheelchair in their room calling out help me and rubbing their right shoulder; Resident 21's pillow and call light were on the floor in front of Resident 21's wheelchair. There were no staff in view. Continued observation revealed several staff members walked by Resident 21's room while Resident 21 was calling out for help, and no one entered the room to assist. Observation of Resident 21 on 2/02/2023 at 10:10 AM revealed Resident 21 was observed lying in bed yelling can I go to the bathroom please? NA-M walked by the room and did not stop. Observation of Resident 21 on 2/02/2023 at 10:15 AM revealed Resident 21 was lying in bed and a family member entered the room and put the call light on shortly after entering the room. On 02/02/23 at 3:15 PM the abatement plan was received from the facility administrator and the IJ was abated at this time and lowered to an E. There was documentation the facility educated the CB not to leave residents alone in the beauty shop; call cords were placed in the beauty shop; and the remainder of the facility staff were educated not to ignore resident requests for assistance and would continue to be educated as they reported for duty. C. Observation of Resident 3's room on 2/02/23 at 9:07 AM revealed Resident 3 was not in their room. There was an oxygen concentrator (a machine used to deliver oxygen to a resident) in the room that was on. Interview with the FA (Facility Administrator) on 2/06/23 at 4:06 PM confirmed the facility staff were not supposed to leave the oxygen concentrators running when they were not in use. The FA called the MS (Maintenance Supervisor) on the phone, and they confirmed the facility staff were expected to shut the concentrators off when the residents were not in their rooms. Review of the facility policy Oxygen Administration dated 6/29/22 revealed the following: turn off oxygen when not in use, if appropriate. 46245 D. Record review of the Good Samaritan Society (GSS) GSS [NAME] Village Incident by Incident Type Log, under slipped or fell , revealed Resident 26 had the following falls: 6/2/2022 at 9:00 PM, 7/25/2022 at 5:43 PM, 8/7/2022 at 11:55 PM, and 1/5/2023 at 5:40 AM. Record Review of Resident 26's Slipped or fell #6437 Incident Report with a date of 7/25/2022 at 5:43 PM, revealed the resident had fallen in resident's room and was found sitting cross legged on the floor in the middle of the room. Resident 26 appeared to have a wet brief. Under the section, Predisposing Physiological Factors, revealed Resident 26 was confused, had gait imbalance, had weakness/fainted, had impaired memory, and was incontinent. Record Review of Resident 26's Slipped or fell #6437 Incident Report with a date of 8/7/2022 at 11:55 PM, revealed the resident had been found sitting on resident's buttocks on the floor in the Solarium between a recliner and wheelchair (w/c). The alarm pad was put away on table by the recliner and was not sounding. The resident was wet. Under the section, Predisposing Physiological Factors, revealed Resident 26 was confused, and had weakness/fainted. Record review of Resident 26's Good Samaritan Society Fall Tool with a date of 6/2/2022 at 9:00 PM, revealed resident had a score of 13 and had a Category of medium risk, but the assessment was incomplete. Record review of Resident 26's Good Samaritan Society Fall Tool with a date of 7/25/2022 at 5:43 PM, revealed resident had a score of 17 and had a Category of high risk. Record review of Resident 26's Good Samaritan Society Fall Tool with a date of 8/8/2022 at 12:02 AM, revealed resident had a score of 18 and had a Category of high risk. Record review of Resident 26's Good Samaritan Society Fall Tool with a date of 1/5/2023 at 5:46 PM, revealed resident had a score of 11 and had a Category of low risk. Resident 26 had one or more falls between 3-12 months. Resident 26's cognition was moderately impaired, and had cognitive status problems of restlessness, reduced insight, confusion, poor memory, impulsive, and difficulty following instructions. Resident 26 had mobility/transfer problems of impaired balance or coordination, observed impulsive/risk-taking behaviors, and equipment/safety. The Fall Tool also reevaluated Resident 26 had incontinence problems. Record review of Resident 26's Minimum Data Set (MDS, a tool for implementing standardized assessment and for facilitating care management in nursing homes) dated 12/5/2022, section G revealed the resident required extensive assist, one-person physical assist for bed mobility, transfers, dressing, toileting, and personal hygiene. It also revealed Resident 26 was not steady and was only able to stabilize with staff assistance for balance when going from a seated to standing position, walking, turning around and facing the opposite direction, moving on and off the toilet, and surface to surface transfers. Further review of Resident 26's MDS under section H, revealed the resident was frequently incontinent of both urine and bowel and was not on a toileting program. Observation on 2/1/2023 at 9:30 AM in Resident 26's room revealed, the resident lying in bed with eyes closed. There was an alarm/position sensor pad underneath Resident 26, and the alarm box was hung on the top handle of the resident's nightstand. There was an alarm/motion sensor pad in Resident 26's wheelchair. Resident 26's call light cord was laying on the floor and the call light was hanging over the bottom bar of the resident's four wheeled walker (4 WW) that was on the right side of the nightstand and was not within the resident's reach. Observation on 2/2/2023 at 10:09 AM in Resident 26's room revealed, a narrow walkway upon entering the resident's room as Resident 26's roommate was sitting in a recliner to the left, there was a nightstand along the wall to the right, and an over the bed table along the right side of the recliner that made a narrow walk space. The roommate's call light cord was strung from the wall, down across the floor, and up over the bed table causing a potential tripping hazard. Resident 26 was observed lying in bed with an alarm pad in place under the resident and the alarm box hanging from the top handle from the nightstand. Resident 26 did not have a call light within reach as it was laying on the floor between the nightstand and a trashcan. Resident 26's over the bed table was parallel right next to the bed, resident's w/c was placed at the foot of the bed (right up against the bed). Observation on 2/6/2023 at 8:27 AM in Resident 26's room revealed, the resident lying in bed with eyes closed and a bed alarm pad in place under the resident. Resident 26's roommate was sitting in a recliner directly to the left upon entrance to the room. The roommate's over the bed table was to the right of the recliner and had made a narrow pathway to walk over to bed B (Resident 26's side) as the roommate's nightstand was catty corner from the recliner. Resident 26's roommate's call light cord was strung from the wall, across the floor, and up over the roommate's over-the-bed table. Observation in the commons area on 2/6/2023 at 1:08 PM, revealed Nursing Assistant-L (NA-L) had wheeled Resident 26 from the dining room to the commons area after lunch and had asked if the resident would wait for NA-L to come back and sat Resident 26 in a chair. Resident 26 had agreed. Observation in Resident 26's room on 2/6/2023 at 1:53 PM, revealed the education Coordinator (EC) entering Resident 26's room and had to move the resident's roommate's over the bed table to the right side of the room to make room make room, so EC could push Resident 26's w/c to the other side of the room. EC had put Resident 26 next to the bed, took the w/c peddles off, and said Maybe we should go to the bathroom before you lay down. Resident 26 agreed and went to the bathroom. EC had said, Oh wait, where is our gait belt? Resident 26 had already stood up, using the grab bar. EC said, Oh too late. The w/c had not been locked and moved slightly backward during the self-transfer. Resident 26 voided. EC had asked Resident 26 to remain seated while EC located a gait belt and the resident agreed. EC located a gait belt on under three pillows that were on Resident 26's recliner. The gait belt had been placed on Resident 26 and EC had assisted cleaning the resident and pulled up her brief and pants. Resident 26 had reached back and held the left arm of the w/c with the resident's left hand and the w/c had moved slightly backward due to the w/c brakes not being locked during the transfer. Interview with EC on 2/6/2023 at 2:06 PM, confirmed the w/c breaks were not locked during two of Resident 26's transfers in the bathroom. EC had said EC would normally lock the w/c breaks before transferring a resident but didn't think about it. EC revealed that EC had not transferred Resident 26, Much. Interview NA-L on 2/6/2023 at 2:09 PM, revealed Resident 26 was to be toileted when they get the resident up out of bed, after lunch, and when they put her back to bed. NA-L had explained Resident 26 would normally skip breakfast. NA-L said Resident 26 would sometimes tell staff if the resident needs to go to the bathroom, but staff needed to check on the resident all the time to see if the resident's brief was soiled. Interview with the DON on 2/6/2023 at 2:41 PM, revealed the DON was who completed incident investigations. The DON felt the root cause analysis had been determined for Resident 26's fall incidents on 7/25/2022 and 8/7/2022, but nothing was mentioned about the resident being incontinent at the time of the fall.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observation, interview, and record review; the facility failed to monitor and implement interventions to prevent pain for 1 of 1 sampled residents, Resident 21. The facility identified a census of 34 at the time of survey. Findings are: Review of Resident 21's quarterly MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) dated 12/21/22 revealed an admitted [DATE]. Resident 21 had a BIMS (Brief Interview for Mental Status) score of 11 which indicated moderate cognitive impairment. Resident 21 required extensive assistance of 2 staff for transfers. Observation of Resident 21 on 2/01/2023 at 9:25 AM revealed Resident 21 was sitting in a wheelchair in their room calling out help me and rubbing their right shoulder; Resident 21's pillow and call light were on the floor in front of Resident 21's wheelchair. There were no staff in view. Continued observation revealed several staff members walked by Resident 21's room while Resident 21 was calling out for help, and no one entered the room to assist. Observation of Resident 21 on 2/02/2023 at 10:15 AM revealed Resident 21 was lying in bed and a family member entered the room and put the call light on shortly after entering the room. Interview with Resident 21's personal representative on 2/01/23 at 10:35 AM revealed Resident 21 fell about 3 weeks ago and had a broken arm and had pain any time Resident 21 was moved. The personal representative revealed Resident 21 had been receiving routine pain medication but did not know if the staff were giving Resident 21 anything to prevent pain before the staff had to move Resident 21 including when Resident 21 got up in their wheelchair or went to the bathroom. Interview with Resident 21 on 2/06/23 at 12:45 PM revealed they had pain in their right foot. Observation of Resident 21 on 2/07/23 at 7:37 AM revealed Resident 21 was sitting in their wheelchair in the living room. Resident 21 had a sling on their right arm and their right wrist was red and swollen. Resident 21 was yelling out and crying in pain and said their hand hurt. RN-B (Registered Nurse) and LPN-N (Licensed Practical Nurse) were standing at the medication carts. RN-B reported Resident 21 had received something for pain. Interview with LPN-N at that time revealed the night shift had gotten Resident 21 up because Resident 21 wanted to get into their wheelchair. There here had been no indication Resident 21 had received anything for pain before the night shift staff got Resident 21 out of bed and into their wheelchair. LPN-N revealed Resident 21 was already up in their wheelchair when they had administered pain medication to Resident 21. Observation of Resident 21 on 2/07/23 at 8:00 AM revealed Resident 21 was sitting in the dining room. Resident 21's face had a grimaced look. When Resident 21 was inquired about how they were doing today, Resident 21 replied, Not too good today. I broke my wrist last night and it really hurts. Resident 21 winced anytime they tried to move. Review of Resident 21's Order Summary Report dated 2/2/23 revealed orders for hydrocodone/apap (an opioid pain medication combined with acetaminophen or Tylenol) 5-325 mg (milligrams) 1 by mouth every 4 hours as needed for moderate pain, tramadol (an opioid pain medication) 50 mg 1 tablet by mouth twice daily and every 8 hours as needed for pain, and acetaminophen 325 mg 2 tablets every 8 hours as needed for pain. Review of Resident 21's Progress Notes dated 2/6/23 revealed the following: 11:03 AM Resident 21 went to the orthopedic physician's assistant for follow up of a fractured right upper arm. Resident 21's splint was removed, and their arm was placed in a splint. At 9:58 PM it was documented Resident 21 stated they were having pain. There was no documentation of any pain medication administered after Resident 21 had received their routine tramadol at bedtime. On 2/7/23, there was no documentation Resident 21 was assessed for pain and no documentation pain medication was administered before Resident 21 was assisted with getting out of bed into their wheelchair on the morning of 2/7/23. Review of Resident 21's MAR (Medication Administration Record) for February 2023 revealed documentation Resident 21 received routine (regularly scheduled) tramadol 50 mg at bedtime on 2/6/23 and routine tramadol at AM pass 2/7/23 and acetaminophen 650 mg at 6:51 AM. There was no documentation Resident 21 received anything for pain during the night or before Resident 21 was assisted with getting up 2/7/23 AM. There were PRN (as needed) hydrocodone/apap, PRN tramadol, and PRN acetaminophen orders on the MAR and no documentation they were administered. Interview with the ADON (Assistant Director of Nursing) on 2/07/23 at 1:48 PM confirmed the staff should have assessed Resident 21 for pain before they assisted Resident 21 to get up for the day, especially since Resident 21 had a broken arm and the cast was removed 2/6/23. The ADON revealed Resident 21 was not very good about asking for anything for pain so the staff should have been proactive with Resident 21's pain management and should not have let Resident 21's pain get out of control. Review of the facility policy Pain Management dated 12/19/22 revealed the following: purpose: to provide residents assistance in pain management. All residents will receive interdisciplinary consultations on assistance in managing pain. Individualized approaches will be developed to address the resident's pain management needs in a holistic manner.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on interview and record review, the facility failed to identify and implement a QA (Quality Assurance) process to prevent repeat deficiencies in the areas of self-determination, preventing a decrease in range of motion, pain management, and food sanitation, which had the potential to affect the residents identified at risk or affected by the deficiencies. The facility identified a census of 34 at the time of survey. Findings are: Results of the recertification standard survey dated 2/7/23 revealed the facility received repeat citations for the following Federal deficiencies: F0561-Self-Determination F0688-Increase/Prevent Decrease in ROM/Mobility F0697-Pain Management F0812-Food Procurement, Store/Prepare/Serve Sanitary Interview with HIM/QAPI (Health Information Management/Quality Assurance and Performance Improvement) on 2/07/23 at 2:01 PM revealed the facility did not have any current action plans in place based on the results of the prior survey to prevent the repeat citations from the current survey. Review of the facility policy 2022 Quality Assurance and Performance Improvement Plan dated March 9, 2022, revealed the following: QAPI Plan Purpose: The Quality Assurance Performance Improvement (QAPI) Plan is designed to outline a comprehensive and data drive QAPI program that focuses on improving the outcomes and experiences of those we serve. The Provider Executive Committee is accountable for continuously assessing and improving the quality of care, treatment, and services provided.

LICENSURE REFERENCE NUMBER 175 12-006.09D2b Based on observation, record reviews, and interviews; the facility failed to monitor the impact of pressure ulcer interventions on the right heel of Resident 77 and therefore an avoidable pressure ulcer advanced from a stage 1 (intact skin with non-blanchable redness over a bony prominence which may be painful) into a stage 5/unstageable (full thickness tissue loss in which the actual depth of the ulcer was completely obscured by eschar) pressure ulcer. The facility census was 114. Findings are: Review of Resident 77's face sheet dated 7-12-16 revealed resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the last completed MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 4-19-16 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 11 which indicated Resident 77's cognition was moderately impaired. Resident 77 required extensive assistance of 2 staff with bed mobility, locomotion on the unit, dressing, toileting, and personal hygiene. Resident 77 did not walk. Resident 77 was at risk for developing a pressure ulcer but did not have a pressure ulcer at the time of the assessment. Interview on 7-13-16 at 10:26 AM with Resident 77 in resident's room revealed resident had a sore on the right heel. Resident 77 revealed the sore had been there since the resident had a cast on the right leg for a fractured leg in April 2016. Observation on 7-13-16 at 11:14 AM revealed an approximate 1 x 1 cm (centimeter) thick, circular, crusted wound on the bony prominence of Resident 77's right heel. Interview on 7-13-16 at 5:31 PM with MA-C (Medication Aide) revealed Resident 77 had a pressure ulcer to the right heel since the cast was taken off of the right leg approximately one month ago. Interview on 7-13-16 at 12:17 PM with LPN-D (Licensed Practical Nurse) revealed there was no treatments to the pressure sore on the right heel except for pressure relief interventions of Prevalon (name brand of a soft boot that relieved pressure from the heel) boots, pillows to elevate the leg, and the RN (Registered Nurse) measured the wound weekly. LPN-D confirmed the site of the wound was on the right heel with a scab without any redness and the scab looked deep. Review of the Progress Notes revealed on 4-22-16 Resident 77 complained of pain in the right heel. The Physician was notified and an appointment made but no nursing assessment was documented on 4-22-16. Review of the Clinic Referral Sheet dated 4-23-16 revealed the facility had Resident 77 seen by the Physician for complaint of right heel pain. The Physician wrote on the sheet the resident's right heel was painful and had a reddened area on exam. Extra padding was added to the heels of the splints for resident's fractured legs and the staff needed to keep pressure off of the heels. An order was written to place a pillow under the calf to avoid pressure on the heels and to reposition the resident frequently. Review of the Progress Notes dated 5-27-16 revealed the resident was seen by the Physician and returned with no splints on resident's legs and an order for [REDACTED]. The wound was tender to touch for the resident. On 6-7-16, there was a follow-up documentation on the wound. No other documentation on the right heel from 6-7-16 to 7-12-16 was found. Record review revealed no pressure wound skin sheets were completed on Resident 77. Review of the Physician orders revealed the following: -Order dated 6-7-16 revealed to observe the right heel eschar and keep soft with lotion two times a day. -Order dated 4-23-16 revealed may use Prevalon boots on both ankles for support and protection. Review of the Care Plan revealed the pressure ulcer was addressed on the right heel dated 6-6-16 with interventions listed. Review of the facility policy titled Pressure Ulcer Practice Guidelines, last revised 12/2015, revealed at a minimum, weekly documentation was recommended to provide a review of the pressure ulcer. Interview on 7-13-16 at 5:08 PM with the DON (Director of Nursing) revealed there was no pressure ulcer documentation monitoring sheets and the DON and ADON (Assistant Director of Nursing) were not aware the resident had a pressure ulcer. Interview on 7-14-16 at 1:29 PM with the DON revealed miscommunication in the facility caused the lack of documentation and monitoring of the wound for progress or decline. .