Every finding on record at Heritage Crossings

License Reference Number 175 NAC 12.006.09(B)(iii)Based on record review and interviews, the facility failed to accurately code a Minimum Data Set (MDS- a comprehensive assessment used to develop a resident's plan of care) reflected that insulin (medication to control blood sugars) was being given. This affected 2 (Resident 37 and 47) out of the six sampled residents. The facility census was 47 at the time of survey. Findings are:Record review of Resident 37's quarterly MDS dated [DATE] revealed that the resident was admitted on [DATE] with a Brief Interview for Mental Status (BIMS- a test used to get a quick snapshot of a resident's cognitive function, scores from 0-15, the higher the score, the higher the cognitive function) scored a 0 which means severe cognitive impairment and that the resident was taking insulin injections.Record review of Resident 37's physician orders revealed no orders for insulin.Record review of Resident 37's list of diagnosis revealed a diagnosis of Type 2 Diabetes Mellitus.Record review of Resident 37's comprehensive care plan revealed:Focus dated 6/19/2024 that the resident is at risk for abnormal blood sugars and a diagnosis of Diabetes.Intervention dated 6/19/2024 that the staff are to administer medications as ordered.Record review of Resident 47's admission MDS dated [DATE] revealed that the resident was admitted on [DATE] with a BIMS score of 0 which means which means severe cognitive impairment and that the resident was taking insulin injections.Record review of Resident 47's physician orders revealed no orders for insulin.Record review of Resident 47's list of diagnosis revealed a diagnosis of Type 2 Diabetes Mellitus.Record review of Resident 37's comprehensive care plan revealed: Focus dated 02/05/2026 that the resident is at risk for abnormal blood sugars and a diagnosis of Diabetes. During an interview on 03/31/2026 at 12:44 PM RN - A, the MDS Coordinator, confirmed that Residents 37 and 47 were not on insulin and it was marked incorrectly on the MDS. RN - A also confirmed that Resident 37 and Resident 47 received Ozempic during the look back period and that Ozempic is not insulin. It was further confirmed that the Resident Assessment Instrument (RAI-a standardized, comprehensive framework used in nursing homes to assess a resident's functional, medical and psychosocial status) is used to ensure MDS accuracy.Record review of the CMS's RAI Version 3.0 Manual revealed that question N0350 is to record the number of days that insulin injections were received during the last 7 days.Review of the Ozempic package insert revealed that Semaglutide (Ozempic) belongs to the glucagon-like peptide-1 (GLP-1) receptor agonist drug class, often referred to as GLP-1. It works by mimicking the GLP-1 hormone to stimulate insulin secretion, lower blood sugar, slow gastric emptying, and increase feelings of fullness to aid in weight loss.

Licensure reference number 175 NAC 12-006.18 The facility failed to ensure staff wear gowns and masks while performing wound care, not wear 2 sets of gloves, and to perform hand hygiene between glove changes for 1 (Resident 4) out of 3 sampled residents to prevent the potential cross contamination. The facility had a census of 38. Findings are: Record review of the facility's policy Enhanced Barrier Precautions (EBP) dated 4/12/24 revealed: It is the policy of [NAME] Senior Living to implement EBP to help prevent the transmission of multidrug-resistant organisms (MDRO). -EBP will be initiated on residents with any of the following: Wounds (chronic wounds such as pressure injuries, diabetic foot ulcer, venous status ulcer, etc), and indwelling medical devices. -Implementation of EBP: Make gowns and gloves available neat or outside of the resident's room. Note: face protection may also be needed if performing activity with the risk of splash or spray (i.e., wound irrigation or tracheostomy care). -High-contact resident care activities include: Wound care for above mentioned wounds (skin tears are not included in chronic wounds). Record review of the facility's undated policy Hand Hygiene Competency revealed: When to wash hands: -before and after gloving. Record review of Resident 4's Clinical Census dated 6/12/25 revealed admission to the facility was on 12/15/22. Record review of Resident 4's Diagnosis Form dated 6/12/25 revealed a diagnosis of pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of sacral (area at the base of the spine) region, Stage 4. Record review of Resident 4's Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities) dated 5/27/25 revealed: -BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score was 14. -The resident had no rejection of care, required maximum assistance with toileting hygiene, bathing, upper/lower dressing, footwear, personal hygiene, rolling left and right in bed and transfers. The resident had a catheter and was frequently incontinent bowels. Record review of Resident 4's Physician Orders dated 6/12/25 revealed an order of: -Cleanse coccyx pressure ulcer daily with normal saline and apply collagen sprinkles to wound bed surface and loosely place Silver Alginate rope dressing in wound bed, skin prep to periphery and cover with waterproof super absorbent adhesive edged dressing every day shift related to pressure ulcer of sacral region, stage 4-order 5/30/25. Observation on 6/12/25 at 10:05 AM of wound cares for Resident 4 by MDSC (Minimum Set Data Coordinator) with SSS (Social Service Supervisor) assisting with repositioning. The MDSC and SSS performed hand hygiene with soap and water x 20 seconds, donned (put on) gloves, but did not put on a gown. MDSC cleaned the bedside table with a cleansing wipe, placed a chux (disposable bed pad) on top of table, and then placed some wound supplies on top of chux. MDSC removed gloves, applied hand gel, then put new gloves on. MDCS put more wound supplies on the chux. MDSC performed hand hygiene with soap and water x 20 seconds and donned 2 gloves on each hand stating, I'm from the old school for wearing 2 gloves. MDSC asked the resident if [gender] had any pain and resident said no. MDSC and SSS positioned resident to the right side. MDSC removed the old dressing, then removed the top set of gloves from each hand without performing hand hygiene, then measured the wound using a Q-tip. MDSC removed gloves, applied hand sanitizer, and donned new gloves. MDSC cleansed the wound with Dermal wound cleanser spraying it into the wound with MDSC's face approximately 15 inches away from wound when spraying the wound with cleanser and did not have goggles or face shield on. MDSC placed gauze into the wound with finger and wiped around the wound bed attempting to remove loose exudate MDSC stated. MDSC said, I forgot, we should have gowns on. MDSC removed gloves and went out of room to get 2 gowns, which the MDSC and SSS put on. MDSC then donned new gloves without first performing hand hygiene. SSS performed hand hygiene x 20 seconds. MDSC cleansed wound again with spray, and removed gloves, performed hand hygiene with alcohol gel and donned new gloves. MDSC placed collagen sprinkles in wound, then Silver Alginate dressing into wound bed. MDSC wiped the peri-wound area with a skin prep and applied a mepilex dressing. Interview on 6/12/25 at 10:40 AM with MDSC confirmed [gender] should have worn a gown during the entire time of performing wound care, not to double glove, and perform hand hygiene between glove changes. Interview on 6/12/25 at 10:42 AM with SSS confirmed [gender] should have worn a gown during the entire time of performing wound care. Interview on 6/12/25 at 11:00 AM with the Administrator confirmed the staff should have had gowns on during wound care, masks on when performing wound care, not wear 2 gloves, and hand hygiene between glove changes.

Licensure Reference Number 175 NAC 12-006.10A2 Based on observation, record review and interview, the facility failed to ensure standards of practice followed with administrating insulin for 2 (Resident 21 and Resident 24) of 2 sampled residents. The facility census was 45. Findings are: Observation on 12/7/23 at 8:35 AM of medication administration revealed Licensed Practical Nurse (LPN)-A removed the lid off a Tresiba Flextouch Pen, and turned the dose selector to 60 units and placed a new needle onto the pen. LPN-A began to walk towards Resident #21 to administer the medication. LPN-A was questioned regarding priming the insulin pen prior to dosing. Interview on 12/7/23 at 8:37 AM with LPN-A revealed (gender) did not know that the insulin pen/needle was to be primed before each dose. Record review of Resident 21's active physician orders revealed: Tresiba Subcutaneous Solution (Insulin Degludec) Inject 60 unit subcutaneously two times a day for Diabetes Mellitus II. Observation on 12/7/23 11:30 AM during medication administration revealed LPN-B removed the lid off the Lispro Pen, turned the dose selector to 20 units and placed the new needle onto the pen. LPN-B began to walk away from cart and towards Resident #24 to administer the medication. LPN-B was questioned regarding priming the insulin pen prior to dosing. An interview on 12/7/23 at 11:32 AN with LPN-B revealed (gender) had never done this and did not know that priming of the pen/needle was needed before each dose. Record review of Resident #20's active physician orders revealed: Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 20 unit subcutaneously before meals for diabetes. An interview on 12/7/23 at 12:15 PM with the facility Director of Nursing confirmed that priming the insulin pens are to be done prior to each dosing. Prefilled Insulin Pen Competency form dated 1.2020 stated under Procedure Step: 10. To prime the pen, make sure the arrow is in the center of the dose window (If you do not see the arrow in the center of the dose window, push in the injection button fully and turn the dose knob until the arrow is seen in the center of the dose window.) 11. Pull the dose knob out in the direction of the arrow until a 0 is seen. 12. Turn the dose knob clockwise until the number 2 is seen. (If the number dialed is too high, simple turn the dose knob backward until the number 2 is seen.) 13. Hold the pen with the needle pointing straight up, tapping the clear cartridge holder so any air bubbles collect near the top. Push the injection button completely using the thumb. Keep pressing and continue to hold the injection button firmly. A stream of insulin should come out the tip of the needle. (If the stream of insulin does not come out, repeat above steps. If after 6 attempts a stream of insulin does not come out the tip, change the needle. If still unable to get insulin flowing out of needle, do not use the pen and contact pharmacy).

Licensure Reference Number 175 NAC 12-006.09D2c Based on observation, interview, and record review, the facility failed to ensure that wound care orders were received for 1 (Resident 26) of 2 sampled resident. Total census was 48. Findings are: An observation on 1/24/2022 at 10:58 AM revealed Resident 26 had a dressing on the left ear and the left arm from mid-Bicep (part of the arm between the shoulder and elbow) to mid-hand. An observation on 10/25/2022 at 11:15 AM revealed Licensed Practical Nurse (LPN)-A performed wound care and placed a dressing on Resident 26's left arm from mid-Bicep to mid-hand. An observation on 10/25/2022 at 11:27 AM revealed LPN-A performed wound care and placed a dressing on Resident 26's left ear. A record review of the facility's Electronic Medical Record (EMR) did not reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the Physician Visit/Communication Form dated 09/27/2022 revealed Resident 26 had a Physician visit on 09/27/2022 for the left arm [CONDITION(S)] (a potentially serious bacterial skin infection) but did not reveal orders for wound care or dressings changes. In an interview with the Director of Nursing (DON) on 10/26/2022 at 08:03 AM, the DON confirmed Resident 26 did not have orders for wound care or dressing changes to the resident's left arm or left ear and LPN-A should not have performed wound care or applied dressings to the left arm or left ear without a physician order.

Licensure Reference Number 175 NAC 12-006.09D6 Based on observation, interview and record review; the facility failed to ensure the working condition for respiratory equipment to prevent potential contamination for Resident 36, and the facility failed to ensure the facility had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected 2 (Resident 36 and Resident 26) of 2 sampled residents. The facility identified with a census of 48 at the time of survey. Findings are: A. An observation on 10/24/22 at 11:40 AM of Resident 36 revealed a Continuous Positive Airway Pressure [([CONDITION(S)]) - a treatment that uses mild air pressure to keep breathing airways open per machine] in the resident's room on the nightstand with the tubing taped on to the machine with medical tape. Interview on 10/24/22 at 11:41 AM with Resident 36 revealed there is a hole in it and I need a new one. Resident 36 confirmed using the [CONDITION(S)] machine at night. A record review of Resident 36's orders dated 4/6/22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident 36's current comprehensive careplan (written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care), with the date initiated on and created on of 3/5/2021 revealed the resident is At risk for altered respiratory function related to Shortness of Breath and [CONDITION(S)]. A record review of the undated facility policy titled, Your [CONDITION(S)]/Bi-Level Unit under Cautions section, #3. If any visible deterioration of a component is apparent (cracking, tears, etc.) the component should be discarded and replaced. In an interview on 10/25/22 at 04:16 PM with the Assistant Director of Nursing (ADON) confirmed the use of the medical tape on the [CONDITION(S)] machine. The ADON confirmed the tape should not be there and staff should have replaced the tubing. B. An observation on 10/24/2022 at 10:55 AM revealed Resident 26 had a Positive Airway Pressure (PAP)(a device used to deliver positive air pressure to a resident's airways to prevent the airway from closing) device and supplies located on the nightstand next to the bed. An observation on 10/25/2022 at 10:49 AM revealed Resident 26 had a PAP device and supplies located on the nightstand next to the bed. In an interview on 10/25/2022 at 11:11 AM, the Infection Preventionist (IP) confirmed the resident wore a PAP device at night that was brought from home. A record review of Resident 26's Order Summary Report dated 10/25/2022 did not reveal a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A record review of Resident 26's Treatment Administration Record (TAR) dated October 2022 did not reveal a treatment order for Resident 26's PAP device. In an interview with the IP on 10/26/2022 at 08:03 AM, the IP confirmed that the facility did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to identify and monitor specific target behaviors for the use of an antianxiety [a class of medications used to treat anxiety] medication for Resident 45, and failed to ensure that an approved diagnoses was identified for the use of an antidepressant medication for Resident 26. This affected 2 (Residents 45 and 26) of 5 residents reviewed for medication use. The facility census was 48. Findings are: Record review of Resident 45's admission Face Sheet revealed that Resident 45 was admitted to the facility on [DATE] and included a diagnosis of Generalized Anxiety Disorder [Anxiety is the minds reaction to stressful, dangerous, or unfamiliar situations and can make the person feel nervous, restless, or tense, have a sense of impending doom and can cause sweating, increased heart rate and rapid breathing]. Record review of Resident 45's admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's plan of care) most recent quarterly MDS dated [DATE] revealed that Resident 45 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 14 which indicated that Resident 45 was cognitively intact, exhibited no behavioral symptoms, had a psychiatric diagnosis of Anxiety, and used an anti-anxiety medication daily. Record review of Resident 45's Medication Administration Record for September 2022 and October 2022 revealed that Resident 45 received [MEDICATION(S)] [an anti-anxiety medication] 0.5 milligrams 1 tab at bedtime each day. The medication was ordered and started on 9/10/22. Record review of Resident 45's Comprehensive Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) dated 9/26/22 identified that Resident 45 used Psychoactive Medications [a class of medications that, when administered, can affect mental processes such as mood, emotions, perceptions, and cognition] but did not identify resident specific target behaviors to be monitored for the use of an anti-anxiety medication. Record review of Resident 45's Electronic Medical Record revealed that no specific target behaviors had been identified and no monitoring for behaviors had been completed since 9/10/22 when the antianxiety medication was started. Interview on 10/26/22 at 11:11 AM with the Assistant Director of Nursing [ADON] confirmed that Resident 45 did take [MEDICATION(S)] daily, and that there were no resident specific target behaviors identified and no behavior monitoring had been completed for the continued use of the [MEDICATION(S)]. B. A record review of the Medication Regimen Review (MRR)(a monthly evaluation of each resident's medication orders by a Pharmacist) Policy, dated 05/21, revealed the Pharmacy reports all findings and recommendations to the Director of Nursing (DON), the attending Physician, the Medical Director, and the Administrator at least monthly. Recommendations are acted upon and documented by the facility staff and/or prescriber. A record review of Resident 26's Order Summary Report dated 10/25/2022 revealed a Physician order for [MEDICATION(S)] (a medication used to treat depression) Tablet 50 milligram (mg)(a metric unit of measure). Give 1 tablet by mouth at bedtime for Continuous Positive Airway Pressure dependence ([CONDITION(S)])(a device used to deliver positive air pressure to a resident's airways to prevent the airway from closing). A record review of Resident 26's Treatment Administration Record (TAR) dated October 2022 revealed a medication that was administered (given) of [MEDICATION(S)] Tablet 50 mg. Give 1 tablet by mouth at bedtime for [CONDITION(S)] dependance. A record review of the Consultant Pharmacist's Medication Regimen Review, dated 08/26/2022 - 09/21/2022, revealed a recommendation to please clarify the indication for the order for Trazadone for [CONDITION(S)] dependance, should this be for sleep? A record review of the Consultant Pharmacist's Medication Regimen Review, Active Recommendations Lacking a Final Response report, dated 09/22/2022 - 10/19/2022, revealed a recommendation to please clarify the indication for the order for Trazadone for [CONDITION(S)] dependence, should this be for sleep? The MRR also had No Response in the Recommendation Status column by the Trazadone recommendation. In an interview with the Assistant Director of Nursing (ADON) on 10/26/2022 at 02:05 PM, the ADON confirmed the Consultant Pharmacist originally sent the recommendation to change the indication for the Trazadone order on 09/21/2022 but the recommendation was not addressed. The recommendation was sent again 10/19/2022 on an Active Recommendations Lacking a Final Response report, and the recommendation had not been addressed. The ADON confirmed Resident 26 did not have an approved diagnosis for Trazadone.

Based on record review and interview, the facility failed to ensure 1 (NA - C) staff member working in the facility as a temporary NA (nurse aide) was assessed for competency prior to working with residents. This had the potential to affect all residents residing in the facility. The facility had a total census of 53 residents. The findings are: A review of NA - C's personnel file revealed NA - C had a hire date of 9/1/2020. Further review of NA - C's personnel file did not reveal verification that NA - C was active on the Nebraska Nurse Aide Registry. A review of the Nebraska Nurse Aide Registry database, accessed on 7/1/21, revealed NA - C was not listed in the database as a nurse aide. A review of nurse aide competencies provided by the facility did not reveal any competency assessments for NA - C. In an interview on 6/29/21 at 3:35 PM, the DON (Director of Nursing) confirmed the facility was unable to locate documentation of the competency assessments that were completed for NA - C at the time NA - C was hired at the facility. In an interview on 6/30/21 at 9:44 AM, the Administrator confirmed NA - C had been working in the facility with residents, performing all nurse aide duties.

Licensure Reference Number 175 NAC 12-006.18 Based on observation and interview, the facility failed to ensure that the vents in the bathrooms of the residents' rooms were cleaned; Room 204,102, 202, 203, 204, 312, 104, 107 and 313. This affected 9 of 9 sampled residents bathroom vents and had fuzzy gray matter in the vent grooves. The facility census at the time of survey was 53. Findings are: Observation on 6/24/21 at 09:47 AM revealed fuzzy gray matter in the vent grooves of the residents bathroom vents, of rooms 204, 102, 202, 204, 203,213, 104, 107, and 313. When checking for vents working, the vents were working and all were able to hold up 1 ply toilet paper, but there was fuzzy gray matter falling out of vent grooves onto surveyor and bathroom floor. Interview with E-HK 06/25/21 at 09:51 AM revealed the house keeping staff deep clean these vents every week.

Licensure Reference Number 175 NAC 12-006.02(8) Based on observation, interview, and record review, the facility failed to ensure resident-to-resident sexual behaviors were reported to the required state agencies for 4 (Residents 2, 27, 29, and 53) sampled residents. The facility had a total census of 53 residents. The findings are: A. A review of Resident 27's progress notes revealed the following: -4/23/2021 at 9:14 PM - (Resident 27) observed in other residents rooms and inappropriately touching them, this nurse had to remind (Resident 27) that isn't appropriate behavior and that it would be better to go back to (Resident 27's) own room. -4/24/2021 at 6:26 AM - Sexually acting out behavior continues. Self-danger observed when (Resident 27) ambulated into hallway with walker with pull-up (underwear) around thighs and pajama bottoms falling to floor. (Resident 27) continued to take steps. Staff come to side immediately and pull clothing up to waist and warn (Resident 27) of fall risk behavior. Action taken by posting a Stop Sign on the door of a female resident which (Resident 27) had entered on evening shift apparently seeking sexual gratification . An observation on 6/28/21 at 4:03 PM revealed Resident 2 lived across the hallway from Resident 27. Resident 2's room door had a Stop Sign taped to it. B. A review of Resident 29's electronic medical record revealed Resident 29 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 29's progress notes revealed the following: -5/17/2021 at 1:37 PM - (Resident 29) was sitting at dining room table completing noon meal when (Resident 27) leaned over (Resident 29) and kissed (Resident 29) on the lips. (Resident 29) looks at (Resident 27) and continued to eat meal. (Resident 27) was easily redirected to room. C. A review of Resident 53's electronic medical record revealed Resident 53 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 27's progress notes revealed the following: -4/20/21 at 6:50 PM - (Resident 27) was temporarily moved to another room in the evening on 4/19/21 to address interactions with another female resident - (Resident 53). Both have dementia and (Resident 53) has become fixated on (Resident 27) .with some very personal exchanges in the commons area and (Resident 27's) room which had a significant impact on other residents and (Resident 27's) roommate. Interventions by staff have been, for the most part, unsuccessful to redirect the two when they are together . A review of Resident 53's progress notes revealed the following: -4/20/21 at 6:05 PM - .(Resident 53) is fixated on (Resident 27) and (Resident 27) returns (Resident 53's) advances in kind. Both are very difficult to redirect. This situation exacerbated over the weekend and continued yesterday with both residents engaging in interactions of a very personal nature in the commons area which had a significant impact on other residents in the area . D. A review of the facility's Abuse and Neglect Prevention Standard Policy, last revised 3/2017, revealed the following: --Definitions - Sexual Abuse: -Federal Definition: Non-consensual sexual contact of any type with a resident. Includes but is not limited to, sexual harassment, sexual coercion, or sexual assault. -Nebraska Definition: Sexual abuse shall include sexual assault and incest. -Sexual exploitation includes but is not limited to, unlawful intrusion and causing, allowing, permitting, inflicting, or encouraging a vulnerable adult to engage in voyeurism, in exhibitionism, in prostitution, or in the lewd, obscene, or pornographic photographing, filming, or depiction of the vulnerable adult. --VII. REPORTING/RESPONSE: -Reporting must be made to the Administrator or Designee and other officials (including State Survey Agency and/or APS where state law provides for jurisdiction in LTC facilities) in accordance with state law through established procedures. Follow the state's specific reporting guidelines and requirements. -Any alleged physical, mental, verbal, or sexual abuse; mistreatment, neglect, misappropriation of resident's property, exploitation, or involuntary seclusion of a resident by a team member is to be reported to the proper authorities. -A. Report all alleged violations involving abuse (physical, mental, verbal, or sexual) immediately, but no later than 2 hours after the allegation has been made. -E. All resident-to-resident altercations must be reported immediately but no later than 2 hours after allegation has been made. -G. After conducting an internal investigation, you must submit a report of investigation results to the state within five working days. the facility will take necessary corrective actions depending on investigation results. -I. Analyze the incidents to determine what changes are needed to prevent future incidents. If allegation was substantiated, begin education immediately to all team members within the next two weeks. E. In multiple interviews on 6/28/21 and 6/29/21, the Administrator and DON (Director of Nursing) confirmed no reports were made to APS (Adult Protective Services) or the State Survey Agency regarding resident-to-resident sexual behaviors involving Residents 2, 27, 29, and 53.

Licensure Reference Number 175 NAC 12-006.02(8) Based on interview and record review, the facility failed to ensure resident-to-resident sexual behaviors were investigated for 4 (Residents 2, 27, 29, and 53) sampled residents. The facility had a total census of 53 residents. The findings are: A. A review of Resident 27's progress notes revealed the following: -4/23/2021 at 9:14 PM - (Resident 27) observed in other residents rooms and inappropriately touching them, this nurse had to remind (Resident 27) that isn't appropriate behavior and that it would be better to go back to (Resident 27's) own room. -4/24/2021 at 6:26 AM - Sexually acting out behavior continues. Self-danger observed when (Resident 27) ambulated into hallway with walker with pull-up (underwear) around thighs and pajama bottoms falling to floor. (Resident 27) continued to take steps. Staff come to side immediately and pull clothing up to waist and warn (Resident 27) of fall risk behavior. Action taken by posting a Stop Sign on the door of a female resident which (Resident 27) had entered on evening shift apparently seeking sexual gratification . An observation on 6/28/21 at 4:03 PM revealed Resident 2 lived across the hallway from Resident 27. Resident 2's room door had a Stop Sign taped to it. B. A review of Resident 29's electronic medical record revealed Resident 29 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 29's progress notes revealed the following: -5/17/2021 at 1:37 PM - (Resident 29) was sitting at dining room table completing noon meal when (Resident 27) leaned over (Resident 29) and kissed (Resident 29) on the lips. (Resident 29) looks at (Resident 27) and continued to eat meal. (Resident 27) was easily redirected to room. C. A review of Resident 53's electronic medical record revealed Resident 53 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 27's progress notes revealed the following: -4/20/21 at 6:50 PM - (Resident 27) was temporarily moved to another room in the evening on 4/19/21 to address interactions with another female resident - (Resident 53). Both have dementia and (Resident 53) has become fixated on (Resident 27) .with some very personal exchanges in the commons area and (Resident 27's) room which had a significant impact on other residents and (Resident 27's) roommate. Interventions by staff have been, for the most part, unsuccessful to redirect the two when they are together . A review of Resident 53's progress notes revealed the following: -4/20/21 at 6:05 PM - .(Resident 53) is fixated on (Resident 27) and (Resident 27) returns (Resident 53's) advances in kind. Both are very difficult to redirect. This situation exacerbated over the weekend and continued yesterday with both residents engaging in interactions of a very personal nature in the commons area which had a significant impact on other residents in the area . D. A review of the facility's Abuse and Neglect Prevention Standard Policy, last revised 3/2017, revealed the following: --Definitions - Sexual Abuse: -Federal Definition: Non-consensual sexual contact of any type with a resident. Includes but is not limited to, sexual harassment, sexual coercion, or sexual assault. -Nebraska Definition: Sexual abuse shall include sexual assault and incest. -Sexual exploitation includes but is not limited to, unlawful intrusion and causing, allowing, permitting, inflicting, or encouraging a vulnerable adult to engage in voyeurism, in exhibitionism, in prostitution, or in the lewd, obscene, or pornographic photographing, filming, or depiction of the vulnerable adult. --V. INVESTIGATION: -A. All allegations of abuse and/or neglect will be investigated and reported in accordance with the state and federal laws. -B. In the situation of an allegation of abuse, the following people will be notified immediately: Administrator, DON, and Social Services. -C. The suspected team member(s) will be suspended immediately while an in-depth, documented investigation is conducted. -D. An interview investigation will be conducted using the Interview Investigation Guidelines and documenting on the Interview Investigation Form. Additional investigation will be completed if there is suspected abuse and/or neglect or any injury of unknown origin. -F. The documents within the incident reporting process and interdisciplinary notes will be reviewed to identify situations, patterns, or trends such as suspicious bruising of residents that may constitute abuse. -G. In the situation that an allegation of abuse was between residents, the investigation procedure would be the same. The resident(s) in question should be immediately moved to a place of safety during the investigation. --VI. PROTECTION: -A. Residents will be protected from harm during an investigation. -B. Residents will be separated or moved to a place of safety away from a harmful or abusive situation to prevent a reoccurrence and for their own protection. E. In multiple interviews on 6/28/21 and 6/29/21, the Administrator and DON (Director of Nursing) confirmed no investigations could be located regarding resident-to-resident sexual behaviors involving Residents 2, 27, 29, and 53.

Licensure Reference Number 175 NAC 12-006.17D Based on observation, record review, and interview; the facility failed to ensure sanitation of the staffs' hands and prevent cross contamination during meal times in the dining room, when staff was working with their masks, touching their faces, and hair, and not providing hand hygiene. This had the potential of affecting 46 of 53 residents. The facility census was 53. Findings are: A. Observation on 06/23/2021 at 12:10 PM revealed kitchen/dining staff and nursing staff in the dining room to pass trays, found DM-G, DM-F and DM-C, and staff helping to pass trays from the dining room, pulling their masks up, and they kept touching their masks and did not hand sanitize. These same staff went to the window of the dining room to pick up plates of food. The staff put thumbs on the rims of plates near food and then served the food to the residents at the tables. Observation on 6/24/2021 at 08:00 AM revealed kitchen and dining staff and nursing staff in the dining room to help pass breakfast trays. The staff were moving their masks and hand hygiene was not completed prior to taking plates from kitchen to the residents' table. Observation on 06/24/21 at 12:21 PM revealed DM-G touching their mask, took 2 plates from kitchen to residents at their tables. Interview with the Dietician on 06/24/21 at 11:28 AM revealed they are in the process of educating more staff, and teaching about hand and mask hygiene and the dining experience. Record review revealed a dietary procedure on Serving Food Safely. This procedure revealed how to conduct hand hygiene. B. During an observation of cares on 06/28/21 at 11:10 AM, NA-K (Nurse Aide) had been observed to pull mask down to answer questions. A record review of the facility policy titled Covid-19 Guidelines and dated 06/25/21 revealed the following instructions on page 1 face masks/respirator will only be removed when a team member is eating/drinking in designated areas and face mask protocol will be followed. An interview on 06/28/21 at 4:40 PM with the DON (Director of Nursing) confirmed staff were not to remove face masks during resident cares or during interviews.

Licensure Reference Number 175 NAC 12-006.05(21) Based on observation, interview and record review; the facility staff failed to treat a facility resident with respect and dignity by entering the resident's room without waiting for permission to enter the room. This affected 1 of 4 sampled residents (Resident 13). The facility identified a census of 58 at the time of survey. Findings are: Observation of Resident (13) during an interview with the resident on 06/23/21 at 3:29 PM revealed a staff member entering room [ROOM NUMBER], where Resident 13 was conversing with another person; the same staff person entered the room [ROOM NUMBER] different time without waiting for permission to enter. Review of Resident 13's Annual MDS (Minimum Data Set- a comprehensive assessment tool used to develop a resident's care plan) dated 4/13/21 revealed an admitted [DATE]. Resident 13 had a BIMS (Brief Interview for Mental Status) score of 14 which indicated Resident 13 was cognitively intact. Review of the nursing home's policy Your Rights and Protections as a Nursing Home Resident revealed residents have the right to be treated with respect and dignity; as well as the booklet given to the resident Getting to Know Us Resident Policies. Confirms all resident have the right to be treated with dignity and respect in all interactions. Interview with SSD 06/30/21 at 2:00PM the expectation that all residents should be treated with dignity and respect at all times.

Licensure Reference Numbers 175 NAC 12-006.12E1 and 12-006.12E7 Based on observation, interview, and record review, the facility failed to store medications in accordance with manufacturer's directions and facility policy for 2 (Residents 103 and 46) of 14 sampled residents. The facility had a total census of 53 residents. The findings are: A. An observation on 6/30/21 at 9:53 AM with MA (Medication Aide) - D revealed a box containing a bottle of liquid lorazepam (a medication used to treat anxiety) for Resident 46 was being stored in the narcotic box on the 200 hallway medication cart. Further observation at this time with MA - D revealed instructions on the box of the liquid lorazepam stated, must be stored under refrigeration 2 - 8 degrees Celsius (35.6 - 46.4 degrees Fahrenheit). An observation and interview with LPN (Licensed Practical Nurse) - A on 6/30/21 at 10:00 AM confirmed the liquid lorazepam was supposed to be stored in the refrigerator. LPN - A reported sometimes staff will keep the liquid lorazepam on the medication cart if it is being given frequently. A review of the facility's medication storage and utilization policy, last updated 3/2019, revealed the following information: -6. Medications requiring refrigeration or storage at temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a refrigerator with a thermometer to allow for temperature monitoring. -7. Temperatures of medication storage refrigerators will be monitored and recorded daily to ensure proper storage. Food and non-medication items will not be stored in the medication refrigerator unless used to administer medications, in which case it must remain separate from internal and external medications. B. An observation with LPN - A on 6/30/21 at 10:02 AM revealed a vial of [MEDICATION(S)] Insulin (a short-acting insulin used to treat Diabetes) in a locked drawer in Resident 103's room. There was no date present on the [MEDICATION(S)] Insulin to indicate when it had first been opened and accessed. An interview with LPN - A at this time confirmed the vial of [MEDICATION(S)] Insulin for Resident 103 was not dated, but should be. A review of the facility's medication storage and utilization policy, last updated 3/2019, revealed the following information: -10. All multi-dose vials, bottles, and containers (e.g. eye drops, nose spray, ear drops) will be dated when opened. -11. Multi-dose vials which have been opened or accessed (e.g. needle punctured) should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2 Based on observation, interview and record review, the facility failed to ensure skin assessments had been completed related to cast/splint for Resident 203. The sample size was 14. The facility identified a census of 53. FINDINGS ARE: A record review conducted on 06/28/21 of the Physician's Progress Note dated 1/6/21 revealed Resident 203 to have had a recent fall with a left finger and wrist fracture approximately 3 weeks prior with a left hand/wrist splint in place. A record review conducted on 06/28/21 of the facility policy titled Skin and Wound Management Standard dated 01/2016, page 10, section J titled casting/splinting/orthotics reads as follows: Check skin integrity at least every 4 hours and PRN (as needed). Document the task by initialing completion on the TAR/ETAR (Treatment Administration Record/Electronic Treatment Administration Record). Remove splint/orthotic for skin checks. If ordered not to remove, request orders for removal or involve Medical Director. The policy then had a hand written note at the bottom of section J which read Need to know what is under there!!!. A record review of the Progress notes dated 3/2/21 through 3/11/21 for Resident 203, revealed skilled assessments to include a skin section with no mention of a splint to left wrist/hand, skin condition or swelling except one entry on 3/10/21. The record review of the Progress notes dated 3/2/21 through 3/11/21 for Resident 203, revealed on 3/4/21 an order had been received from the physician stating continue current splint, can take off for bathing and gentle range of motion, x-rays within 4 weeks. A review of an email from an anonymous reporter dated 3/15/21 stated that the facility staff were aware of the swelling to the left hand of Resident 203 due to the splint wrap being placed on too tightly after a bath on 3/4/21. The reporter stated that on 3/7/21 it had been noted that the swelling was worse and food and red dried drainage surrounding cracked flaking skin existed below the splint wrap upon removal. A record review on 06/30/21 of the TAR dated June 2021 revealed no checks of the left upper extremity and splint for Resident 203 existed. An interview with the facility Director of Nursing on 6/30/21 at 11:45 AM confirmed that no CMS (circulation, movement, sensation) checks or skin checks existed for Resident 203 related to the left hand/wrist and should have.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on observation, interview and record review; the facility failed to follow physician's orders related to the oxygen use for Resident 5. The sample size was 14. The facility identified a census of 53. FINDINGS ARE: An observation on 06/23/21 revealed Resident 5 wore supplemental oxygen. The observation revealed an oxygen concentrator in the room but no portable oxygen tank. An interview conducted on 06/23/21 at 10:48 AM revealed that Resident 5 removed the oxygen during meals. An observation on 06/24/21 at 11:48 AM revealed Resident 5 in the dining room with no oxygen in place. An observation on 06/28/21 at 11:52 AM revealed Resident 5 in the dining room with no oxygen in place. A record review conducted on 06/29/21 at 10:43 AM, of the active orders list for Resident 5, revealed the following oxygen order ; Oxygen via nasal cannula continuous at 2LPM. every shift. A record review conducted on 06/29/21 at 10:43 AM, of the active orders list for Resident 5 revealed no order to remove oxygen or use intermittently. An interview on 06/29/21 at 11:55 AM with the facility DON (Director of Nursing), after review of the use of oxygen for Resident 5, confirmed that an order to allow Resident 5 to go without oxygen did not exist.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B1(2) Based on record review and interview, the facility failed to ensure a significant change assessment was completed for Resident 50 related to a decline in ADL's (Activities of Daily Living). The sample size was 14. The facility identified a census of 53. FINDINGS ARE: A record review completed on 06/24/21 at 11:45 AM of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 03/09/2021 and 06/08/2021, section G revealed an increase in assistance required to complete bed mobility, transfer ability, dressing and toileting. A record review completed on 06/24/21 at 11:45 AM of the MDS's dated 03/09/2021 and 06/08/2021 revealed no significant change assessment had been completed related to the change in ADL status. An interview conducted on 06/29/21 at 10:58 AM with the facility MDS nurse confirmed that no significant change had been completed related to the increased level of assistance required for ADL's. An interview with the facility DON (Director of Nursing) on 06/30/21 at 11:21 AM revealed that the facility did not have a Change of Condition Policy and followed the MDS.

Based on record review and interview, the facility failed to ensure advanced notice of discharge from Medicare A services was provided for 1 resident, (Resident 12) of 3 sampled residents. The facility identified a census of 53 at the time of survey. Findings are: Record review of Resident 12's, Notices of Non Coverage revealed the resident had been on Medicare A since 12/4/20. Was given the Notice of Medicare Non -Coverage and the Skilled Nursing Advance Beneficiary Notice dated on 12/09/20. The resident was discharged from Medicare A on 02/03/2021. Interview with the SSD (Social Services Designee) revealed Notices of Non Coverage had been given to and signed by the resident's Power of Attorney on 12/09/20. The resident was discharged from Medicare A on 02/03/2021. Record review of Resident 12, revealed the resident's admitted to the facility was 01/17/2017.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications related to pain and behaviors for Resident 22. The sample size was 14. The facility identified a census of 53. FINDINGS ARE: During an interview on 6/23/21 at 11:40 AM, Resident 22 had voiced having knee pain related to a fall. During the interview, Resident 22 had reported no x-rays or medical attention had been provided related to knee pain. A record review of the incident log on 6/24/21 revealed a fall had occurred on 01/30/21 for Resident 22. The record review revealed no injury noted with fall that had occurred on 01/30/21. An interview on 06/28/21 at 02:20 PM with the facility Administrator confirmed a fall date for Resident 22 of 01/30/21 with no injury noted. A record review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The review of this note revealed that Resident 22 had been placed on [MEDICATION(S)] (a medication used to control seizures that is also used to relieve nerve pain) 100mg 1 capsule by mouth two times a day related to OTHER CHRONIC PAIN. During an interview with the Administrator on 06/28/21 at 02:20 PM, it was confirmed that the facility expectation was that pain would be assessed daily for anyone taking routine pain medication. A record review of the MAR (Medication Administration Record) dated June 2021 for Resident 22 revealed no pain assessment ratings had been documented. A record review of the Progress Notes dated 06/16/21 through 06/28/21 for Resident 22 revealed no documentation of pain. A record review of the documentation titled Behavior/Intervention Monthly Flow Record dated June 2021 revealed no episodes of Anxious or Depressed mood for Resident 22. The record review of the Behavior flow records dated March 2021, April 2021 and May 2021 also revealed no episodes of anxious or depressed behaviors for Resident 22. An interview on 06/28/21 at 3:50 PM with LPN-J (Licensed Practical Nurse) revealed that Resident 22 had been placed on [MEDICATION(S)] for increased pain and depression. During the interview with LPN-J, after review of the behavior documentation for June 2021, confirmed no episodes of pain or behaviors had been documented.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D6 Based on observation, interview and record review, the facility failed to ensure the provision of respiratory care in accordance with facility policy and professional standards to prevent contamination related to the cleaning and storage of nebulizer equipment for Resident 205. FINDINGS ARE: An observation on 06/23/21 at 11:01 AM revealed a nebulizer kit for Resident 205 connected together in one piece after use and stored inside a black cloth bag and resting on the air vent. An observation on 06/24/21 at 12:09 PM revealed the nebulizer kit for Resident 205 to be wrapped in a paper towel together in one piece and resting on the air vent. An observation on 06/29/21 at 11:30 AM revealed a nebulizer kit to be wrapped in a paper towel and resting inside a black bag. The observation revealed the kit to have fluid in the chamber. An observation with the facility DON (Director of Nursing) on 06/29/21 at 11:35 AM of the nebulizer kit storage for Resident 205 confirmed the storage was not according to facility policy and did not prevent the potential for infection. A record review of the facility policy title Nursing Facility Nebulizer Equipment Cleaning/Disinfecting Protocol: and dated 06/25/21, revealed instructions as follows: After every use: Rinse neb set (mask/pipe and reservoir) with tap water and allow to air dry. Place neb set in black antimicrobial bag between uses. The record review of the facility policy also stated every treatment- wash with soapy water and rinse after every use. Allow to air dry.

Licensure Reference Number 175 NAC 12-006.04D2 Based on interview and record review, the facility failed to ensure the dietary manager had the required credentials to meet the regulatory guidelines for the position. This had the potential to affect all residents residing in the facility. The facility census was 59. The findings are: In an interview on 9/3/19 at 4:03 PM, the Dietary Manager stated (gender) title is actually Interim Dietary Manager. The Dietary Manager stated (gender) graduated from the Dietary Program at Southeast Community College and was waiting to take the test to become a Certified Dietary Manager. The Dietary Manager stated that the facility has a dietician that comes twice a month. Observation during this interview also revealed the Dietary Manager's name tag identified a title of Dietary Manager. In an interview on 9/4/19 at 9:37 AM, the Administrator confirmed the Dietary Manager is not a Certified Dietary Manager. The Administrator stated the Dietary Manager has a date scheduled to take the test, but (gender) does not know when it is. The Administrator stated one of their housekeeping staff was a Certified Dietary Manager and had been mentoring the Dietary Manager. A record review of a Certificate from Southeast Community College, revealed the Dietary Manager received a Certificate in Dietary Manager on (MONTH) 20, (YEAR). An interview on 9/4/19 at 10:27 AM with Housekeeping Staff B confirmed (gender) was a Certified Dietary Manager, but was not the designated department manager and does not work in the kitchen at all. Housekeeping Staff B stated (gender) only worked in housekeeping.