Every finding on record at Hillcrest Firethorn

Licensure Reference Number 175 NAC 006.11DBased on observations, interviews and record reviews, the facility failed to ensure that food served to the residents was at a safe and appetizing temperature. This had the potential to affect all 68 residents who eat from the kitchen. The census at the time of the survey was 68. Findings are: Record review of the FDA Food Code 2022, a science-based guideline published by the Food and Drug Administration to regulate food service facilities to create uniform safety rules, revealed in the section titled 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding that bacterial growth or toxins can occur when foods remain in the danger zone for too long. The danger zone is temperatures between 41 and 135 degrees Fahrenheit (F). Interview with Resident 11 on 08/03/2026 at 7:16 AM revealed that the hot food and drinks are mostly cold. Interview with Resident 86 on 08/03/2026 at 9:44 AM revealed that the hot food is usually cold or lukewarm. Interview with Resident 61 on 08/03/2026 at 1:41 PM revealed that food is good but cold. Resident 61 also revealed that they rarely get a hot meal. Interview with Resident 27 on 08/03/2026 at 2:50 PM revealed that the hot food is served cold. Interview with Resident 48 on 08/03/2026 at 10:11 AM revealed that the food is not hot but kind of warm. Interview with Resident 52 on 0 8/03/2026 7:20 AM revealed the food is cold! Interview with Resident 5 on 08/03/2026 at 9:24 AM revealed that the food could be warmer, by the time they receive it, the food is lukewarm. Interview with Resident 6 on 08/03/2026 at 8:30 AM revealed that they have never had hot food, it's usually cold. Observation on 08/04/2026 at 7:25AM revealed the Food Service Supervisor (FSS) assembled breakfast trays for residents who chose to eat in their rooms instead of the dining room. The facility uses a system that requires the residents to call in their order prior to the scheduled meal. This produces a meal ticket for each resident. The cook (C) referenced each ticket, took a serving of the requested hot foods from the steam table, and put the food on a plate. The C then covered each plate with cling wrap and placed them under the warming lights where as many as 4 plates were kept at a time. The FSS took the plate of food, placed it on a tray and covered it with an insulated cover. The FSS then placed 6 trays on a stainless steel, open cart. Interview with the FSS on 08/04/2026 at 8:40 AM acknowledged that the open carts expose the trays of food to the cool air more than the insulated cart does. The FSS revealed that they (the facility) found that the large, insulated cart did not keep the food any warmer than the open carts. A request by the surveyor for a test tray to be made after the final resident's tray was assembled and served. An observation on 08/04/2026 at 9:15 AM revealed breakfast trays being passed out by staff members to the residents in their rooms. After the final room tray was delivered on 08/04/2026 at 9:30 AM, a temperature test of the food on the test tray was performed. The FSS used the facility's thermometer and revealed the temperature of the biscuits and gravy was 121.4 degrees F and the scrambled eggs were 109.2 degrees F. Interview with the FSS revealed that it is the facility's expectation that when the food leaves the kitchen it is at least 135 degrees F (Fahrenheit) and the FSS expects the temperature to drop about 12 degrees F before it gets to the residents. The FSS confirmed that neither of the hot foods on the test tray were at an appetizing temperature and should have been. The FSS revealed that they would not eat the cold breakfast as served. The FSS revealed that the residents have been told that if they want their food to be hot, they should come to the dining room. The FSS confirmed that the residents have a right to eat in their rooms and they have the right to be served hot food even when they choose to eat in their rooms. Record review of a Concern Form (a type of written grievance form) dated 12/17/2025 revealed that Resident 92 complained that food is always cold and never at a reasonable time. Record review of a Concern Form dated 03/26/2026 revealed that Resident 91 filed a complaint regarding cold coffee. Record review of Resident Council Meeting Minutes dated 06/07/2026 revealed under Culinary that the new cart is not keeping the food any warmer. Record review of the facility's policy titled Hillcrest Health and Living Culinary Food Preparation Policy dated 01/01/2026 revealed that hot foods will be delivered promptly and protected to ensure food temperature and food safety. Interview with FSS at 9:32 AM on 8/04/2026 revealed that when food leaves the kitchen the expected holding temperature is 135 degrees or higher. FSS confirmed that facility needed to increase the breakfast temperatures. Interview on 08/04/2026 at 4:00 PM with the Administrator revealed that it is the facility's expectation that residents be allowed to choose to eat in their rooms or in the dining room and receive foods served at an appetizing temperature at either location.

Licensure Reference Number 175 NAC 12.006.05 (D)Licensure Reference Number 175 NAC 12.006.05 (E) Based on record reviews and interviews, the facility failed to provide informed consent, including the risks and or possible side effects, or alternative treatment to 4 residents (Residents 2, 46, 51, and 61) or their responsible parties in advance of administration of psychotropic medications (medications that affects behavior, mood, thoughts, or perception used to manage psychotic disorders). The sample was 5 residents. The facility census was 68. Findings are: A. Record review of Resident 61's admission Record with a printed date of 08/04/2026 revealed that Resident 61 was admitted to the facility on [DATE] with diagnoses of mild major depressive disorder (MDD), generalized anxiety disorder, and unspecified dementia without other behavioral disturbances. Record review of Resident 61's: Order Summary Report with a printed of 08/04/2026 revealed an order for 0.5 milligrams (MG) of Alprazolam to be taken at bedtime for anxiety, 2 MG Aripiprazole to be taken in the morning for depression, 300 mg of Bupropion to be taken daily for depression, 10 mg of Donepezil to be taken at bed time for dementia, and 10 mg of Escitalopram to be taken daily for depression. Record review of Resident 61's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) revealed that Resident 61 takes medications to treat depression and anxiety. Record review of Resident 61's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) revealed under Section C-Cognitive Patterns a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score: of 12 revealing that Resident 61 is cognitively intact. Section N of the MDS revealed that Resident 61 takes antianxiety and antidepressant medications. Record reviews of Resident 61's Electronic Medical Records (EMR) revealed that the facility failed to inform the residents in advance of the risks and benefits of the medications and failed to inform the residents of treatment alternatives and other options available to the residents. A record review of the facility's policy titled Unnecessary Medication Policy with a date of 01/01/2026 revealed in the section titled Policy and Guidelines number 3 that prior to initiating or increasing a psychotropic medication the resident will be informed of the benefits, risks, and alternatives to the medications. Interview on 08/06/2026 at 10:38AM with the Director of Nursing (DON) confirmed that the facility did not provide information of the risks and benefits of the medications and did not inform the residents of treatment alternatives or the other options available prior to administering the medication to the residents. B. Review of facility census sheet revealed that Resident 46 was initially admitted [DATE]. The resident was hospitalized from [DATE] to 7/12/2026 and again from 7/22/2026 to 7/27/2026 prior to returning to facility. Review of diagnoses from medical record reveal that Resident 46 came to the facility following a replacement of their left hip joint. Current diagnoses are infection due to left hip prosthesis, pain in left hip, congestive heart failure, anxiety, bipolar disorder, nicotine dependence, alcohol abuse and chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe). Review of the medication administration record for Resident 46 revealed Fluoxetine (medication for depression) was started for Resident 46 on 7/28/2026. The fluoxetine was discontinued on 8/04/2026 and mirtazapine (an antidepressant medication) was ordered and initiated on 8/04/2026. A Minimum Data Set (MDS) assessment (comprehensive assessment required for all nursing facility residents) was completed for Resident 46. This assessment showed a Brief Interview for Mental Status score of 10, which indicated moderate cognitive impairment. Review of Resident 46's Electronic Medical Record did not reveal any documentation to show that Resident 46 or their family received informed consent regarding benefits, risks, possible side effects and alternative treatments in advance of receiving the antidepressant medications fluoxetine or mirtazapine. Review of facility policy titled Hillcrest Health and Living Unnecessary Medication Policy, dated 1/01/2026 revealed: - Policy: Residents are not prescribed medications unless they are necessary to treat a specific condition, as diagnosed and documented in the medical record, and the medication is beneficial to the resident, as evidenced by monitoring and documentation of the resident's response to the medications(s). - Definition: A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include: Antidepressants - Policy and Guidelines: Prior to initiating or increasing psychotropic medications the resident will be informed of the benefits, risks, and alternatives to the medication. Interview with facility Administrator (ADM), Director of Nursing and MDS Coordinator on 8/5/26 at 9:45 AM confirmed that the informed consents for the psychotropic medications for Resident 46 were not located in the medical record. ADM confirmed that the facility did not provide written informed consent for psychotropic medications. C. Review of Resident 51's census sheet revealed they were originally admitted to the facility on [DATE]. Diagnoses in Resident 51's clinical record at the facility were reviewed and revealed myocardial infarction, muscle weakness, unsteadiness on feet, depression, benign hypertrophy (non-cancerous enlargement) of the prostate with urinary retention, chronic kidney disease, mild cognitive impairment and hyperlipidemia (elevated level of cholesterol in the blood). Review of Resident 51's Medication Administration Record (MAR) revealed resident receiving escitalopram (medication for depression) and trazodone (an antidepressant prescribed for difficulty sleeping). Review of Minimum Data Set (MDS, a standardized assessment completed for all nursing home residents) completed in July 2026 revealed a Brief Interview for Mental Status was completed with a score of 15, which indicated intact cognition. Resident 51 was noted to have received antidepressant medications during the MDS assessment period. Review of facility policy titled Hillcrest Health and Living Unnecessary Medication Policy, dated 1/01/2026 revealed: - Policy: Residents are not prescribed medications unless they are necessary to treat a specific condition, as diagnosed and documented in the medical record, and the medication is beneficial to the resident, as evidenced by monitoring and documentation of the resident's response to the medications(s). - Definition: A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include: Antidepressants - Policy and Guidelines: Prior to initiating or increasing psychotropic medications the resident will be informed of the benefits, risks, and alternatives to the medication. Review of Resident 51's Electronic Medical Record did not reveal any documentation to show that Resident 51 or their family received informed consent regarding benefits, risks, possible side effects and alternative treatments in advance of receiving the antidepressant medication escitalopram. Interview with facility Administrator (ADM), Director of Nursing and MDS Coordinator on 8/5/26 at 9:45 AM confirmed that the informed consents for the psychotropic medications for Resident 51 were not located in the medical record. ADM confirmed that the facility did not provide written informed consent for psychotropic medications. D. A record review of the admission Record with a printed date of August 4, 20206 for Resident 2 revealed they admitted to the facility on [DATE] with the diagnosis of Aphasia following Cerebral Infarction (a language disorder caused by tissue damage in brain regions controlling speech and comprehension) , Dysphagia, Oropharyngeal phase (difficulty moving food and liquid from the mouth, through the throat, and into the esophagus) , Depression (a persistent sad or empty mood, loss of interest in favorite activities, ongoing fatigue or low energy, changes in sleep patterns like insomnia or oversleeping, and difficulty concentrating or making decisions), Insomnia (disorder that makes it hard to fall asleep, stay asleep, or get restful sleep), and a history of other Mental and Behavioral Disorders (a documented past diagnosis of a psychiatric or behavioral condition that is no longer actively treated or present, but remain relevant). A record review of the physicians' orders for Resident 2 revealed orders for Temazepam 30 mg at bedtime (medication used for the short-term treatment of severe insomnia) with a start date of 6/24/26 and Sertraline HC (increases serotonin levels (a chemical messenger and hormone that carries signals between nerve cells in the brain) to help improve mood, ease anxiety, and regulate emotional well-being) 100 mg give 2 tablets with a start date of 6/5/26 for depression at bedtime. A record review of the Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care), dated 11/12/2025 revealed Resident 2 uses antidepressant medication related to depression. Resident 2 uses hypnotic medications related to insomnia dated 4/16/26. A record review of the Unnecessary Medication policy with the effective date of 1/1/26 revealed: Policy and Guidelines: 3) Prior to initiating or increasing a psychotropic medication the resident will be informed of the benefits, risks, and alternatives to the medications. An interview on 8/5/26 at 9:45 AM with the Administrator and the MDS coordinator confirmed that the Informed consents for the psychotropic medications for Resident 2 could not be located in the medical record. The Administrator confirmed that the facility did not provide written informed consent of the benefits, risk, and alternative to the medications for Resident 2 and a consent form should of been completed with each psychotropic medications.

Licensure Reference Number 175 NAC 007.01 (C)Based on record reviews, interviews, and observations, the facility failed to ensure that the large trash dumpster outside the facility was covered. This had the potential to affect all residents living at the facility. The census at the time of the survey was 68.Findings are:Record review of the FDA Food Code 2022, a science-based guideline published by the Food and Drug Administration to regulate food service facilities to create uniform safety rules, revealed in section 5-501.110 Storing Refuse, Recyclables, and Returnable that all trash units must be inaccessible to insects and rodents. Section 5-501.113 Covering Receptacles revealed that receptacles must be covered with tight fitting lids when kept outside.Record review of the facility's policy titled Disposal of Garbage and Refuse dated 05/23/2017 revealed that all refuse containers and dumpsters should be kept covered.Observations with the Dietary Manager (DM) on 08/24/2026 at 3:04 PM of the garbage area located behind the facility revealed that there was nothing covering the large dumpster containing trash. The DM confirmed that there was nothing covering the trash dumpster.Observation and interview on 08/24/2026 at 3:50 PM with the Administrator (Adm) and the Director of Environmental Services (DES) confirmed that the trash dumpster was not covered.

Licensure Reference Number 175 NAC 006.09(H)(iii)Based on record reviews, observations, and interviews, the facility failed to ensure that the nurse followed providers' orders for wound care for Resident 5. This had the potential to affect all residents who receive care at the facility. The census at the time of the survey was 68.Findings are:Record review of Resident 5's admission Record printed on 08/04/2026 revealed that the resident was admitted to the facility on [DATE] with a primary diagnosis of Diabetes Mellitus Type 2 (T2DM, a common form of diabetes that develops especially in adults and most often in obese individuals and that is characterized by high blood sugar that causes damage to the small blood vessels, resulting in hard to heal wounds) with a diabetic foot ulcer. Record review of Resident 5's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) in section M1040 B revealed that Resident 5 has a Diabetic foot ulcer.Record review of Resident 5's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) revealed that Resident 5 is at risk for impaired skin integrity related to vascular wounds to the left lower extremity (LLE), a diabetic foot ulcer, and right lower extremity (RLE) amputation, a history of pressure ulcers and non-healing wounds. On 02/16/26 culture results from a wound infection to the LLE was received from the wound clinic with an intervention to perform dressing to LLE, keep clean, dry and intact as ordered, Record reviews of orders received from the provider at the wound clinic on 06/24/2026, 06/18/2026, 07/16/2026, and 07/303/2026 revealed the following handwritten wound care orders: wash wounds twice a day with soap and water, apply a topical antibiotic cream to the wounds on the lower left leg, cover with gauze and secure, then apply double (2) Tubigrips (a tubular, elastic support bandage) from the toes to the knee. This bandage is to be kept on at all times. Observation on 08/04/2026 at 11:00AM revealed Registered Nurse A (RN-A) gathering the supplies needed to perform Resident 5's wound treatment to the lower left leg. RN-A used hand sanitizer to perform hand hygiene (HH), donned a gown and applied gloves.RN-A then removed the dirty dressing from Resident 5's leg and disposed of it in a lined trash can.RN-A then removed the dirty gloves, performed HH and applied clean gloves.RN-A then applied soap to a clean, warm, wet, washcloth.RN-A then used the washcloth to clean the wounds, removing the old antibiotic cream.RN- A then used a clean wet washcloth to rinse the wounds.RN-A then removed the dirty gloves, performed HH and applied clean gloves.RN-A then applied the antibiotic cream, covered the wounds with a nonstick dressing and wrapped the lower leg with gauze.RN-A then applied an ACE bandage starting at the toes and ending at the knee.Interview during the wound treatment with RN-A at 11:11 AM revealed that they like to use the ACE bandage instead of the Tubigrip because the wound tends to leak through the Tubigrip.Interview with RN-A 08/04/2026 at 12:45 PM revealed that Resident 5 goes to the wound clinic every other week. RN-A revealed that Resident 5 may have an order to use either the Tubigrip or an ACE bandage but was not sure.Interview with the Director of Nursing (DON) on 08/04/2026 at 1:05PM confirmed that Resident 5's wound care orders are to apply Tubigrip and not an ACE bandage. DON confirmed that it is the facility's expectation that all provider's orders are followed as written.

Licensure Reference Number 175 NAC 12-006.18Licensure Reference Number 175 NAC 12-006.18 B Licensure Reference Number 175 NAC 1-005.06 Based on observation and interview and record review, the facility failed to ensure proper EBP (Enhanced Barrier Precautions, an infection control strategy that focuses on prevention the spread of multidrug resistant organism (MDRO) were followed when providing bolus tube-feeding for one (Resident 2) of 1 sampled residents. The facility census was 68. Findings are; A record review of the admission Record with a printed date of August 4, 2026 for Resident 2 revealed that Resident 2 was admitted to the facility on [DATE] with the diagnosis of Aphasia following Cerebral Infarction (a language disorder caused by tissue damage in brain regions controlling speech and comprehension) , Dysphagia, Oropharyngeal phase (difficulty moving food and liquid from the mouth, through the throat, and into the esophagus) , Depression (a persistent sad or empty mood, loss of interest in favorite activities, ongoing fatigue or low energy, changes in sleep patterns like insomnia or oversleeping, and difficulty concentrating or making decisions), Insomnia (disorder that makes it hard to fall asleep, stay asleep, or get restful sleep), and a history of other Mental and Behavioral Disorders (a documented past diagnosis of a psychiatric or behavioral condition that is no longer actively treated or present, but remain relevant). A record review of the physician orders revealed Resident 2 had orders for: -Enteral: Elevate HOB (head of bed) 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding is stopped five times a day.-Enteral: Flush feeding tube with 115mL of water five times a day.-split gauze around g-tube (gastrostomy tube - is a medical device placed directly through the skin of the abdomen into the stomach to deliver nutrition, fluids, and medications when a person cannot swallow safely or take in enough food) site, change daily and PRN (as needed) every shift.-May comingle (mix) meds via g-tube every shift. -Tube feeding: replace graduate and syringe every 24 hours clearly labeled with date, every night shift.- Enteral Nutrition via Gravity or Bolus (a method of delivering liquid formula or water into a feeding tube using only natural downward pull) : Osmolite 1.2 at 310 mL (milliliters) three times a day via bolus per G-tube. A record review of the care plan reveals Resident 2: requires tube feeding related to Dysphagia, Chewing problem, Swallowing problem Date Initiated: 06/18/20268/04/2026 10:33 AM An observation on 8/3/26 at 7:30 AM revealed there was no sign for EBP outside of Resident 2 room or inside Resident 2 room. An observation on 8/4/26 at 8:00 AM revealed outside of Resident 2 room there was no posted sign for Enhanced Barrier Precautions, nor inside of room. A record review of facility's EBP/Isolation tracker revealed that Resident 2's name was on the list for EBP. An observation on 8/3/26 at 6:30 AM of the Enhanced Barrier Precaution signs posted revealed:Providers and staff must also wear gloves and a gown for the following High-Contact resident care Activities: 1) Device care or use: central lines, urinary catheter, feeding tube, and tracheostomy. A record review of the Enhanced Barrier Precaution (EBP) for Prevention of Multidrug-Resistant Organism (MDRO) Transmission with the effective date of 1/1/26 revealed:Policy: The facility will implement Enhanced Barrier Precautions for residents who meet criteria for MDRO colonization or infection, or who have indwelling medical devices, to prevent the spread of MDRO's during high-contact resident care activities. -CDC (Centers for Disease Control and Prevention) recommended infection-control practice requiring the use of gloves and gowns during high-contact resident care activities, regardless of resident isolation status-High-Contact Resident care activities that involve close physical contact and increase risk of MDRO transmission, including dressing, bathing/showing, transferring, providing hygiene, changing linens, Device care( e.g. catheters, feeding tubes, tracheostomies) and wound care.-Required Personal Protective Equipment (PPE) during high-contact care activities staff must wear gloves, gowns-The facility will post standardized signage outside the resident's room indicating when EBP is required, PPE location and high contact activities list. An observation on 8/4/26 at 7:45 AM with RN-A preparing Resident 2 medications that would be going into Resident 2 g-tube. RN-A did gather all medications (pills and liquid medications) and crushed the pills and added to a plastic medication cup of water. RN-A did measure the liquid medications and added to the plastic medication cup of water. RN-A did complete hand hygiene. RN-A explained to Resident 2 that RN was going to administer Resident 2 medications. RN-A did lay a barrier down on the tray table and gather the syringe and graduate with 110cc of water. The Director of Nursing was in the room with the observation of RN-A. RN-A applied gloves and checked residual (the amount of formula, fluid, and digestive juices left in the stomach after a feeding). RN-A poured some water into the syringe that was placed in the g-tube. RN-A then poured the medication into the syringe alternating the medication and the water. RN-A finished with the medication pass. RN- A gather the syringe and graduate and placed in the bathroom countertop on a barrier. RN-A did not apply a gown when performing g-tube administration of medication for Resident 2. An interview on 8/4/26 at 8:30 AM with the Director of Nursing confirmed that RN-A did not apply the gown when performing g-tube medication administration on Resident 2 that is part of the EBP. The Director of Nursing confirmed that Resident 2 did not have any EBP signs on Resident 2 door or any where in Resident 2 room. The Director of Nursing confirmed that RN-A was not wearing a gown when performing g-tube medication administration with Resident 2 and RN-A should have. The Director of Nursing confirmed that there was no EBP signs in Resident 2 room and there should have been.

Licensure Reference Number 175 NAC 12-006.11(E) Based on observations and interview the facility failed to label and date opened packages of food in the walk- in freezer and failed to cover items in the walk in refrigerator and to discard processed food items passed the 7 day date to prevent the potential for food borne illness. This had the potential to affect all 56 residents. The facility census was 56. Findings are: An observation on 3/26/25 at 7:30 AM of the walk-in freezer revealed: -An open box of beef patties not dated and open to air, -An open box of chicken patties not dated and open to air, -An open box of chicken fillets not dated and open to air, -An open box of breakfast potatoes not dated and open to air. An observation on 3/26/25 at 7:30 AM of the walk-in refrigerator revealed: -A serving pan of soup with a ladle notch dated 3/16. No saran wrap over the serving pan or the area for the ladle notch to sit in. -A serving pan of rice with no saran wrap or tin foil coving rice that appeared dried with a lid with a ladle notch dated 3/17. An interview on 3/26/25 at 8:15 AM with the DM (Dietary Manager) confirmed that the items listed above were opened packages of food that should have been labeled, dated and sealed. A record review of the facility policy Proper Food Storage dated 2/22/22 revealed: -all food products must be covered -clearly label all food with product or item name, preparation date, used by, expiration date or sell by date and prepared by. -perishable foods discarded after 3 days. A record review of the Nebraska Food Code dated 2017 revealed revealed that 81-2.282(2)(c ) Food shall be deemed to be adulterated (unsafe) if it has been manufactured, processes, packages, stored, or held under unsanitary conditions where it may have become unsafe for use as food and 3-501.14 and: P (i) Cooled to 1 C (34 F) within 48 hours of reaching 5 C (41 F) and held at that temperature until consumed or discarded within 30 days after the date of PACKAGING; P (ii) Held at 5 C (41 F) or less for no more than 7 days, at which time the food must be consumed or discarded.

Licensure Reference Number 175 NAC 1-005.06(D) Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP- Specifically gowning and gloving to prevent the spread of bacteria resistant infection), for 4 (Resident 26, 17, and 34) of 7 sampled residents. The facility staff identified census of 56. Finding are: A record review of the facility Hand Hygiene Policy dated 03/01/2022 revealed: A. Hand Hygiene Guidance 1. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: - Immediately before touching a patient - Before performing an aseptic (practice and procedure to prevent infection (e.g., placing an indwelling device) or handling invasive medical devices - Before moving from work on a soiled body site to a clean body site on the same patient - After touching a patient or the patient's immediate environment - After contact with blood, body fluids, or contaminated surfaces - Immediately after glove removal 2. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritation to hands and, in the absence of a sink, are an effective method of cleaning hands. B. Non-Surgical Hand Hygiene Technique 1. Handwashing with soap and water (either non-antimicrobial or antimicrobial) - Wet hands with running water-avoid using hot water, to prevent drying of skin - Apply hand washing agent to hand - Vigorously rub hands together for at least 15-20 seconds, covering all surfaces - Dry hands thoroughly with a disposable towel(s) - Use disposable towel to turn of the water. C. Gloves and Hand Hygiene 1. Gloves are not a substitute for hand hygiene prior to donning gloves, before touching the patient or the patient environment 2. Change gloves and perform hand hygiene during patient care, a. Gloves have been damaged b. Gloves have become visible soiled with blood or body fluids following a task c. Moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs 4. Never wear the same pair of gloves in the care of more than one patient 5. Carefully remove gloves to prevent hand contamination. Record review of the facility Infection Prevention and Control Policy Effective date 03/01/2022 revealed: Infection Control Program Requirements: 1. All team members will adhere to Standard Precautions to reduce the risk of exposure and prevent the transmission of infection of guests and personnel. 2. Gowns or aprons: Must be impervious and worn when there is a potential for blood or body fluid spatters or sprays. Examples may include venipunctures, catheter, or ca care of an incontinent guest. Record review of Resident 34's medical record revealed Resident 34 was admitted to the facility on [DATE] with a BIMS (Brief Interview of Mental Status 0 lowest to 15 highest) score of 6, suggesting severe cognitive impairment and a diagnosis of Neuromuscular Dysfunction of Bladder, unspecified (Loss of bladder control from nerve damage to bladder.) Resident 34's plan of care revealed Resident 34 needed AM (morning) peri-care, (soap and water or wet wipes to clean the genital areas on male or female) suprapubic catheter care (Urinary tube to drain the bladder through the location in lower abdomen), and transfer to the recliner using an EZ-Stand Lift (Lift used to allow the resident to stand on lift and be moved by staff). An observation on 3/31/2025 at 8:40 AM revealed Nurse Tech NT-C and NT-D (Nursing Technician) entered Resident 34's room to perform peri-cares, suprapubic catheter care and to transfer resident from the bed to the chair using an EZ Stand-Lift. NT-C and NT-D put on a gown and gloves to provide suprapubic catheter care to Resident 34 who was lying in bed. NT-C and NT-D proceeded to provide peri care using front to back wiping technique with wet wipes per facility policy and procedure. NT-D and NT-C then went into the bathroom to perform hand hygiene. NT-D washed hands for 12 seconds and then put on clean gloves and NT- C washed hands for 14 seconds and then put on clean gloves. NT-C and NT-D proceeded to get the Resident 34 dressed and used the EZ-Stand lift sling to transfer resident from the bed to the chair. NT-D cleaned the EZ-Stand lift with sanitizer wipes but did not clean the EZ -Stand lift sling that was used on this Resident. The lift sling was placed on the EZ-Stand lift bar and pushed out of the room into the hallway. NT-C went into the bathroom and removed (gender) gloves and gown and washed hands with soap and water for 10 seconds before drying them with a paper towel. NT-D went into the bathroom and removed gloves and gown and (gender) washed hands with soap and water for 14 seconds before drying them with a paper towel. An interview on 04/01/2025 at 09:10 AM with NT-D revealed that staff use the EZ-Stand lift and lift sling on all the Residents in the facility that need it. A record review of the Admission Record with the printed date of 9/9/24 revealed Resident 45 was admitted to the facility on [DATE] with the diagnosis of Unspecified Hydronephrosis (excessive fluid in a kidney,) Obstructive and Reflux Uropathy (Blockage in the urinary tract) Retention of urine, Disorientation (feeling lost, confused, or having a reduced sense of time, place, direction), Other Amnesia (loss of memory). A Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) dated 03/03/2025 revealed that Resident 45 had a BIMS (Brief Interview for Mental Status) of 10 for a scale of (00-15) suggesting moderate cognitive impairment and needed morning Foley catheter care (Cleaning the tube that is in the bladder and drains urine, typically into a bag). A record review of Admission Record revealed Resident 17 admitted with diagnosis of Obstructive Uropathy, Kidney Disease, Benign Prostatic Hyperplasia without lower urinary tract symptoms (Enlargement of prostate (Gland below the bladder in a male) that can cause urinary difficulty), and muscle weakness. An observation of Resident 17 on 04/01/2025 at 10:37 AM revealed: - Licensed Practical Nurse (LPN)-F washed hands for 35 seconds and put on gloves and gown and then put soap and hand towels on bedside table covered with towel. - LPN-F put water in basin with washcloths and sat on bedside table and then LPN-F took off gloves and cleaned hands with sanitizer and put on clean gloves - LPN-F put towel over Resident 17's lower abdomen just below (gender) supra pubic catheter site. - LPN-F took off Slit Sponge with dried area size of a dime and colored light brown from catheter site. - LPN-F used the same gloves put and put hands in clean water basin and took out a wash cloth and cleaned around suprapubic catheter site. - LPN-F used the second wash cloth from basin and rinsed off catheter site and catheter tubing and dried area with clean towel. - LPN-F changed gloves and sanitized hands and put on clean gloves. - LPN-F opened 4x4 Slit Sponge dressing and applied it around the catheter tubing at opening on abdomen and then removed gloves and gown and performed hand hygiene. Interview on 04/01/2025 at 11:06 AM with CCC-A revealed: When providing catheter care and cleaning the skin for Resident 17's suprapubic catheter site the staff member should have changed gloves after handling the dirty Slit Site 4x4 dressing and put on clean gloves after hand hygiene was performed prior to putting hands into the clean basin of water to wash the catheter site. 48271 A record review of the Admission Record with the printed date of 3/31/25 revealed that Resident 26 was admitted to the facility on [DATE] with the diagnosis of Multiple Sclerosis (Chronic autoimmune disease that affects the central nervous system which includes the brain and spinal cord),Edema (swelling caused by fluid in your body's tissues), Neuromuscular Dysfunction of the bladder (damage to the nerves involved in the bladder control ,disrupts the communication between the brain and the bladder leading to various urinary problems), Hypertension ( a condition where the force of blood against the artery walls is consistently too high), Peripheral Vascular Disease (a condition that affects the blood vessels outside of the heart and brain),Colostomy (a Surgical procedure that creates and opening (stoma)in the abdominal wall to divert stool from the colon (large intestine) to an external bag), Urostomy (a surgical procedure that creates an opening (stoma) in the abdomen to divert urine from the kidneys directly to a collection bag on the outside of the body), Above the knee amputation of both right and left leg, Pressure Ulcer of /Sacral Region (a localized area of skin and underlying tissue damage that occurs over the bony prominence of the sacrum) Stage 3, and Depression(a common mental health condition characterized by persistent feelings of sadness, loss of interest, and low energy levels that can significantly impact daily life. A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities dated 1/13/25 revealed a BIMS (Brief Interview for Mental Status, a test 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 15 indicating the resident is cognitively intact. An interview on 3/26/25 at 10 AM with Resident 26 confirmed that (gender) prefers to sleep in the power wheelchair. An observation on 03/26/25 at 11:04 AM revealed that Resident 26 was sleeping in (gender) power wheelchair. A record review of the Physicians orders with the printed date of 3/31/25 revealed orders for: -Apply Calmoseptine to right ischial (buttock) area Twice a day and PRN (when needed), may cover with gauze to promote adherence. -Colostomy Bag and Wafer, change two times a week and PRN -Change Urostomy on Tuesday and Friday (bath days) and PRN A record review of the Care Plan (written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) dated 8/19/24 indicated the need for Enhanced Barrier Precautions. An observation on 03/27/25 at 9:25 AM with NT-D revealed (gender) washed hands for 20 seconds and applied gloves. NT-D then unhooked catheter tubing from catheter bag before transferring Resident 26 to lay down in bed for wound care treatment. NT-D did not put on a gown. CCC-A and NT-D did not have gowns on when transferring Resident 26 to lay down in bed for the wound treatment to (genders) buttocks. Both CCC-A and NT-D had rolled Resident 26 side to side. Resident 26 did not have on a brief or underwear. CCC-A confirmed that the gowns were locked up in the bottom drawer and did not know why the drawer was locked. CCC-A confirmed that there was an Enhanced Barrier Precaution sign taped to the closet door. Observation of RN-B performing hand hygiene and gathered supplies for the wound treatment. RN-B did apply gloves. RN-B did not put on the gown. RN-B did not wash the old cream off the buttocks of Resident 26, and (gender) applied the new cream. NT-D and CCC-A assisted Resident 26 back into wheelchair. NT-D then reattached the catheter tubing to the catheter bag. Both CCC-A and NT-D washed hands before leaving the room. A record review of the sign attached to the closet door revealed Enhanced Barrier Precautions: Everyone must: Clean their hands, including before entering and when leaving the room. Providers and Staff must also wear gloves and a gown for the following High contact Resident Care Activities. Dressing, Bathing/showering, transferring, changing linens. Providing hygiene, changing briefs, or assisting with toileting. Device care or use: central lines, urinary catheter, feeding tube, tracheostomy, wound care: any skin opening requiring a dressing. A record review of the Hillcrest Firethorn Enhanced Barriers Precautions Effective date 4/1/24 revealed Initiation of Enhanced Barrier Precautions: A) The facility will have the discretion in using EBP for residents who do not have a chronic wound oar indwelling medical device and are infected or colonized with an MDRO (Multidrug-Resistant Organism) that is not currently targeted by CDC (Center for Disease Control). B) An order for Enhanced Barrier Precautions will be obtained for residents with any of the following, wounds (e.g., chronic venous stasis ulcers) and or indwelling medical devices (e.g central lines, urinary catheters, tube feeding, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. An interview on 3/27/25 at 10:00 AM with RN-B confirmed that (gender) did not wear a gown while performing the wound cares and should have put on a gown. RN-B confirmed that (gender) should of cleaned Resident 26 bottom before applying the new cream to Resident 26's bottom. An interview on 3/27/25 at 10:00 AM with NT-D confirmed that (gender) should have put on a gown before performing cares for Resident 26. An interview on 3/27/25 at 10:00 AM with the CCC-A confirmed that Resident 26 is in Enhanced Barrier Precautions. CCC-A confirmed that any staff member taking care of Resident 26 wounds, colostomy or urostomy should be in Enhanced Barrier Precautions. CCC-A confirmed that (gender), RN-B and NT-D should have been in Enhanced Barrier Precautions and was not in Enhanced Barrier Precautions. CCC-A confirmed that RN-B did not clean off the old barrier cream to Resident 26 bottom and should of been cleaned off before applying the new cream to Resident 26's bottom.

Licensure Reference Number NAC 12-006.12(D)(i) Based on observation, interview and record review; the facility failed to ensure that medications were stored in locked compartments for 3 (Residents 38, 30, and 112) of 6 residents sampled for medication administration. The facility census was 56. Findings are: Record review of facility provided policy dated 1/1/23 titled Medication Management revealed: -patients may self administer medications if they are deemed competent to do so by the nursing team. A self administer assessment should be completed to determine competency. -all medications that are requested to be available at bedside for patient self administration should be stored in a lockbox issued to the patient. The patient should be educated on the need for the medication safety and security and should be asked to notify the primary nurse of medications administered for documentation purposes. Review of undated facility provided policy titled Self Administration of Medications revealed: 1. DCS or qualified designee will complete an assessment of competency 2. an order will be obtained that resident can self administer medications, stating that the resident is capable of self medicating 3. nursing team member will observe resident for changes in behavior or condition 4. residents who choose to self medicate must keep their medications secured, by keeping the medications in a locked container in their room A. Record review of Resident 38's Quarterly Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 1/27/25 revealed that the resident was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 15, which indicated the residents cognition is intact. Record review of Resident 38's physician order dated 7/1/2024 revealed an order for Systane complete ophthalmic solution and to instill one drop in left eye three times a day. Wait 5 minutes between drops. During an observation on 03/31/25 at 7:37 AM revealed an unlabeled bottle of artificial tears were on Resident 38's on the nightstand in (gender) room. The resident self-administered several drops in each eye. Record review of Resident 38's nursing assessments revealed no evidence of a self medication administration assessment being completed. Record review of Resident 38's physician orders revealed no order to keep medication at bedside. During an interview on 03/31/25 at 12:14 PM Registered Nurse (RN) - H corporate nurse consultant confirmed that Resident 38 did not have a self medication administration assessment completed and should have, it was further confirmed that the medication did not say may keep at bedside. In an observation on 04/01/25 at 8:18 AM Resident 38 had artificial tears on (gender) nightstand. In an interview on 04/01/25 at 8:18 AM Resident 38 Resident 38 stated (gender) used the eye drops when (gender) needs them. B. Record review of Resident 30's Admission MDS dated [DATE] revealed resident was admitted to the facility on [DATE] with a BIMS score of 15. Record review of Resident 30's physician orders dated 3/7/2025 revealed Deep Sea Nasal Spray solution 1 spray in each nostril four times a day, may keep at bedside and self administer. Observation on 03/31/25 at 9: 38 AM revealed an undated bottle of deep nasal spray floor stock in Resident 30's room on the tray table. During an interview on 3/31/25 at 9:39 AM Resident 30 stated (gender) uses it 4, 5, or 6 times everyday whenever (gender) needs it. During an interview on 3/31/25 at 12:34 PM RN - H corporate nurse consultant confirmed that Resident 30's medication was not secured and should have been. In an observation on 04/01/25 at 8:05 AM Resident 30's nasal spray on tray table in room. 45484 C. A record review of Resident 112's Admission Record revealed the resident was admitted on [DATE] with respiratory failure, heart failure, irregular heart rate, rectal cancer, high blood pressure, glaucoma (a condition in which increased pressure in the eye can lead to gradual loss of vision), and diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). A record review of Resident 112's Admission MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 11, which indicated the resident had moderate cognitive impairment. An observation made on 03/26/2025 at 1:50 PM revealed two bottles of latanoprost (eye drops used to treat glaucoma) solution and a tube of combination diphenhydramine (an antihistamine that blocks a chemical in your skin that cause redness, itching, and pain) and zinc (a substance that can soothe the skin and help with wound repair) cream in a plastic basin on the bathroom counter, and two bottles of miconazole (an anti-fungal medication) powder on the bathroom counter. A record review of Resident 112's Order Summary Report dated 03/27/2025 revealed the following orders: Latanoprost Solution 0.005 % Instill 1 drop in both eyes at bedtime for GLAUCOMA, and Antifungal External Powder 2 % (Miconazole Nitrate (Topical)) Apply to abd [abdominal] folds topically every shift for Excoriation [redness and irritation] The orders did not include directions for the resident to keep the medications at bedside or self-administer them, and there was no order for the diphenhydramine-zinc cream. An observation made on 03/27/2025 at 12:21 PM revealed two bottles of latanoprost solution and a tube of combination diphenhydramine and zinc cream in a plastic basin on the bathroom counter, and two bottles of miconazole powder on the bathroom counter. An observation on 03/31/2025 at 8:00 AM revealed two bottles of latanoprost solution and a tube of combination diphenhydramine and zinc cream in a plastic basin on the bathroom counter, and two bottles of miconazole powder on the bathroom counter. An interview on 03/31/2025 at 8:00 AM with the Clinical Care Coordinator (CCC) B confirmed there were two bottles of latanoprost eye drops, a tube of diphenhydramine-zinc cream, and two bottles of miconazole powder were unsecured in Resident 112's bathroom. CCC B confirmed that the resident was not capable of self-administration of medication, and the medications should not be unsecured in the resident's room.

Licensure Reference Number 175 NAC 12-006.10(A)(i) Based on observations and interviews, the facility failed to assess the resident for safe self-administration (something is done or given by oneself, rather than by someone else, particularly in the context of medications or tests) of medications and obtain orders for bedside medication for 2 Residents (Resident 2 and 40) out of 6 sampled residents. The facility census was 56. Findings are: A record review of the facility policy Hillcrest Firethorn Medication Management Policy dated 1/1/23 revealed in the policy explanation and compliance guidelines: -Patients may self-administer medications if they are deemed competent to do so by the nursing team. A self-administer assessment should be completed to determine competency. Hillcrest Health Services Self-Administration of medication with no date policy: The Director of Clinical Services or designee will assess the ability to self-administer medications of residents requesting to self-administer. -The Director of Clinical Services or qualified designee will complete an assessment of competency. -An order will be obtained that resident can self-administer medications, stating that he resident is capable of self-medicating. -The nursing team members will observe resident for changes in behaviors or condition during their daily interactions with the resident. A. A record review of the Admission record with a printed date of 3/27/25 revealed Resident 2 was admitted to the facility on [DATE] with the diagnosis of fracture (broken bone) of right lower leg, depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities previously enjoyed), anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), hypertension (a condition in which the force of blood against the walls of the arteries is consistently too high) and edema (a medical condition characterized by the excessive accumulation of fluid in the body's tissues). A record review of the Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities) dated 3/7/25 revealed a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 15, which indicated the resident was cognitively intact. A record review of Resident 2's physician's orders with a printed dated of 3/27/25 revealed orders for: -Breztri Aerosphere Inhalation (a prescription inhaler used to treat COPD, 2 puff inhale orally two times a day, -Fluticasone Propionate Nasal Suspension (corticosteroid medication used to treat inflammatory conditions such as allergic rhinitis (hay fever), nasal polyps, and asthma), 2 spray in each nostril one time a day, -lubricating Plus Eye Drops (provide moisture and relief for dry eyes due to temporary causes, like being tired or being in a dry climate) 0.5 % Instill 1 drop in both eyes every 6 hours as needed. A record review of Resident 2's medical records revealed no evidence of a self-administration assessment being done or a doctor's orders to self-administer medications. An observation on 03/31/25 at 9:45 AM revealed Resident 2 sitting in a recliner with a medicine cup full of pills, an inhaler, eye drops, a nebulizer treatment (using a device to convert liquid medication into a fine mist (aerosol) that can be inhaled, delivering the medication directly to the lungs and respiratory system for conditions like asthma or COPD (a common lung disease causing restricted airflow and breathing problems) full of medicine, and a bottle of nasal spray sitting on tray table. Resident 2 stated (gender) does take (gender) medication after eating breakfast and will do the nebulizer treatment after taking (gender) pills. Resident 2 confirmed that (gender) had already done the nasal spray. An observation on 04/01/25 at 10:01 AM with Resident 2 sitting in recliner with a medicine cup full of pills in the cup sitting on the tray table with a glass of water, an inhaler, eye drops on side compartment of tray table and a bottle of nasal spray. An interview on 4/1/25 at 11:00 AM with Clinical Care Coordinator (CCC)-A confirmed that Resident 2 did not have an order for self-administration of medications and an assessment for safe self-administration of medications for Resident 2 had not been done and it should have been done. B. A record review of the Admission Record with the printed date of 3/27/25 revealed Resident 40 was admitted to the facility on [DATE] with the diagnosis of pheumothorax (a medical condition where air enters the pleural space, the area between the lung and chest wall), Bronchiectasis (a chronic lung condition characterized by the permanent widening and thickening of the airways (bronchi) in the lungs), Respiratory failure (a condition where the lungs are unable to adequately perform their primary function of gas exchange, leading to either dangerously low oxygen levels (hypoxemia) or dangerously high carbon dioxide levels (hypercapnia) in the blood), and anxiety disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A record review of the MDS dated [DATE] revealed a BIMS score of 12 indicating Resident 40 had moderate cognitive impairement. Record review of Resident 40's physician's orders with a printed date of 3/27/25 revealed orders for: -Ipratropium-Albuterol Inhalation Solution 0.5-2.5 ml (Ipratropium-Albuterol), 1 vial inhale orally via nebulizer four times a day. A record review of Resident 40's medical records revealed no evidence of a self-administration assessment for medication being done or of a doctor's order for Resident 40 to self-administer medication. An observation on 3/26/25 at 12:54 PM revealed Resident 40 sitting in recliner with a nebulizer treatment (using a device to convert liquid medication into a fine mist (aerosol) that can be inhaled, delivering the medication directly to the lungs and respiratory system for conditions like asthma or COPD) sitting on the side table with liquid medicine in nebulizer cup. Resident 40 confirmed that (gender) will do the nebulizer treatment in a little while. Resident 40 confirmed that (gender) does the nebulizer treatments 4 times a day. An observation on 3/27/25 at 12:30 PM revealed Resident 40 sitting in recliner with a nebulizer treatment sitting on the side table with liquid medicine in nebulizer cup. An interview on 3/27/25 at 12:31 PM with Registered Nurse (RN)-B confirmed that (gender) is not aware of any residents on the long-term side having any orders for the residents to self-administrator medications. An interview on 3/27/25 at 1:00PM with CCC-A confirmed that there was medicine in the medication cup of the nebulizer treatment and that it should have not been left in the medication cup and not have the resident do the nebulizer treatment. CCC-A confirmed that there is no self-administration of medication with Resident 40 and Resident 40 does not have a physicians order to self -administered medications.

Licensure Reference Number 174 NAC 12-006.09(H)(iv) Based on record review and observation, the facility failed to provide the facility's outlined bowel management program for 1 (Resident 3) of 3 residents sampled and instead provided digital stimulation for Resident 3. The facility also failed to provide prompt medical attention for 1 (Resident 1) of 4 sampled residents. Facility census was 65. Findings are: A. A record review of Resident 3's progress notes dated 2/16/2025 revealed that at 3:00 AM the resident was placed on the bedpan, and with digital stimulation, expelled large, formed stool. Interview on 2/19/25 at 4:16 PM with Resident 3 confirmed that it was definitely uncomfortable when that nurse stuck (gender) finger in my butt and that the resident prefers to have a bowel movement while sitting on a bedpan and not laying in bed. A record review of Resident 3's Admission Minimum Data Set (MDS -a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 1/30/25 revealed that the resident was admitted to the facility on [DATE], with a Brief Interview for Mental Status (BIMS - a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 12 which indicates moderate cognitive impairment, frequently incontinent of bowel, dependent for transfers, no bowel toileting program, and that constipation was not present. A record review of Resident 3's Comprehensive Care Plan (CCP - written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) dated 2/3/2025, revealed no focus area related to constipation. A record review of Resident 3's Medical Administration Record (MAR) from 2/1/25 through 2/19/25 revealed that the resident did not receive any bowel meds as needed to promote a bowel movement. A record review of Resident 3's current physician orders revealed that the resident had orders for a suppository and enema to be used if needed to promote bowel movement. Resident 3 had no other bowel medication orders to be used as needed. In an interview on 2/19/25 at 3:47 PM, Registered Nurse (RN) - A confirmed they were not supposed to do digital stimulation on any residents. In an interview on 2/19/25 at 3:51 PM, RN - B confirmed that digital stimulation should not be done unless the resident is a quadriplegic and cannot move their own bowels and that this resident does not have those diagnosis. In an interview on 2/19/25 at 3:57 PM, the Clinical Care Coordinator (CCC) confirmed that digital stimulation should not have been done to this resident. In an interview on 2/19/25 at 4:41 PM, the Director of Nurses (DON) revealed that the night nurse checked Resident 3's rectum and that BM was present. The nurse then gave the resident a suppository. It was further confirmed that the suppository was not documented as given in the resident's MAR and should have been documented. In an interview on 2/20/25 at 8:59 AM the DON confirmed there was no staff education completed regarding bowel management, prevention of constipation or digital stimulation. In an interview on 2/20/25 at 8:43 AM, Medication Technician (MT) - C confirmed that on the night of 2/16/25 the night nurse came out of Resident 3's room and said (gender) had digitally stimulated the resident and assisted the resident onto (gender) left side to have a bowel movement. MT - C was instructed to go back in the resident's room and check on the resident in a little bit. The resident was not on a bedpan. In an interview on 2/20/25 at 9:25 AM, Resident 3 revealed that (gender) likes to sit up in bed on the bedpan to have a bowel movement (BM) and that he doesn't like to have a BM while laying down in bed and the nurse did not put him on the bedpan the night of 2/16/25. A record review of the facility policy dated 1/1/2023, titled Bowel Management Policy revealed that interventions to promote bowel movements include a well balanced diet, encourage adequate fluids, encourage exercise, allow enough time for adequate evacuation and review medications causing constipation, and to check for daily stool softener. In an interview on 2/20/25 at 11:34 AM with DON confirmed there was not a bowel assessment performed for Resident 3 and agreed that digital stimulation would cause discomfort and that no new interventions were put into place after hard stool had been identified on 2/14/25 with the resident. In an interview on 2/20/25 at 2:04 PM Licensed Practical Nurse (LPN) - G confirmed that (gender) stuck (gender) finger approximately 1 inch into resident's 3's rectum and that the resident yelled ow during the process and LPN - G continued to insert finger to remove hard stool. 45641 B. A record review of Resident 1's Clinical Census dated 02/19/2025 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 1's Medical Diagnosis dated 02/19/2025 revealed the resident had diagnoses of Neuromuscular Dysfunction of the Bladder (nerves controlling the bladder were damaged), Paraplegia (paralysis of the legs or lower body), and Spinal Stenosis, Lumbar Region (spinal canal narrows and compresses nerves in lower back). A record review of Resident 1's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 01/23/2025 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 13 which indicated the resident was cognitively aware. The resident required supervision or touching assistance with personal and oral hygiene (cleaning). partial moderate assistance with lower body dressing and bathing, substantial/maximal assistance with upper body dressing, and the resident was dependent on staff for toileting and footwear. The resident had an indwelling catheter (cath)(a tube inserted in the bladder to help restore urine output). A record review of Resident 1's Care Plan with an admitted [DATE] revealed the resident had a suprapubic (SP) )(a tube inserted in through the skin into the bladder to allow urine flow) cath related to Neurogenic Bladder (lack of bladder control due to brain, spinal cord, or nerve damage), SP cath was removed 02/05/2025 and a Foley cath was placed on 02/05/2025. A record review of the facility's Grievance Log dated 11/25/2024 - 02/10/2025 revealed Resident 1's family/Healthcare Durable Power of Attorney (POA) )(a person designated to make medical decisions for the resident) submitted a grievance on 02/05/2025 related to Resident 1's SP cath being removed when not ordered - only ordered to remove the stitch from the SP cath and the POA was upset because the facility did not notify the POA prior to the Urologist's (a physician that specializes in the urine system) office calling the POA. The grievance was taken by the Director of Nursing (DON), but it did not reveal a time. The resolution was Foley cath placed, antibiotic started, guest okay and concerns from guest. APRN there and visited with guest and family. Family requested a transfer to another facility and was transferred on 02/06/2025. A new surgery was scheduled with Urology. Administration followed up with POA and resident doing well. A record review of the facility's Concern Form dated 02/05/2025 revealed the same as above. The Concern Form had a Receipt Of Concern date of 02/05/2025, but did not reveal the time blank had been completed. A record review of Resident 1's Order Summary dated 02/19/2025 revealed that the physician ordered: Please remove SP suture on 02/05/2025. One time only, for 1 day. A record review of Resident 1's Urologist's Orders dated 01/29/2025 revealed that the Urologist ordered: Please remove SP suture on 02/05/2025 per discharge paperwork on 01/22/2025. A record review of Resident 1's Urologist's Urologic Surgery Operative Note dated 01/22/2025 revealed the resident had a SP cath placed and the cath was secured to the skin with a suture. Suture removal in 2 weeks. Catheter to be exchanged for the first time in 6 weeks, then monthly thereafter. A record review of Resident 1's Progress Notes dated 02/19/2025 revealed an entry on 02/05/2025 at 5:43 AM that Licensed Practical Nurse (LPN)-E removed Resident 1's SP cath and there was 900 milliliters (ml) output. A record review of Resident 1's Progress Notes dated 02/20/2025 revealed that multiple late entries were added in Resident 1's progress notes on 02/20/2025 regarding the events that occurred on 02/05/2025. A record review of Resident 1's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated February 2025 revealed Registered Nurse (RN)-F marked completed on the 02/05/2025 at 6:00 AM order to: Please remove SP suture on 02/05/2025, one time only for 1 day. A record review of Resident 1's Advanced Practice Registered Nurse (APRN)-D's Acute visit follow-up note dated 02/05/2025 at 8:45 AM revealed nursing did communicate that the resident was not feeling well and was concerned about having Influenza (flu). The Acute visit note revealed that APRN-D examined the resident about 11:00 AM and the resident had complaints of some dizziness, headache, body ache, and congestion. The resident was further assessed, and it was noted that the resident's SP cath was inadvertently (accidentally) removed by nursing early that morning and a dressing was covering the site. Nursing did a bladder scan, and the resident had 150 cubic centimeters (cc) per the bladder scan. A foley catheter was placed and the resident had immediate drainage of about 200cc. The Acute visit did not reveal what time the Foley cath was placed. APRN-D reported having multiple conversation with the Urology office regarding scheduling the resident to have the SP cath replaced. APRN-D did discuss the SP cath inadvertently being removed with the resident's family and POA, but it did not reveal a time for the conversation. In a telephone interview on 02/19/2025 at 10:05 AM, Resident 1's family/POA confirmed on 02/05/2025 Resident 1 had a spinal cord injury and underwent surgery. At that time a SP cath was placed and resident spent some time at a sub-acute hospital before being transferred to the facility on [DATE]. The resident had an order that was clearly written (per conversation with staff of the facility) to remove the SP cath suture in 2 weeks, but the LPN removed the entire catheter. The POA was upset because the staff did not put another cath back in right away, the nurse that removed the SP cath didn't say anything, and no other staff that worked with the resident noticed the SP cath was removed. The POA confirmed somehow the APRN noticed it, scanned the bladder, and said there was 100 cc's in bladder. When the POA arrived at the facility, the POA told the facility the POA didn't care how much was in the bladder, they wanted something in the resident to allow the resident to urinate. The POA confirmed at 11:30-11:45 AM the APRN called the Urologist's office and the Urologist's called the POA, the facility did not. At 12:30 PM the daughter arrived at the facility and there was still no cath in Resident 1, so the POA told the staff the POA wanted a meeting with the Administrator and DON and requested a Foley cath be put in. The POA confirmed the Foley was placed within 20 minutes of that. The resident was transferred to another facility on 02/06/2025 and Resident 1 had a second surgery for a new SP cath to be inserted without sutures on 02/10/2025. The POA confirmed the resident was supposed to move back home on 02/17/25, but now the family is hoping to get the resident home by 03/03/2025. The POA confirmed the POA, and the resident was upset because of the pain and discomfort of have the Foley cath placed and another surgery to place another SP cath, not to mention the financial burden of the surgery and the additional time that the resident had to stay in a nursing facility. In a telephone interview on 02/19/2025 at 10:33 AM, a staff member at the Urologist's office confirmed the order for suture removal was sent to the facility 01/29/2025, the Urologist sent an order for a Foley cath placement on 02/05/2025 at 11:51 AM, and Resident 1 underwent a new SP cath insertion surgery on 02/10/2025. In an interview on 02/19/2025 at 2:40 PM, APRN-D confirmed that APRN-D discovered that the SP cath was pulled inadvertently. APRN-D confirmed APRN-D was shocked to discover it. The resident told APRN-D that the nurse took out the SP cath. APRN-D confirmed the resident's brace was removed and seen just a dressing there. That was about 11:30 AM. The resident just said it didn't feel good. APRN-D confirmed it was removed at 5:30 AM. APRN-D told staff to call the Urologist. APRN-D confirmed that APRN-D stepped in and facilitated the process to get the resident scheduled for replacement SP cath. APRN-D confirmed it was discovered between 11:00 AM - 11:15 AM the SP cath had been removed and the family/POA showed up at the facility at 12:30 PM. The Urologist said to put a Foley cath in, and it was not inserted until 12:30 PM - 1:00 PM. APRN-D told the staff to call the family and the Urologist when APRN-D discovered the SP cath had been removed. In a telephone interview on 02/20/2025 at 7:05 AM, RN-F confirmed RN-F was the nurse that marked completed on the suture removal order, but RN-F was not the nurse that removed it. LPN-E was the night nurse that removed the SP cath. RN-F confirmed LPN-E told RN-F in report that the SP cath had been removed and RN-F confirmed RN-F didn't think it was supposed to be removed but went on with RN-F's day passing meds and cares for the residents. RN-F found out the SP cath was not supposed to be removed from the Clinical Care Coordinator (CCC) and Resident Assessment Instrument Coordinator (RAIC). CCC and RAIC called the Urologist's office, and the nurse was very upset and informed CCC and RAIC that a Foley cath would have to be inserted because they would not be able to get a SP cath back in Resident 1's insertion site because it had been too long at that point. CCC inserted the Foley cath. RN-C confirmed RN-C thought it was 10:00 AM - 10:30 AM when CCC and RAIC notified RN-F the SP was not supposed to be removed. The nursing assistants (NA)'s did not say anything about the cath not being there during their cares. She said the NA's were supposed to drain the bag every 2 hours or so. LPN-E came in later that same day and did mention LPN-E got wrote up and worked that night shift. In a telephone interview on 02/20/2025 at 8:08 AM, LPN-E confirmed LPN-E was passing meds to Resident 1 and looked at the SP cath site. Resident 1 told LPN-E the resident couldn't wait until the SP cath was removed that day. LPN-E later looked at order and the order said remove SP cath. LPN-E confirmed LPN-E did not click to enlarge the order on the computer screen and did not see it said remove SP cath suture. LPN-E confirmed LPN-E did proceed to remove the suture and SP cath. Resident 1 did not question why LPN-E was removing the SP cath. LPN-E confirmed LPN-E did not realize the error until later that day when the DON called LPN-E. LPN-E came to work later that day and was talked to and written up. LPN-E was given verbal education regarding if a resident had an SP cath it was usually in forever, enlarge order to read through, and make sure LPN-E did what the order said and not what the resident said. LPN-E confirmed it was an honest mistake. In an interview on 02/20/2025 at 1:00 PM, CCC confirmed CCC had been entering late entries in the progress notes on 02/20/2025 regarding the timelines CCC thought was accurate on the events that occurred on 02/05/2025. In an interview on 02/20/2025 at 9:43 AM, the DON confirmed the facility did not have a following provider's order policy, that would be per best practice. In an interview on 02/20/2025 at 11:35 AM, the DON confirmed there was not an order to remove the SP cath and it should not have been removed, just the suture that was placed in the SP cath.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 1) of 4 sampled resident's provider and resident's representative were notified of an emergent (unexpected) significant change in medical condition. The facility census was 65. Findings are: A record review of the facility's undated Change In Condition Or Status Of Guest/Elder/Resident policy revealed the nurse would notify the resident's attending physician or on-call physician when there has been an accident or incident involving the resident, a significant change in the resident's physical/emotional/mental condition, a need to alter the resident's medical treatment significantly, the need to transfer the resident to a hospital/treatment center, or a discovery of injuries of an unknown source. Notification to the resident and/or representative would be made when there was a significant change in the resident's physical, mental, or psychosocial status. Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status. The nurse should document pertinent information in the medical record. A record review of Resident 1's Clinical Census dated 02/19/2025 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 1's Medical Diagnosis dated 02/19/2025 revealed the resident had diagnoses of Neuromuscular Dysfunction of the Bladder (nerves controlling the bladder were damaged), Paraplegia (paralysis of the legs or lower body), and Spinal Stenosis, Lumbar Region (spinal canal narrows and compresses nerves in lower back). A record review of Resident 1's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 01/23/2025 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 13 which indicated the resident was cognitively aware. The resident required supervision or touching assistance with personal and oral hygiene (cleaning), partial moderate assistance with lower body dressing and bathing, substantial/maximal assistance with upper body dressing, and the resident was dependent on staff for toileting and footwear. The resident had an indwelling catheter (cath)(a tube inserted in the bladder to help restore urine output). A record review of Resident 1's Care Plan with an admitted [DATE] revealed the resident had a suprapubic (SP)(a tube inserted in through the skin into the bladder to allow urine flow) cath related to Neurogenic Bladder (lack of bladder control due to brain, spinal cord, or nerve damage), SP cath was removed 02/05/2025 and a Foley cath was placed on 02/05/2025. A record review of the facility's Grievance Log dated 11/25/2024 - 02/10/2025 revealed Resident 1's family/Healthcare Durable Power of Attorney (POA)(a person designated to make medical decisions for the resident) submitted a grievance on 02/05/2025 related to Resident 1's SP cath being removed when not ordered - only ordered to remove the stitch from the SP cath and the POA was upset because the facility did not notify the POA prior to the Urologist's (a physician that specializes in the urine system) office calling the POA. The grievance was taken by the Director of Nursing (DON), but it did not reveal a time. The resolution was Foley cath placed, antibiotic started, guest okay and concerns from guest. APRN (Advanced Practical Registered Nurse-APRN's are Registered Nurses who have advanced education and training in a specific area of nursing. They can diagnose and treat patients/residents, order tests and prescribe medication) there and visited with guest and family. Family requested a transfer to another facility and was transferred on 02/06/2025. A new surgery was scheduled with Urology. Administration followed up with POA and resident doing well. A record review of the facility's Concern Form dated 02/05/2025 revealed the same as above. The Concern Form had a Receipt Of Concern date of 02/05/2025, but did not reveal the time blank had been completed. A record review of Resident 1's Order Summary dated 02/19/2025 revealed that the physician ordered: Please remove SP suture on 02/05/2025. One time only, for 1 day. A record review of Resident 1's Urologist's Orders dated 01/29/2025 revealed that the Urologist ordered: Please remove SP suture on 02/05/2025 per discharge paperwork on 01/22/2025. A record review of Resident 1's Urologist's Urologic Surgery Operative Note dated 01/22/2025 revealed the resident had a SP cath placed and the cath was secured to the skin with a suture. Suture removal in 2 weeks. Catheter to be exchanged for the first time in 6 weeks, then monthly thereafter. A record review of Resident 1's Progress Notes dated 02/19/2025 revealed an entry on 02/05/2025 at 5:43 AM that Licensed Practical Nurse (LPN)-E removed Resident 1's SP cath and there was 900 milliliters (ml) output. A record review of Resident 1's Progress Notes dated 02/20/2025 revealed that multiple late entries were added in Resident 1's progress notes on 02/20/2025 regarding the events that occurred on 02/05/2025. A record review of Resident 1's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated February 2025 revealed Registered Nurse (RN)-F marked completed on the 02/05/2025 at 6:00 AM order to: Please remove SP suture on 02/05/2025, one time only for 1 day. A record review of Resident 1's Activities of Daily Living (ADL) - Bed Mobility task dated 01/20/2025 - 02/06/2025 revealed on 02/05/2025 at 9:07 AM the staff performed Bed Mobility on the resident. A record review of Resident 1's ADL - Toilet Use task dated 01/20/2025 - 02/06/2025 revealed on 02/05/2025 at 9:08 AM the staff assisted the resident with toileting. A record review of Resident 1's Monitor - Skin Observation task dated 01/20/2025 - 02/06/2025 revealed on 02/05/2025 at 9:09 AM the staff observed the resident's skin and documented the resident did not have a new skin condition. A record review of Resident 1's Advanced Practice Registered Nurse (APRN)-D's Acute visit follow-up note dated 02/05/2025 at 8:45 AM revealed nursing did communicate that the resident was not feeling well and was concerned about having Influenza (flu). The Acute visit note revealed that APRN-D examined the resident about 11:00 AM and the resident had complaints of some dizziness, headache, body ache, and congestion. The resident was further assessed, and it was noted that the resident's SP cath was inadvertently (accidentally) removed by nursing early that morning and a dressing was covering the site. Nursing did a bladder scan, and the resident had 150 cubic centimeters (cc) per the bladder scan. A foley catheter was placed and the resident had immediate drainage of about 200cc. The Acute visit did not reveal what time the Foley cath was placed. APRN-D reported having multiple conversation with the Urology office regarding scheduling the resident to have the SP cath replaced. APRN-D did discuss the SP cath inadvertently being removed with the resident's family and POA, but it did not reveal a time for the conversation. In a telephone interview on 02/19/2025 at 10:05 AM, Resident 1's family/POA confirmed on 02/05/2025 Resident 1 had a spinal cord injury and underwent surgery. At that time a SP cath was placed and resident spent some time at a sub-acute hospital before being transferred to the facility on [DATE]. The resident had an order that was clearly written (per conversation with staff of the facility) to remove the SP cath suture in 2 weeks, but the LPN removed the entire catheter. The POA was upset because the staff did not put another cath back in right away, the nurse that removed the SP cath didn't say anything, and no other staff that worked with the resident noticed the SP cath was removed. The POA confirmed somehow the APRN noticed it, scanned the bladder, and said there was 100cc in bladder. When the POA arrived at the facility, the POA told the facility the POA didn't care how much was in the bladder, they wanted something in the resident to allow the resident to urinate. The POA confirmed at 11:30-11:45 AM the APRN called the Urologist's office and the Urologist's called the POA, the facility did not. At 12:30 PM the daughter arrived at the facility and there was still no cath in Resident 1, so the POA told the staff the POA wanted a meeting with the Administrator and DON and requested a Foley cath be put in. The POA confirmed the Foley was placed within 20 minutes of that. The resident was transferred to another facility on 02/06/2025 and Resident 1 had a second surgery for a new SP cath to be inserted without sutures on 02/10/2025. The POA confirmed the resident was supposed to move back home on 02/17/25, but now the family is hoping to get the resident home by 03/03/2025. The POA confirmed the POA and the resident was upset because of the pain and discomfort of have the Foley cath placed and another surgery to place another SP cath, not to mention the financial burden of the surgery and the additional time that the resident had to stay in a nursing facility. In a telephone interview on 02/19/2025 at 10:33 AM, a staff member at the Urologist's office confirmed the order for suture removal was sent to the facility 01/29/2025, the Urologist sent an order for a Foley cath placement on 02/05/2025 at 11:51 AM, and Resident 1 underwent a new SP cath insertion surgery on 02/10/2025. In a telephone interview on 02/20/2025 at 7:05 AM, RN-F confirmed RN-F was the nurse that marked completed on the suture removal order, but RN-F was not the nurse that removed it. LPN-E was the night nurse that removed the SP cath. RN-F confirmed LPN-E told RN-F in report that the SP cath had been removed and RN-F confirmed RN-F didn't think it was supposed to be removed but went on with RN-F's day passing meds and cares for the residents. RN-F found out the SP cath was not supposed to be removed from the Clinical Care Coordinator (CCC) and Resident Assessment Instrument Coordinator (RAIC). CCC and RAIC called the Urologist's office, and the nurse was very upset and informed CCC and RAIC that a Foley cath would have to be inserted because they would not be able to get a SP cath back in Resident 1's insertion site because it had been too long at that point. CCC inserted the Foley cath. RN-C confirmed RN-C thought it was 10:00 AM - 10:30 AM when CCC and RAIC notified RN-F the SP was not supposed to be removed. The nursing assistants (NA)'s did not say anything about the cath not being there during their cares. She said the NA's were supposed to drain the bag every 2 hours or so. LPN-E came in later that same day and did mention LPN-E got wrote up and worked that night shift. In a telephone interview on 02/20/2025 at 8:08 AM, LPN-E confirmed LPN-E was passing meds to Resident 1 and looked at the SP cath site. Resident 1 told LPN-E the resident couldn't wait until the SP cath was removed that day. LPN-E later looked at order and the order said remove SP cath. LPN-E confirmed LPN-E did not click to enlarge the order on the computer screen and did not see it said remove SP cath suture. LPN-E confirmed LPN-E did proceed to remove the suture and SP cath. Resident 1 did not question why LPN-E was removing the SP cath. LPN-E confirmed LPN-E did not realize the error until later that day when the DON called LPN-E. LPN-E came to work later that day and was talked to and written up. LPN-E was given verbal education regarding if a resident had an SP cath it was usually in forever, enlarge order to read through, and make sure LPN-E did what the order said and not what the resident said. LPN-E confirmed it was an honest mistake. In an interview on 02/20/2025 at 11:35 AM, the DON confirmed there was not an order to remove the SP cath and it should not have been removed, just the suture that was placed in the SP cath. In an interview on 02/19/2025 at 2:40 PM, APRN-D confirmed that APRN-D discovered that the SP cath was pulled inadvertently. APRN-D confirmed APRN-D was shocked to discover it. The resident told APRN-D that the nurse took out the SP cath. APRN-D confirmed the resident's brace was removed and seen just a dressing there. That was about 11:30 AM. The resident just said it didn't feel good. APRN-D confirmed it was removed at 5:30 AM. APRN-D told staff to call the Urologist. APRN-D confirmed that APRN-D stepped in and facilitated the process to get the resident scheduled for replacement SP cath. APNR-D confirmed it was discovered between 11:00 AM - 11:15 AM the SP cath had been removed and the family/POA showed up at the facility at 12:30 PM. The Urologist said to put a Foley cath in, and it was not inserted until 12:30 PM - 1:00 PM. She told the staff to call the family and the Urologist when APRN-D discovered the SP cath had been removed. APRN-D confirmed the facility did not contact the APRN-D about the SP cath removal, APRN-D discovered it during the resident assessment. In an interview on 02/20/2025 at 11:26 AM, the DON confirmed the resident's representative was not notified of the SP cath removal until 12:00 PM when the family arrived at the facility and had a meeting with the facility's administration. The urology clinic had notified the POA, not the facility. The DON confirmed it was less than an hour from when the facility's administration was notified of the SP cath removal until the facility notified the family. The DON confirmed it was the DON's expectation that the nurse would notify the family immediately of an emergent significant change in the resident's medical condition. The DON did not confirm the SP cath being removed was an emergent significant change, but confirmed it was not a need to call 911 situation, but it was a situation that required medical attention. In an interview on 02/20/2025 at 1:00 PM, CCC confirmed CCC had been entering late entries in the progress notes on 02/20/2025 regarding the timelines CCC thought was accurate on the events that occurred on 02/05/2025. CCC confirmed that if the day shift nurse questioned if the SP cath was removed, RN-F should have immediately contacted the CCC, provider and resident's representative. CCC confirmed that after the CCC was notified the SP cath had been removed, they did not contact the resident's representative immediately, and they wanted to formulate a plan before contacting family between 11:20 AM and 12:30 PM. The CCC confirmed the facility formulated the plan without the resident's representative's input. CCC confirmed the resident was able to make the resident's own decisions and they told the resident during the bladder scan that they were probably going to have to re-insert the Foley cath.

Licensure Reference Number 175 NAC 12-006.17D Based on observation, record review and interview; the facility failed to perform hand hygiene to prevent the spread of infection and prevent cross contamination during catheter care and wound care for 1 resident (Resident 14) of 1 sampled resident. The facility census was 60. Findings are: A record review of Resident 14's Clinical Resident Profile printed 4/10/2024 revealed an admitted [DATE] and readmitted [DATE] with the diagnoses of multiple fractures of the pelvis and lumbosacral spine, parkinsonism (a motor syndrome that manifests as rigidity, tremors, and slow movement), chronic kidney disease (progressive damage and loss of kidne function) and an in-house acquired pressure ulcer (localized skin and soft tissue injuries that form as a result of prolonged pressure and shear, usually exerted over bony prominences) to the sacrum (a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis). An observation on 4/10/2024 at 7:45 AM with LPN (Licensed Practical Nurse)-B and NT (Nurse Tech)-C with CCC (Clinical Care Coordinator)-A in room, revealed NT-C transfer Resident 14 from the wheelchair to the bed in preparation for catheter care and wound care. Both LPN-B and NT-C were already gowned and gloved. NT-C pulled shorts and brief down to expose the area. NT-C took several incontinence wipes out of the package and washed along the resident's groin . NT-C used additional wipes to clean the resident's genitalia. NT-C reached into the package for additional wipe to wash the catheter tubing from the meatus on down the tubing. NT-C reached into the package again for a wipe and cleaned the catheter tubing again. A wipe was sticking out of the package and NT-C poked it back into the package. NT-C then pulled a wipe out of the package and washed between the resident's legs. NT-C shut the incontinence wipes package and partially pulled the residents brief up. NT-C then removed soiled gloves. NT-C put applied clean gloves without performing hand hyigene. NT-C then emptied the urinary drain bag into a graduate per protocol and emptied the graduate into the toilet and rinsed the graduate with water and emptied into the toilet. NT-C then removed soiled gloves. NT-C applied new gloves without performing hand hyigene. Resident 14 was then positioned to [gender] side and LPN-B washed sacral area with soap and water. LPN-B removed soiled gloves and applied new gloves without performing hand hyigene. LPN-B then applied calmoseptine cream to sacral area and inner buttocks. LPN-B then removed soiled gloves and applied new gloves without performing hand hyigene. LPN-B opened a package of 4x4 dressing. LPN-B then removed gloves and applied new gloves without performing hand hyigene. LPN-B applied the 4x4 dressing to the sacral area. The resident's brief was pulled up and the resident rolled onto [gender] back. LPN-B removed soiled gloves and applied new gloves without performing hand hyigene and placed the tube of calmoseptine on back of the toilet and emptied the water bins. An interview on 4/10/2024 at 8:15 AM with the CCC-A confirmed that no hand hygiene was completed during catheter care or wound care after removal of soiled gloves and application of new gloves. The CCC-A also confirmed that NT-C should have performed hand hygiene after washing groin and genitalia and applied new gloves before wiping down the catheter tubing. The CCC-A further confirmed NT-C should not have reached back into the incontinence wipes package with soiled gloves. The CCC-A also confirmed LPN-B did not perform hand hygiene between cleansing of sacral area and application of clean dressing. An interview on 4/10/2024 at 8:25 AM with the ADM (Administrator) and DON (Director of Nursing) confirmed that hand hygiene should be performed between removal of soiled gloves and application of new gloves. An interview on 4/10/2024 at 8:50 AM with NT-C revealed [gender] performed hand hygiene when [gender] entered the room and when [gender] left the room. NT-C revealed [gender] didn't realize when gloves should have been removed or when hand hygiene should have been performed. NT-C revealed [gender] didn't want to break contact with the resident by having to go near the door for hand sanitizer. A record review of the facility policy Hand Hygiene Policy dated 2/23/2022 revealed: A.Hand Hygiene Guidance: 1.healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: a. immediately before touching a patient, b. before performing an aseptic task or handling invasive medical devices, c. before moving from work on a soiled body site to a clean body site on the same patient, d. after touching a patient or the patient's immediate environment, e. after contact with blood, body fluids, or contaminated surfaces, f. immediately after glove removal. D. Gloves and Hand Hygiene: 1. wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or potential infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment occur. 2. gloves are not a substitute for hand hygiene a. if your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment 3. change gloves and perform hand hygiene during patient care, if a. gloves have been damaged, b. gloves have become visibly soiled with blood or body fluids following a task, c. moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs.

Licensure Reference Number 175 NAC ,d+[DATE].11E Based on observation, interview, and record review; the facility kitchen staff failed to label and date opened packages of food in the walk-in refrigerator and dry storage, failed to dispose of expired food from the walk-in refrigerator, and failed to perform hand hygiene while prepping room trays for lunch to prevent the potential of spread of infection and cross contamination. This had the potential to affect all 60 residents. The facility census was 60. Findings are: A. An observation on [DATE] at 7:50 AM of the walk-in refrigerator revealed: -an open box of jalapeno peppers not dated, -an open box of lemons not dated, -an open bag of dried out carrots not dated, -container of lettuce dated [DATE], -an open container of coleslaw with open date of [DATE] and use by date of [DATE], -an open package of baby spinach with use by date of [DATE]. An observation on [DATE] at 8:00 AM of the dry storage room revealed: -a package of opened fettucine with a hole in it not dated, -a package of opened ziti noodles closed shut with a bread tie and not dated, -a large open bag of panko crumbs dated [DATE] not closed shut sitting on top of a bin. An interview on [DATE] at 8:30 AM with the DM (Dietary Manager) confirmed that all listed above were opened packages of food that should be labeled and dated, and all the above listed expired food should not be on the shelves available for use. All expired food items were removed by the CDM at this time. A record review of the facility policy Proper Food Storage dated [DATE] stated: 2. all food products must be covered, 3. label all foods removed from their original container, 4. clearly label all food with product or item name, preparation date, use by, expiration or sell by date and prepared by, 10. perishable foods discarded after 3 days. B. An observation on [DATE] at 11:55 AM in the kitchen revealed DA (Dietary Aide)-F lick his bare fingers with [gender]'s tongue to separate meal tickets, rub [gender] nose with the back of [gender] bare hand while prepping room trays by setting drinks on the tray, pulling desserts from the cooler and setting them on the trays, setting wrapped silverware on the trays along with the plate of food served up by the cook. DA-F then stopped to wash hands at the sink with soap and water for 10 seconds and then immediately adjusts the ball cap on [gender] head while touching [gender] hair and continued rearranging meal tickets. At 12:15 PM, DA-F washed hands at the sink with soap and water for 20 seconds. At 12:18 PM, DA-F then licks [gender] fingers again to sort meal tickets and preps additional room trays for lunch. An interview on [DATE] at 1:05 PM with the DM confirmed that DA-F should have washed [gender] hands after licking fingers and touching hair before continuing to prep room trays for lunch and was not done. A record review of the Nebraska Food Code, ,d+[DATE].14, food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: A. after touching bare human body parts other than clean hands and clean, exposed portions of arms, F. during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, I. after engaging in other activities that contaminates the hands.

Licensure Reference Number 175 NAC 12-006.09C1c Based on record review and interview; the facility failed to review and revise the baseline care plan for 1 (Resident 68) of 1 sampled resident after a fall with major injury. The facility census was 60. Findings are: A record review of Resident 68's Medical Diagnosis sheet dated 4/9/2024 revealed the resident was admitted on [DATE] with diagnoses of ground level fall, fracture of second cervical vertebra (a bone in the neck), dorsalgia (back pain), major depressive disorder (persistently depressed mood or loss of interest in activities), congestive heart failure (the heard doesn't pump blood as well as it should), macular degeneration (loss in the center of the field of vision), osteoporosis (bones are brittle and weak), stress incontinence (involuntary, sudden loss of urine), muscle weakness, and polyneuropathy (numbness and tingling in the hands or feet). A record review of Resident 68's discharge Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 4/1/2024 identified Resident 68 exhibited moderately impaired cognition with a Brief Interview of Mental Status (BIMS score can range from 0 to 15, with lower scores indicating a decline in cognitive performance ) score of 8 indicating Resident 68 is moderately cognitively impaired. A record review of Resident 68's Fall Risk assessment dated [DATE] indicated the resident was at risk for falls with a score of 10. A record review of Resident 68's Baseline Care Plan (BCP) dated 3/28/2024 indicated Resident 68 was admitted due to generalized weakness and history of a fall. The BCP further stated to encourage use of the call light prior to ambulation and to wait for assistance and to wear gripper socks. A record review of Resident 68's Comprehensive Care Plan (CCP) that was initiated on 3/28/2024 had no focus, goals, or interventions for falls. A record review of an Incident Report completed by the DON (Director of Nursing) dated 4/1/2024 at 12:10 PM revealed Resident 68 transferred [gender] self in the bathroom and fell reaching for the walker. The report stated Resident 68 was sent to the emergency room for evaluation and was admitted for a rib fracture. The report further revealed the plan of care will be updated with interventions for frequent checks and offer the bathroom. A record review of Resident 68's BCP on 4/9/2024 at 9:13 AM revealed no new fall interventions after the resident's fall on 4/1/2024 with resulting rib fracture. A record review of Resident 68's CCP on 4/9/2024 at 9:05 AM revealed no focus, goals, or interventions for falls. A record review of Resident 68's CCP on 4/9/2024 at 4:30 PM revealed a fall focus related to confusion, deconditioning, gait/balance problems and history of falls with fall interventions in place. An interview on 4/9/2024 at 2:30 PM with the NT-E (Nurse Tech) regarding which residents [gender] was caring for were at risk for falls on the unit, revealed [gender] was unaware that Resident 68 was at risk for falls. An interview on 4/9/2024 at 3:20 PM with the DON and ADM (Administrator) regarding what interventions were put in to place after the fall with major injury on 4/1/2024, as they were not present on the BCP or CCP, revealed the resident had a BCP. No response was received from either the DON or ADM in response to the BCP having no updated interventions in place or that the CCP initiated 3/28/2024 had no focus on falls. An interview on 4/10/2024 at 10:20 AM with LPN-D (Licensed Practical Nurse) regarding who can update the care plan, LPN-D stated anybody. LPN-D further revealed that if the nurse did not know how to update the care plan, the CCC (Clinical Care Coordinator)-A could assist. When asked how soon [gender] would update a care plan if [gender] had a resident fall, LPN-D said, right away. A record review of the facility policy Fall Risk Management Policy dated 1/1/2023 stated it is the policy of the facility that patients are assessed for their level of fall risk and implement appropriate interventions to mitigate the risk of falling and/or risk of injury with falls. The policy further revealed the following: 2. Determining appropriate interventions: e. fall risk interventions should be reviewed by the interdisciplinary team as needed and can be included in the Quality Assurance, Huddle, Risk, and/or All Team Meetings. f. care plan interventions are reviewed during interdisciplinary team meetings assuring interventions continue to be appropriate for the patient. g. care plan interventions should be monitored and/or audited for consistent application in the care of the patient. Care plan interventions can be listed on the MAR/TAR and/or nurse tech care plan according to the Plan of Care policy. A record review of the undated facility policy Comprehensive Care Planning stated: 9. Assessments of guests are ongoing and care plans are revised as information about the guest and the guest's conditions change. 10.The Interdisciplinary Team is responsible for the review and updating of care plans: a. when there has been a significant change in the guest's condition, b. when the desired outcome is not met, c. when the guest has been readmitted to the facility from a hospital stay.

Based on record review and interview, the facility failed to ensure a Level II PASARR (A Level II is necessary to confirm the indicated Mental Illness (MI)/Intellectual Disability (ID) diagnosis and to determine whether placement or continued stay in a Nursing Facility is appropriate) was completed after receiving a new diagnosis of PTSD (Post Traumatic Stress Disorder), Major Depressive Disorder (MDD) and Anxiety Disorder, for 1 of 1 sampled residents (Resident 28). The facility identified a census of 60. Findings are: A record review of the demographic information dated 4/9/24 revealed that the facility had accepted Resident 28 for admission on 6/16/20 with a primary diagnosis of Spinal Stenosis, Lumbosacral region (when the space inside the backbone is too small causing pressure on the spinal cord). A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 1/29/24, Section C, revealed Resident 28 had a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 15 indicating Resident 28 was oriented and had no confusion. A record review of the Level I PASARR (Preadmission Screening and Resident Review that is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) on file dated 6/13/2020 revealed that the document indicated no MD/ID for Resident 28 at the time of admission. A record review of the diagnosis list dated 4/9/24 revealed Resident 28 to have a PTSD diagnosis dated 8/11/23, MDD dated 8/11/23, and an Anxiety Disorder diagnosis dated 8/11/23. An interview on 4/9/24 at 2:30 PM with the Director of Transitions (Admissions), after review of the current diagnosis list for Resident 28, confirmed that Resident 28 did have MD/ID diagnoses and should have had a level II PASARR initiated in 8/2023 and did not. The Director of Transitions voiced (gender) would initiate the level II PASARR. An interview on 04/10/24 at 3:22 PM revealed that the Director of Transitions had initiated a level II PASARR screen for Resident 28 and voiced that Resident 28 did in fact trigger for MD/ID and the need for a level II screen. A record review of the undated policy titled Identification Screen (PASRR) read as follows: Policy: An identification screen will be done prior to admission to see if the gest is eligible for placement. Identification screen (PASRR) will also be completed as needed for change in diagnosis or condition. 4. Resident's will be monitored for change in condition including diagnosis changes that would require a new PASRR to be completed.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on observations, interviews, and record review, the facility failed to ensure bath belts were utilized to ensure safety during [NAME] pool bathing. This had the potential to effect 29 of 37 residents who received [NAME] pool baths on Wilderness Ridge North and Wilderness Ridge South. The facility census was 63. Findings are: Observation on 5/15/23 at 3:45 PM revealed the bath chair on Wilderness Ridge had open slots for a bath belt to slide in to. No belt was in place in the chair and no belt was observed in the tub room. Interview of NA-F (Nursing Assistant) on 5/15/23 at 3:45 PM revealed there are slots for the use of a bath belt but belts are not used for every resident. NA-F reported having provided baths for about 4 months and was not trained to use a bath belt on any resident except for a Resident who had lower extremity amputations. Interview with NA-H on 05/16/23 at 8:31 AM revealed NA-H was the bath aid on 5/16/23. NA-H revealed the safety belt is utilized per resident preference in the [NAME] pool bath. NA-H revealed [gender] utilized personal judgement to decide what residents would be safe without the safety belt in place during a [NAME] pool bath. Interview of LPN-G (Licensed Practical Nurse) on 05/16/23 at 8:11 AM revealed the expectation was a safety belt was to be utilized at all times when a resident was in the [NAME] pool. Interview with the DON (Director of Nursing) on 5/16/23 at 9:06 AM revealed the facility had no policy and procedure for the use of safety belts during whirlpool bathing. The DON revealed the facility's goal is to ensure every resident is as safe as possible. Record review of the Manufacturer's directions for use for the Cascade Sit-bath Model # 360010-12L revealed the following: The purpose of this manual is to provide you with a recommended procedure to help you obtain the maximum efficiency and safety from your Sit-Bath System. Prior to the bath, perform the following preparation steps. #2. Check that the seat belt is in place and ready to strap in the Resident after they are in the tub.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09 Based on record review and interview, the facility failed to complete post fall neurological assessments for Resident 111. The facility census was 63. Findings are: Record review of Resident 111's History and Physical dated 1/28/23 revealed the following diagnoses: Small bowel obstruction, Dementia, Diabetes and Atrial Fibrillation. Record review of a Huddle Report revealed Resident 111 had an unwitnessed fall in the Resident 111's room on 2/14/23 at 2:00 PM. Record review of policy and procedure with an effective date of 2/1/23 revealed neurological checks should be completed after an unwitnessed fall; a. every 15 minutes x 4 b. every 30 minutes x 4 c. every hour x 4 d. every 4 hours x 4 e. every 8 hours x 3. Record review of the post fall neurological checks completed after Resident 111's fall on 2/14/23 revealed the last 24 hours of neurological checks were not documented. Interview with LPN-I (Licensed Practical Nurse) on 5/12/23 at 9:00 AM revealed the protocol post fall was to call for a nurse and perform neurological checks every 15 minutes for first hour then every 30 minutes for 2 hours, hourly for 4 hours and every 8 hours for the next 24 hours. Interview with the DON (Director of Nursing) on 05/15/23 at 10:40 AM confirmed documentation of the every 8 hours x 3 neurological checks on Resident 111 could not be found.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D6 Based on observation, interview and record review; the facility failed to ensure cleaning and storage of respiratory equipment for Resident 2, 9, 49, and 113. The sample size was 16. The facility identified a census of 63. Findings are: A. An observation on 01/12/22 at 09:38 AM revealed Resident 49 had an oxygen cannula hanging down the side of the couch and a [CONDITION(S)] (Continuous Positive Airway Pressure -- a treatment that uses mild air pressure to keep your breathing airways open) mask resting face down on the nightstand, still intact and attached to the machine. An observation on 01/13/22 at 09:35 AM revealed Resident 49's nebulizer kit to be intact and resting on the tray table and Resident 49's [CONDITION(S)] mask to be resting face down on the nightstand. An interview on 1/13/22 at 04:45 PM with the facility Regional Nurse Consultant, revealed that the care and storage of respiratory equipment had been identified as a problem during the facility mock survey conducted on 1/4/22 and that staff had been re-educated. The interview confirmed that the observations of respiratory equipment did not meet facility policy or expectations related to storage and care. A record review of the Policy titled Nebulizer Mask Cleaning and revised on 8/10/2018 revealed the following procedure steps: 1. take apart nebulizer tubing, mask and/or aerosol chamber 2. wash the mask and aerosol chamber with warm water (may use soap) daily after each use. 3. rinse all soap off with clean water, 4. place on towel on clean surface and allow to air dry 5. place in respiratory bag for storage. B. An interview on 01/12/22 at 09:49 AM with Resident 113 revealed the resident had required oxygen, aerosol treatments and a [CONDITION(S)] at night since contacting Covid-19. An observation on 01/12/22 at 10:07 AM revealed the nebulizer kit used by Resident 113 to be intact and resting on the nebulizer machine. The observation revealed the [CONDITION(S)] mask to be resting face down on the nightstand. An observation on 01/13/22 at 01:34 PM revealed Resident 113's oxygen tubing draped over the tray table and not placed in a bag. The observation revealed Resident 113's [CONDITION(S)] mask to be intact and resting face down on the night stand. C. Observation on 1-12-22 at 1:49 PM revealed Resident 2's liquid oxygen portable tank on the floor. The tubing for the portable tank was resting on the floor, including the nasal cannula (the part that goes in the Resident's nose). Resident 2 also had a Trilogy machine (a type of machine used to assist the Resident with breathing) present in the room, and the mask for this was on the floor. Resident 2 also had a nebulizer machine (a machine that delivers medications to the lungs) on the night stand, and the set for this was in a plastic bag. An observation on 1-13-22 at 10:40 AM revealed the set for the nebulizer in the drawer of Resident 2's night stand, not in a bag. An observation on 1-18-22 at 11:24 AM of Resident 2's room revealed the nebulizer set on top of the night stand, not in a bag. An observation on 1-19-22 at 9:02 AM of Resident 2's room revealed the nasal cannula for the liquid oxygen portable tank lying on the seat of the wheelchair, and the nebulizer set on top of the night stand, neither of them in bags. A interview with Licensed Practical Nurse (LPN) B on 1-19-22 at 9:02 AM confirmed that the nasal cannula and nebulizer set should each be in a bag with the date on it. D. Observation on 01/12/22 at 3:40 PM of Resident 9's [CONDITION(S)] revealed the head gear, tubing and mask laying on the floor in Resident 9's room, with the mask face down on floor. Observation on 01/13/22 at 02:20 PM of Resident 9's [CONDITION(S)] equipment laying on the nightstand with the mask face down. No bag was noted in Resident 9's room. Record review of the facility's Use of [CONDITION(S)] and [CONDITION(S)] policy, dated 5/23/17 revealedthe general guidelines for cleaning, the masks, nasal pillows and tubing. Clean daily by placing in warm soapy water. Mild dish detergent is recommended but not required. Rinse with warm water and allow it to air dry between uses. Store in proper receptacle. Interview on 01/19/22 at 02:45 PM with Regional Nurse Consultant confirmed the guidelines for cleaning and that a proper receptacle would be a bag in the resident's room.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on record review and interview, the facility failed to ensure residents were free of unnecessary medications related to the monitoring of behaviors and side effects of medications for Resident's 20, 31, 45, and 49. The sample size was 5. The facility identified a census of 63. Findings are: A. A record review of the MAR/TAR (Medication Administration Record/Treatment Administration Record) dated January 2022 revealed an order for [MEDICATION(S)] (an antipsychotic medication used to treat such diseases as [CONDITION(S)], depressive disorder and [CONDITION(S)]) with an area which reads S/S (signs/symptoms) [CONDITION(S)] or Depression, side effects which is blank from 1/1/22 through 1/12/22. A record review of the MAR/TAR dated December 2021 revealed an order for [MEDICATION(S)] with an area which reads S/S [CONDITION(S)] or Depression, side effects which is blank from 12/1/21 through 12/31/21. A record review of the running Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) with a print date of 1/12/22 for Resident 31 revealed no target behaviors or medication side effects to monitor for. An interview with the Regional Nurse Consultant on 1/13/22 at 03:19 PM confirmed that during a mock survey on 1/4/22 the lack of behavior monitoring and medication side effect monitoring was identified as a concern and had continued to be a concern. B. A record review of the MAR/TAR dated January 2022 for Resident 45 revealed no target behaviors or side effect monitoring related to the use of Trazadone (a medication used to treat depression disorders and sleep disorders). A record review of the MAR/TAR dated January 2022 for Resident 45 revealed an order for [MEDICATION(S)] (a fast acting tranquilizer used to treat anxiety and panic disorders) 0.25mg (milligrams) by mouth every 4 hours as needed for anxiety, with no stop date. An interview with the Regional Nurse Consultant on 01/19/22 at 01:45 PM revealed that the facility pharmacy handled the stop dates and would contact the physician to see if medication should be continued or discontinued. A record review of the document titled RELYCARE LTC LINCOLN, CIII-CV Prescription - Immediate Response Required and dated 01/03/22 for Resident 45 regarding the [MEDICATION(S)], contained a refill date that read 5x (five times). An interview on 1/19/22 at 02:04 PM with the Regional Nurse Consultant after review of the RELYCARE LTC LINCOLN, CIII-CV Prescription - Immediate Response Required document dated 01/03/22 for Resident 45, confirmed that a 5x refill was not appropriate for the [MEDICATION(S)] stop date. C. A record review of the Physician's Orders, dated 1/13/22 for Resident 49 revealed an order for [MEDICATION(S)] (an antidepressant medication), [MEDICATION(S)] (an antianxiety medication), [MEDICATION(S)] (an antidepressant medication) and Trazadone (an antidepressant medication). A record review of the MAR dated January 2022 for Resident 49 revealed an area which read S/S Depression and side effects connected to the [MEDICATION(S)] and the [MEDICATION(S)] which were blank. A record review of the MAR dated January 2022 for Resident 49 revealed an area which read S/S [CONDITION(S)] and side effects connected to the Trazadone which was blank. A record review of the MAR dated January 2022 for Resident 49 revealed an area which read S/S Anxiety and side effects connected to the [MEDICATION(S)] which was blank. D. A review of the Physician's Orders from 8-9-21 revealed that Resident 20 was on [MEDICATION(S)] (an antipsychotic used to increase the effectiveness of some antidepressants) and [MEDICATION(S)] (an antidepressant) with a diagnosis of depression for both. A review of Resident 20's MAR and TAR with a print date of 1-12-22 revealed that Resident 20 was on [MEDICATION(S)] and [MEDICATION(S)]. There was a space under each of these medication names on the MAR for staff to document signs and symptoms (s/s) of depression, and a space under [MEDICATION(S)] to document side effects. Neither of the spaces listed any of the side effects of the medications or the s/s of depression to monitor for. A review of Resident 20's MAR and TAR, Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care), and nurse tech care plan revealed that weekly behavior charting and side effect monitoring were to be done. The CCP did not identify any specific target behaviors or side effects to monitor. A review of the facility's Comprehensive Care Plan Policy and Procedure dated 10/18/18 it revealed under section 5 that therapy plans of care, nurse tech care plan, medication/treatment records and physicians orders were part of the comprehensive care plan. An interview with the Regional Nurse Consultant on 1-18-22 at 1: 41 PM confirmed there were no target behaviors identified on the MAR printed 1/12/22, the comprehensive care plan, or the nurse tech care plan.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on record review and interview, the facility failed to notify the physician of a significant weight loss for Resident 31 and Resident 113. The sample size was 16. The facility identified a census of 63. Findings are: A. A record review of the facility Matrix (a document used to identify pertinent care categories for all residents) revealed Resident 31 had been noted to have a weight loss. A record review of the document titled Face Sheet with a run date of 1/12/22 revealed Resident 31 was admitted on [DATE]. A record review of the weights for Resident 31 revealed a weight of 121 lbs (pounds) on 12/3/21 and a weight of 111 lbs on 1/4/22 which was a weight loss of 8.26% in 1 month. A record review of the vitals sheet for Resident 31 since admission revealed the following: -1/12/2022 at 12:39 PM, the resident's weight was 112 lbs; -1/4/2022 at 2:41 PM, the resident's weight was 111 lbs; -12/22/2021 at 11:02 AM, the resident's weight was 112.50lbs; -12/15/2021 at 11:12 AM, the resident's weight was 120.60 lbs; -12/10/2021 at 12:49 PM, the resident's weight was 120.00 lbs; -12/3/2021 at 1:31 PM, the resident's weight was 121.00 lbs; -11/24/2021 at 1:35 PM, the resident's weight was 125.00 lbs; -11/22/2021 at 1:30 PM, the resident's weight was 117.20 lbs. A record review of the Progress Notes for Resident 31 revealed the following dietary notes dated 1/12/22 by the facility RD (Registered Dietician) : -Guest diet is Heart healthy, regular thin liquids, appetite is poor, avgerage recorded meal intake is 25-50%. Guest flatly refuses any supplements except magic cup at dinner, which is recorded as 50-75% acceptance. I did revisit about CIB but does refuse. Weight is stable at 112 lbs. ( 12/30-01/12) but did have a weight loss of 5-8 lbs. or 5.0-6.6% in the past two months. Guest PEG tube was removed in December per guest wishes. Coccyx is dark red but no breakdown at this time. Guest lunch meal was chicken noodle soup and cranberry juice. Guest has 3 bags of candy on the table also. Continue to monitor weight and supplement of magic cup. An interview on 01/19/22 at 08:22 AM with the facility RD, after review of weights for Resident 31, confirmed Resident 31 had a significant weight loss. The interview confirmed no documentation or notification was made to the physician related to the significant weight loss. B. An interview conducted on 01/12/22 at 09:58 AM with Resident 113 revealed a weight loss of 57 lbs overall since getting Covid-19 (a mild to severe respiratory illness that is caused by a coronavirus). A record review of the document titled Face Sheet with a run date of 1/12/22 revealed Resident 113 had been admitted on [DATE]. A record review of the vitals for Resident 113 since admission are as follows: 1/13/2022 at 12:54 PM, weight was 237.80 lbs; 1/12/2022 at 12:45 PM, weight was 237.40 lbs; 1/12/2022 at 11:31 AM, weight was 236.20 lbs; 1/11/2022 at 8:55 AM, weight was 237.40 lbs; 1/7/2022 at 11:32 AM, weight was 239.00 lbs; 12/31/2021 at 2:53 PM, weight was 250.60 lbs. A record review of the weights dated 12/31/21 through 1/13/22 for Resident 113 revealed a weight loss of 5.2% since admission. A record review of the Progress Notes dated 12/31/21 through 1/12/22 for Resident 113 revealed no physician notification related to weight loss. An interview with the RD on 01/18/22 at 10:45 AM after review of the weights since admission, confirmed Resident 113 had a weight loss of 5.2% since admission. After review of the Progress Notes dated 12/31/21 through 1/12/22 for Resident 113 the RD confirmed no physician notification had been done. A record review of Progress Notes dated 1/12/22 for Resident 113 revealed a note written by the facility RD which read as follows: wts. Have been stable between 236-239#. Admit was 250# is error. Receiving liquacel for BID - 1oz for wound healing, has a good appetite. Receives an PB and J sandwich (90% acceptance) for HS snack r/t low BS range at morning accuchecks (48-111) Wound being followed by [NAME]. Diet is Carb count and thin liquids. Provided with Carb counting education. A record review of Progress Notes for Resident 113 revealed the following dietary note related to Resident 113's weights, dated 1/18/22 at 1:28 PM: Per nursing, the resident went to the doctor today and weighed 250 lbs., they reweighed the resident and weight was 249 lbs. The resident didn't have a weight loss, the resident continues to have [CONDITION(S)]. An interview with the RD on 01/18/22 at 10:45 AM after review of the Progress Notes dated 12/31/21 through 1/19/22 for Resident 113 confirmed conflicting statements related to the accuracy of weights and confirmed that no physician notification existed related to a weight loss for Resident 113.