Every finding on record at Hillcrest Nursing Home

Nebraska Reference Number 175 NAC 1-005.06(A) and 12-006.18 Based on observations, interviews and record reviews, the facility failed to have an infection control program that ensured tracking and trending was fully completed and to implement interventions for concerns that were identified to prevent antibiotic overuse, failed to utilize handwashing and gloving techniques to prevent potential cross contamination during personal care for 1(Residents 10) of 4 sampled residents. The facility identified a census of 62. Findings are:A. Record review of Resident 10's Minimum Data Set (MDS) (a federally mandated assessment that aides the facility in identifying a resident's care needs) dated 4/11/2026 revealed the following: Section C: the Brief Interview for Mental Status (BIMS) (a screening tool that helps determine a resident's level of cognition, with a score of 0 to 15, 15 being [NAME] cognitively intact) revealed a score of 3. Section GG: revealed toilet use coded as dependent. Section H: revealed the resident was occasionally incontinent of urine and frequently incontinent of bowel. Section I: revealed urinary tract infection within the last 30 days. Section M: no skin concerns noted An observation on 5/6/2026 from 8:48 AM to 9:45 AM of Resident 10 revealed the resident receiving incontinent care by Nurse Assistant (NA) B and NA-C. NA-B and NA-C entering the room and applying gloves without the benefit of hand hygiene (HH). Both NA's assisted with putting the residents' pants and shoes on for the day. NA- C tucks the soiled brief under the resident then obtained 1 wipe to cleanse the groin area, using the same wipe for 3 swipes. NA-C and NA-B rolled the resident while wearing the soiled gloves and continued cares. NA-C obtained another wipe and swiped 3 times to the center of the buttocks. and with the same soiled gloves obtained a new brief and and tucked it under the resident. NA-C then dipped the soiled gloves into an unlabeled specimen cup to obtain a pink cream to apply to the resident's bottom and then squeezed a large amount of powder over the cream. The NA's rolled the resident over and NA-C used the same soiled glove to dip into the pink cream and apply to Resident 10's groin area. As the NA's completed peri-care the resident voided on the new brief and sheets on the bed. NA-C changed gloves without hand hygiene and NA-B kept the soiled gloves on. Further observations revealed NA-B when cleansing the resident did not wash the residents hip areas. NA-C, with the soiled gloves still on, sat the resident up on the side of the bed to finish dressing Resident 10. NA-B then used a personal wipe to wipe the floor after bagging up the soiled laundry. NA-B left Resident 10's room without completing hand hygiene. An interview with NA-B on 05/07/2026 at 7:18 AM regarding the observed incontinent care confirmed missed opportunities for hand hygiene and properly caring for soiled linen. An interview with director of nursing (DON) on 05/06/2026 at 12:30 PM confirmed staff is expected to toilet the residents before and after meals and before activities, and to do hand hygiene with glove changing. Record review of facility policies and procedures for perineal care revised 11/2023 indicates staff will avoid cross contamination by proper glove use and hand hygiene and soiled linens and briefs will be handled per infection control procedures. Record review of facility policies and procedures for handwashing/hand hygiene indicates staff are expected to perform hand hygiene with alcohol-based hand sanitizer before applying non-sterile gloves as well as after removing gloves, and staff will wash hands with soap and water when gloves are visibly soiled. B. Record review of the undated facility policy titled Infection Prevention and Control revealed under Procedure: 1. Investigate, control, and prevent infections in the facility. 5. All staff will be required to wash their hands or use sanitizer after each direct resident contact. Record review of the facility infection control binder that contained the facility information regarding infections and tracking and trending each month revealed the following: July to December of 2025: A facility map that did not have any documentation on it as well as a seating chart of the facility dining room that did not have any documentation on it. January to February of 2026: A facility map that did not have any documentation on it as well as a seating chart of the facility dining room that did not have any documentation on it. A printed report from the facility electronic health record titled The Infection Surveillance Report revealed the number of Healthcare Associated Infections (HAI's) and a summary by infection category. This generated report did not have a complete list of room numbers, signs and symptoms, labs, number of days on antibiotics or other required information for tracking and trending infections. An interview with the Infection Preventionist nurse (IP) on 5/7/2026 at 10:15 AM confirmed that the only documentation in the Infection Control binder was the Infection Surveillance Report and the other forms were blank. The IP also confirmed that this report only has the number of infections, type of infection and medication ordered. Record review of the facility Quarterly Quality Assurance Meeting (QA)notes dated 1/20/2026 indicated there were 10 Urinary Tract Infections (UTI's) the previous month. Under Focus Audits it is listed for infection prevention to do peri-care audits and catheter cares/hygiene teach to prevent UTI's. The Infection Surveillance Report showed 6 UTI's for December (the previous month), which did not match the QA report. Record review of the facility Quarterly Quality Assurance Meeting notes dated 2/17/2026 indicated there were 8 UTI's the previous month. Under Focus Audits it is listed for infection prevention to do peri-care audits and catheter cares/hygiene teach to prevent UTI's, no additional information added, repeated the January QA notes. The Infection Surveillance Report showed 0 UTI's for January (the previous month), which did not match the QA report. Record review of the facility Quarterly Quality Assurance Meeting notes dated 3/17/2026 indicated there were 5 UTI's the previous month. Under Focus Audits it is listed for infection prevention to do peri-care audits and catheter cares/hygiene teach to prevent UTI's, no additional information added, repeated the January QA notes. The Infection Surveillance Report showed 0 UTI's for February (the previous month), which did not match the QA report. Record review of the facility Quarterly Quality Assurance Meeting notes dated 4/21/2026 indicated there were 6 UTI's the previous month. Under Focus Audits it is listed for infection prevention to do peri-care audits and catheter cares/hygiene teach to prevent UTI's, no additional information added, repeated the January QA notes. The Infection Surveillance Report showed 7 UTI's for March (the previous month), which did not match the QA report. An interview with the Director of Nursing (DON) on 5/6/2026 from 11:00 AM to 12:15 PM confirmed that the facility tracks and trends infections by printing the Infection Surveillance Report. The DON also stated that the report was not working accurately during the first part of the year. The DON revealed that the wound nurse was to begin doing peri-care audits and hand hygiene audits based off a Performance Improvement Plan (PIP) for UTI's that was dated 3/17/2026. Record review of the undated Quality Performance Improvement Plan that was created post-Covid outbreak 3/17/2026 revealed the facility would begin doing weekly audits of Peri care completion and catheter care. The PIP also indicated toileting and incontinence care every two hours, re-educate on hand hygiene before and after care and glove changes between tasks. Record review of the wound nurse audits revealed that the audits were actually education regarding how to perform peri-care and hand hygiene with return demonstration of hand washing and not audits. There was no further documentation found regarding actual peri-care observations/audits. An interview with the Registered Nurse (RN) E (the wound nurse) on 5/6/2026 at 12:45 PM confirmed that the forms produced were education not observations of actual peri-care or hand hygiene during cares. Record review of the facility Handwashing Competency Audit, which started 4/14/2026 revealed the following each week: 4/14 to 4/20/2026: 38 out of 122 staff members completed, for a 32.1% compliance rate. 4/21 to 4/28/2026: 2 out of 124 staff members completed, for a 32.2% compliance rate. 4/29 to 5/5/2026: 17 out of 126 staff members completed, for a 45.2% compliance rate. 5/6 to current: 1 out of 126 staff members completed. No compliance rate figured. During an interview with the DON on 5/7/2026 at 10:30 AM the DON confirmed the Infection Surveillance Report was used for last year to track and trend does not have all the information needed to completely track and trend infections and does not match the QA numbers.

Licensure Reference Number NAC 175 12-006.11(E) Based on observation, record review, and interview, the facility failed to label frozen food packages with contents or dates. This had the potential to affect all 62 residents.A record review of a facility policy, Food Storage Policy, last revised November 2023 revealed the following:Food shall be stored at least 6 inches off the floor. All food and supplies should be stored in compliance with federal and state regulations.All foods shall be clearly labeled with contents, dated with the opening date, and discarded if not dated or expired. Frozen foods shall be dated and properly rotated. An observation on 5/04/2026 at 12:43 PM in the kitchen's walk-in freezer, the first food rack to the left revealed the following:On the 2nd shelf from the top: 2 clear unlabeled plastic bags (each bag greater than gallon-sized) of breaded food items.On the 3rd shelf, 1 clear unlabeled gallon-sized bag of shredded/cut food, 1 clear unlabeled gallon-sized bag of 20 pale brown patties.On the 4th shelf, 2 clear unlabeled bags (each bag greater than gallon-sized) of breaded food items, next to an unlabeled food object wrapped in plastic. On the floor, 1 unlabeled clear plastic bag of 10 breaded patties, the top of the bag tied in a knot. An interview on 5/04/2026 at 12:52 PM with Dietary Cook-A (DC-A) confirmed the bag of meat patties on the floor should have been labeled, dated, and not been on the floor. An interview on 5/04/2026 at 1:01 PM with DC-A confirmed bags of food did not have labels that included contents of the bags or dates to indicate when the items should be used. The interview confirmed the bags did not state whether the item contained cooked or uncooked meat. An interview on 5/06/2026 at 11:54 AM with the Director of Dietary (DD) confirmed the bags in the freezer should have been labeled with contents and the relevant dates.

175 NAC Licensure reference number 12-006.09(H)(iii)(1), 12-006.09(H)(iii)(2)Based on record review, interview, and observations, the facility staff failed to evaluate and implement interventions to prevent additional pressure ulcer development for 1(Residents 37) of 3 sampled residents. The facility identified a census of 62. Record review of Resident 37's Minimum Data Set (MDS) (a federally mandated assessment that aids the facility in identifying a resident's care needs) dated 02/16/2026 revealed the following: Section GG: revealed toileting was coded as dependent, bed mobility required partial/moderate assistance and transfers were coded as dependentSection J: revealed use of pain medications and non-medication pain management.Section M: revealed no skin concerns noted. Record review of Resident 37's care plan dated 03/02/2026 revealed the resident had been identified as being at risk for skin breakdown. There was no evidence of the resident's pressure ulcer to their left heel being addressed or of any interventions being put into place to treat the current pressure ulcer or to prevent additional pressure ulcers to the right heel from developing. Record review of Resident 37's Braden Scale (a standardized tool used by healthcare professionals to assess a resident's risk of developing pressure injuries and guide preventative care with a score of 19-23 indicating a low or no risk, 15-18 indicates mild risk, 13-14 indicates a moderate risk and 12 points or below indicates high to very high risk of developing a pressure injury). The following dates of assessment were completed: 02/10/2026 Braden Score on admission: 13 (moderate risk)02/17/2026 Braden Score: 16 (mild risk)03/03/2026 Braden Score: 17 (mild risk)03/10/2026 Braden Score: 14 (moderate risk) Further record review revealed no further Braden assessments were completed for this resident since the last one completed 03/10/2026. Record review of skin evaluation from Resident 37's chart dated 04/29/2026 states no current skin issues. Record review of skin evaluation from Resident 37's chart dated 05/03/2026 indicates new wound, unstageable, in-house acquired to left heel measuring 1.4 centimeters (cm) in length, 1.2 cm in width, no undermining or tunneling noted, 100% eschar (a piece of dead tissue that is cast off from the surface of the skin, particularly after a burn injury, but it can also be seen in conditions such as pressure ulcers). An observation on 05/06/2026 at 6:56 AM revealed Resident 37 laying in bed on the resident's back with entire bottom portion of bilateral feet pressed against the footboard of the bed. Observation revealed no heel offloading to right foot; a soft blue boot was in place to the left foot. An observation on 05/07/2026 at 7:10 AM revealed the resident scooted down in bed with entire bottom of bilateral feet pressed against the footboard with soft blue boot applied to left foot, no interventions to right foot.An observation on 05/06/2026 at 7:30 AM revealed LPN-D and Assistant Director of Nursing (ADON) performing would care to Resident 37's left heel. During the observation, LPN-D stated, regarding left heel wound, Yeah, it's scabbed and we just found it on Sunday (May 3, 2026). Observation further revealed the resident crying in bed after wound care complete stating My leg hurts really bad!.An observation on 05/06/2026 at 6:57 AM revealed Resident 37 crying and grimacing during transfers and shoe application related to left foot pain. When tennis shoes are applied Resident 37 states, Oh that hurts my foot! I should be wearing my booty! NA-B responded, Oh, you can put that on later if you want, but right now I need you to have your shoes on to go to the bathroom. Resident 37 was observed to be a one person assist transfer taking three small steps with the use of 4-wheeled walker to wheelchair. An observation of 05/06/02026 at 9:26 AM revealed Resident 37 sitting in a recliner with tennis shoes in place, resting heels on cross bar of footrest of recliner, applying pressure to bilateral heels. An additional observation at 10:28 AM revealed Resident 37 sitting in a recliner with a blue padded boot applied to the left foot with no interventions to prevent additional pressure injuries from occurring were in place to right foot. An interview with Registered Nurse (RN)-E on 05/06/2026 at 12:48 PM confirmed there were no interventions in place to prevent additional pressure ulcers. RN-E confirmed Resident 37 was at risk of developing a pressure ulcer as the resident sat in the recliner throughout the day resting heels on the crossbar section of the footrest on recliner.

Licensure reference number: 12-09(H)(iv)(6)Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent urinary tract infections (UTIs) and maintain bladder continent for one (Resident 10) of one resident reviewed for urinary continence and infection prevention. The facility failed to implement the resident's toileting interventions despite recurrent urinary tract infections, ongoing urinary symptoms, decline in condition, and a history of urosepsis. These failures place the resident at risk for worsening infections, skin complications, discomfort, decline in continence status, and hospitalization. The facility identified a census of 62.Record review of the facility policy titled Perineal Care last revised on 11/2023 revealed under section Policy states Perineal care will be provided routinely and as needed to maintain cleanliness, prevent infection, reduce odor, protect skin integrity, and promote resident dignity and comfort after incontinent episodes. Staff will provide care in a respectful, sanitary, and individualized manner according to resident needs and physician orders. Record review of Resident 10's Minimum Data Set (MDS) (a federally mandated assessment that aides the facility in identifying a resident's care needs) dated 4/11/2026 revealed the following: Section C: : the Brief Interview for Mental Status (BIMS) (a screening tool that helps determine a resident's level of cognition, with a score of 0 to 15, 15 being [NAME] cognitively intact) revealed a score of 3 which indicated the resident had severe cognitive impairment.Section GG: revealed toilet use coded as dependent.Section H: revealed the resident was occasionally incontinent of urine and frequently incontinent of bowel.Section I: revealed urinary tract infection within the last 30 days. Record review of Resident 10's undated Care Plan revealed staff were to Offer/assist with frequent toileting around meals and activities and at bedtime to promote continence. Record review of Resident 10's Progress Notes revealed Resident 10 experienced recurrent infections and multiple antibiotic courses during 2026. Record review of the progress notes from January 2026 to April 2026 revealed the following:On 01/23/2026 the staff documented the resident's Bactrim (an antibiotic medication) would be discontinued on 01/24/2026.On 02/10/2026 the Nurse practitioner (NP) was in the facility and assessed the resident. The NP wrote a new order for Augmentin (antibiotic medication) to be given twice a day for the diagnosis of sinusitis. On 02/17/2026 prior to breakfast the resident was incontinent of a bowel movement (BM) and required assistance with personal care. That day was the last day of their antibiotic for sinusitis.On 02/20/2026 at 11:56 AM the resident complained of generalized back pain rated at a 4 out of 10 and was given an as needed pain medication. At 12:05 PM the resident had complaints of headache and chest pain in addition to back pain. The resident was shaking and has shallow breathing and their oxygen saturation 85%. At 12:12 PM emergency medical services arrived and transported the resident to the hospital. Later on 02/20/2026 staff documented the resident had received intravenous (IV) Rocephin (an antibiotic medication) for UTI. The resident also had new orders for Cephalexin (an antibiotic medication) 250 milligrams (MG) twice daily for 5 days for UTI and Paxlovid (antiviral medication) for 5 days for diagnosis of COVID-19. There was also an order for Vancomycin (antibiotic to treat Clostridioides difficile (C-Diff), a toxin producing bacterium that infects the colon, causing diarrhea and colitis, most often after antibiotic use) started QID (four times per day) for 10 days.On 02/24/2026 the provider follow-up note revealed the resident's gastrointestinal (GI) panel was positive for C-Diff, and leukocytosis/UTI.On 03/02/2026 the resident receive their last dose of Vancomycin and was still experiencing loose stoolsOn 03/08/2026 the stop and watch tool was utilized and noted that resident was requiring more help with ADLs, eating and drinking less, and was tired and weakOn 03/10/2026 the resident's urine culture was received from the emergency department and revealed greater than 100,000 enteric gram-negative rods.On 03/13/2026 the resident was observed to be moaning and stating I don't feel good to staffOn 03/16/2026 the resident was not acting themself. The resident was sitting in a chair in the dining room with their eyes closed, and their hands and feet were noted to be shakingOn 03/17/2026 the provider was updated on the resident's decline and a urinalysis (UA) with micro was ordered by the NP.On 03/19/2026 the facility received the resident's UA results which were abnormal.On 03/19/2026 the resident received a new order for Cipro (an antibiotic medication) 500mg BID for 14 days for UTIOn 03/26/2026 staff documented the resident's Cipro was discontinued on 03/20/2026 because the urine culture was negative.On 04/02/2026 Resident 10 was transferred to the hospital related to tremors and tachycardia (increased heartrate). The resident was admitted to the hospital with a diagnosis of urosepsis (a life-threatening, emergency condition where a urinary tract infection (UTI) spreads to the bloodstream, causing a severe, overactive inflammatory response).On 04/05/2026 hospital discharge documentation revealed Sepsis from urinary source and positive C-Difficile infection. The resident returned to the facility with an order for vancomycin. An observation on 05/04/2026 from 1:19 PM to 4:45 PM Resident 10 was noted to be sitting in the common area by the nurse's station until becoming incontinent of bowel, at which time the resident was taken to resident room where staff laid the resident down in bed and provided peri-cares and then returned the resident to the common area where the resident remained until 4:45 PM. During this continuous observation, Resident 10 was never observed to be placed on the toilet for eliminating bowels or bladder and was never offered any type of hydration. An observation on 05/05/2026 from 7:04 AM to 8:47 AM revealed Resident 10 had been in therapy, in the dining room and the common area before being transported back to the room and placed in a recliner. No toileting assistance was offered. Observations of Resident 10 on 05/05/2026 at 9:07 AM, 10:00 AM, 1:55 PM, 2:57 PM and 4:02 PM revealed Resident 10 sitting or sleeping in the recliner. No toileting assistance was observed during the survey observation period. Interview with NA-B 05/06/2026 at 6:32 AM confirmed that resident had not been toileted during the observation period the previous day. An observation of Resident 10 getting morning care on 5/6/2026 at 6:36 AM revealed the resident was incontinent of bowel movement and the staff provided cares in bed and then got resident up for the day and took them to dining area. An observation on 5/6/2026 from 8:48 AM to 9:45 AM revealed Resident 10 laid down in their bed and two nurse aides provided peri-cares and changed the resident's brief. After the new brief had been placed under the resident, the resident urinated on it, requiring the staff to then change the new brief as well as the resident's soiled bedding. An interview with director of nursing (DON) on 05/06/2026 at 12:30 PM confirmed staff was expected to toilet the residents before and after meals and before activities.

Licensure Reference Number 175 NAC 12-006.09(H)(i)(3)Based on observation, interview, and record review, the facility failed to provide assistance with oral care in accordance with the resident's assessed needs and plan of care for three (Resident 10. 37. and 40) of four sampled residents. The facility identified a census of 62. A. In accordance with the facility's policy titled: Activities of Daily Living (ADL) last revised 11/2020, under policy reads: The facility will, based on the resident's comprehensive assessment and consistent with the resident's need and choices, ensure a resident's abilities in ADLs do no deteriorate unless deterioration is unavailable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. Record review of facility policy titled Personal Hygiene, last revised 11/2023 under section 3 – oral care – indicate oral care will be provided at least twice daily and as needed. Resident 10's Minimum Data Set (MDS) (a federally mandated assessment that aids the facility in identifying a resident's care needs) dated 4/11/2026 revealed the following: Section C: the Brief Interview for Mental Status (BIMS) (a screening tool that helps determine a resident's level of cognition, with a score of 0 to 15, 15 being [NAME] cognitively intact) revealed a score of 3. Section E: no behaviors noted Section GG: revealed bed mobility, transfers and eating required substantial/maximal assistance. Toilet use was coded as dependent. Section H: revealed the resident was occasionally incontinent of urine and frequently incontinent of bowel. Section I: revealed urinary tract infection within the last 30 days. Section K: revealed no difficulty swallowing. Section L: revealed no dental concerns. Section M: revealed no skin concerns. Record review of Resident 10's care plan dated 06/20/2026 revealed the resident required staff to Offer/assist with frequent toileting around meals and activities and at bedtime to promote continence. The care plan further revealed I need moderate assistance to complete grooming and hygiene tasks. I have natural teeth and will need assistance to brush my teeth twice a day and as needed. An observation on 05/05/2026 at 8:03 AM revealed a new toothbrush, basin and toothpaste in Resident 10's room dated 05/01/2026 with the package opened but not removed from the package. No other oral care supplies are noted to resident's room. An observation on 05/06/2026 at 7:48 AM revealed staff beginning morning cares for Resident 10. Observation revealed staff completing peri-care, dressing and grooming tasks. Observation further revealed no oral care was provided to the resident prior to the resident being transported from the room at 8:16 AM. Interview with NA-B on 05/07/2026 at 7:18 AM regarding the observed care confirmed staff missed the opportunity to provide oral care to the resident in accordance with Resident 10's care plan. An interview with the Director of Nursing (DON) on 05/06/2026 at 12:39 PM revealed expectations for morning care include peri-care, lotion to extremities, applying compression stockings if ordered, brushing teeth, washing face, combing hair and toileting depending on the resident. B. In accordance with the facility's policy titled: Activities of Daily Living (ADL) last revised 11/2020, under policy reads: The facility will, based on the resident's comprehensive assessment and consistent with the resident's need and choices, ensure a resident's abilities in ADLs do no deteriorate unless deterioration is unavailable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. Record review of facility policy titled Personal Hygiene, last revised 11/2023 under section 3 – oral care – indicate oral care will be provided at least twice daily and as needed. Record review of Resident 37's Minimum Data Set (MDS) (a federally mandated assessment that aids the facility in identifying a resident's care needs) dated 02/16/2026 revealed the following: Section C – the Brief Interview for Mental Status (BIMS) (a screening tool that helps determine a resident's level of cognition, with a score of 0 to 15, 15 being fully cognitively intact) revealed a score of 2. Section GG: revealed eating required supervision/touch assistance, toileting was coded as dependent, bed mobility required partial/moderate assistance and transfers were coded as dependent Section H: revealed the resident was occasionally incontinent of urine and always continent of bowel. Section J: revealed use of pain medications and non-medication pain management. Section M: revealed no skin concerns noted. Section O: revealed oxygen therapy. An observation on 05/05/2026 at 8:02 AM revealed a new toothbrush, basin and toothpaste in Resident 37's room dated 05/01/2026 but still in package, not having been opened yet and no other oral care supplies noted to resident's room. An observation on 05/06/2026 at 8:18 AM revealed NA-B assisting Resident 37 with morning cares. During the observation, Resident 37 repeatedly stated I can't hear you, I need my hearing aids! NA-B stated, They are in the med cart, we will get them later. Observation revealed the resident continued without hearing aids throughout cares despite repeated requests. Observation further revealed no oral care, hand washing or face washing being offered or provided to Resident 37 during the observed morning cares prior to resident leaving room for the day. Despite the resident requiring assistance with ADL care tasks, staff did not observe or assist the resident with brushing teeth or oral hygiene. An interview with the Director of Nursing (DON) on 05/06/2026 at 12:39 PM revealed expectations for morning care include peri-care, lotion to extremities, applying compression stockings if ordered, brushing teeth, washing face, combing hair and toileting depending on the resident. C. Record review of Resident 40's Census Data revealed the resident was admitted to the facility on [DATE]. A record review of Resident 40's Diagnosis List revealed a diagnosis of unspecified dementia (a usually progressive condition marked by the development of multiple cognitive deficits [such as memory impairment, aphasia, and the inability to plan and initiate complex behavior]) was added on 8/4/2021. A diagnosis of long term (current) use of anticoagulants (medicines that help prevent blood clots) was added on 8/4/2021. Record review of a quarterly MDS dated [DATE], Resident 40 had a BIMS score of 99 which indicated the resident was cognitively impaired. Resident 40 required supervision to complete oral hygiene. Record review of Resident 40's Care Plan dated 4/19/2026 revealed an intervention to provide set up help for grooming and hygiene tasks initiated on 9/16/2025. An observation on 5/4/2026 at 12:42 PM revealed unopened oral hygiene products dated 5/1 in Resident 40's bathroom in basin on the sink. An observation on 5/5/2026 at 10:34 AM revealed, in Resident 40's bathroom, the same toothbrush wrapper was opened to the bristles, but the toothbrush was not removed, and there were no water spots or toothpaste on the wrapper. An observation on 5/6/2026 at 1:20 PM revealed, in Resident 40's bathroom, the toothbrush in the wrapper looking the same as it was in the prior observation. Further observation in the cabinet in Resident 40's bathroom revealed no personal toothbrush inside, however, there was another unopened toothbrush inside.

Licensure Reference Number 175 NAC 12-006.09 & 12-006.09(H)(iv)(5) Based on record review and interview the facility staff failed to follow the bowel elimination protocol to prevent constipation for two (Resident 26 and Resident 24) of two sampled residents. The facility census was 62. Findings are:A. Review of a policy titled, Bowel and Bladder Management, effective date 11/2023 with revision date 8/2023, indicates the following: -Quality Assurance The facility will monitor bowel and bladder program effectiveness through audits, care plan reviews, skin reviews, fall tracking, and infection monitoring. -Bowel Management Nursing will monitor bowel patterns and report: constipation, diarrhea, impaction symptoms, abdominal distention, changes in bowel habits. As needed (PRN) and scheduled bowel medication will be administered pre physician orders. The physician and responsible party will be notified of significant changes as appropriate. B. Record review of Resident 26's Electronic Medical Record (EMR) revealed the following: Resident 26 admitted on [DATE] with diagnoses that include: constipation (when the stool moves too slowly through the large intestine), ulcerative colitis (a chronic inflammatory bowel disease that causes long-lasting inflammation and ulcers in the lining of the large intestine), and non-Alzheimer's dementia (a usually progressive condition marked by the development of multiple cognitive deficits). Record review of Resident 26's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems), dated 4/9/2026, revealed the following: -Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 6 (which indicated the resident had severe cognitive impairment.) -Always incontinent of bowels. -Required substantial/maximal assistance for toilet transfers. Record review of Resident 26's Care Plan dated 1/30/2026, revealed the resident had incontinence of bladder and bowel. Interventions include offer/assist with frequent toileting around meals and activities and at bedtime to promote continence (initiated 11/11/2025) and resident needs moderate to substantial assistance with grooming and hygiene tasks (initiated 11/25/2025). Record review of Resident 26 EMR revealed that Resident 26 did not have a bowel movement on the following dates: 1/6/2026-1/9/26, 1/12/2026-1/15/2026, 1/20/2026-1/21/2026, 1/23/2026-1/24/2026, 1/30/2026-1/31/2026, 3/28/2026-3/29/2026, 4/13/2026-4/16/2026, 4/21/2026-4/22/2026, and 4/27/2026-4/28/2026 Record review of Resident 26's Order Listing Report dated 5/6/2026 listed the following medications: -acidophilus probiotic blend oral capsule (a dietary supplement that contains beneficial bacteria to support digestive health), give 1 capsule by mouth one time a day for gut health. -bisacodyl rectal suppository (a medication that contains a stimulant laxative to treat constipation) 10 milligrams (MG), insert 1 suppository rectally as needed for constipation one time a day. -milk of magnesia (MOM) concentrate oral suspension (a medication that includes a liquid laxative and an antacid which treats constipation) 2400 MG/10 milliliter (ML), give 30 ml by mouth as needed for constipation once daily. During an interview on 5/6/2026 at 9:30 AM, Licensed Practical Nurse (LPN) -G revealed that the night shift provides a list of residents that need bowel intervention based on the Bowel Elimination Protocol and that the medication aide assigned to the specific resident area also receives the list of residents that need intervention and will follow the Bowel Elimination Protocol. LPN-G revealed that the nurses don't necessarily look at what the nurse aides (NA) or medication aides (MA) chart. Record review of the Bowel Elimination Protocol, not dated, revealed the following: -2nd Day-(48 hours without a bowel movement (BM)) If the resident complains or abdominal/bowel discomfort, please offer a natural laxative foot/fluid (i.e. prune juice, prunes). Only place the name on the list if the resident is complaining or discomfort and requesting intervention. -3rd Day-(72 hours without a BM) Give 30mL of MOM PO (or whatever PRN is ordered by their physician) . 4th Day-(96 hours without a BM) Dulcolax/glycerin suppository to be given on 10p-6a shift.Document on the MAR, progress notes. (Charge nurse to perform focused assessment and document the findings.If bowel sounds are absent, the physician needs to be notified immediately.) 5th Day-(120 hours without BM) Advance to an enema as ordered, notify provider, and continue with bowel evaluation each shift until resolved. Document in the progress notes, medication administration record (MAR), and below. During an interview on 5/7/2026 at 9:06AM, LPN-G confirmed Resident 26 did not have a bowel movement during the date ranges as identified above. LPN-G confirmed that per the facility Bowel Elimination Protocol interventions should have been initiated by the 2nd day and they were not. An interview on 5/7/2026 at 11:40 AM with the Director of Nursing (DON) confirmed Resident 26 had not had a bowel movement for the dates identified above and the staff did not follow the facilities Bowel Elimination Protocol for Resident 26. C. Record review of Resident 24's Census Data revealed the resident was admitted to the facility on [DATE]. A record review of Resident 24's Diagnosis List revealed a diagnosis of cerebral infarction (a localized area of brain cell death resulting from prolonged lack of blood flow) was added on 4/13/2026. A diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (a result from damage to the brain's left hemisphere that causes complete and partial loss of movement affecting the right dominant side, potential aphasia [speech difficulty], and requires extensive rehabilitation) was added on 4/13/2026. A diagnosis of adult failure to thrive (a syndrome in older adults characterized by a complex, often unintentional, decline in physical and mental health, marked by weight loss, malnutrition, dehydration, and functional impairment) was added on 5/5/2026. A diagnosis of muscle weakness (a reduced ability to exert force with muscles, often feeling like extra effort is needed to move arms, legs, or other body parts) was added on 4/13/2026. A diagnosis of polymyalgia rheumatica (a disorder that causes muscle pain and stiffness in your neck, shoulders, and hips) was added on 4/13/2026. A diagnosis of pain, unspecified (a disorder characterized by the sensation of marked discomfort, distress or agony) was added on 4/13/2026. A diagnosis of unspecified dementia with agitation (a usually progressive condition marked by the development of multiple cognitive deficits [such as memory impairment, aphasia, and the inability to plan and initiate complex behavior] with a common, distressing symptom characterized by restlessness, verbal/physical aggression, and pacing) was added on 4/13/2026. A diagnosis of disorientation (a state of confusion regarding time, place, or identity, often caused by underlying issues like infections, dehydration, medication side effects, or head injuries) was added on 4/13/2026. Record review of an admission MDS dated [DATE] revealed Resident 24 had a BIMS score of 99 which indicated Resident 24 was cognitively impaired. Resident 24 was dependent on toileting hygiene. A record review of Resident 24's current Care Plan revealed a focus of I have impaired mobility and weakness r/t stroke with right-sided hemiplegia. I am incontinent of bladder and bowel initiated and revised on 5/4/2026. Interventions listed included I need total assistance with toileting hygiene and moderate to substantial assistance to transfer on and off the toilet. Offer/assist with frequent toileting around meals and activities and at bedtime to promote continence initiated on 5/4/2026. Another intervention included was restorative program as ordered to build strength and endurance, promote independence with ADLs, promote bowel/bladder continence, and ensure nutritional needs are met initiated on 5/4/2026. Further record review of Resident 24's current Care Plan revealed a focus of I have acute right arm pain post CVA with right-sided hemiplegia. I am usually able to let staff know when I am having pain. I am taking opioid medication for pain management initiate and revised on 5/4/2026. An intervention included monitor/document for side effects of pain medication. Observe for constipation initiated on 5/4/2026. There were no interventions included in the care plan for constipation. A record review of Resident 24's Orders revealed an order for fentanyl transdermal patch 72-hour 25mcg/hour (Fentanyl), apply 1 patch trans-dermally every 72 hours related to polymyalgia rheumatica; pain, unspecified and remove per schedule started 4/28/2026. Further review of Resident 24's orders revealed the practitioner ordered Docusate Sodium Capsule 100 mg, give 1 capsule by mouth every 24 hours as needed for constipation started 4/14/2026 with no routine bowel medications were ordered. A record review of Resident 24's Bowel Elimination Documentation revealed that Resident 24 did not have a bowel movement on 4/27/2026, 4/28/2026, 4/29/2026, 4/30/2026, 5/2/2026, 5/3/2026, 5/4/2026, 5/5/2026, and 5/6/2026. A record review of the Medication Administration Record (MAR) revealed no documentation for the docusate sodium capsule for constipation being administered from 4/27/2026 through 4/30/2026 and 5/2/2026 through 5/6/2026. T An interview with Medication Aide (MA)-N on 5/7/2026 at 9:45 AM confirmed that if residents don't have a bowel movement, they would get prune juice on day 2, Milk of Magnesium (over-the-counter treatment for constipation) on day 3, and a suppository (inserted rectally and will help promote a bowel movement to relieve constipation) on day 4. MA-N confirmed that the nurses print out a list showing residents that have not had bowel movements and how long it has been since their last bowel movement. MA-N was shown the bowel elimination documentation for Resident 24 from 5/2/2026 through 5/6/2026 and reviewed Resident 24's MAR for May and confirmed that the resident should have been administered medication to help with the constipation.

Based on record review and interviews, the facility failed to monitor 2 (Residents 6 and 20) of 2 sampled residents for adverse effects following dialysis treatments. The faciity identified a census of 62 residents. Record review of a facility policy titled, Hemodialysis Access, dated November 2024, revealed the following:The stated purpose of the policy was to ensure safe monitoring, protection, and documentation, of dialysis access sites and prevent complications for residents receiving dialysis.The dialysis site (for example, a fistula, a surgically created connection between an artery and vein to provide long term access for dialysis) would be assessed on admission/readmission, upon return from dialysis, and with any change in condition.After residents return from dialysis, care of the fistula includes 1. Assess dressing; 2. Check for bleeding; 3. Verify thrill and bruit (the audible and palpable signs of turbulent blood flow that mean a fistula is functioning); 4. Monitor for hypotension (low blood pressure); 5. Document findings. Record review of the face sheet for Resident 6 revealed they were admitted on [DATE] with end stage renal disease (final stage of kidney failure where kidneys can no longer function on their own), dependence on renal dialysis, pulmonary hypertension (a type of high blood pressure that affects the arteries in the lungs and right side of the heart), cardiomegaly (enlarged heart), systolic and diastolic heart failure (when the heart does not pump effectively or relax normally between heartbeats), coronary artery disease (a narrowing or blockage of the arteries that supply oxygenated blood to the heart muscle) , type 2 diabetes mellitus (a metabolic disorder where the body cannot effectively regulate blood sugar), and bipolar disorder (a long term mental health condition that causes extreme mood swing and energy levels).A record review of Resident 6's comprehensive minimum data set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities) dated 5/1/26 revealed Resident 6 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score 15 of a possible 15 points, indicating they were cognitively intact.A record review of Resident 6's undated Care Plan revealed the following:Resident 6 had dialysis scheduled three times a week at an outside facility.Obtain, record, and report vital signs as ordered per protocol, initiated 2/17/2025 and last revised 5/20/2025.Assess fistula for inflammation, pain, bleeding after dialysis and as needed, initiated 12/2/16.Use a stethoscope to listen for blood flow (bruit) in a fistula, initiated 12/2/16.Palpate the fistula for a thrill (the purring/vibrating sensation that indicates blood is flowing through, initiated 12/2/16.A record review of Resident 6's Dialysis Communication records from 2/27/26 to 5/4/26 revealed the following:Of the 28 separate dates reviewed, all 28 records were missing vital signs after Resident 6 returned to the facility post-dialysis.7 of the 28 records did not have vital signs recorded by the facility before or after dialysis.On 3/23/26, in dialysis notes, Resident 6 had a very large fluid gain over the weekend, and dialysis staff were unable to remove all extra fluid, and requested the facility stress the importance of the fluid restrictions with Resident 6.B.Record review of the face sheet for Resident 20 revealed they were admitted [DATE] with diagnoses of end stage renal disease, chronic obstructive pulmonary disease (a progressive lung and airway disease that restricts breathing) type 2 diabetes, hypertension (high blood pressure), and coronary artery disease.Record review of Resident 20's quarterly MDS assessment dated [DATE] revealed Resident 20's BIMS score was 15 out of 15 indicating they were cognitively intact.A record review of Resident 20's care plan revealed the resident had dialysis scheduled three times a week, and stated the facility would obtain, record, and report vital signs as ordered per protocol, date initiated 2/17/2025, last revised 5/20/2025.A record review of Resident 20's Dialysis Communication records from 3/2/26 to 5/6/26 revealed the following:Of the 26 separate dates reviewed, all 26 were missing vital signs after Resident 20 returned to the facility post-dialysis.On 4/10/26, in the dialysis facility notes, no dressing was on the CVC (central venous catheter) site, and a request was written to avoid removing the CVC dressing, and monitor for infections symptoms due to exposure.A record review of a facility document dated 5/5/26 revealed Resident 20 had gone to the hospital for a procedure, and the resident should elevate their upper extremity as much as possible to control swelling, avoid showering for 24 hours, lift less than 20 pounds for 2 weeks, follow a renal diet, and follow up with the vascular surgery/cardiology specialist.An interview on 5/05/2026 at 3:15 PM with Licensed Practical Nurse-G (LPN-G) revealed Resident 20 was at a hospital having a new fistula created on 5/5/26.A record review of Resident 20's nursing progress notes revealed a note dated 5/06/2026 at 3:20 AM that stated Resident 20 returned from the hospital at 8:30 PM on 5/5/26 by facility van. The right fistula was palpated, and the incision was intact. Vitals signs were included in the note. The progress notes also revealed a new order for hydrocodone/acetaminophen tablets (a narcotic pain reliever with an anti-inflammatory) was received at 5:49 PM on 5/5/26. No other information about Resident 20's condition after the fistula placement was revealed.A record review of the Resident 20's vital sign in the electronic medical record revealed blood pressures charted at the following times:5/4/2026 4:54 PM 90 / 60 millimeters of mercury (mmHg)5/6/2026 6:24 AM 124 / 72 mmHg5/6/2026 4:34 PM 89 / 52 mmHg5/6/2026 8:39 PM 95 / 65 mmHgAn interview on 5/06/2026 at 1:59 PM with Medication-Aide O (MA-O) revealed care on the day of dialysis included different medications being held or administered per physician order, a numbing medication used on the access site for some residents, and taking the blood pressure and in the morning prior to the resident leaving the facility. The interview also revealed no additional care was required afterward.An interview on 5/7/26 at 8:45 AM with the Director of Nursing revealed the nursing staff took vital signs prior to any dialysis residents leaving the facility to go to dialysis, and that no vital signs were taken when they returned, their access sites were assessed each shift routinely, but no extra cares were given after returning from receiving dialysis services to check for bleeding or changes. The interview also revealed there was no policy about how to provide care on the day of dialysis.

Based on interview and record review, the facility failed to ensure 1 (Resident 7) of 5 residents' medication regimens were free from unnecessary bowel management medications. The facility identified a census of 62 residents.Record review of Resident 7's care plan revealed Resident 7 was admitted on [DATE] with diagnoses of coronary artery disease, atrial fibrillation (a type of irregular heart rhythm), Diabetes Mellitus Type 2 (a metabolic disorder where the body can't use insulin effectively), dementia (a progressive condition marked by the development of multiple cognitive and behavioral problems), macular degeneration (an eye disease that commonly leads to vision loss), and a history of falling. A record review of Resident 7's most recent quarterly minimum data set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities) dated 2/26/26 revealed Resident 7 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) scored 15 of a possible 15 points, indicating they were cognitively intact. A record review of Resident 7's physician orders revealed an active order for polyethylene glycol (an osmotic laxative with the brand name MiraLAX), 17 grams (g) twice a day to treat constipation, beginning 4/24/25. A record review of Resident 7's physician orders revealed an active order for docusate sodium (Colace, a stool softener) 100 milligram (mg) twice a day to treat constipation, beginning 4/24/2025.A review of Resident 7's bowel record in Point Click Care (PCC) revealed the following:During April 2026, Resident 7 had a BM documented on at least 2 shifts/day for 13 of 30 days and no BMs on 1 of 30 days.During March 2026, Resident 7 had a BM documented on at least 2 shifts/day for 19 of 31 days and did not have any days where zero BMs were charted.During February 2026, Resident 7 had a BM documented on at least 2 shifts/day for 16 of 28 days and 1 day where there was no BM charted.A record review of the website miralax.com revealed the recommended directions for adults to take MiraLAX included using 17 grams of MiraLAX once a day for a maximum of 7 days. An interview on 5/06/2026 at 10:39 AM Resident 7 revealed their usual routine included having 2-3 bowel movements (BMs) per day, which they felt was too often. The interview also revealed they were taking medications to prevent constipation.An interview on 5/06/2026 at 3:20 PM with the Director of Nursing (DON) revealed Resident 7 complained about their bowels to the facility. The interview also confirmed Resident 7 was taking MiraLAX to aid in having routine bowel movements, and that 2-3 bowel movements were too many in one day on a routine basis, and they were unsure why the MiraLAX was ordered by the physician twice daily.

Licensure Reference Number 175 NAC 12-006.02(H)Based on record review and interview, the facility failed to thoroughly investigate a fracture for 1 resident (Resident 3) of 3 sampled residents. The facility census was 67.Findings are:Review of a facility policy titled Freedom from Abuse, Neglect, and Exploitation dated 12/2023 revealed it was the facilities policy to ensure all residents had the right to be free from abuse including physical abuse. The policy stated it was the responsibility of the Director of nursing to direct the steps of investigation into occurrences of possible abuse.A review of the Resident Dashboard revealed the facility admitted Resident 3 on 03/07/2025 with diagnosis of Chronic Kidney Disease (CKD), where the kidneys do not function properly, and Congestive Heart Failure (CHF), a condition where the heart does not pump blood properly resulting in a buildup of fluid.The comprehensive Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 11/21/2025 revealed Resident 3 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15 indicating the resident was cognitively intact. The resident was documented to have received set up and clean up assistance with eating, partial to moderate assistance with bed mobility, and supervision or touching assistance with transfers and toilet use. Record review of a facility supplied document titled Incident by Date Report dated 12/16/2025 revealed Resident 3 suffered an incident on 11/12/2025 at 8:50 PM.Record review of a facility supplied document titled Injury and dated 11/12/2025 revealed documentation that on 11/12/2025 Resident #3 stated that thy used to sink to assist themselves into a standing position and heard a pop from their left shoulder and having pain in their left shoulder. The resident was sent to the emergency room for evaluation.Record review of Resident 3's Progress Notes dated 11/12/2025 at 11:57 PM revealed documentation that the nurse received a report from the local emergency room that Resident 3 X-Ray results were ok but the resident was going to be admitted to the hospital for an exacerbation of their Congestive Heart Failure.Record review of Resident 3's Progress Notes Dated 11/14/2025 at 6:00 PM revealed that Resident 3 re admitted to the facility at 3:45 PM with a diagnosis of a subacute fracture to their left shoulder and that their arm was in a sling.Record review of a facility supplied document titled Discharge Summary Note and dated 11/14/2025 revealed that Resident 3 was diagnosed with a left acromion (the highest point of the shoulder) fracture and compression fracture in their 8th thoracic (lower back) vertebrae (back or spinal bones). Record review of a facility supplied document titled Nursing Home Nursing Communication and dated11/19/2025 revealed documentation that Resident 3 provider communicated to the facility that the resident had a left shoulder/acromion fracture and a compression fracture of the 8th thoracic bone.In an interview completed on 12/16/2025 at 2:15 PM with the facility Director of Nursing (DON), the DON reported they did not investigate if the Resident 3 did or did not have a compression fracture. The DON confirmed that on 11/19/2025 the facility was notified by the resident's provider that the resident had a compression fracture to the 8th thoracic bone. The DON confirmed a investigation into had not been completed to find the possible/probable etiology of the compression fracture.

Licensure Reference Number NAC 175 12-006.12(A) Based on interview and record review the facility failed to provide an indication and rationale for the use a prophylactic antibiotic for one (Resident 17) of three residents. The facility identified a census of 63. Findings are: A record review of the facility's Antibiotic Stewardship Policy dated July 2022 revealed the infection preventionist will monitor individual resident antibiotic regimens including: a. Reviewing clinical documentation supporting antibiotic orders b. Compliance with start/stop dates and/or days of therapy A record review of an admission face sheet for Resident 17 revealed the resident was admitted to the facility on [DATE]. A record review of a Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 1/13/25 revealed in Section C that Resident 17 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 13/15, indicating the resident was cognitively intact. Section H revealed that Resident 17 had a foley catheter (a thin, flexible tube inserted into the bladder to drain urine). Section N revealed that Resident 17 was on an antibiotic. A record review of Resident 17's diagnosis list revealed the following diagnoses: -Benign prostatic hyperplasia with lower urinary tract symptoms (a condition where the prostate gland, located below the bladder in men, enlarges with age). -Calculus in bladder (a hard, mineral deposit that forms in the urinary bladder). -Personal history of urinary tract infections (an infection of the urinary tract, which includes the kidneys, ureters, bladder, and urethra). -Obstructive and reflux uropathy (a condition where urine flow is blocked within the urinary tract, causing urine to back up and potentially damage the kidneys). A record review of Resident 17's physician orders dated 2/11/25 revealed an order for: Cephalexin Oral Capsule 500 milligrams (mg) (an antibiotic- medications used to treat bacterial infections); give one capsule by mouth one time a day for prophylactic with a start date of 11/22/24. An interview on 2/11/25 at 10:42 AM with Registered Nurse (RN)-A confirmed that Resident 17 was taking the antibiotic prophylactically but RN-A was unsure why. RN-A revealed that Resident 17 had an artificial bladder and had a history of complications as a result of that, including urinary tract infections. RN-A revealed that the antibiotic was ordered by the urologist (a doctor who specializes in diagnosing and treating conditions of the urinary tract and reproductive system). RN-A confirmed that the order did not have a clear indication, diagnosis, or stop date and was not being reviewed by the pharmacist or physician for a rationale for its continuation. An interview on 2/12/25 at 2:45 PM with Director of Nursing (DON) confirmed that Resident 17's use of a prophylactic antibiotic did not have a duration and was not reviewed with a rationale for its continuation. The DON confirmed that it should have been.

Licensure Reference Number 175 NAC12-006.11E Based on observations, interviews, and record review, the facility kitchen staff failed to store food under sanitary conditions, complete hand hygiene while preparing and serving food, and maintain proper freezer temperatures to keep frozen foods solid. This had the potential to affect all residents. The facility identified a census of 63 at the time of the survey. Findings are: A. An observation during the initial kitchen tour on 1/22/2024 beginning at 12:41 PM of the storage room revealed the following: - 1 bag of Trio cheese sauce mix - the bag had been damaged and was spilling out the light yellow powder contents - 1 Knorr [NAME] sauce mix which had been left open to air and other possible contaminant did not have an opened on date or use by date - 5 bags of Hospitality Mini Marshmallows with a best by date of 12/1/23 - 1 container of Kosher Pickle Chips with a best by date of 8/28/2023 - 4 Karo Syrup containers with best by dates of 12/2/23 - 1 Sahara Burst Pineapple Juice with a best by date of 12/6/23 - Cleaning supplies stored on a shelf within the food storage area An observation during the initial kitchen tour on 1/22/2024 beginning at 12:41 of the reach-in-refrigerator revealed the following: - 1 squeeze bottle of Ranch without a preparation or use by date - 1 squeeze bottle of [NAME] Lynch without a preparation or use by date An observation during the initial kitchen tour on 1/22/2024 beginning at 12:41 of the walk-in refrigerator revealed the following: - 1 opened package of roast beef in a clear Ziploc bag without an opened on or use by date - 1 clear package containing five boiled eggs without an opened or use by date - 1 carton of grape juice with a best by date of 11/25/23 - 1 carton of pineapple juice with a best by date of 1/9/23 - 1 roll of ground beef mix thawing on a shelf above juices and sauce mixes A record review of the Nebraska Food Code 2017, section 3-501.17 (A) revealed Except when packaging food using a reduced oxygen packaging method as specified under 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded . A record review of the undated facility's policy Storage of Food and Supplies included food storage area should be used for food only, cleaning supplies should be store in entirely separate and specific areas, all food will be dated - month, date, and year, and no food will be kept longer than the expiration date on the product. B. An observation on 1/23/2024 at 11:08 AM revealed Dietary Aide (DA)-M had entered the kitchen, prepared the resident drinks while touching the rim of each cup without the benefit of hand hygiene prior to initiating the task. An observation on 1/23/2024 at 11:18 AM revealed DA-M had entered the kitchen and had began to fill dressing bottles without the benefit of hand hygiene prior to initiating the task. A continuous observation on 1/24/2024 beginning at 8:43 AM revealed DA-F had disposed of a bag that had contained juices from raw porkchops then had grabbed an onion from the refrigerator, DA-F then proceeded to cut the onion up without having performed hand hygiene between the food preparation tasks. The continuous observation also revealed two other occurrences of DA-F having completed hand hygiene practices of 14 seconds and 18 seconds during food preparation. An observation on 1/24/2024 at 11:43 AM revealed DA-E had completed washing dishes and then assisted with serving food without the benefit of performing hand hygiene between tasks. A record review of the Nebraska Food Code 2017, section 2-301.14 read Food employees shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in food preparation. A record review of the Center for Disease Control article Handwashing: A Healthy Habit in the Kitchen, last reviewed on 7/18/2022, listed recommendations to scrub hands for at least 20 seconds for the most effective benefits of hand washing. A record review of the facility's policy Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices with a revision date of 11/2023 included employees must wash their hands whenever entering or re-entering the kitchen, before coming in contact with any food surfaces, after handing raw meat, and during food preparation to prevent cross contamination when changing tasks. C. An observation on 1/24/2024 at 9:17 AM revealed the freezer temperature was 28 degrees. An interview on 1/24/2024 at 9:23 AM with the Food Services Supervisor (FSS) revealed the freezer had not been working and a maintenance request was placed on 1/15/2024. The FSS revealed Pardes, a refrigeration repair company, had been out on 1/16/2024 and would be out again today. An observation on 1/24/2023 at 9:45 AM revealed food in the freezer, including ice cream and breaded corn dogs were no longer solid. The temperature was 38 degrees in the freezer. An interview on 1/24/2024 at 9:45 AM with the Registered Dietician (RD) confirmed the ice cream was no longer solid. The RD also confirmed the temperature was 38 degrees and stated the temperature was rising quickly to the danger zone. An interview on 1/24/2024 at 9:54 AM with the Administrator revealed the Administrator was aware of the freezer problem and had a plan to move items to downstairs freezer or to another facility if needed. An observation on 1/24/2024 at 12:24 PM revealed the temperature of the freezer was 40 degrees. The observation also revealed no measures to relocate the food in the freezer had been completed. A record review of the undated facility's policy Procedure for Freezer Storage included the freezer should be maintained at a temperature of 0 Fahrenheit (F) to -10 F. A record review of the facility's Refrigerator and Freezer Temperature Record with a date of January 2024 had directions of 2) If temperatures are not within range, recheck within the next 30 minutes. If still not within range notify [NAME] (Person in charge) and follow policy. Document on back of dorm date, time, who you notified, and what was done. The document also revealed had recorded temperatures of: - +7 on 1/12/2024 at 5:30 AM, - +16 on 1/12/2024 at 9:00 PM, - +8 on 1/13/2024 at 5:30 AM, - +16 on 1/13/2024 at 9:00 PM, - +9 on 1/14/2024 at 5:30 AM, - +15 on 1/14/2024 at 8:00 PM, - +20 on 1/15/2024 at 7:30 AM, - +15 on 1/15/2024 at 8:00 PM, - +19 on 1/16/2024 at 5:30 AM, - +15 on 1/16/2024 at 6:00 PM, - +18 on 1/17/2024 at 5:30 AM, - +15 on 1/17/2024 at 8:00 PM, - +20 on 1/18/2024 at 5:30 AM, - +16 on 1/18/2024 at 8:00 PM, - +18 on 1/19/2024 at 5:30 AM, - +15 on 1/19/2024 at 8:00 PM, - +7 on 1/20/2024 at 5:30 AM, - +15 on 1/20/2024 at 8:00 PM, - +8 on 1/21/2024 at 5:30 AM, - +16 on 1/21/2024 at 8:00 PM, - +18 on 1/22/2024 at 5:30 AM, - +20 on 1/22/2024 at 8:00 PM, - +19 on 1/23/2024 at 5:30 AM, - +20 on 1/23/2024, - +20 on 1/24/2024 at 5:30 AM. The document revealed the temperature was 39 at an undetermined time in the PM slot on 1/24/2024. The back of the document revealed no documentation of date, time, who was notified, and what had been done to correct out of range temperatures.

Licensure Reference Number 175 NAC 12-006.04D2a Based on an interview and record reviews, the facility failed to have a qualified Dietary Manager. This had the potential to affect all residents. The facility identified a census of 63 at the time of survey. Findings are: A record review of the Hillcrest Nursing Home Facility Assessment Tool with a date of 8/8/2017, under Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies read: Food and nutrition services - Director - 1 (40 hours) support staff - 8 day registered dietician - 2 days/week. A record review of the Hillcrest Nursing Home Job Description for Dietary Director, with a revised date of 12/15, read the qualifying include currently certified as dietary manager or completed a course in dietary management or equivalent or be a registered dietician . An interview on 1/24/2024 at 12:10 PM with the Registered Dietician (RD) confirmed the RD is not full time and the Food Services Supervisor (FSS) is not certified at this time.

Licensure Reference Number 175 NAC 12-006.11D Based on observations, interviews, and record reviews, the facility failed to follow a recipe in a method to preserve nutritive value. This had the potential to affect all residents who consumed these meals. The facility had identified a census of 63 at the time of survey. Findings are: A continuous observation of meal preparation of Smothered Pork Chops on 1/24/2024 at 8:43 AM to 9:20 AM prepared by Dietary Aide (DA)-F revealed the following: - DA-F had seasoned porkchops with an unmeasured amount of black pepper and garlic - DA-F had filled a pot with an unmeasured amount of water then had placed on the stove to bring it to a boil - DA-F had cut an unmeasured amount of onions and then added the onions into the pan with hot water - DA-F had added an unmeasured amount of an opened bag, approximately 1/4 remaining of the bag, of Pork Roast Gravy Mix into the boiling water and onions - DA-F had added an entire second bag of Pork Roast Gravy Mix into the boiling water with the first gravy mix and onions - When DA-F had been asked about the measurements, DA-F obtained a measuring cup out of drawer, but did not use it and later put it back into drawer - DA-F had not had a recipe open or available for reference during meal preparation An interview on 1/24/2024 at 8:55 AM with DA-F revealed a measurement of just a little bit of seasoning for the porkchops. An interview on 1/24/2024 at 9:23 AM with the FSS confirmed there was a recipe for the Smothered Porkchops to follow and had provided a copy. A record review of the facility provided recipe for Smothered Pork Chops revealed measurements for 20 servings included 3/4 teaspoon of salt, 1/2 teaspoon of black pepper, 2 1/2 tsp of garlic powder, 3/4 teaspoon of thyme, 3/4 teaspoon of rosemary, and 3/4 each of yellow onion. A record review of the label of the Pork Roast Gravy Mix revealed directions to add 11.3 ounces of gravy mix to 4 quarts of water. The label also revealed each bag was 11.3 ounces. An observation of meal preparation of tacos on 1/24/2024 at 9:15 AM by DA-F revealed DA-F had dumped taco seasoning into a 1-cup measuring cup over already cooked ground beef. DA-F had overfilled the measuring cup and had caused the seasoning to overflow onto the ground beef below. A record review of the taco seasoning label read to brown ten pounds of ground then stir in 2 cups of taco seasoning.

Licensure Reference Number 175 NAC 12-006.17D Based on observation, interview, and record review, the facility failed to implement the required infection prevention and control practices while administering medications to 3 (Residents 25, 28, and 466) of 4 sampled residents. The facility census was 63. The findings are: A. An observation of medication administration on 1/24/24 from 7:23 AM to 7:34 AM revealed Registered Nurse (RN)-J performed hand hygiene (HH) with Alcohol Based Hand Rub (ABHR) at the medication cart, then RN-J took a printed copy of Resident 28's insulin orders and the resident's plastic storage container (which contained supplies for insulin administration) into the resident's room and closed the door. RN-J put on gloves and opened the plastic storage container. RN-J then stated they needed additional supplies, opened the door to the room, obtained a syringe and safety cap from the supply cart in the room next to the resident's room, went back into the resident's room and closed the door with their gloved hand. RN-J then prepared and administered the required doses of insulin to the resident while continuing to wear the same pair of gloves. RN-J then removed their gloves, disposed of trash and syringes in the required receptacles and performed HH via ABHR. A continued observation of medication administration on 1/24/24 from 7:23 AM to 7:34 AM revealed RN-J obtained Resident 466's plastic storage container (which contained supplies for insulin administration) and a printed copy of the resident's insulin order and took them into the resident's room, closing the door behind them. RN-J performed hand hygiene (HH) with Alcohol Based Hand Rub (ABHR) in the resident's room and put gloves on. After reviewing the resident's insulin order and opening the plastic storage container, RN-J stated they needed additional supplies. RN-J opened the door to the resident's room, obtained a syringe from the supply cart in the room next to the resident's room, went back into the resident's room and closed the door with their gloved hand. RN-J then prepared and administered the required dose of insulin to the resident while continuing to wear the same pair gloves. RN-J then removed their gloves, disposed of trash and syringes in the required receptacles and performed HH via ABHR. An interview on 1/24/24 at 2:30 PM with RN-J confirmed RN-J did not remove their gloves prior to opening Resident 28's door and obtaining a syringe and safety cap from the supply cart in the room next to the resident's room and that RN-J continued to wear the same gloves after returning to the resident's room while preparing and administering Resident 28's insulin. RN-J also confirmed RN-J did not remove their gloves prior to opening Resident 466's door and obtaining a syringe from the supply cart in the room next to resident's room and that RN-J continued to wear the same gloves after returning to the resident's room while preparing and administering Resident 466's insulin. A record review of facility policy Standard Precautions Policy and Procedures dated 08/2023, Section 2. revealed Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. B. An observation of medication administration performed by Medication Aide (MA)-K on 1/24/24 from 7:36 AM to 8:00 AM revealed MA-K at the medication cart outside the dining room with Resident 25's Medication Administration Record (MAR) pulled up on the computer screen. MA-K compared each medication label to the MAR and popped each into a plastic medication cup. Once MA-K had all medications for Resident 25 in the medication cup, the medication cart was locked, and the computer screen was cleared. MA-K performed hand hygiene (HH) with Alcohol Based Hand Rub (ABHR), then took the medications to the resident at their table in the dining room. MA-K handed the medication cup to the resident who poured some of the medications into their own hand, placed the cup with the remaining medications on the table and swallowed the medications from their hand with water. The resident then poured more medications into their own hand from the cup and again sat the cup on the table. The resident dropped one of the pills from their hand into the seat of their wheelchair. MA-K picked the pill up with their bare hand and placed the pill into the resident's hand. Resident 25 then put the pill in their mouth and swallowed it with water. MA-K threw away the empty medication cup, performed HH with ABHR, and documented the medications as administered in the resident's MAR. An interview on 1/24/24 at 7:56 AM with MA-K confirmed MA-K did pick up one of Resident 25's pills with their bare hand when the resident dropped the pill onto their wheelchair seat and placed the pill back into the resident's hand.

Licensure Reference Number 175 NAC 12-006.09D7b Based on observations, interviews, and record review, the facility failed to implement interventions and ensure the resident's environment was free from accident hazards to reduce the risk of falls. This affected 1 (Resident 472) of 3 sampled residents. The facility had identified a census of 63 at the time of the survey. Findings are: A record review of Resident 472's Face Sheet revealed the resident admitted into the facility on [DATE] with diagnoses of: fracture of left ilium, strain of left quadricep muscles, pain in bilateral hips, dementia, depression, and hypertension. A record review of Resident 472's admission Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents), dated 1/15/2024 revealed Resident 472 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated Resident 472 had severe cognitive impairment. The MDS also revealed Resident 472 had impairment of his left lower extremities and used a walker and wheelchair. The MDS also revealed Resident 472 required max assistance with oral hygiene, toileting, bathing, dressing, personal hygiene, transfers, and repositioning. The MDS also revealed Resident 472 had a fall history prior to admission and had sustained one fall since admission. The MDS also revealed Resident 472 had a bed and chair alarm in use daily. A record review of Resident 472's Care Plan, dated 1/9/2024, revealed safety interventions due to falls at home that had included keeping the bed in low position, bed and chair alarms, and non-slip footwear. The Care Plan also noted a fall on 1/10/2024 with an intervention to implement anti-lock brakes on the wheelchair. Resident 47'2 Care Plan revealed the resident was on high-risk medication with a possible adverse side effect of dizziness. The Care Plan revealed barriers to Resident 472 being able to discharge as dementia, confusion, weakness, and impaired mobility. An observation on 1/23/2024 at 1:15 PM revealed Resident 472 had on regular white socks and Resident 472's walker and wheelchair were across the room, not within reach. An observation on 1/23/2024 at 2:48 PM revealed Resident 472 had on regular white socks and the walker and wheelchair remained not within reach. An observation on 1/24/2024 at 9:59 AM revealed Resident 472's bedside table containing the call light and water were not within reach. The observation also revealed Resident 472's walker and wheelchair were also not within reach. An observation on 1/24/2024 at 2:43 PM revealed Resident 472's bedside table to be close, but the call light was positioned in the furthest corner away and not within Resident 472's reach. Resident 472's walker and wheelchair were also not within reach. Resident 472 was wearing regular white socks. An interview on 1/24/2024 at 3:03 PM with Nurse Aide (NA) -G revealed that NA-G was aware of where to find resident Care Plans. NA-G confirmed Resident 472 needed to have the bed in low position and supervision to prevent falls, but was unaware of any other interventions in place. An interview on 1/24/2024 at 3:05 PM with Medication Aide (MA)-H revealed MA-H was not aware of Resident 472 having any fall intervention in place but was aware of the interventions being located in the Care Plans. An interview on 1/24/2024 at 3:08 PM with Licensed Practical Nurse (LPN)-I confirmed LPN-I was the nurse responsible for overseeing Resident 472's care. LPN-I revealed the process of rounding on residents to ensure staff were implementing appropriate fall interventions but stated I haven't been over on [specific hall] much today because I have been dealing with another resident on another hall. A record review of the facility's Call Light Policy with a revision date of 11/2021, under section General Guidelines, read When the resident is in bed or confined to a chair be sure the call light is within easy reach. An interview on 1/25/2024 at 8:34 AM with Registered Nurse (RN) -N revealed RN-N conducts spot auditing after breakfast and rounding every two hours to ensure resident's interventions are in place. The interview also revealed RN-N's expectation would be to keep wheelchairs and walkers nearby if not specified otherwise on the care plan.

Licensure Refeference Number 175 NAC 12-006.09 Based on observation, interviews and record review, the facility failed to implement measures for a contracture of the left hand for 1 (Resident #26) of 1 sampled resident. The facility census was 63 Finding are: Record review of Resident #26's Electronic Medical Adminstration Record (EMAR a legal record of the medications administered to a patient at a facility by a health care professional) for the month of January 2024 revealed Resident #26's admitted was 10/3/19. Record review of Resident #26's EMAR for the month of January 2024 revealed Resident #26's had a diagnosis of unspecified intracranial injury with loss of consciousness of unspecified duration, sequela. Record review of Resident #26's Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities) dated 10/26/23 revealed Resident #26 had a Brief Interview for Mental Status (a test used to get a quick snapshop of a resident's cognitive function, scored 0-15, the higher the score, the higher the cognitive function) score of 0 which indiciated the resident was severely cognitivley impaired. Resident #26's MDS revealed [gender] required moderate assistance with dressing and maximum assitance with personal hygiene. Record review of Resident #26's Care Plan revealed the resident had an intervention to apply a green hand splint to the left hand as ordered. Record review of Resident #26's EMAR for the month of January 2024 revealed an order to apply a palm pillow to the resident's left hand in the morning and remove it at night. The EMAR also indiciated the palm pillow may be removed during meals. The EMAR revealed the left palm pillow was applied on 1/22/2024-1/24/2024. An observation on 1/22/24 at 2:55 PM revealed, Resident #26 was sitting in [gender] recliner and looking forward. The palm pillow was not in/on Resident #26's left hand. An observation on 1/23/24 at 10:13 AM of Resident #26 revealed the resident did not have the palm pillow in [gender] left hand. An observation on 1/23/24 at 1:30 PM revealed Resident #26 was sitting in the recliner watching TV with no palm pillow in the left hand with their left hand closed tight. An observation on 1/24/24 at 10:00 AM revealed Resident #26 was in the Sensory Room with other residents and staff without the palm pillow in their left hand. An interview on 1/24/24 at 11:04 AM with Nursing Aide (NA)-B confirmed that the palm pillow should be on Resident #26. NA-B confirmed the night shift staff assisted Resident 26 in getting up for the day and NA-B failed to check and/or place Resident 26's left hand palm pillow. An interview with the Director of Nursing at 11:45 AM on 1/24/24 confirmed that resident should have the palm pillow on and the aide should have done this.

Licensure Reference Number 175 NAC 12-006.17A Based on observation, interview, and record review, the facility failed to provide a sanitary environment by failing to ensure all staff were informed regarding COVID positive residents' quarantine status. This had the ability to affect all residents. Facility census was 43. Record review revealed Resident #22 tested positive for COVID on Friday, 11/25/2022. Record review also revealed Resident #22 was to be in quarantine from Friday, 11/25/2022 through Friday 12/2/2022. On 11/28/2022 an observation revealed Resident #22 was walking down a resident hallway with no mask in place and no staff escort. Resident #22 was stopped in the hallway by NA-C (Nurse Assistant-A) beside the Social Service office. NA-C stated to Resident #22, I'll check to see if you can come out. You just stay right there. Stay right there. I'll go check. Resident #22 was left standing in the hallway by the Social Service office with no PPE (Personal Protective Equipment) in place. Continued observation revealed NA-C returned to where Resident #22 continued standing in the hallway. Resident #22 was escorted back to the resident room by NA-C. On 11/30/22 an interview with NA-C revealed the status of quarantine for Resident #22 had not been communcated to the front line staff to ensure the front line staff were aware of Resident #22's quarantine status. The interview revealed the resident was still in quarantine until Friday 12/2/2022 per the facility COVID policy/procedure/protocol. An interview with the Infection Preventionist confirmed the resident was allowed to stand in the hallway by the Social Service office without a mask in place and while under COVID quarantine. The interview also confirmed quarantine for Resident #22 was to be through Friday 12/2/2022 due to the resident testing positive for COVID on Friday 11/25/2022. The interview also confirmed the status of the quarantine for Resident #22 was unknown due to lack of clear and up to date information delivered to the front line staff in a timely manner. An interview with the Director of Nursing confirmed Resident #22 was allowed to stand in the hallway be the Social Services office without any personal protective equipent in place and while under COVID-19 quarantine. The interview verified the quarantine for Resident #22 was to be through Friday 12/2/2022 due to the resident testing positive for COVID on Friday 11/25/2022. The Director of Nursing verified that the quarantine status for Resident was unclear to front line staff which led to Resident #22 being left standing in the hallway unsupervised while staff verified the residents COVID quarantine status. An interview with the Administrator verified that lack of clear and up to date information regarding the COVID/quarantine status of Resident #22 led to the resident being left in the hallway alone without a mask in place while staff verified the residents COVID/quarantine status.

Licensure Reference Number: 175 NAC 12-006.11E Based on observations and interviews, the facility failed to prevent build up of ice and condensation where frozen foods were stored inside the walk in freezer. This failure had the potential to affect all residents. Facility census was 61. Findings are: Observation on 7-13-21 at 11:02 AM of the walk in freezer located off the kitchen area revealed it had condensation and ice build up located on the freezer ceiling, back wall, and on food items located in boxes next to the condenser. Observation on 7-14-21 at 11:19 AMof the walk in freezer located off the kitchen area revealed it had condensation and ice build up located on the freezer ceiling, back wall, and on food items located in boxes next to the condenser. Staff interview on 7/14/21 at 11:42 AM with the Dietary Manager, who verified that the walk in freezer had condensation and ice build up on the ceiling, back walls and food items located in boxes next to the condenser. The Dietary Manager confirmed this could lead to cross contamination of the food items located in the walk in freezer, which could affect all residents. Staff interview on 7/14/21 at 11:46 AM with the Administrator, who verified that the walk in freezer had condensation and ice build up on the ceiling, back walls and food items located in boxes next to the condenser. Administrator confirmed this could lead to cross contamination of the food items located in the walk in freezer, which could affect all residents. Review of the 7/21/16 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: 3-303.12-A) Packaged food may not be stored in direct contact with undrained ice. Source; Quality Assurance & Food Safety, December 2016 quotes the Food and Drug Administration and he United States Department of Agriculture/Food and Safety Inspection Service realted to condensation in guidance documents with the most recent a draft from the Food Satiety Modernization Act. The Preventive rule discusses condensation build up as a Hazard for listeria, salmonella, and molds that produce mycotoxins (Substances produced by mold growing in food that cause illness or death when ingested by man).

Licensure Reference Number 175 NAC 12-007.04D Based on observations and interviews, the facility failed to ensure that bathroom vents were functional in four rooms (Rooms 313, 410, 417, and 421) which had the potential to impact four sampled residents (Residents 16, 47, 20, and 36) and one non-sampled resident (Resident 43) who occupied these rooms. Facility census was 61. Sample size was 20. Findings are: During the initial pool process on the morning of 7/13/21, bathroom vents were found not functioning in Rooms 313, 410, 417, and 421. On 7/14/21 at 7:30 AM, another observation verified the vents were still not working in Room 313 which was occupied by Residents 16 and 43, Room 410 which was occupied by Resident 47, Room 417 which was occupied by Resident 20, and Room 421 which was occupied by Resident 36. On 7/14/21 at 8:00 AM, an observation with the facility's Maintenance Director verified the bathroom vents were not working in Rooms 313, 410, 417, and 421. The Maintenance Director stated vents were checked regularly as part of room audits, so they were not sure why these vents were not working. On 7/14/21 at 8:08 AM, this concern was reviewed with the facility's Administrator and the Maintenance Director.

Licensure Reference Number: 175 NAC 12-006.18 Based on observations and interviews, the facility failed to provide a homelike environment for one resident (Resident # 27) out of 20 sampled residents as there were no personal items in the resident's room. Facility census was 61. Findings are: Observation on 7-12-21 at 4:36 PM of the resident room occupied by Resident 27, identified that the walls contained no personal or facility items. Resident interview on 7-12-21 at 4:36 PM revealed that Resident 27 confirmed wanting to have personal items in the room consisting of personal pictures and a small table where personal items could be placed. Observation on 7-13-21 at 1:15 PM of the resident room occupied by Resident 27 revealed that the walls contained no personal or facility items. Resident interview on 7-13-21 at 1:33 PM with Resident 27 confirmed that staff had not spoken to her about getting personal belongings from home. Resident 27 also verified not being clear as to whom a conversation should have been held with about obtaining personal belongings that could have been brought to the facility and placed in the room to have made it feel more like home. Staff interview on 7-13-21 at 2:06 PM with the Administrator and Social Services Representative confirmed that they had failed to make Resident 27's room homelike. Administrator and Social Services Representative both verified that Resident 27 had requested personal items from home in order to make the room feel more homelike, but this was not accomplished.

Licensure Reference Number: 175 NAC 12-006.10D Based on record reviews and interviews, the facility failed to transcribe a medication order for a diuretic medication (medication to reduce swelling) for one sampled resident (Resident 4). The failure resulted in a 14 day delay in the medication being provided to the resident and resulted in the resident's continued leg swelling and development of blisters. Sample size was four current residents. Facility census was 77. Findings are: Record review of Resident 4's Face Sheet printed on 1/24/18 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of Resident 4's electronic medical record and chart revealed the following: - from the Departmental Notes an entry dated 12/15/17 at 4:37 p.m. revealed the resident was seen and received new orders from the physician. - A Message from Organization: (name of clinic). New Medication (a web-based communication tool with communication from the clinic to the facility) dated 12/15/17 and generated on 12/16/17 revealed the physician also started (Resident 4) on 20 mg (milligrams) of [MEDICATION NAME] PO (by mouth) daily. An Electronic Prescription via Sure Scripts form from the clinic to the pharmacy revealed an order dated 12/15/17 for Resident 4 was written for [MEDICATION NAME] 20 mg oral tab with instructions to administer 1 (one) Tablet by mouth once daily. - 12/23/17 at 3:34 p.m. from the Departmental Notes the resident was assessed with [REDACTED]. 2+ indicated indention of the skin 2-4 millimeters deep which does not rebound for 10-15 seconds when pushed inward) to BLLE (bilateral lower extremities) . - A Nursing Communication form sent to the physician on a follow up visit dated 12/29/17 revealed the resident was being seen in Follow-up and requested the physician Please look @ (at) red, raised open areas to L (left) lower leg . The physician provided a communication note from the visit which read: See web message from 12/15/17. Patient (Resident 4) should be on [MEDICATION NAME] (Generic name for [MEDICATION NAME]) 20 mg by mouth once daily. - Departmental Notes entry dated 12/29/17 at 5:30 p.m. recorded the resident had an appointment with the physician. Orders are as follows. See web message from 12.15.17. Patient (Resident 4) should be on [MEDICATION NAME] 20 mg by mouth once daily . - e-Medication Administration Record [REDACTED]. - Departmental Notes entry dated 1/18/18 at 12:12 p.m. revealed an entry by the Registered Dietitian which read: Current weight 215# (215 pounds). Admit weight was 195# in October. Dr reviewed weight of 214# with no dietary changes last month . [MEDICATION NAME] was added last month and increased this month, so we may see some weight fluctuations due to [MEDICAL CONDITION] changes . Record review of a facility Investigation Report dated 1/16/18, forwarded to the State Agency, revealed the facility investigated the delay in the order implementation for Resident 4's [MEDICATION NAME]. The investigation was initiated after Resident 4's spouse reported to the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) Coordinator on 1/9/18 that Resident 4's [MEDICATION NAME] order was missed by the nursing staff when ordered on [DATE] and not started until 12/29/17. The spouse reported the resident's legs had some increased [MEDICAL CONDITION] with blisters to the lower extremities due to the resident not receiving [MEDICATION NAME]. The report acknowledged the error in getting the medication order transcribed and administering the medication to the resident. The Potential Causal factors revealed the physician sent the order over the Portal (the electronic computerized communication system between clinic and facility) and that the order had not been opened by the nurse on duty. The facility determined that once an order is opened on the portal per facility protocol, it is to be entered into the computer, if it is opened staff have no way to know it is a new order and has not been entered into the computer. The investigation Outcome revealed the order for [MEDICATION NAME] was missed on the Portal and the resident had not received (the resident's) [MEDICATION NAME] for 13 days. The report revealed It was noted by the Primary care Physician that there was increased swelling with small pinpoint blisters to lower extremities (for Resident 4) bilaterally. Primary Care Physician felt this increased swelling and blisters were caused by resident not receiving (the resident's) [MEDICATION NAME]. Interview with the ADON (Assistant Director of Nursing) and MDS Coordinator on 1/24/18 9:45 a.m. confirmed Resident 4 received a physician's orders [REDACTED]. Due to a problem with the computerized communication portal, the order was not transcribed and the medication was not started until after the physician alerted the facility to the mistake on 12/29/17. The ADON confirmed the facility investigated the issue and verified the omission of the original order resulted in the resident experiencing increased swelling and blisters.

Licensure Reference Number: 175 NAC 12-006.09 Based on record reviews and interviews, the facility failed to: 1) Provide follow up assessment, care, and treatment and obtain medical treatment for one sampled resident (Resident 4) with ongoing pain symptoms and bruising related to a [MEDICAL CONDITION]. Facility census was 96. Findings are: Record review of Resident 4's closed medical record revealed the "face sheet" printed on 9/3/14 recorded the resident was admitted to the facility on [DATE] and date of birth was 5/13/1927. The form listed an admitting [DIAGNOSES REDACTED]. Record review of the resident's current MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) revealed the resident was assessed during a seven day period ending on 8/6/14. The assessment recorded Resident 4 was unable to conduct a mental status interview based on "resident is rarely/never understands". The assessment recorded Resident 4 required "extensive assistance (resident involved but needed staff support for weight bearing)" and one staff assist in order to move in bed and transfer across surfaces. The assessment recorded the resident was on a "scheduled" pain regiment but had not received an PRN (as needed) medication nor any non-medication interventions related to pain. The assessment recorded that the staff were unable to perform a pain assessment with the resident due to the "resident is rarely/never understood". The MDS recorded that the resident's pain was identified by staff through "facial expressions". Record review of Resident 4's "Weekly Nursing Summary" form dated 8/18/14 revealed the resident was "bed or chair bound" and transferred and positioned with staff assistance and use of a "sit to stand" mechanical lift. The summary recorded the resident had no pain. Record review of Resident 4's "Interdisciplinary Progress Notes" revealed no documentation of the resident's condition between 6/26/14 and 8/27/14. On 8/27/14, RN (Registered Nurse)-A documented at 8:20 a.m. that RN-A assessed Resident 4 for "c/o (complaint of) R (right) knee/hip pain. Res (resident) able to bend knee c (with) some pain one time et (and) no s/sx (signs and symptoms) of pain the next." The entry recorded that RN-A contacted a family member about sending the resident to the emergency room or clinic and that the family member provided resident history to RN-A and requested to keep the resident comfortable and continue with scheduled Tylenol. Record review of Resident 4's "Treatment Record" for August of 2014 revealed an entry for the charge nurse or Medication Aide to record the resident's response to pain on the day shift. The form documented the resident had not expressed pain between 8/1/14 and 8/26/14 but had "s/s (signs and symptoms)" of pain on 8/27; 8/28; and 8/29/14. Interview with RN-A on 9/16/14 at 1:45 p.m. revealed that RN-A was asked by an LPN (Licensed Practical Nurse) to examine Resident 4 on 8/27/14 due to the resident experiencing unusual ongoing pain. RN-A recalled assessing the resident who was in bed and "facial grimacing" from pain. RN-A felt the pain was significant and the resident was "hurting" enough that might warrant medical attention at the emergency room or clinic. RN-A stated having called the resident's family. The family member explained the resident had a history of [REDACTED]. RN-A stated the resident received routine Tylenol three times daily but normally did not have pain. RN-A stated suggesting the medical attention because the pain was "out of character" for this resident. Phone interview with Resident 4's family member on 9/17/14 at 10:30 a.m. verified the family member received a phone call from RN-A on the morning of 8/27/14. The family member recalled RN-A reporting pain symptoms and that RN-A stated the resident's leg had "flopped". The family member asked if the routine Tylenol had been given and it hadn't. The family member recalled instructing the staff to administer the Tylenol and further assess and keep the family informed if the resident did not improve. Record review of an investigation summary completed on 8/31/14 documented by the facility DON (Director of Nursing) revealed the DON assessed Resident 4 on 8/28/14 after LPN-C requested the assessment due to "complaint of pain to right hip and knee". The DON recorded the resident was alert, pleasant, and cooperative and yelled out when the DON touched the leg stating "your hands are cold". LPN-B manipulated Resident 4's right leg at hip and knee joint and Resident 4 responded by saying "Owe (sic)". The DON identified the resident's right thigh as "slightly puffy at outer mid thigh but with repositioning appeared to reduce puffiness." The DON recorded a "yellow to light purple linear area on inner right thigh proximal to groin" and attributed the discoloration to the resident's brief being too tight. LPN-B was "advised by DON to take action as needed and continue to comply with resident and family requests." This investigation report was not included in the resident's medical record. Record review of Resident 4's Interdisciplinary Progress Notes revealed no further assessment or follow up on the resident's pain until an entry dated 8/29/14 at 11:10 a.m. by LPN-B. The note recorded a "4 cm (centimeter) x (by) 3 cm ecchymotic (bruised) area to R outer vaginal lip. Resident having increased R hip pain et clutches at area when repositioned or HOB (head of bed) raised. "At 12:35 p.m., the entry documented the resident's family member was contacted about the bruise and stated will come to the facility. An entry on 8/29/14 at 1:40 p.m. by LPN-B revealed "Resident to E.R. (emergency room ) via ambulance (sic). Bed hold sent with (family member)". An entry on 8/29/14 at 2:00 p.m. by LPN-B revealed "(Name of physician) notified via fax of bruise." Interview with LPN-B on 9/15/14 at 2:25 p.m. verified LPN-B worked as a charge nurse and was responsible for the care of Resident 4 on 8/27/14 through 8/29/14. LPN-B stated on 8/27/14 Resident 4 was observed with a "lot of hip pain". LPN-B stated the resident was cognitively impaired and incapable of rating pain and inconsistent in describing pain. LPN-B stated Resident 4 remained in bed on 8/27 and 8/28 due to pain issues. LPN-B stated the resident would continually grab at the hip, knee, and groin area. The resident received Tylenol three times a day which seemed to help. LPN-B verified the physician was not contacted of the pain and the family was not notified of the ongoing pain except on the initial call on 8/27/14. LPN-B described the resident's leg as not shortening but the knee was "not controlling". LPN-B did not notice any rotation of the limb. LPN-B verified the resident had bruising and LPN-B contacted the family of this. The physician was not notified of bruising until after the resident was transported to the emergency room . Telephone interview with Resident 4's family member on 9/17/14 at 10:30 a.m. verified the family arrived at the facility on 8/29/14 after noon following a phone conversation with LPN-B. The family member reported observing Resident 4 in significant pain with a bruised thigh and visible leg deformity. The family member stated the DON assured them the resident's leg wasn't broken and the bruising was due to the resident's brief. The family member reported requesting the resident be transported to the E.R. by ambulance. Record review of a "Prehospital Care Report" documented by the city Volunteer Fire Department responders revealed the following documentation related to Resident 4's condition upon their arrival on 8/29/14. "The patient was found lying supine in bed with obvious deformity to the right leg (external rotation) . . . Patient is A/O (alert and oriented) to person place and complains of right hip pain 8/10 (10 being worst pain possible) worse upon moving. There is yellowish/brown bruising around the interior aspect of the upper right thigh/hip/pelvis region. Black/blue bruising around the right knee appears like figure (sic for finger) prints . . . 50 mcg (micrograms) of [MEDICATION NAME] (a narcotic pain relief medication) was administered IV (intravenously) for pain prior to moving/splinting . . . Pain 10/10 additional 50 mcg of [MEDICATION NAME] administered after moving . . . [MEDICATION NAME] administered IV for pain patient moved into (hospital) . . ." Record review of the hospital "E.R. Supplementary Documentation Record" on 8/29/14 at 2:00 p.m. revealed "Observations" documenting "dark purple/yellow bruise right side. Purple bruising noted . . . at 2:20 Resident 4 "smiles with conversation . . . at 5:00 p.m. complains of pain to right hip, [MEDICATION NAME] 2 mg (milligrams) IVP (per intravenous push administration)" At 6:17 p.m. the resident was transported per ambulance to another hospital. Record review of the emergency room report 8/29/14 regarding Resident 4's evaluation revealed the chief complaint as "hip pain". Subjective documentation of the assessment described that the pain was present two days ago and the family was not told of the ongoing pain until today. The nursing home reported to the family the resident was complaining of pain and had not been out of bed. The family reported observing the "Patient's foot was pointed in the wrong direction at which point the patient was transported . . . The patient received some pain medication while in the ambulance and was somnolent (sedated), but talking to us a little bit. (The resident) did complain of pain in the right hip." The assessment recorded: "Extremities: Right lower extremity is externally rotated with foot at a 90 degree angle. Bruising noted medially along the whole thigh. Is tender to palpation (touch) along the medial (inner) aspect of the thigh." The physician diagnosed a "Closed [MEDICAL CONDITION] femur" and planned to transport to an orthopedic floor at a different hospital. An x-ray report for Resident 4 on 8/29/14 revealed the findings had discovered a fracture "approximately 14 cm" obliquely oriented displaced and angulated of the "proximal one-third of the femur." Record review of the hospital discharge summary dated 9/2/14 revealed Resident 4's discharge [DIAGNOSES REDACTED]. Interview with the facility Administrator and DON on 9/15/14 at 3:00 p.m. verified the resident's pain symptoms were discovered on the morning of 8/27/14. The DON verified the family was notified and staff were instructed to administer the routine Tylenol and monitor. The Administrator and DON verified there was no nursing documentation of the resident's condition in the resident's chart between 8/27/14 at 8:20 a.m. until an entry describing a bruise on 8/29/14 at 11:10. The DON verified having assessed the resident and observing the bruise on 8/28/14 as written in the DON investigative report. The Administrator and DON verified Resident 4's physician had not been notified of the resident's condition between 8/27/14 and 8/29/14 except for the fax describing the bruise after the resident was transported to the hospital. The DON and Administrator verified the family was not notified of the resident condition and remaining in bed due to pain except for an initial report on 8/27/14 and the reported bruise on 8/29/14 at 11:10 a.m.