Every finding on record at Good Samaritan Society - St Luke's Village

Licensure Reference Number 175 NAC 12-006.11Based on record review, observation, and interview the facility failed to ensure the amount of protein served at a meal was in the amount stated on the facility supplied menu for 32 residents (1, 3, 5, 6, 7, 10, 11, 12, 13, 14, 15, 16, 17, 18, 20, 21, 23, 25, 26, 27, 29, 30, 31, 32, 34, 35, 36, 37, 38, 39, 46, and 47) of 36 residents. The facility census was 36.Findings are:Record review of a facility supplied document titled Dining Manager BBQ Chicken Thigh dated 2026 revealed a portion description to reflect 3 ounces of chicken thigh boneless.A.In an observation of meal service on 04/09/2026 from 11:40 AM through 12:15 PM Dietary [NAME] D (Cook-D) used red handled tongues to place a single piece of cooked chicken on to Resident 1, 5, 6, 10, 11, 12, 13, 14, 15, 16, 17, 18, 20, 21, 23, 25, 27, 29, 30, 31, 32, 35, 37, 38, 46, and 47's plates. The plate was then served to each resident with the piece of chicken on it. The [NAME] did not weigh each piece of the chicken to ensure that each resident received the recipe stated 3-ounce portion.In an interview completed at 12:10 PM with Cook-D, Cook-D confirmed that not all of the pieces of chicken were the same size. The cook confirmed that they did not weigh the pieces of chicken to ensure each resident received the recipe stated 3-ounce portion, so they had no idea how much chicken/protein menu item the resident was provided.B.In an observation of meal service on 04/09/2026 from 11:40 AM through 12:15 PM Cook-D used red handled tongues to scoop up pieces of cut up chicken onto Resident3, 7, 26, 34, 36, and 39's plates. The plates were then served to each of the residents with the unmeasured amount of chicken on them. The cook did not use a measured scoop to place a portioned amount of the cut-up chicken on to the residents' plates.In an interview completed at 12:10 PM with Cook-D, Cook-D confirmed that they did not use a measured scoop to place a portioned amount of the cut-up chicken onto the resident's plate. The cook confirmed that by not using a measured scoop they did not know the portion size that was served to each of the residents of the chicken/protein meal item.In an interview completed on 04/09/2026 at 12:30 PM with the facility Dietary Manager (DM), the DM confirmed that Cook-D did not weigh or measure the chicken/protein that was served to the residents and should ensure each resident received the recipe stated 3 ounce portion of chicken/protein.

Licensure Reference Number 175 NAC 1-005.06(D)Licensure Reference Number 175 NAC 12-006.18(D)Based on record review, observations, and interviews, the facility failed to ensure that hand hygiene was completed during the administration of medications between each resident who received medications. This affected 8 of 8 sampled residents (Residents 30, 34, 3, 46, 47, 15, 26 and 39). The facility census was 36.Findings were:.Record review of the facility policy Hand Hygiene - Enterprise dated 11/13/2025 revealed that the purpose of the policy was;To define terms related to hand hygieneTo guide compliance for hand hygiene with the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) Moments of Hand Hygiene recommendations.To establish hand hygiene as the single most important factor in preventing the spread of disease-causing organisms to patients and personnel in healthcare settingsTo provide guidance regarding lotion use, glove use, and fingernail careThe definition of hand hygiene: a general term that applies to either handwashing or applying hand sanitizer. Handwashing includes washing hands with soap and water. Hand sanitizer involves using a waterless antiseptic agent. Antiseptic hand sanitizer was defined as applying a waterless alcohol based antiseptic agent to all surfaces of the hands to reduce the number of organisms present. Waterless agents do not require water. Hand sanitizer should be at least 60% alcohol.This policy also stated:All employees are responsible for maintaining adequate hand hygiene by adhering to specific infection control practices.The preferred method of hand hygiene for most patient care settings was the use of an alcohol-based hand sanitizer (ABHS).Access to hand hygiene products was provided in all work units (wall mounted, attached to carts or positioned on counters).Gloves are a protective barrier for healthcare workers (HCW) according to standards precautions.Gloves should never be reused or sanitizedHand hygiene should be performed after glove removal.The procedure stated: HCW will use waterless ABHS or soap and water to clean their hands when:Entering the patient roomBefore preparing or administering medications.If gloves are used, hand hygiene must be completed before donning gloves and after removing gloves regardless of the task completed.Record review of the Regional Organization's check off Hand Hygiene Clinical Skill Checklist for Medication Aide (MA) F which was completed during the training courses for Certified Nursing Assistant and Medication Aide training revealed that on 12/09/2025 The RN Educator had signed off the skills checklist stating that MA-F had met and passed all the procedural and skills steps about hand hygiene and hand washing and knew when this was to be completed. Step one stated that hand hygiene is performed at the Moments of Hand Hygiene including but not limited to; 1) Before entering a room, 2) before performing a clean task, 3) After bodily fluid or glove removal, and 4) after exiting a room. Hand Hygiene is performed before touching anything in a healthcare zone and when leaving a patient zone.In an interview with the Infection Control Preventionist (IP) on 4/13/2025 at 9:30 AM revealed that as the IP, all staff were given training on hand hygiene (HH) on an annual basis. The staff that float to all of the regional facilities are given the training during orientation and receive the infection control training prior to coming into the facility as a traveler or float person. These traveler/float personnel are trained with the same information that the regular staff receive and then work within the same medical system just in different buildings throughout the state. The IP also revealed that HH is important to reduce the incidents of infections. Audits are performed monthly to address any issues that are seen within the facility.Observations on 4/13/2026 during the time period from 3:20 PM to 4:20 PM revealed the following:At 3:20 PM Medication Aide (MA) F opened the computer screen to prepare medications for Resident 30. The medication (med) cart was unlocked, opened, and medications were retrieved from the cart drawer for Resident 30. MA-F popped one med from the bubble pack (A specialized packing for meds taken daily in which only one dose of a med is in each bubble) and placed the med in a med cup. MA-F also removed two bottles of eye drops from another drawer. MA-F went to the room of Resident 30, obtained the resident's blood pressure and administered the pill in the med cup. MA-F administered both eye drops, one drop in each eye, handed the resident a Kleenex to wipe eyes, left the room, charted the med on the computer administration record, then clicked on the name of the next resident. MA-F did not perform hand hygiene (HH) before or after the administration of the meds to Resident 30.At 3:29 PM MA-F unlocked and opened the cart and removed meds for Resident 34 and put two meds into the med cup. MA-F then took one med out of the med cup and laid it on the surface of the med cart, then took the other med and put into a plastic pouch to crush the med. MA-F then filled the med cup with pudding, poured the contents of the pouch into the med cup, stirred, opened the capsule of the second med and poured that into the med cup, and reviewed the med list on the computer screen. MA-F found two more meds that needed to be given to the resident, opened the cart drawer once again, removed the two meds from the drawer and bubble pack, put each of these meds into another pouch to crush, then added these to the pudding and stirred. MA-F then handed the meds to Resident 34 who was seated next to the med cart. Once the meds were administered, MA-F charted the meds on the computer record. MA-F did not do hand hygiene before or after the med administration. MA-F then clicked on the next resident on the computer screen.At 3:35 PM MA-F walked down the hall to see if Resident 3 was ready for the evening administration of meds. Resident 3 requested to wait until mealtime instead of having the meals at that time. MA-F did not use HH after entering or exiting Resident 3's room.At 3:38 PM MA-F unlocked and opened the med cart, clicked on the resident's name on the computer, pulled the meds out of the cart drawer and popped the meds out of the bubble pack for Resident 46, put the meds in a med cup, and then tried to give the meds to the Resident 46. MA-F walked to Resident 46's room. Resident 46 was not in the room. MA-F was told that Resident 46 was outside seated in a chair, so MA-F walked to the facility exit, opened the door and went outdoors, looked outside for the resident while carrying the medications and a small 3 ounce cup of water, then reached out and opened the door to go back into the facility carrying the meds and the water. MA-F asked the charge nurse about the meds and handed the medication to the charge nurse after labeling the meds. MA-F did not use HH to sanitize hands prior to the start of the medication pass, after going outside, and prior to preparing to administer the medications to the next resident.At 3:46 PM MA-F returned to the med cart, clicked on the next resident's name on the computer screen, unlocked and opened the med cart. Resident 3 was sitting in a wheelchair beside the med cart and asked for a pain pill. MA-F asked Resident 3 what was hurting. MA-F removed the sock from the right foot of Resident 3 to find that the small band aide on the top of Resident 3's foot was curled up, MA-F called for the charge nurse to assist in an assessment and asked Resident 3 how much pain the foot wound was causing. MA-F used ABHS at this time to do HH. MA-F then unlocked and opened the narcotic box and retrieved a bubble pack, obtained one pain pill, gave the pain pill to Resident 3 with a small glass of water, and then charted the medication in the narcotic record book and in the computer on the medication record. MA-F did not use ABHS at this time to do HH prior to starting the next medication administration.An unknown resident was seated near the med cart to the north side and across the hall nearest the nurses' station and asked for help with the foot pedals of the wheelchair. MA-F bent down and assisted the unknown resident with the foot pedal of the wheelchair, and returned to the med cart, and did not perform HH.At 3:56 MA-F selected the next resident from the computer screen to prepare the next resident's meds. MA-F unlocked the cart, opened the drawer and pulled out the bubble pack needed, put the single med in a med cup and then opened another drawer and retrieved an oral inhaler. Both medications and a 3-ounce glass of water were taken to Resident 47, who was, at the time, ambulating down the 300 hallway with a therapy aide. The resident took the med from MA-F and gave med cup back to MA-F. Then the resident took the glass of water from MA-F, drank the water and handed the empty cup to MA-F. MA-F returned to the med cart, discarded the med cup and glass, and charted the medications on the computer administration record. MA-F did not use HH.At 4:01 MA-F unlocked and opened the med cart and removed one med for Resident 15. MA-F added the med to a med cup, put applesauce in the med cup for the resident, poured a 3-ounce glass of water, locked the cart, and walked down the hall to the room of Resident 15. MA-F gave Resident 15 the med, took the empty med cup back to the med cart, and discarded the med cup in the med cart trash. MA-F did not use HH.At 4:06 MA-F unlocked and opened the med cart and removed 4 medications for Resident 26. MA-F removed all 4 medications and put them in a med cup, locked the med cart, then walked down the hall to the room of Resident 4. MA-F assisted Resident 26 while they took their meds, put a new plastic bag into the trash can in the room of Resident 26, threw the empty med cup in the trash can, then went back to the med cart. Med-F did not use HH after the medication administration or after handling the trashcan. MA-F then charted the medications on the chart.At 4:12 MA-F unlocked and opened the med cart, retrieved one medication from the cart for Resident 39, then returned the medication to the drawer. MA-F stated that Resident 39 has a hard time swallowing sometimes and took the large pill from the med cup with both hands, broke the pill in half, then went to the resident's room to give Resident 39 the med. No HH was used before entering the room or after leaving the room or after returning to the med cart. End of observations at 4:20Interview with MA-F on 4/13/2026 at 3:25 PM revealed that MA-F had just completed the Medication Aide course in January 2026. At that time MA-F had passed all required courses for the MA licensure as well as competencies that included Medication Passes and Infection Control at a facility near Omaha. MA-F revealed that as a Float staff employee there are several facilities that float staff can sign up to work in.Interview with MA-F on 4/13/2026 at 4:20 PM revealed that throughout the medication pass MA-F remembered only using HH only one time which was after removing the sock of Resident 3 and then putting the sock back on. MA-F confirmed that HH is supposed to occur each time one starts a resident's med pass and when that med pass is completed. MA-F confirmed not using ABHS or soap and water to cleanse hands. MA-F confirmed this was an infection control issue.Interview with Regional Educator (RE) at 3:45 PM on 4/14/2026 confirmed that hand hygiene is taught too all of the float staff before they are allowed to float to other facilities within the company. Hand Hygiene is an important aspect of keeping the residents safe within the facility and for this individual to not perform hand hygiene only once during the med pass was a real concern and could pose a threat for infection control in the facility.Interview with the facility Director of Nursing (DON) on 4/14/2026 at 3:55 PM confirmed that float staff are expected to use HH just like full time and part time staff in the facility.

Licensure Reference Number 175 NAC 12-006.10(D)Based on record review, observations, and interviews, the facility failed to ensure that the medication error rate was less than 5% with an actual medication error rate of 20% based on 25 observations. The facility census was 36.Record review of the facility policy Medication Errors dated 03/02/2026 revealed the purpose of the of the policy was to provide guidance in documenting and auditing medication errors. The location will have medication error rates of 5% or less and those residents are free of significant medication errors. Medication errors were defined as the observed of identified preparation of administration of medications or biologicals which are not in accordance with the prescriber's order, manufacture's specifications (not recommendations) regarding the preparation and administration of the medication or biological or accepted professional standards and principles which apply to professionals providing services. Accepted professional standards and principles include the carious practice regulation in each state, and current commonly accepted health standards established by national organizations. Significant medication errors were defined as those which cause the resident discomfort or jeopardizes his or her health and safety. Significance may be subjective or relative depending on the individual situation and duration.Record review of the facility policy Medication Administration Including Scheduling and Medication Aides dated 3/30/2026 revealed that the purpose of the policy was to promote understanding of medication therapy, to administer medications correctly and in a timely manner, to provide direction regarding medication aides. Medications are to be administered according to the Six Rights. All employees passing medications are familiar with action and adverse reactions of medications. The procedure was to:Wash hands prior to beginning a med pass and follow the administration of medication for each resident. If hands are visibly soiled wash hands with soap and water, if hands are not visibly soiled use of an alcohol-based hand rub (ABHS) is acceptable.Review the Medication administration record (EMAR) for medications due.Check for allergies.Follow the 6 Rights: right medication, right dose, right resident, right route, right time, and right documentation.Perform three checks: read the label on the medication container and compare to the EMAR, look at the medication when placing in the med cup, and look at the meds just before administration. Do not touch the medication with ungloved hands, and if a medication falls on the floor, discard it and use a new med.Record review of the document Nursing Rights of Medication Administration dated 01/2025 by the National Library of Medicine stated the five rights of medication are the right patient (ensuring the medication is administered to the person it is prescribed for), the right drug (ensuring the medication being administered is identical to what is prescribed), the right route (ensuring the medication is administered in the correct way as prescribed), the right time (ensuring the medication is administered at the correct time intervals), and the right dose (ensuring the medication is administered at the prescribed dose).A.Review of the April 2026 Electronic Medication Administration Record (EMAR) for Resident 23 revealed orders for:Humalog Kwikpen subcutaneous (under the skin into the fatty tissue and not the muscle) insulin injection 10 units subcutaneously with meals andHumalog Kwikpen subcutaneous insulin per sliding scale (a dose that is dependent upon the actual blood sugar reading) to give 9 units for a blood sugar for blood sugar readings between 251 and 300. Record review of the Instructions for Use of the Humalog Kwikpen with copyright date of 2023 revealed the following:Attach the new needlePrime the needle before each injection to remove air from the needle and cartridge that may collect during normal use and to ensure the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin.Prime the needle with 2 units of insulin.Select the required dose on the dose nob.Insert the needle into the skin and hold the dose knob in and slowly count to 5.Remove the needle from the injection site and discard in a sharps container. Record review of the facility policy Medication: Insulin Administration, Insulin Pens, Insulin Pumps dated 10/31/2025 revealed the purpose of the policy was to administer insulin injections correctly. The procedure for the use of the insulin pen was to cleanse the skin site with alcohol, wipe the tip of the needle hub with alcohol, attach the needle and screw it until it is snug, turn the dosage knob to 2 units to prime the pen, point the needle upwards and depress the injection button. The dial the ordered dose of the insulin and then inject the insulin, make sure to wait about 10 seconds until the full dose of insulin has been delivered.Observation on 4/13/2026 at 11:32 AM of RN-B, who administered insulin to Resident 23 with a Humalog Kwik-pen. RN-B took Resident 23's blood sugar with results of 295. RN-B reviewed the order for Resident 23 who had two orders for the insulin. RN-B took the insulin pen, attached a new needle to the pen, and walked with Resident 23 to their room. RN-B then dialed in the amount of insulin that was needed for both the regular order and the sliding scale doses (19 units total) into the insulin pen and injected the insulin into Resident 23's left lower quadrant of the abdomen, pushed the injection button, and immediately removed the insulin pen after pressing the injection button. Then left the room of the resident. Interview with RN-B on 4/13/2026 at 11:40 who confirmed the needle was not primed with 2 units of insulin prior to the administration of the insulin. RN-B also confirmed that the needle had not been held in place for 6 seconds after the administration of the insulin. I had no idea that the insulin pen needed to be left in place for that length of time. I will be holding it for 10 seconds from now on though.B.Record review of the April 2026 EMAR for Resident 30 revealed that this resident had orders for two different eye drops;Refresh tears ophthalmic solution (an eye drop for extremely dry eyes). Instill one drop in both eyes twice a day for severe dry eyes. Artificial Tears solution 1.4% (an eye drop for dry eyes). Instill one drop in both eyes before meals and at bedtime for dry eyes.Record review of the undated quick sheet provided by the facility. This revealed that a quick sheet is a synopsis of the procedure without rationales or citations and is intended to be a review of how to perform a procedure and not for the first time or novice user. There was an ALERT that stated avoid touching the eye with the tip of the applicator to prevent contamination. Ask the patient to lie supine or to sit back in the chair with the neck slightly hyperextended.When administering the eye drops:Ask the patient to look at the ceiling before administering the eye drops.Hold a tissue in the non-dominant hand on the patient's cheekbone just below the lower eyelid,While holding the tissue, gently press downward with the thumb or forefinger against the bony orbit to expose the lower conjunctival sacWith the dominant gloved hand resting on the patient's forehead, hold the filled medication eye drops perpendicular to the eye just above the lower conjunctival sac. Do not allow the tip of the dropper to touch the eye. Ophthalmic medications should be sterile.Instill the drops into the conjunctival sac that is exposed. Do not touch the eye or any other surface.If more than one eye drop or medication is prescribed, allow 5 minutes between the medications.IF the eye drop falls on the outer lid margins or the resident blinks, repeat the procedure.Then ask the resident to close their eye for at least one minute.Record review of the facility Job Description for Medication Aide Long Term Care Float staff revealed that the Medication Aide (MA) serves as caregiver who provides resident-centered nursing care and daily living assistance to assigned residents under the supervision of a charge nurse and included administering prescribed medications as delegated by a licensed nurse and with their scope of practice as defined by state regulations. Individuals must complete yearly competency testing. Individuals must administer medications as prescribed by physicians.Record review of the Transcript Report for Medication Aide (MA)-F printed on 4/14/2026 revealed that this was an interagency training report and whose position listed was Medication Assistant, Certified, long-term care, float. MA-F had taken the following courses with the completion dates listed:Hazardous Drugs - 12/2/2025Medication Administration - 12/17/2025Record review of the Certified Medication Aide preceptor records dated 12/9/2025 revealed that MA-F had to do a self-assessment and then a preceptor had to initial. The self-assessment scale was as follows: 1.) Unfamiliar with skill. 2.) Uncomfortable performing skill. 3.) Able to perform without supervision. 4.) Able to teach skills to new employees.Listed were the following competencies and skills with MA-F's self-assessment score.Demonstrates appropriate delivery of oral medications - 4Demonstrates or verbalizes how to use a metered dose inhaler - 4Demonstrates the appropriate delivery of eardrops and eye drops - 4These self-assessments were signed off by SW who was determined to be another Medication Aide at the regional level.In an interview with the Infection Control Preventionist (IP) on 4/13/2025 at 9:30 AM revealed the staff who float to all the regional facilities, interagency staff, are given training during the orientation and competencies are completed at that time as well before they are allowed to go to other facilities. Audits are performed monthly to address any issues that are seen within the facility.Interview with MA-F on 4/13/2026 at 3:25 PM revealed that they completed the Medication Aide course in January 2026. At that time MA-F had passed all required courses for the MA licensure as well as competencies so they could pass medications. After Medication Aide and Med Administration courses and tests are passed, then float staff are allowed to sign up for around 13 or 14 different facilities and can float or travel between all of them and work in each facility. Observation on 4/14/2026 at 3:20 PM of Medication Aide (MA) F who prepared and administered 2 eye medications for Resident 30, who was seated upright in a chair in their room. MA-F told Resident 30 that it was time for their eye drops. MA-F put one finger on the outer edge of the upper lid and pulled the eye up and out and asked Resident 30 to open the left eye, then dropped the eye drop in the eye while touching the eye lashes. Then MA-F touched the outer edge of the upper lid of the right eye, pulled up and outward and told the resident to open the right eye and dropped the eye drop in the eye and touched the eye lashes. MA-F then handed Resident 30 a Kleenex to wipe both cheeks. MA-F capped the first bottle of eye drops and immediately picked up the second bottle of eye drops, pulled the upper lid of the left eye up and out and dropped the second drop into the eye and touched the eye lashes of the left eye. MA-F then tried to put the eye drop in the right eye as the upper eye lid was pulled out and upward and the eyelashes were again touched. Resident 30 then asked if MA-F would put the eye drop in the resident's eye. MA-F stated to the resident that the eye drop was in the right eye and handed the resident another Kleenex to wipe the eyes and right cheek. MA-F did not try to insert another eye drop.Interview on 4/13/2026 at 4:20 PM revealed that MA-F did not know that eye drops are supposed to be given 5 minutes apart. MA-F confirmed that the eye drops were given about 1 minute apart. MA-F revealed not knowing that one was not supposed to touch the eye drop bottle on the eye lashes and that this could and would contaminate the bottle of eyedrops. Confirmed that the bottle of eye drops did touch the eye lashes. Confirmed that no pocket of the lower eyelid was formed when inserting the eye drops to assist with the instillation of the eye drops. C.Record review of the April 2026 EMAR of Resident 47 revealed there was an order for Budesonide-Formoterol (an inhaled corticosteroid used for long-term maintenance treatment of asthma) inhalation aerosol 160-4.5 micrograms to inhale 2 puffs orally twice a day related to dyspnea (trouble breathing).Observation on 4/13/2026 at 3:56 PM of MA-F gave Resident 47 the oral Budesonide, who inhaled two puffs, then returned the medication to MA-F. Resident 47 was ambulating in the hallway with a therapy aide at the time.Interview on 4/13/2026 at 4:20 PM with MA-F who revealed that it would have been better to have Resident 47 take the medication once that resident had returned to their room. MA-F confirmed that Resident 47 did not rinse and spit after the administration of the med because the medication was given while Resident 47 was ambulating in the hallway with therapy. MA-F confirmed they did not know why it was important to rinse and spit even though the order stated that this was to be completed. MA-F confirmed the order did state that the resident was to rinse mouth and spit this out.D.Record review of the April 2026 EMAR for Resident 26 revealed an order for Tamsulosin (a medication for urine retention) 0.4 mg once daily after meal in the evening.Observation on 4/13/2026 at 4:06, MA-F prepared and administered 4 medications for Resident 26 while reviewing medications at the med cart and double checking with the electronic medication record on the computer screen. MA-F gathered all 4 mediations and then went to the room of Resident 26 and administered the medications. MA-F went back to the med cart and logged the medications as given.Interview on 4/13/2026 at 4:20 with MA-F it was revealed that MA-F did not know what error had occurred with the administration of the medications for Resident 26. The 4 medications were pulled back out of the medication cart and MA-F reviewed each medication with the computer screen to be certain that the correct medications had been given. Then MA-F stated that the medication was supposed to be given after the meal and not before the meal. MA-F confirmed that they look at all the medications but doesn't always read the entire order for the medications. MA-F confirmed that the medication was given at the wrong time.Interview with the Regional Educator (RE) on 414/2026 at 3:45 confirmed that the staff members who are allowed to float between different facilities with the organization are competency tested prior to being allowed to float or travel to other facilities. The RE:Confirmed that insulin pens must be primed before dialing the amount of insulin to be injectedConfirmed that insulin pens must be held in place for at least 6 seconds while injecting the insulin.Confirmed that bottles of eye drops cannot be touched to any surfaces including eye lashes because then the bottle becomes contaminated. TheConfirmed when giving eye drops that there is a specific method for giving eye dropsConfirmed that when administering eye drops, that one must wait 5 minutes between each eye dropConfirmed that physician orders must be followed as writtenConfirmed that Budesonide administration requires the resident to rinse and spit after oral inhalation of the medication to prevent further medical concerns such as oral thrush (a fungal infection), hoarseness, throat irritation, or dental issues.Confirmed that the Medication Aides are supposed to follow the Five Rights of Medication Administration and this includes giving the medications at the right time.

Licensure Reference Number 175 NAC 12-006.09(H)Based on observation, record review, and interview the facility failed to ensure that it implemented care and services for hemodialysis (a life-sustaining medical treatment that filters waste, toxins, and excess fluids from the blood when the kidneys have failed) resident nutrition as required for 1 of 1 resident reviewed (Resident 3). The facility census was 36.Findings are:Record review of the facility policy titled Dialysis Services dated 9/30/25 revealed that residents who receive dialysis may receive services at on outside dialysis service or by a contract dialysis company. The facility will be responsible for transportation to and from dialysis. Care plan care specific to the resident. The clinical monitoring-dialysis assessment is available for use in monitoring the resident receiving dialysis. Record review of the Outpatient Dialysis Services Coordination Agreement dated 9/9/19 revealed that the obligations of the facility includes ensuring that all appropriate medical and administrative information accompanies the resident at the time of referral to the dialysis center. The long term care facility will ensure that residents are prepared to spend an extended length of time at the dialysis center and have received proper nourishment and any medications prescribed before coming to the dialysis center. Record review of the facility admission Agreement dated 10/2025 revealed that the facility agrees to furnish the resident with food and nutrition services included in the daily rate. Record review of the facility Resident's Rights for Skilled Nursing Facilities dated 11/28/16 revealed that a facility must treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The resident has the right to reside and receive services in the facility with reasonable accommodation of individual needs and preferences. The resident has the right to choose schedules (including sleeping and waking times) consistent with his or her interests, assessments, and plan of care. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. Record review of the admission Record dated 4/8/26 for Resident 3 revealed that Resident 3 admitted into the facility on 6/20/24. Resident 3 had a diagnosis of end stage renal (kidney) disease (a condition where kidneys are damaged or cannot filter blood properly, causing waste and fluid to build up in the body).Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 3/4/26 for Resident 3 revealed that Resident 3 receives hemodialysis treatment. Record review of the comprehensive care plan dated 4/8/26 for Resident 3 revealed that Resident 3 requires hemodialysis related to chronic kidney disease. Interventions included dialysis three times weekly at the dialysis center: Monday, Wednesday, and Friday. Chair time is scheduled for 7:00 AM for approximately 4 hours. Adjust medications on dialysis days as ordered. Send meal to dialysis with resident Monday, Wednesday, and Friday as resident requests.Interview on 4/9/26 at 11:20 AM with Resident 3 revealed that Resident 3 leaves the facility for dialysis around 7:15 AM on Mondays, Wednesdays, and Fridays. Resident 3 revealed that some early morning medications are provided before Resident 3 leaves and some medications are sent with Resident 3 to dialysis. Resident 3 revealed that Resident 3 does not get breakfast before leaving for dialysis. Record review of the Point of Care task (electronic medical record documentation of care provided to a resident) titled What percentage of the meal was eaten dated 4/9/26 for Resident 3 over the past 30 days revealed that the result was documented as Resident Not Available for the breakfast meal on 3/11/26 (Wednesday dialysis day), 3/13/26 (Friday dialysis day), 3/16/26 (Monday dialysis day), 3/18/26 (Wednesday dialysis day), 3/20/26 (Friday dialysis day), 3/23/26 (Monday dialysis day), 3/25/26 (Wednesday dialysis day), 3/30/26 (Monday dialysis day), 4/1/26 (Wednesday dialysis day), 4/3/26 (Friday dialysis day), and 4/6/26 (Monday dialysis day). Record review of the Point of Care task titled What percentage of the meal was eaten dated 4/14/26 for Resident 3 over the past 30 days revealed that the result was documented as Resident Not Available for the breakfast meal on 4/8/26 (Wednesday dialysis day) and 4/10/26 (Friday dialysis day).Record review of the Point of Care task titled What percentage of the meal was eaten dated 4/9/26 for Resident 3 over the past 30 days revealed that the result was documented as 76-100% eaten for the breakfast meals on 3/12/26, 3/14/26, 3/15/26, 3/17/26, 3/19/26, 3/21/26, 3/22/26, 3/24/26, 3/26/26, 3/27/26, 3/28/26, 3/29/26, 3/31/26, 4/2/26, 4/4/26, 4/5/26 (Resident 3 ate 76-100% of the breakfast meal on all non-dialysis days).Record review of the Point of Care task titled What percentage of the meal was eaten dated 4/14/26 for Resident 3 over the past 30 days revealed that the result was documented as 76-100% eaten for the breakfast meals on 4/7/26, 4/9/26, 4/11/26, 4/12/26, and 4/16/26 (Resident 3 ate 76-100% of the breakfast meal on all non-dialysis days).Observation on 4/9/26 at 8:18 AM (a non-dialysis day for Resident 3) in the facility dining room revealed that Dietary Aide-I (DA-I) delivered the breakfast meal to Resident 3. The meal consisted of 2 fried eggs, 2 slices of toast, a bowl of cream of wheat, and a small yogurt cup. Resident 3 poured a small cup of brown sugar on the cream of wheat and began to eat.Observation on 4/9/26 at 8:35 AM in the facility dining room revealed that Resident 3 pushed themself back from the dining room table and propelled themself out of dining room. Resident 3 ate 100% of the provided breakfast meal.Observation on 4/13/26 at 7:21 AM in the room of Resident 3 revealed that Resident 3 was not in the room. The wheelchair of Resident 3 was gone.Interview on 4/13/26 at 7:26 AM with Nurse Aide-J (NA-J) revealed that Resident 3 left for dialysis before 6:00 AM, prior to NA-J starting their shift. NA-J revealed that they were not sure if Resident 3 gets breakfast before leaving. Interview on 4/13/26 at 11:19 AM with Transportation Driver (TD) revealed that TD thinks that Resident 3 eats before TD takes Resident 3 to dialysis on Monday, Wednesday, and Friday. TD revealed that Resident 3 is usually waiting in the tv area by the nurse's station for TD to take Resident 3 to dialysis. Interview on 4/13/26 at 11:27 AM with Resident 3 confirmed that Resident 3 was not provided with any breakfast this morning. Resident 3 confirmed that the facility does not provide any breakfast meal prior to dialysis on Monday, Wednesday, or Friday. Interview on 4/13/26 at 12:53 PM with Resident 3 confirmed that the staff never ask if the resident would like a breakfast meal before leaving for dialysis. Resident 3 confirmed that Resident 3 would like breakfast to eat before leaving for dialysis. Interview on 4/13/26 at 12:59 PM with Registered Nurse-B (RN-B) revealed that RN-B sees Resident 3 prior to leaving for dialysis around 6:30 AM. RN-B revealed that the RN does not provide any breakfast to Resident 3 before dialysis. RN-B revealed that nourishment is probably provided by the night staff, like toast, when the night staff gives Resident 3 their early morning medications before dialysis. Interview on 4/13/26 at 1:02 PM with the facility Dietary Manager (DM) revealed that Resident 3 does not receive the breakfast meal prior to leaving for dialysis. Observation on 4/14/26 at 8:37 AM (a non-dialysis day for Resident 3) revealed that Dietary Aide-I (DA-I) delivered a bowl of oatmeal and a plate with biscuits and gravy to Resident 3. DA-I sat the items on the table for Resident 3. Observation on 4/14/26 at 8:57 AM in the facility dining room revealed that Resident 3 sat at the table. Resident 3 ate 100% of the biscuits and gravy and 100% of the oatmeal. Resident 3 drank a 1/2 cup of cappuccino. Resident 3 used a spoon to eat ice chips from a tall Styrofoam cup. Interview on 4/14/26 at 10:03 AM with Resident 3 revealed that the resident's family does not come to dialysis or bring food to dialysis. Resident 3 revealed that patients are not allowed to eat at dialysis. Resident 3 confirmed that they eat all of the breakfast meal on non-dialysis days and would like a breakfast meal on dialysis days. Interview on 4/14/26 at 10:33 AM with the facility Director of Nursing (DON) confirmed that Resident 3 is to be provided a pre-dialysis meal. The DON confirmed that the facility did not have documentation of pre-dialysis meals provided to Resident 3.

Licensure Reference Number 175 NAC 12-006.09Based on record review and interview, the facility failed to follow a provider order to hold/not administer a medication based on ordered parameters for 1 resident (Resident 9) of 1 sampled residents. The facility census was 36.Findings are:Record review of Resident 9's Physician Orders on 04/09/2026 revealed Resident 9 had an order for Carvediol (a medication used to help regulate blood pressure) 12.5 milligrams with directions to administer one tablet by mouth twice daily (AM (morning) and HS (night) and to hold the medication if the systolic (top number) of the blood pressure was less than 100 or the diastolic (bottom number) of the blood pressure was less than 55.Record review of Resident 9's Medication Administration Record (MAR) for the month of February 2026 revealed the following:-On 02/02/2026 a blood pressure documented of 107/53 in the HS. The MAR also revealed documentation that the residents' Carvediol 12.5 milligrams was signed as administered indicating the resident received the HS dose of the medication though the residents diastolic blood pressure was less than 55.-On 02/07/2026 a blood pressure documented of 107/54 in the AM and HS. The MAR also revealed documentation that the residents Carvediol 12.5 milligrams were signed as administered indicating the resident received both the AM and HS dose of the medication though the residents diastolic blood pressure was less than 55. -On 02/08/2026 a blood pressure of 102/52 was documented in the AM and HS for Resident 9. The MAR also revealed documentation that the residents Carvediol 12.5 milligrams were signed as administered indicating the resident received both the AM and HS dose of the medication though the residents diastolic blood pressure was less than 55. Record review of Resident 9's MAR for the month of March 2026 revealed the following:-On 03/07/2026 a blood pressure documented of 129/35 in the HS. The MAR also revealed documentation that the residents' Carvediol 12.5 milligrams was signed as administered indicating the resident received the HS dose of the medication though the residents diastolic blood pressure was less than 55.-On 03/27/2026 a blood pressure documented of 132/52 in the HS. The MAR also revealed documentation that the residents' Carvediol 12.5 milligrams was signed as administered indicating the resident received the HS dose of the medication though the residents diastolic blood pressure was less than 55.In an interview completed on 04/13/2026 at 10:20 AM with Medication Aide H (MA-H), MA-H stated that the Medication Aides or who ever is giving Resident 9 their medications takes their blood pressure first and then if the residents blood pressure is not above the parameters written in the order they do not give the medication or they hold the medication. The MA stated that if they do not give the medication, they do not sign out the medication as given in the MAR and let the nurse know that the medication was not administered due to the residents' blood pressure. The MA confirmed that Resident 9 should not receive their Carvediol medication if their systolic blood pressure was not greater than 100 and their diastolic blood pressure was not greater than 55. The MA confirmed that the medication should be held if either number was outside of the parameters.In an interview completed on 04/13/2026 at 11:15 AM with the facility Director of Nursing (DON), the DON confirmed that Resident 9's Carvediol medication should have been held and not administered when their systolic blood pressure was less than 100 and their diastolic blood pressure was less than 55 per the providers parameters. The DON confirmed that Resident 9 received their Carvediol medication when they should not have due to their blood pressure being outside of the providers ordered parameters.

Licensure Reference Number 175 NAC12-006.09 (F)Based on record review, observation, and interview, the facility failed to review and revise a residents care plan when the residents care needs changed for 1 resident (Resident 19) of 3 sampled residents. The facility census was 36.Findings are:Record review of a facility policy titled Care Plan and dated 12/01/2025 revealed each resident will have an individualized, person-centered, comprehensive plan of care that will be modified to reflect the care currently required/provided for the resident.Record review of an admission Record revealed the facility admitted Resident 19 on 02/11/2026 with diagnosis of Cerebral Infarction (a loss of blood flow to an area of the brain causing tissue death resulting in sudden weakness, speech difficulties, and vision loss) and generalized muscle weakness.The 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 03/27/2026 revealed that Resident 19 had short- and long-term memory problems and severely impaired cognitive skills for daily decision making. The resident required partial to moderate assistance with eating and was dependent on staff assistance for transfers and toilet use. The resident was documented to have an indwelling urinary catheter (a tube inserted into the bladder to drain urine).Record review of resident 19's Care Plan on 04/09/2026 revealed a focus of the resident required Enhanced Barrier Precautions (EBP) due to having an indwelling foley catheter dated 02/16/2026. The focus of the resident had the potential of impairment of skin integrity dated 02/13/2026 with a intervention listed to watch the placement of the foley catheter drain tub and not dated. The focus of the resident having an activities of daily life self-performance deficit with a revision date of 03/10/2026 with an intervention listed of toilet use and the resident having a foley catheter with directions to provide catheter cares twice daily and as needed dated 02/16/2026.Record review of Resident 19's Progress Notes revealed documentation on 04/03/2026 at 8:24 AM that the resident had removed their indwelling foley catheter. The residents provider was notified of this and the provider gave guidance to not replace the catheter at this time.In an observation completed on 04/08/2026 at 11:22 AM Resident 19 was observed to be sitting in their room in their recliner. There was no visible evidence that the resident had an indwelling foley catheter. There was no signage indicating the resident was on Enhanced Barrier Precautions (EBP) and no isolation personal protective equipment items were observed inside or outside of the residents room.In an observation completed on 04/09/2026 at 07:47 AM Resident 19 was observed to be lying in their bed in their room flat on their back. There was no visible evidence that the resident had an indwelling foley catheter. There was no signage indicating the resident was on EBP and no isolation personal protective equipment items were observed inside our outside of the residents room.In an interview completed on 04/13/2026 at 10:15 AM with Registered Nurse B (RN-B), RN-B confirmed that Resident 19 no longer had a indwelling foley catheter and was no longer on EBP.In an interview completed on 04/13/2026 at 1:52 PM with the facility MDS Coordinator (MDSC), the MDSC confirmed that Resident 19's care plan was not accurate and up to date reflecting the residents current care needs due to the care plan reflecting the resident had an indwelling foley catheter and requiring EBP.In an interview completed on 04/13/2026 at 3:15 PM with the facility Director of Nursing (DON), the DON confirmed that Resident 19's care plan was up to date reflecting the current care needs by the resident and should have been.

Licensure Reference Number 175 NAC 12-006.09(D)Based on record review and interview the facility failed to complete Care Area Assessments (a core component of the Resident Assessment Instrument(RAI), used in Medicare/Medicaid-certified nursing homes to evaluate a resident's functional status, identify potential care problems, and develop an individualized care plan (CAA's)) for 2 residents (Resident 9 and Resident 19) of 2 sampled residents. The facility census was 36.Findings are:Record review of a facility policy titled Minimum Data Set 3.0 Resident Assessment Instrument and dated 10/27/2025 revealed completion of the CAA includes direction for completion to include in the analysis of findings area the employee to describe in narrative format the relationship that the risk factors/complications and confounding problems have on the residents triggered CAA. In the section titled Care Plan Considerations yes or no should be chosen if the care area will be addressed in the care plan with a rational for the decision to be included.A.Review of the 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 03/18/2026 for Resident 9 revealed the resident triggered for the CAA areas of Visual Function, Functional Abilities, Urinary Incontinence, Psychosocial Well-Being, Falls, Nutritional Status, Dental Care, Pressure Ulcer/Injury, and Psychotropic Drug Use.Review of Resident 9's CAA Worksheet for the comprehensive MDS dated [DATE] revealed the following:-The Visual Function CAA in the analysis of findings area no descriptive narrative that formats the relationship that the risk factors/complications and confounding problems have on the resident. In the Care Plan Considerations section, it was documented that Visual Functions would be addressed on the care plan. There was no overall objective documented and no description of the impact or the rational for this care plan decision documented. The CAA was signed as completed by the MDS Coordinator (MDSC) on 03/20/2026.-The Functional Abilities CAA in the analysis of findings area no descriptive narrative that formats the relationship that the risk factors/complications and confounding problems have on the resident. In the Care Plan Considerations section, it was documented that Visual Functions would be addressed on the care plan. There was no overall objective documented and no description of the impact or the rational for this care plan decision documented. The CAA was signed as completed by the MDSC on 03/20/2026.-The Urinary Incontinence CAA in the analysis of findings area no descriptive narrative that formats the relationship that the risk factors/complications and confounding problems have on the resident. In the Care Plan Considerations section, it was documented that Visual Functions would be addressed on the care plan. There was no overall objective documented and no description of the impact or the rational for this care plan decision documented. The CAA was signed as completed by the MDSC on 03/20/2026.-The Psychosocial Well-Being CAA in the analysis of findings area no descriptive narrative that formats the relationship that the risk factors/complications and confounding problems have on the resident. In the Care Plan Considerations section, it was documented that Visual Functions would be addressed on the care plan. There was no overall objective documented and no description of the impact or the rational for this care plan decision documented. The CAA was signed as completed by the MDSC on 03/20/2026.-The Falls CAA in the analysis of findings area no descriptive narrative that formats the relationship that the risk factors/complications and confounding problems have on the resident. In the Care Plan Considerations section, it was documented that Visual Functions would be addressed on the care plan. There was no overall objective documented and no description of the impact or the rational for this care plan decision documented. The CAA was signed as completed by the MDSC on 03/20/2026.- The Nutritional Status CAA in the analysis of findings area no descriptive narrative that formats the relationship that the risk factors/complications and confounding problems have on the resident. In the Care Plan Considerations section, it was documented that Visual Functions would be addressed on the care plan. There was no overall objective documented and no description of the impact or the rational for this care plan decision documented. The CAA was signed as completed by the Dietary Manager on 03/18/2026.-The Dental Care CAA in the analysis of findings area no descriptive narrative that formats the relationship that the risk factors/complications and confounding problems have on the resident. In the Care Plan Considerations section, it was documented that Visual Functions would be addressed on the care plan. There was no overall objective documented and no description of the impact or the rational for this care plan decision documented. The CAA was signed as completed by the MDSC on 03/20/2026.-The Pressure Ulcer/Injury CAA in the analysis of findings area no descriptive narrative that formats the relationship that the risk factors/complications and confounding problems have on the resident. In the Care Plan Considerations section, it was documented that Visual Functions would be addressed on the care plan. There was no overall objective documented and no description of the impact or the rational for this care plan decision documented. The CAA was signed as completed by the MDSC on 03/20/2026.-The Psychotropic Drug Use CAA in the analysis of findings area no descriptive narrative that formats the relationship that the risk factors/complications and confounding problems have on the resident. In the Care Plan Considerations section, it was documented that Visual Functions would be addressed on the care plan. There was no overall objective documented and no description of the impact or the rational for this care plan decision documented. The CAA was signed as completed by the MDSC on 03/20/2026.In an interview completed on 04/13/2026 at 1:52 PM with the facility MDSC, the MDSC confirmed that Resident 9's CAA's for the comprehensive assessment dated [DATE] were not completed as outlined in the facility policy and should have been.B.Review of the comprehensive MDS dated [DATE] for Resident 19 revealed the resident triggered for the CAA areas of Cognitive Loss/Dementia, Visual Function, Communication, Functional Abilities, Urinary Incontinence, Psychosocial Well-Being, Activities, Falls, Nutritional Status, Dehydration/Fluid Maintenance, Dental Care, Pressure Ulcer/Injury, and Pain.Review of Resident 19's CAA Worksheet for the comprehensive MDS dated [DATE] revealed the following:-The Cognitive Loss/Dementia CAA in the analysis of findings area no descriptive narrative that formats the relationship that the risk factors/complications and confounding problems have on the resident. In the Care Plan Considerations section, it was documented that Visual Functions would be addressed on the care plan. There was no overall objective documented and no description of the impact or the rational for this care plan decision documented. The CAA was signed as completed by the MDSC on 04/01/2026.-The Visual Function CAA in the analysis of findings area no descriptive narrative that formats the relationship that the risk factors/complications and confounding problems have on the resident. In the Care Plan Considerations section, it was documented that Visual Functions would be addressed on the care plan. There was no overall objective documented and no description of the impact or the rational for this care plan decision documented. The CAA was signed as completed by the MDSC on 04/01/2026.-The Functional Abilities CAA in the analysis of findings area no descriptive narrative that formats the relationship that the risk factors/complications and confounding problems have on the resident. In the Care Plan Considerations section, it was documented that Visual Functions would be addressed on the care plan. There was no overall objective documented and no description of the impact or the rational for this care plan decision documented. The CAA was signed as completed by the MDSC on 04/01/2026.-The Communication CAA in the analysis of findings area no descriptive narrative that formats the relationship that the risk factors/complications and confounding problems have on the resident. In the Care Plan Considerations section, it was documented that Visual Functions would be addressed on the care plan. There was no overall objective documented and no description of the impact or the rational for this care plan decision documented. The CAA was signed as completed by the MDSC on 04/01/2026. -The Urinary Incontinence CAA in the analysis of findings area no descriptive narrative that formats the relationship that the risk factors/complications and confounding problems have on the resident. In the Care Plan Considerations section, it was documented that Visual Functions would be addressed on the care plan. There was no overall objective documented and no description of the impact or the rational for this care plan decision documented. The CAA was signed as completed by the MDSC on 04/01/2026.-The Psychosocial Well-Being CAA in the analysis of findings area no descriptive narrative that formats the relationship that the risk factors/complications and confounding problems have on the resident. In the Care Plan Considerations section, it was documented that Visual Functions would be addressed on the care plan. There was no overall objective documented and no description of the impact or the rational for this care plan decision documented. The CAA was signed as completed by the MDSC on 04/01/2026.-The Activities CAA in the analysis of findings area no descriptive narrative that formats the relationship that the risk factors/complications and confounding problems have on the resident. In the Care Plan Considerations section, it was documented that Visual Functions would be addressed on the care plan. There was no overall objective documented and no description of the impact or the rational for this care plan decision documented. The CAA was signed as completed by the MDSC on 04/01/2026.-The Falls CAA in the analysis of findings area no descriptive narrative that formats the relationship that the risk factors/complications and confounding problems have on the resident. In the Care Plan Considerations section, it was documented that Visual Functions would be addressed on the care plan. There was no overall objective documented and no description of the impact or the rational for this care plan decision documented. The CAA was signed as completed by the MDSC on 04/01/2026.- The Nutritional Status CAA in the analysis of findings area no descriptive narrative that formats the relationship that the risk factors/complications and confounding problems have on the resident. In the Care Plan Considerations section, it was documented that Visual Functions would be addressed on the care plan. There was no overall objective documented and no description of the impact or the rational for this care plan decision documented. The CAA was signed as completed by the MDSC on 04/01/2026.-The Dehydration/Fluid Maintenance CAA in the analysis of findings area no descriptive narrative that formats the relationship that the risk factors/complications and confounding problems have on the resident. In the Care Plan Considerations section, it was documented that Visual Functions would be addressed on the care plan. There was no overall objective documented and no description of the impact or the rational for this care plan decision documented. The CAA was signed as completed by the MDSC on 04/01/2026.-The Dental Care CAA in the analysis of findings area no descriptive narrative that formats the relationship that the risk factors/complications and confounding problems have on the resident. In the Care Plan Considerations section, it was documented that Visual Functions would be addressed on the care plan. There was no overall objective documented and no description of the impact or the rational for this care plan decision documented. The CAA was signed as completed by the MDSC on 04/01/2026.-The Pressure Ulcer/Injury CAA in the analysis of findings area no descriptive narrative that formats the relationship that the risk factors/complications and confounding problems have on the resident. In the Care Plan Considerations section, it was documented that Visual Functions would be addressed on the care plan. There was no overall objective documented and no description of the impact or the rational for this care plan decision documented. The CAA was signed as completed by the MDSC on 04/01/2026.-The Pain CAA in the analysis of findings area no descriptive narrative that formats the relationship that the risk factors/complications and confounding problems have on the resident. In the Care Plan Considerations section, it was documented that Visual Functions would be addressed on the care plan. There was no overall objective documented and no description of the impact or the rational for this care plan decision documented. The CAA was signed as completed by the MDSC on 03/20/2026.In an interview completed on 04/13/2026 at 1:52 PM with the facility MDSC, the MDSC confirmed that Resident 19's CAA's for the comprehensive assessment dated [DATE] were not completed as outlined in the facility policy and should have been.

Licensure Reference Number 175 NAC 12-006.05(G)Based on record review and interview, the facility failed to complete documentation of non pharmalogical interventions used prior to the administration of an as needed psychotropic medication for 1 resident (Resident 19) of 2 sampled residents. The facility census was 36.Findings are:Record review of a facility policy titled Psychotropic Medications and dated 12/09/2025 revealed before administration of a non-emergency psychotropic medication documentation in Point Click Care (PCC) the residents electronic medical health record) or POC (Point of Care) observations of mood, symptoms or behaviors that cause the resident distress and or endanger the resident or others and responses to interventions used.Record review of an admission Record revealed the facility admitted Resident 19 on 02/11/2026 with diagnosis of Cerebral Infarction (a loss of blood flow to an area of the brain causing tissue death resulting in sudden weakness, speech difficulties, and vision loss) and generalized muscle weakness.The 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 03/27/2026 revealed that Resident 19 had short- and long-term memory problems and severely impaired cognitive skills for daily decision making. The resident required partial to moderate assistance with eating and was dependent on staff assistance for transfers and toilet use.Record review of Resident 19's Physician Orders revealed Resident 19 had orders for the following:-Lorazepam (an anti-anxiety psychotropic medication) Oral Concentrate 2milligrams per 1 milliliter with directions to give 0.5 milliliters every 4 hours as needed for anxiety with a start date of 04/03/2026 and revised on 04/07/2026.-Ativan (an anti-anxiety psychotropic medication) Oral Tablet 0.5 milligrams with directions to give 1 tabled by mouth every 4 hours as needed for anxiety or restlessness dated 04/02/2026.-The resident took Ativan for restlessness and anxiety. Target behaviors are increased restlessness, calling out for help despite needs being met. Attempt non pharmalogical interventions of 1) reposition, 2) offer toileting, 3) offer snack/drink, 4) provide one on one with the resident offering to hold their hand, 5) take the resident for a wheel chair ride outside if the weather was permitting.Record review of Resident 19's Electronic Medical Health Record (EMHR) for the month of April 2026 revealed:-On 04/08/2026 at 11:12 AM Resident 19 was administered the Lorazepam medication. There was no documentation in PCC or POC of observations of mood, symptoms, or behaviors that caused the resident distress and or endanger the resident or others and responses to and interventions used prior to the administration of the medication.-On 04/09/2026 at 9:10 AM Resident 19 was administered the Ativan medication with documentation stating the charge nurse requested the medication to be administered due to the resident appearing restless. There was no documentation in PCC or POC of the responses to and interventions used prior to the administration of the medication.-On 04/13/2026 at 10:08 AM Resident 19 was administered the Lorazepam medication with documentation stating the medication was administered per the charge nurse request and the resident appeared anxious. There was no documentation in PCC or POC of the responses to and interventions used prior to the administration of the medication.In an interview completed on 04/14/2026 at 11:30 AM with the facility Director of Nursing (DON), the DON confirmed that documentation in PCC or POC of the responses to and interventions used prior to the administration of the as needed psychotropic medication were not present for the medication administrations on 04/08/2026, 04/09/2026, and 04/13/2026 and should have been.

Licensure Reference Number 175 NAC 12-006.09(H)(iv)(5)Based on record review and interview the facility failed to provide care and services to promote regular bowel movements for 1 resident (Resident 19) of 2 sampled residents. The facility census was 36.Findings are:Record review of a facility supplied document titled Bowel Protocol and not dated revealed on day one with no bowel movement to do nothing, on day two with no bowel movement to do nothing, on day three with no bowel movement to push fluids, and for prune juice to be given in the morning at breakfast by the day shift medication aide. If no bowel movement throughout the day to then administer Milk of Magnesia (a medication used to promote bowel movements) in the evening shift by around 3pm. On day four if no bowel movement for night shift charge nurse to administer a suppository and if no bowel movement to repeat the prune juice at breakfast by the medication aide and Milk of Magnesia by the medication aid. On day five if no bowel movement for the night shift charge, nurse to administer an enema (a medication used to promote bowel movements).Record review of an admission Record revealed the facility admitted Resident 19 on 02/11/2026 with diagnosis of Cerebral Infarction (a loss of blood flow to an area of the brain causing tissue death resulting in sudden weakness, speech difficulties, and vision loss) and generalized muscle weakness.The 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 03/27/2026 revealed that Resident 19 had short- and long-term memory problems and severely impaired cognitive skills for daily decision making. The resident required partial to moderate assistance with eating and was dependent on staff assistance for transfers and toilet use. The resident was documented to always be incontinent of bowel.Record review of Resident 19's Electronic Medical Health Record (EMHR) POC Response History Toileting Question 5 for 03/16/2026 through 04/13/2026 revealed documentation that on 03/25/2026 (Day 1), 03/26/2026 (Day 2), 03/27/2026 (Day 3), 03/28/2026 (Day 4), 03/29/2026 (Day 5) and 03/30/2026 (Day 6) Resident 19 did not have a documented bowel movement. Record review of Resident 19's Medication Administration Record (MAR) for the month of March 2026 revealed the following:-An order for Milk of Magnesia Suspension with directions to administer 30 milliliters every 12 hours as needed for constipation with a start date of 03/23/2026. This medication was not signed as administered from 03/25/2026 through 03/30/2026. -An order for Bisacodyl Laxative Suppository 10 milligrams with directions to insert u suppository every 24 hours as needed for constipation dated 03/23/2026. This medication was documented as administered on 03/30/2026 (Day 6 without a documented bowel movement) at 1:41 PM. Record review of Resident 19's Progress Notes from 03/25/2026 through 03/30/2026 revealed no documentation of the resident having a bowel movement or the resident receiving an intervention to promote the resident to have a bowel movement.Record review of Resident 19's Electronic Medical Health Record (EMHR) POC Response History Toileting Question 5 for 03/16/2026 through 04/13/2026 revealed documentation that on 04/02/2026 (Day 1), 04/03/2026 (Day 2), 04/04/2026 (Day 3), 04/05/2026 (Day 4), and 04/06/2026 (Day 5) Resident 19 did not have a documented bowel movement. Record review of Resident 19's MAR for the month of April 2026 revealed the following:-An order for Milk of Magnesia Suspension with directions to administer 30 milliliters every 12 hours as needed for constipation with a start date of 03/23/2026. This medication was not signed as administered from 04/02/2026 through 04/06/2026. -An order for Bisacodyl Laxative Suppository 10 milligrams with directions to insert u suppository every 24 hours as needed for constipation dated 03/23/2026. This medication was not signed as administered from 04/02/2026 through 04/06/2026. Record review of Resident 19's Progress Notes from 04/02/2026 through 04/06/2026 revealed no documentation of the resident having a bowel movement or the resident receiving an intervention to promote the resident to have a bowel movement.In an interview completed on 04/14/2026 at 10:35 AM with the facility Director of Nursing (DON), the DON confirmed that Resident 19 went without a documented bowel movement from 03/25/2026 to 03/30/2026 and 04/02/2026 to 04/06/2026. The DON confirmed that the facilities protocol to promote bowel movements for residents was not followed and should have been.

Licensure Reference Number: 175 NAC 12-006.09 Based on record reviews and interviews, the facility failed to follow physician orders for 1 of 4 sampled residents (Resident 1). The facility census was 42. The facility Administrator was notified on 4/16/25 at 7:48 PM of an Immediate Jeopardy (IJ) which began on 3/18/25. The IJ was removed on 4/16/25, as confirmed by surveyor onsite verification. Findings are: Review of Resident 1's Baseline Care Plan (BCP, a plan of care for the resident that includes the minimum information needed to provide effective, person-centered care immediately upon admission) last updated on 04/16/2025 revealed the resident was admitted to the facility on [DATE] from another facility for long term care. Further review of the BCP revealed Resident 1 has a communication problem related to Down's Syndrome (a disorder causing distinct facial appearance, intellectual disability, developmental delays), is non-verbal, takes an anticonvulsant, dependent for all care needs, and has a nutritional problem related to full reliance on Gastric tube feedings (PEG-Tube; a feeding tube inserted through the skin and into the stomach, bypassing the mouth and esophagus, for food and medicine). A review of Resident 1's Physician Orders for the month of 03/2025 revealed: -Dilantin Oral Suspension 125 mg/5 ml (used to treat certain type of seizures) Give 8 ml via PEG-Tube two times a day. Start Date: 02/25/2025 -Phenytoin Oral Tablet Chewable 50 mg (used to control certain type of seizures) Give 3.5 tablet via PEG-Tube every 12 hours PRN, if we run out of liquid Dilantin. Start Date: 02/25/2025 A record review of the Medication Administration Record (MAR) from March 1st through March 31, 2025 for Resident 1 revealed that the liquid Medication Dilantin was documented as see nurse notes for the 4 PM dose on 3/18/25 and 3/19/25. On 3/20/25 and 3/21/25 both 8 AM dose and 4 PM dose was documented as drug not available. On 3/23/25 for 4 PM dose and 3/25/25 for 8 AM dose was documented as drug not available. The MAR further revealed the Phenytoin Oral Tablet had no documentation from 3/18/25 through 3/20/25, and on 3/21/25 and 3/23/25 was documented as unknown and 3/25/25 Phenytoin was documented as effective. There was no other documentation for the month of March on the MAR. A record review of the MAR from April 1st through April 30, 2025 for Resident 1 revealed no documentation that Dilantin was administered for 8 AM on 4/8/2025, and the noon dose on 4/12/2025 and 4/13/2025. MAR further revealed no documentation that Phenytoin was administered for the Month of April 2025 A review of Resident 1's progress note dated 03/20/2025 revealed that Licensed Practical Nurse-B (LPN-B) sent a communication to the pharmacy stating, call placed to pharmacy and asked about resident's Dilantin refill. Medication is back ordered and should be delivered tomorrow. Review of Resident 1's progress notes for the month of March 2025 did not reveal any further documentation for Dilantin or Phenytoin. A record review of progress notes dated 04/16/2025 revealed that Resident 1 went to the hospital on 04/04/2025 in the early am due to a seizure. The hospital notes reveal the residents' Dilantin levels were low, a new order was placed to increase the Dilantin. An interview with the pharmacy on 04/16/2025 at 4:50 PM confirmed the pharmacy did not have Dilantin or Phenytoin available to deliver to the facility from 3/18/25 through 3/21/2025. A review of Resident 1's communication form titled, Doctor of Medicine (MD)/Nursing Communications dated 03/28/2025 revealed on 03/23/2025 Phenytoin Oral Tablet Chewable 50 milligram (mg) give 3.5 tablet via PEG-Tube every 12 hours as needed for epilepsy use if we run out of liquid Dilantin administered due to liquid not available. The communication was signed by the physician on 03/31/2025. No other communication to the physician was found on notification that the medication was not available or provided. An interview with the DON and the Administrator (ADM) on 04/16/2025 at 5:10 PM confirmed there was no further documentation on the MAR or progress notes for providing the medication Dilantin on dates 3/18/2025-3/21/2025, 3/21/25, 3/23/25, and 3/25/25. The DON and the Administrator also confirmed that there was no documentation on the MAR to show that the medication Dilantin or Phenytoin Oral Tablet had been administered for the listed dates. DON and ADM further confirmed there was no documentation of administration of the medications on 04/08/2025 for the AM dose, 04/12/2025 noon dose, and 4/13/2025 noon dose. The DON and the ADM confirmed that the physician was not directly notified within 24 hours of the missing medication, and that the medication was not provided and should have been. A review of a facility policy titled, Medication: Administration Including Scheduling and Medication Aides dated 04/08/2025 revealed: -If a medication is given but not signed for, the person who administered the medication has 24 hours to sign, provided there is definitive evidence that the medication was administered. If not signed for within 24 hours, it is considered a medication error, and a SAFE Event Report must be completed. -Medication Errors: A SAFE Event Report will be completed for all medication errors. If medication is not available for 24 hours, the provider must be notified that the medication is not available and must give directions for how to proceed. The facility removed the immediate jeopardy with the following Abatement Statement: Resident 1's primary care provider was notified by the ADM and DON on 4/16/25 at 7:36 PM of the missing does of Dilantin. Resident 1 is currently in the hospital. All licensed nursing staff were immediately educated on the Policy Local Pharmacy Medication Ordering-R/S, LTC that were on shift 4/16/25. All licensed nursing staff will be educated prior to the next schedule shift. If a medication is not available, we will notify the physican immediately to get further direction and work with the pharmacy to get medication from another pharmacy. DON or designee with implement an end of shift checklist to monitor an potential missed medication and educate licensed nursing staff on checklist. DON or designee with audit for any unavailable or missed medications daily for 2 weeks, weekly for 2 weeks, and then monthly for 2 months until 100% compliance reached and brought to QAPI for further review and recommendations. At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level.

Licensure Reference Number: 175 NAC 12-006.12 Based on record reviews and interviews, the facility failed to ensure pharmacy provided medications for 1 of 4 sampled residents (Resident 1). The facility census was 42. The facility Administrator was notified on 4/16/25 at 7:48 PM of an Immediate Jeopardy (IJ) which began on 3/18/25. The IJ was removed on 4/16/25, as confirmed by surveyor onsite verification. Findings are: Review of Resident 1's Baseline Care Plan (BCP, a plan of care for the resident that includes the minimum information needed to provide effective, person-centered care immediately upon admission) last updated on 04/16/2025 revealed the resident was admitted to the facility on [DATE] from another facility for long term care. Further review of the BCP revealed Resident 1 has a communication problem related to Down's Syndrome (a disorder causing distinct facial appearance, intellectual disability, developmental delays), is non-verbal, takes an anticonvulsant, dependent for all care needs, and has a nutritional problem related to full reliance on Gastric tube feedings (PEG-Tube; a feeding tube inserted through the skin and into the stomach, bypassing the mouth and esophagus, for food and medicine). A review of Resident 1's Physician Orders for the month of 03/2025 revealed: -Dilantin Oral Suspension 125 mg/5 ml (used to treat certain type of seizures) Give 8 ml via PEG-Tube two times a day. Start Date: 02/25/2025 -Phenytoin Oral Tablet Chewable 50 mg (used to control certain type of seizures) Give 3.5 tablet via PEG-Tube every 12 hours PRN, if we run out of liquid Dilantin. Start Date: 02/25/2025. A review of Resident 1's Medication Administration Record (MAR) dated 03/01/2025-03/31/2025 revealed that the resident was admitted to the facility on [DATE] from another facility for long term care. MAR for Resident 1 further revealed that the liquid Medication Dilantin was documented as see nurse notes for the 4 PM dose on 3/18/25 and 3/19/25. On 3/20/25 and 3/21/25 both 8 AM dose and 4 PM dose was documented as drug not available. On 3/23/25 for 4 PM dose and 3/25/25 for 8 AM dose was documented as drug not available. The MAR further revealed the Phenytoin Oral Tablet had no documentation from 3/18/25 through 3/20/25, and on 3/21/25 and 3/23/25 was documented as unknown and 3/25/25 Phenytoin was documented as effective. There was no other documentation for the month of March on the MAR. A record review of the MAR from April 1st through April 30, 2025 for Resident 1 revealed no documentation that Dilantin was administered for 8 AM on 4/8/2025, and the noon dose on 4/12/2025 and 4/13/2025. MAR further revealed no documentation that Phenytoin was administered for the Month of April 2025 A review of Resident 1's progress note dated 03/20/2025 revealed that Licensed Practical Nurse-B (LPN-B) sent a communication to the pharmacy stating, call placed to pharmacy and asked about resident's Dilantin refill. Medication is back ordered and should be delivered tomorrow. Review of Resident 1's progress notes for the month of March 2025 did not reveal any further documentation for Dilantin or Phenytoin. A record review of progress notes dated 04/16/2025 revealed that Resident 1 went to the hospital on 04/04/2025 in the early am due to a seizure. The hospital notes reveal the residents' Dilantin levels were low, a new order was placed to increase the Dilantin. An interview with the pharmacy on 04/16/2025 at 4:50 PM confirmed the pharmacy did not have Dilantin or Phenytoin available to deliver to the facility from 3/18/25 through 3/21/2025. A review of Resident 1's communication form titled, Doctor of Medicine (MD)/Nursing Communications dated 03/28/2025 revealed on 03/23/2025 Phenytoin Oral Tablet Chewable 50 milligram (mg) give 3.5 tablet via PEG-Tube every 12 hours as needed for epilepsy use if we run out of liquid Dilantin administered due to liquid not available. The communication was signed by the physician on 03/31/2025. No other communication to the physician was found on notification that the medication was not available or provided. An interview with the DON and the Administrator (ADM) on 04/16/2025 at 5:10 PM confirmed there was no further documentation on the MAR or progress notes for providing the medication Dilantin on dates 3/18/2025-3/21/2025, 3/21/25, 3/23/25, and 3/25/25. The DON and the Administrator also confirmed that there was no documentation on the MAR to show that the medication Dilantin or Phenytoin Oral Tablet had been administered for the listed dates. DON and ADM further confirmed there was no documentation of administration of the medications on 04/08/2025 for the AM dose, 04/12/2025 noon dose, and 4/13/2025 noon dose. The DON and the ADM confirmed that the physician was not directly notified within 24 hours of the missing medication, and that the medication was not provided and should have been. The DON provided a facility checklist titled Nurse Shift Change Checklist dated 7/7/15 revealing: Purpose: Includes a list of items that need to be completed during the shift. 1. Verify all medications and treatments have been administered on either the clinical dashboard or eMAR (Electronic Medication Administration Record). A review of a facility policy titled, Medication: Administration Including Scheduling and Medication Aides dated 04/08/2025 revealed: -If a medication is given but not signed for, the person who administered the medication has 24 hours to sign, provided there is definitive evidence that the medication was administered. If not signed for within 24 hours, it is considered a medication error, and a SAFE Event Report must be completed. -Medication Errors: A SAFE Event Report will be completed for all medication errors. If medication is not available for 24 hours, the provider must be notified that the medication is not available and must give directions for how to proceed. A review of a facility policy titled, Local Pharmacy Medication Ordering dated 09/03/2024 revealed: -Purpose: To assist in resolving issues in receiving medications from a pharmacy. -If the medication is not available, notify the ordering physician immediately to determine whether the order should be changed tor starting the medication can wait until the medication is available from the pharmacy. Document in Progress Notes. The facility removed the immediate jeopardy with the following Abatement Statement: Resident 1's primary care provider was notified by the ADM and DON on 4/16/25 at 7:36 PM of the missing does of Dilantin. Resident 1 is currently in the hospital. All licensed nursing staff were immediately educated on the Policy Local Pharmacy Medication Orderins-R/S, LTC that were on shift 4/16/25. All licensed nursing staff will be educated prior to the next schedule shift. If a medication is not available, we will notify the physican immediately to get further direction and work with the pharmacy to get medication from another pharmacy. DON or designee with implement an end of shift checklist to monitor an potential missed medication and educate licensed nursing staff on checklist. DON or designee with audit for any unavailable or missed medications daily for 2 weeks, weekly for 2 weeks, and then monthly for 2 months until 100% compliance reached and brought to QAPI for further review and recommendations. At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level.

Based on observation, record review, and interview the facility failed to ensure they had either a full time Registered Dietitian (RD) or that the Director of food and nutritional services met the regulatory requirements. This had the potential to affect all 41 residents who consumed foods prepared in the facility kitchen. The facility census was 41. Findings are: A record review of an untitled document provided by the facility revealed the Dietary Manager (DM)'s legal name and that the DM had completed 270 contact hours in the nutrition and food service professional training program on 12/12/2023. There was no evidence that the DM had received a certification from this training. An interview on 01/22/2025 at 11:00 AM with the DM confirmed the DM was the facility's director of food and nutritional services and that the DM did not have an educational degree or certification to meet the regulatory requirements. An interview on 01/22/2025 at 11:12 AM with the RD confirmed that the RD did not work full time within the facility. The RD also confirmed that the DM did not have an educational degree or certification to meet the regulatory requirements.

Licensure Reference Number 175 NAC 12-006.04(B)(i) Based on record review, and interview the facility failed to ensure staff completed initial orientation per facility policy for 1 of 5 sampled staff members. This had the potential to affect all residents who resided within the facility. The facility census was 41. Findings Are: A record review of a facility policy titled Orientation and dated 07/21/2023 revealed orientation must be completed with in 30 days of the employee's start date. A record review of an untitled document supplied by the facility on 01/28/2025 revealed Registered Nurse (RN)-F's date of hire was listed as 06/25/2024. A record review of a document supplied by the facility on 1/28/2025 titled General Staff Nurse Pathway revealed RN-F's name and a start date of 05/31/2025. In the section titled Competency Validation, the competency or skills for Residents Rights and Special Care Population: Dementia were initialed and dated 12/23. A record review of an untitled, facility-supplied document that was dated 12/31/24 revealed RN-F had completed the facility orientation pathway and submitted it to their manager. The document revealed that RN-F had completed training on emergency procedures and abuse and neglect on 09/18/2024. In an interview on 01/28/2025 at 1:10 PM with the facility Director of Nursing Services (DNS), the DNS confirmed that RN-F did not complete their initial orientation within 30 days of hire per facility policy. In an interview on 01/28/2025 at 1:10 PM with the facility Administrator (Admin), the Admin confirmed that RN-F did not complete their initial orientation within 30 days of hire per facility policy.

Licensure Reference Number 175 NAC 12-006.18(B) Based on observation, interview, and record review; the facility failed to ensure that staff performed hand hygiene as required and did not place potentially soiled hangers in the clean linen cart during laundry delivery service to prevent the potential for cross-contamination for 21 (Residents 9, 37, 25, 20, 192, 15, 24, 29, 18, 26, 32, 33, 7, 13, 10, 1, 14, 16, 91, 30, 21) of 21 residents observed. The facility census was 41. Findings are: A record review of a facility policy titled Laundry, Resource Packet, dated 08/30/2024 revealed: -Transporting Clean Laundry/Laundry Passes -Package, transport and store clean clothes and linens to ensure their cleanliness and to reasonably protect them from dust and soil. -Clean linen carts are to be covered at all times including during storage and distribution. -Appropriate PPE shall be worn during laundry/linen passes when entering an isolation room. -Follow infection prevention procedures to reduce the possibility of contamination. -Perform hand hygiene between laundry/linen passes. An observation on 01/22/2025 at 12:25 PM revealed Laundry Aide-L (LA-L) was pushing a covered cart down 300 hall. LA-L stopped in front of room [ROOM NUMBER] (Residents 9 & 37), opened the cart through a zipper to retrieve the clothing items, then walked into the room to deliver the items. Upon walking out of the room, LA-L was observed holding several clothing hangers from the room and placed them back into the covered cart. LA-L then pushed the covered cart to room [ROOM NUMBER], retrieved clothing from the covered cart, and delivered it to the resident in room [ROOM NUMBER] (Resident 25). LA-L was then observed pushing the cart towards room [ROOM NUMBER] (Residents 20 & 192), then retrieving the clothing for that room from the covered cart and entering room [ROOM NUMBER] and coming out with empty hangers, placing them into the covered cart. LA-L was then observed pushing the cart to room [ROOM NUMBER] (Resident 15), retrieving the clothing from the covered cart and entering room [ROOM NUMBER] with clothing in hand and coming out with empty hangers, placing them into the covered cart. LA-L then pushed the cart towards room [ROOM NUMBER] (Residents 24 & 29), retrieving the clothing from the covered cart for that room and going into room [ROOM NUMBER] and coming out with empty hangers, placing them into the covered cart. LA-L did not perform hand hygiene as required while delivering laundry into each of these residents' rooms. On 01/22/2025 at 1:07 PM LA-L was observed carrying clothing through 300 hall and entering room [ROOM NUMBER] (Resident 18) carrying out empty hangers, not performing hand hygiene before or after leaving the room. On 01/27/2025 at 12:08 PM LA-L was observed pushing a covered clean laundry cart down 100 hall. LA-L stopped in front of room [ROOM NUMBER] (Resident 26), opened the covered cart through a zipper to retrieve the clothing items, then walked into room [ROOM NUMBER] to deliver the items. Upon walking out of the room, LA-L was observed holding several clothing hangers from the room and placed them back into the covered cart. LA-L pushed the covered cart to room [ROOM NUMBER] (Residents 32 & 33), retrieved clothing from the covered cart and delivered it to the residents in room [ROOM NUMBER]. LA-L was then observed pushing the cart towards 103 (Resident 7). LA-L was observed retrieving the clothing through the covered cart then entering room [ROOM NUMBER] and coming out with empty hangers, placing them into the covered cart. LA-L then pushed the cart towards room [ROOM NUMBER] (Resident 13), retrieving the clothing for that room and going into the room and coming out with empty hangers, placing them into the covered cart. LA-L then pushed the cart towards room [ROOM NUMBER] (Resident 10), retrieving the clothing for that room, entering the room and coming out with empty hangers, placing them into the covered cart. LA-L then pushed the cart towards room [ROOM NUMBER] (Resident 1), retrieving the clothing for that room, entering and coming out with empty hangers, placing them into the covered cart. LA-L then pushed the cart towards room [ROOM NUMBER] (Resident 14), retrieving the clothing, entering the room and coming out with empty hangers, placing them into the covered cart. LA-L then pushed the cart towards room [ROOM NUMBER] (Residents 16 & 91), retrieving the clothing for that room and going into the room and coming out with empty hangers, placing them into the covered cart. LA-L then pushed the cart towards room [ROOM NUMBER] (Resident 30), retrieving the clothing, entering the room and coming out with empty hangers, placing them into the covered cart. LA-L then pushed the cart towards room [ROOM NUMBER] (Resident 21), retrieving the clothing for that room, entering the room and coming out with empty hangers, placing them into the covered cart. LA-L did not perform hand hygiene as required while delivering laundry into each of these residents' rooms. An interview with the facility Administrator (Admin) on 01/27/2025 at 1:03 PM confirmed that staff were expected to perform hand hygiene between rooms while delivering resident laundry.

Licensure Reference Number 175 NAC 12-006.09(I) Based on record review, observation, and interview the facility failed to use cause analysis to place intervention to prevent accidents for 1 (Resident 35) of 2 sampled residents to prevent accidents. Facility states census of 41. Findings are: Record review of a facility policy titled Fall Prevention and Management dated 07/29/24 revealed to complete Fall Scene Huddle Worksheet and that the care plan is to be reviewed and updated with any changes or new interventions. Record review of the Admission Record revealed the facility admitted Resident 35 on 06/20/24 with diagnoses of type 2 diabetes (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production), hypertension (which is high blood pressure), and retention of urine (a condition where a person is unable to completely empty their bladder). Record review of the quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems), with an Assessment Reference Date (ARD) of 12/31/2024 revealed Resident 35 had a Brief Interview for Mental Status (BIMS: a brief screener that aids in detecting cognitive impairment), score of 13 indicating the resident was cognitively intact. The resident required supervision or touching assistance with toilet use and transfers and was independent with bed mobility. The resident used assistive devices of wheelchair and walker for mobility throughout the facility. The resident was coded to be occasionally incontinent of bladder and always continent of bowel and did not have a toileting program. Record review of Resident 35's electronic medical health record revealed: -On 12/12/24 Resident 35 was found on the floor of their room the resident indicated they fell while trying to get to the bathroom. -On 12/22/24 Resident 35 was found on the floor of their room the resident was attempting to self-transfer due to having to go to the bathroom. -On 12/29/24 Resident 35 was found on the floor of their room the resident was attempting to ambulate independently to the bathroom. Record review of Resident 35's Care Plan revealed no focuses or interventions involving the resident's urinary incontinence, urinary retention, or falls due to need to toilet. In an interview with Resident 35 on 01/22/24 at 9:30 AM revealed that [gender] had suffered from frequent falls due to having to go to the bathroom and not being able to wait for staff assistance. In an interview completed on 01/23/2025 at 9:30 AM with Nurse Aide C (NA-C), NA-C revealed that Resident 35 had suffered from falls. The NA-C revealed the resident often would not wait for staff assistance for help going to the bathroom and would fall. The NA denied the resident being on scheduled or other toileting plan. In an interview completed on 01/23/2024 at 2:45 PM with the DNS, the DNS confirmed that documentation for Resident 35 revealed the falls were associated with the residents need to toilet. The DNS confirmed that the residents care plan had no focuses or interventions placed to assist the resident with his falls due to toileting needs.

Licensure Reference Number 175 NAC 12.006.09D3(5) Based on record review and interview, the facility failed to ensure bowel care management was provided to prevent constipation for one (Resident 30) of two sampled residents. The facility identified a census of 41. Findings are: A record review of Resident 30's Admission Record, revealed that the resident had been admitted into the facility on [DATE] with a primary diagnosis of chronic respiratory failure with hypoxia (a condition where the body is unable to effectively exchange oxygen and carbon dioxide in the lungs over a prolonged period of time). A record review of the Significant Change Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 12/16/24, Section C, revealed Resident 30 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment score: 13-15: indicating cognitively intact, 8-12: indicating moderately impaired and 0-7: indicating severe impairment) score of 06 which indicated severe cognitive impairment. Section H, question H0400 revealed it was coded as a 3 indicating that Resident 30 was always incontinent of bowel. A record review of the undated Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) for Resident 30 revealed that it contained the following problem statement, goal and interventions related to constipation, Observe/monitor/document/report to health care provider PRN (when needed) s/s (signs and symptoms) of complications related to constipation: change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, bradycardia (slow, low pulse), swollen abdomen, vomiting, small loose stools, fecal smearing, bowel sounds, sweating, abdomen tenderness, guarding, rigidity. The resident is at risk of constipation R/T (related to) Decreased mobility, Medications side effects. The resident will have a normal bowel movement at least every 3 days through the review date. A record review of bowel documentation for the last 30 days for Resident 30 revealed no Bowel Movement (BM) had been documented 12/31/24 through 1/5/25 for a total of 5 days. A record review of the Medication Administration Record (MAR) dated December 2024 and January 2025 revealed no as needed (PRN) medications had been documented for bowel care management during the timeframe of 12/31/24 through 1/27/25. An interview with the Director of Nursing (DON) on 1/23/25 at 10:38 AM revealed that the facility did not have any standing orders or bowel protocol policy to prevent constipation. During the interview on 1/23/25 at 10:38 AM with the DON revealed that the facility expectations and process was that the evening nurse would look at the bowel report pulled from the Electronic Medical Record (EMR) and if no BM in 3 days, PRN bowel medications were given on evening shift. If the resident had no PRN bowel medications available a call would be placed to the physician and orders would be obtained. If PRN bowel medications were already in place, those medications would be given that evening. If those PRN medications did not result in the resident having a BM then staff would be instructed to give the next available PRN, as example, give PRN Milk of Magnesia an over-the-counter (OTC) laxative used for the treatment for constipation and if no results then the resident would be given a PRN Dulcolax suppository (a rectal medication used to treat constipation or to empty the bowels) and if no results from that, the resident would be given a PRN Fleets enema (works by increasing water in the intestine to hydrate and soften the stool to help produce a bowel movement) and if still no bowel movement, the nurse would notify the physician. After review of the BM documentation and the MAR dated December 2024 and January 2025 the DON confirmed that staff did not follow facility expectations related to bowel management for Resident 30.

Based on record review and interviews, the facility failed to provide life saving measures to a resident who desired cardiopulmonary resuscitation (CPR, a lifesaving attempt combination of rescue breathing and chest compressions when someone's heart has stopped ) for 1 (Resident 39) of 42 residents sampled. The facility census was 41. Findings are: Initiation of Cardiopulmonary resuscitation (CPR) -If cardiac arrests occur, CPR must be initiated unless the resident has: -A valid DNR 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 such as a living will or durable power of attorney (DPOA) for healthcare, recognized under state law (weather statutory or a recognized by the courts of the state), and relating to the provision of healthcare when the individual is incapacitated. -The resident has obvious signs of clinical death (e.g., rigor mortis (the stiffening of muscles that occurs after death), dependent lividity (a discoloration of the skin that occurs after death), decapitation (separation of the head from the body), transection (the [NAME] of a part of the body) or decomposition (the state or process of decay). -The initiation of CPR could cause injury or peril to the rescuer. A record review of Resident 39's Admission Record revealed a admitted [DATE]. A record review of Resident 39's Progress Notes dated [DATE] revealed Resident 39 was admitted with diagnosis of acute on chronic diastolic heart failure (Which is a condition in which the heart muscle is unable to pump enough blood to meet the bodies needs for blood and oxygen). The Progress Note further revealed that Resident 39's wishes were reviewed with the resident and family and Resident 39 was documented as wanting to have CPR performed. A record review of Resident 39's Progress Notes dated [DATE] revealed that 2 Nursing Assistants (NA) reported to the Nurse on duty at the time, that the resident in room [ROOM NUMBER] is dead. The nurse further wrote, intention to try CPR, but resident had total back repaired wearing a brace to support chest/upper back, resident has pacemaker (an implanted device that regulates heart's rhythm and rate by sending electrical pulses) and the resident was cold and discolored at extremities. An interview on [DATE] at 3:10 PM with the Director of Nursing Services (DNS) revealed that (gender) received a phone call from the nurse on duty at the time of the incident and was alerted that the resident was found absence of vitals, cool to the touch and blue on the mouth. DNS further reveals, the nurse also stated that the call light was within reach and CPR was not initiated because the resident was cool to the touch, blue on the mouth and oxygen would not register. The DNS was then asked about the timeline and revealed (gender) was notified that the resident was found at 3:30 AM and the DNS states (gender) was called at 3:49 AM. The DNS revealed not knowing why (gender) was not notified sooner and did not interview the nurse on duty at the time as to the reason why (gender) was not notified immediately. DNS further confirmed that all staff were not re-educated on the this incident and or the facility policy regarding CPR. An interview on [DATE] at 4:57 PM with Registered Nurse-F (RN-F) revealed RN-F was on duty at the time of the incident. RN-F stated (gender) saw Resident 39 around 1:00 AM and the 2 NA's on duty that evening assisted Resident 39 to the bathroom and nothing seemed different with Resident 39. RN-F further revealed that another resident at the facility had deceased , the mortician and family were present at the facility talking with the nurse and completing paperwork when the same 2 NA's stated they heard a beeping noise and checked on Resident 39, then notifying RN-F the resident was unresponsive. RN-F revealed that after assisting the mortician and family of the recently deceased resident, RN-F went to Resident 39's room [ROOM NUMBER] at 3:30 AM, hearing a beeping noise while finding the resident unresponsive. The blankets were thrown on the floor, RN-F could not recall if the oxygen tubing was on, off, or if they themselves took the tubing from Resident 39. RN-F revealed the beeping was from the continuous glucose monitor alerting a low blood sugar. RN-F revealed that (gender) checked Resident 39's code status, grabbed the automated external defibrillator (AED) machine (a medical device designed to analyze the heart rhythm and deliver an electric shock to victims of ventricular fibrillation to restore the heart rhythm to normal), checked pulse and provided a sternum rub (a painful stimulus applied to the sternum to assess a person's level of consciousness). RN-F revealed there was no pulse, (gender) did not initiate CPR, however (gender) called the DNS at 3:49 AM and they made the decision to not perform CPR. RN-F was interviewed on the policy for providing CPR and stated (gender) was aware of what the policy states on when and who is to receive CPR and that for this incident involving Resident 39, CPR was not initiated. Record review of a policy titled, Advance Directive including Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) dated [DATE]. The purpose is to provide each resident the opportunity to make decisions related to medical care and select a proxy. To define a process to make resident decisions known. And to provide early defibrillation due to cardiac arrest to residents, staff and visitors. Initiation of Cardiopulmonary resuscitation (CPR) -If cardiac arrests occur, CPR must be initiated unless the resident has: -A valid DNR 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 such as a living will or durable power of attorney (DPOA) for healthcare, recognized under state law (weather statutory or a recognized by the courts of the state), and relating to the provision of healthcare when the individual is incapacitated. -The resident has obvious signs of clinical death (e.g., rigor mortis (the stiffening of muscles that occurs after death), dependent lividity (a discoloration of the skin that occurs after death), decapitation (separation of the head from the body), transection (the [NAME] of a part of the body) or decomposition (the state or process of decay). -The initiation of CPR could cause injury or peril to the rescuer.

Licensure Reference Number 175 NAC 12-006.09(H)(vi) Based on record review and interview, the facility failed to develop a care plan with measurable goals and interventions to address the care and treatment for residents with dementia for 2 (Residents 31 and 35) of 2 sampled residents. The facility census was 41. Findings are: Review or a facility policy titled Psychotropic Medications dated 12/30/2024 revealed behavioral interventions are individualized, non-pharmacological approaches that are provided as part of a supportive physical and psychosocial environment and are directed toward understanding, preventing, relieving and or accommodating a resident's distress or loss of abilities as well as maintaining or improving a residents mental physician or psychosocial wellbeing. A. A review of an Admission Record indicated the facility admitted Resident 31 on 08/30/2023 with diagnoses of dementia (which is a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior. The quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems), with an Assessment Reference Date (ARD) of 10/29/2024 revealed Resident 31 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment), score of 10 indicating the resident was moderately cognitively impaired. The MDS was coded to reflect the resident received routine antidepressant (a medication used to treat depression) and antianxiety (a medication used to decrease anxiety symptoms) medications. Review of Resident 31's Physician Orders on 01/22/2025 revealed Resident 31 had routine orders to receive antipsychotic and antidepressant medications. Review of Resident 31's Care Plan revealed no measurable goal or intervention related to the resident receiving antipsychotic medication. There were no specific target behaviors or interventions to prevent or manage behaviors listed on Resident 31's Care Plan. In an interview completed on 01/23/2025 at 9:30 AM with Nurse Aide C (NA-C), NA-C stated that Resident 31 had the behavior or repeating the same statements or requesting the same thing over and over again. In an interview completed on 01/23/2025 at 10:30 AM with Licensed Practical Nurse E (LPN-E), LPN-E stated resident specific target behaviors are documented in progress notes and on each resident's treatment administration record. The LPN confirmed that Resident 31 had no specific target behaviors listed on their treatment administration record. In an interview completed on 01/27/2025 at 11:14 AM with the facility Director of Nursing Services (DNS) the DNS confirmed Resident 31 did not have any specific target behaviors listed on the resident's treatment administration record or on the residents Care Plan. B. A review of an Admission Record indicated the facility admitted Resident 35 on 06/20/2024 with diagnoses of type 2 diabetes (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production), hypertension (which is high blood pressure), and retention of urine (a condition where a person is unable to completely empty their bladder). The quarterly MDS, with an ARD of 12/31/2024 revealed Resident 35 had a BIMS score of 13 indicating the resident was cognitively intact. The MDS was coded to reflect the resident received routine antipsychotic and antidepressant medications. Review of Resident 35 Physician Orders on 01/22/2025 revealed Resident 35 had routine orders to receive antipsychotic and antidepressant medications. Review of Resident 35 Care Plan revealed no measurable goal or intervention related to the resident receiving antipsychotic or antidepressant medication. There were no specific target behaviors or interventions to prevent or manage behaviors listed on Resident 35's care plan. In an interview completed on 01/23/2025 at 9:30 AM with Nurse Aide C (NA-C), NA-C stated that Resident 35 would become inpatient when waiting for staff to come and assist them so when staff would enter the room the resident would be short tempered with them. In an interview completed on 01/27/2025 at 11:14 AM with the facility Director of Nursing Services (DNS) the DNS confirmed Resident 35 Care Plan did not address the residents use of antipsychotic or antidepressant medications.

Licensure Reference Number 175 NAC 12.006.09B Based on record review and interview the facility failed to ensure 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) accuracy related to psychotropic medication use for one (Resident 13) of one sampled resident. The facility identified a census of 41. Findings are: A record review of Resident 13's Admission Record, reviewed on 1/22/25, revealed that Resident 13 had been admitted into the facility on [DATE] with a primary diagnosis of hemiplegia (paralysis or weakness on one side of the body). A record review of the Quarterly MDS dated [DATE] revealed Resident 13 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) (score: 13-15: indicating cognitively intact, 8-12: indicating moderately impaired and 0-7: indicating severe impairment) score of 15 which indicated no cognitive impairment. A record review of the Medication Administration Record (MAR) dated January 2025 revealed Resident 13 was receiving the following medications which affected mood and behavior, *Clonazepam Oral Tablet 0.5 milligrams (mg) Give 0.5 mg by mouth at bedtime for anxiety. Start date: 02/19/2024. *Escitalopram Oxalate Oral Tablet 20 mg Give 1 tablet by mouth one time a day related to Major Depressive Disorder, recurrent. Start date: 02/10/2024. *Mirtazapine Oral Tablet 15 mg Give 1 tablet by mouth at bedtime related to Major Depressive Disorder, recurrent. Start date: 02/09/2024. *Olanzapine Oral Tablet 2.5 mg Give 2.5 mg by mouth at bedtime related to Major Depressive Disorder, recurrent. Start date: 09/22/2024. A record review of the Quarterly MDS dated [DATE] for Resident 13, Section N, question N0450 reads A. did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA assessment, whichever is more recent? With an answer of 0 indicating antipsychotics were not received. An interview on 1/27/25 at 11:02 AM with the Director of Nursing (DON) after review of the MDS dated [DATE] for Resident 13, confirmed that Section N, question N0450 was coded incorrectly and did not reflect the antipsychotic medication that Resident 13 was taking and should have. The DON also confirmed that the facility did not have a MDS policy but followed the Resident Assessment Instrument (RAI) manual. A record review of the RAI manual (Version 3.0) revealed that it contained the following guidance related to completion of the MDS, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status.

Based on record review, observation, and interview the facility failed to report an accident with major injury within the required time frames for 1 (Resident 31) of 2 sampled residents. The facility states census of 41. Record review of a facility policy titled Fall Prevention and Management dated 07/29/24 revealed to report to the state and regulatory agency when appropriate. A review of an Admission Record indicated the facility admitted Resident 31 on 08/30/23 with diagnoses of dementia (which is a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior), history of falls, and atrial fibrillation (which is when the heart has an irregular rhythm). Record review of the quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems), with an Assessment Reference Date (ARD) of 10/29/2024 revealed Resident 31 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment), score of 10 indicating the resident was moderately cognitively impaired. The resident required substantial/maximal assistance with toilet use, transfers, and bed mobility. The resident used a wheelchair for propulsion throughout the facility. Record review of Resident 31's Progress Notes revealed that on 01/05/25 the resident suffered a fall and was taken to the hospital for care. Documentation further revealed the resident returned to the facility on the same day with sutures to the right hand. In an interview with the Director of Nursing Services (DNS), the DNS confirmed that the facility did not report Resident 31's fall with injury to the state or regulatory agency per facility policy and regulatory guidelines.

Licensure Reference Number 175 NAC 12-006.02 Based on observation, interview, and record review, the facility administration failed to utilize its resources to attain or maintain the highest practicable physical and/or psychosocial well-being of each resident as identified by the deficient practices cited. This had the potential to affect all residents residing in the facility. The facility had a total census of 40 residents. The findings are: A. F600: The facility failed to protect all facility residents' right to be free from verbal abuse. In an interview on 11/29/22 at 11:31 AM, the Administrator reported they were not made aware of the allegations of verbal abuse by a facility staff member until after the surveyor had notified facility staff that Immediate Jeopardy had been identified on the afternoon of 11/17/22. The Administrator reported they were notified by the LTC (Long Term Care) Manager via phone. B. F710: The facility failed to ensure a physician approved or wrote admission orders for 1 resident reviewed. C. F727: The facility failed to ensure a Registered Nurse was provided at least 8 consecutive hours a day, 7 days a week. D. F801: The facility failed to ensure the Dietary Department Director met qualifications. E. F865: The facility failed to ensure the QAPI (Quality Assurance Performance Improvement) Committee identified and corrected quality of care issues. In an interview on 11/28/22 at 4:24 PM, the Administrator reported the QAPI process had been pretty informal. The Administrator confirmed the facility had no minutes or documentation from QAPI meetings over the last several months. F. An interview was conducted with the Facility Administrator on 11/29/22 at 11:31 AM. During the interview, the Administrator reported they were the Administrator for two buildings in town owned by the corporation. The Administrator stated they were in this facility approximately twice a week, for about four to five hours. The Administrator reported they spent the majority of their time at the second facility and the LTC Manager was responsible for the day-to-day operations of this facility. The Administrator confirmed the LTC Manager was not a licensed Nursing Home Administrator and held no other professional healthcare license.

Licensure Reference Number 175 NAC ,d+[DATE].02(8). Based on observation, interview, and record review, the facility failed to protect residents' right to be free from verbal abuse by facility staff NA G (Nurse Aide). This had the potential to affect all residents residing in the facility. The facility had a total census of 40 residents. The findings are: In confidential interviews on [DATE] from 10:25 AM - 2:26 PM, facility residents reported the following: -NA G was unkind, had yelled at them, and had made them cry on more than one occasion. They were fearful of retaliation if they reported NA G's actions to administration. They sometimes felt unsafe living at the facility due to NA G's behavior. -NA G was abrupt and scared them when they first arrived at the facility. -NA G yelled at them in front of a bunch of people for asking for help, including other residents and staff. They felt embarrassed and sad. -NA G scolded them for using their call light for assistance. NA G is unkind and aggressive at times. They had witnessed NA G yelling at other residents. They had voiced their concerns to DON (Director of Nursing) C. -Scared of a staff member that yells at them and is unkind. Fearful to disclose staff member's name, but reported they were working that day. A review of a document titled, CNA (Certified Nursing Assistant) Complaint, and dated [DATE] revealed the following information documented by DON C: -Met with CNA privately in my office. [CNA] tells me that [CNA] is concerned because there is a staff member who scream, yells, belittles (both staff and residents) and makes others feel terrible. States [NA G] is terrible. -States that [CNA] and other new staff have talked of quitting due to this behavior. States that residents have complained to [CNA] and staff about this behavior. Feels that residents and staff are afraid of retaliation if they complain. -CNA states that [they] heard that St. Luke's had a high turnover in staff. [CNA] states that [CNA] feels that [NA G's] negative behavior has been one reason for the high turnover. [CNA] states [CNA] has known people who have worked here previously and reports that one past employee told [CNA] that they would not step in the building for a million dollars. -CNA reports after the recent death of a female resident, [NA G] told the reporting CNA the bitch died . Per [CNA's] report, this was said in the community room [in] front of other residents. Reports [CNA] has observed three new staff members crying after an interaction with [NA G]. States [CNA] has heard both staff and residents say they are thinking of calling the state about this behavior. In CNA's words, [CNA] feels that this behavior is elder abuse. Observations on [DATE] from 11:00 AM - 2:25 PM revealed NA G was working in the facility providing direct care to facility residents. A review of the facility's as-worked schedule revealed NA G worked the following hours after allegations of abuse were reported to facility administration: -[DATE] - worked 12 hours, 6:00 AM - 2:30 PM and 6:00 PM - 10:00 PM -[DATE] - worked 12 hours, 6:00 AM - 2:30 PM and 6:00 PM - 10:00 PM -[DATE] - worked 8 hours, 6:00 AM - 2:30 PM A review of the facility's daily staffing sheet for [DATE] revealed NA G was working day shift as the bath aide. In an interview on [DATE] at 12:07 PM, the LTC (Long Term Care) Manager reported they first learned of the allegations of verbal abuse involving NA G on [DATE]. The LTC Manager stated DON C reported to them a nurse aide who desired confidentiality had reported allegations of verbal abuse involving NA G. The LTC Manager reported they instructed DON C to get more information because the allegations were vague and hearsay. An interview was conducted with DON C on [DATE] at 1:21 PM. During the interview, DON C stated they were new to their role and to long-term care and were receiving mentoring from IDON (Interim Director of Nursing) D. DON C reported a nurse aide had come to them and reported allegations of verbal abuse involving NA G on [DATE]. DON C further reported the nurse aide had requested confidentiality, but had reported observing NA G use profane language, scolding residents for using their call lights, and being verbally abusive to residents. DON C stated they had taken the weekend to [NAME] it over and then reported the allegations to IDON D and the LTC Manager on [DATE] at 2:30 PM. DON C reported they were instructed at that time to get more information from the nurse aide who confidentially reported the abuse allegations. DON C stated they visited again with the nurse aide on [DATE] and the nurse aide expressed fear of retaliation for themselves and residents for speaking up. DON C stated they had not worked any further on the investigation since that time. DON C reported IDON D and the LTC Manager had not been involved in the investigation and had put it back on DON C to do. An interview was conducted with IDON D on [DATE] at 9:30 AM. During the interview, IDON D reported they first learned of the allegations of verbal abuse involving NA G from DON C on [DATE] in the afternoon. IDON D stated the LTC Manager was also present at that time and the LTC Manager instructed DON C to get more information, as the information they had was vague. IDON D reported they gave DON C a binder with the investigation process in it. IDON D stated they had not been involved in investigating the allegations of abuse. A review of the facility's Abuse and Neglect Policy and Procedure, last revised [DATE], revealed the following: -Alleged or suspected violations involving any mistreatment, neglect, exploitation or abuse including injuries of unknown origin will be reported immediately to the administrator. In the absence of the administrator from the location, the following individuals have the administrative authority of the administrator for purposes of immediate reporting of alleged violations: the director of nursing services or the supervisor of social services. These designated individuals are delegated the authority by the administrator to: -1. Intervene in any situation in order to protect residents. -2. Remove any individual from the location if necessary for the protection of residents or employees, including but not limited to employees, visitors, contractors or family members. -3. Call local law enforcement for assistance with interventions necessary for the protection of resident or employees. -4. Call 911 for any type of emergency assistance. -The location will have evidence that all alleged or suspected violations are thoroughly investigated and will prevent further potential abuse while the investigation is in progress. Results of all investigations will be reported to the administrator or designated representative and to other officials in accordance with state law, including to the state survey and certification agency within five working days of the incident, or sooner as designated by state law. If the alleged or suspected violation is verified, appropriate corrective action will be taken. -PROCEDURE -1. If an employee receives an allegation of abuse, neglect, exploitation or misappropriation of resident property or witnesses suspected abuse, neglect or misappropriation of resident property, the employee will take measures to protect the resident, provided the safety of the employee is not jeopardized. The employee will then repot the allegation to a supervisor. -2. The charge nurse or licensed nurse will be notified immediately, assess the situation to determine whether any emergency treatment or action is required and complete an initial investigation. If this is an injury of unknown origin, he or she also will attempt to determine the cause of the injury. The charge nurse also will ensure that any potential for further abuse is eliminated by taking one of the following actions: -a. If this is an allegation of employee to resident abuse, the employee will be removed from providing direct care to all residents. Additionally, the employee will be placed on suspension pending the results of the internal investigation. -4. Notification procedures: -a. Alleged or suspected violations involving any mistreatment, neglect, exploitation or abuse including injuries of unknown origin will be reported immediately to the administrator. An interview was conducted with the Administrator on [DATE] at 11:31 AM. During the interview, the Administrator stated they first learned of the allegations of verbal abuse involving NA G on the afternoon of [DATE]. The Administrator confirmed the allegations of verbal abuse should have been reported to them immediately on [DATE]. The Administrator further confirmed DON C or the LTC Manager should have suspended NA G and immediately started an investigation into the alleged verbal abuse after it was reported to them on [DATE] and [DATE] in accordance with the facility's Abuse and Neglect Policy and Procedure. A review of a facility investigation dated [DATE] revealed the facility had initiated the process to terminate NA G's employment after allegations of verbal abuse were substantiated as evidenced by findings in resident interviews completed by the facility on [DATE]. On [DATE] at 4:05 PM, the facility provided the following plan to abate the immediacy of the situation: -1. Immediate suspension of accused employee (NA G) -2. Interview all residents to ensure there are no other issues/concerns for abuse and neglect with other staff currently employed. This includes in regards to their safety, understanding of reporting process and retaliation. -3. Training all staff on Abuse & Neglect Policy and understanding of reporting requirements for the safety of the residents and their well-being. This is to include management team members and leadership team members. -4. Charge Nurses will continue the training of oncoming staff members to ensure Abuse & Neglect Policy and understanding of reporting requirements are reviewed and signed off on prior to working. -5. Training completed with Administrator, (DON), (IDON), and LTC Manager by corporate Risk Team on How to investigate alleged abuse and neglect as well as the Abuse and Neglect Policy and Procedure via Webex on [DATE]. -6. Center will order flip charts and other educational abuse and neglect procedure to ensure that a quick reference is available to staff when suspected abuse/neglect arises.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09 Based on record review and staff interview, the facility failed to: 1) assess deterioration of medical status on 1/12/11; 2) assess elevated temperatures; 3) assess the cause of vaginal/rectal bleeding; 4) assess the effectiveness of pain relief medications; and 5) assess tolerance of catheter change. The facility census was 51 at the time of the survey and the survey sample size was 13. This affected Resident 3. Findings are: A. According to the medical file for Resident 3 the FACE SHEET and [DIAGNOSES REDACTED]. Record review of the IPN (Interdisciplinary Progress Notes) and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -On 1/1/2011 at 11:30 AM [MEDICATION NAME] 5/325 mg (milligrams) 1 tablet given per the MAR for back pain with no assessment of the intensity of the pain or the effectiveness of pain medication. -On 1/1/11 at 11:00 PM [MEDICATION NAME] 5/325 mg 2 tablets given per the MAR for back pain with no assessment of the effectiveness of pain medication. -On 1/3/11 at 5:20 PM [MEDICATION NAME] 5/325 mg 2 tablets given per the MAR for leg pain with no assessment of the effectiveness of pain medication. -On 1/5/11 at 11:20 AM [MEDICATION NAME] 5/325 mg 2 tablet given per the MAR for leg pain with no assessment of the effectiveness of pain medication. B. Record review of the IPN (Interdisciplinary Progress Notes) and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. -On 1/5/2011 at 2:00 AM, a recorded temperature of 100.2 degrees Fahrenheit and at 4:00 AM a recorded temperature of 100.0 degrees Fahrenheit with no follow up temperature taken until 11:30 PM at which time it was documented at 100.5 degrees Fahrenheit. -On 1/7/2011 at 1:30 PM, documentation showed the resident had blood clots in the mouth with no further assessment of the mouth documented in the medical record. -On 1/9/2011 at 3:15 AM, a recorded temperature of 100.5 degrees Fahrenheit with [MEDICATION NAME] 5/325 2 tablets given. At 5:25 AM the temperature continued at 99.9 degrees Fahrenheit with no further assessment of the temperature until 1/12/11. C. Record review of the IPN (Interdisciplinary Progress Notes) and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -On 1/11/2011 at 4:30 PM the urinary catheter was changed and a urinalysis collected and sent to the laboratory for an analysis. No assessment was documented of how Resident 3 tolerated the procedure or the condition of the urine collected. (urinalysis results revealed white blood cells, red blood cells, and bacteria. Normal results would be negative). D. Record review of the IPN (Interdisciplinary Progress Notes) and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -On 1/1/2011 at 8:00 AM, a note that the resident had bloody mucous vaginal discharge. -On 1/3/2011 at 2:00 PM, a note that the resident had blood tinged mucous vaginal drainage. -On 1/4/2011 at 8:00 PM, the resident had a liquid brown stool with scant blood noted. Review of the IPN found no further documentation of the assessment of the bloody drainage . E. Review of the IPN found no documentation on 1/12/11 of the following resident condition before calling 911: -No assessment of vital signs (blood pressure, temperature, pulse, respiration, oxygen saturation), -No assessment of changes in appetite, -No assessment of specific cognitive changes. -No mention of the inital lab values. Interview with RN-B (Registered Nurse) on 1/19/11 at 9:42 AM confirmed RN-B was the nurse in charge of the care of Resident 3 on the day shift of 1/12/11. RN-B reported that the morning on 1/12/2011 Resident 3 was deteriorating as the resident did not eat, had dull eyes, would only respond when spoken to, had a low blood pressure, and increased temperatures through the night. Due to the concern RN-B reported calling 911 for an emergency transfer of Resident 3 to the local hospital. RN-B confirmed the assessment of the resident had not been documented in the resident's medical record and the receiving facility did not receive the information.