Every finding on record at Hillcrest Shadow Lake LLC

Licensure Reference Number 175 NAC 12-006.09(J)(i)(1). Based on interview and record review the facility failed to identify and implement interventions for a significant weight loss for 1 (Resident 4) of 3 residents sampled. The facility census was 96. The findings are:A.Record review of Resident 4's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-Brief Interview of Mental Status (BIMS) was scored as a 14. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact.-required set up assistance with eating.-required extensive assistance with upper body dressing.-required total assistance with hygiene, bathing, toileting, lower body dressing, bed mobility and transfers.-weighed 219 pounds (lb). Record review of Resident 4's Dietary Progress Notes (DPN) dated 04-08-2026 revealed the Registered Dietician (RD) had assessed Resident 4's nutritional status and the RD would monitor weight trend and provide nutrition interventions. Record review of Resident 4's Electronic Health Record (EHR) under the weights and vitals section, revealed on 04-03-2026 Resident 4's weight was 219.1 lbs and on 04-22-2026 Resident 4's weight was 207.0 lbs equaling a 12.1 lb weight loss resulting in a 5.5% weight loss in 19 days. Record review of Resident 4's DPN revealed no nutritional assessment or dietary interventions for the 5.5% weight loss on 04-22-2026. An interview conducted on 05-07-2026 at 9:35 AM with the RD revealed a reweigh was not requested and obtained and confirmed no new interventions had been initiated for the weight loss on 04-22-2026. An interview conducted on 05-07-2026 at 2:00 PM with the Director of Nursing confirmed the 5.5% weight loss in 19 days was a significant weight loss and new nutritional interventions were not implemented for Resident 4.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1) & 12-006.09(H)(iii)(2). Based on observation, interview and record review the facility failed to evaluate, monitor, and implement interventions for pressure ulcer prevention and promotion of wound healing for 2 (Resident 1 and 3) of 4 residents sampled. The facility census was 95. Findings are:A. Record review of the facility policy titled Skin integrity, Wound, Ulcer Assessment Prevention Treatment Documentation Policy dated 02-11-2021 revealed all team members are responsible for preventing, caring for, and providing treatment to any guest that has altered skin integrity. A licensed nurse/physician/therapist may stage a wound and determine etiology. Measurement of the wound must be completed upon identification. For admissions, wounds must be measured when completing the admission skin assessment. Wounds are measured in 3 dimensions length, width, and depth. Measurements must be completed routinely and documented on a wound progress assessment form on all identified impaired skin integrity issues. B. Record review of Resident 3's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 11-21-2025 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-had a diagnosis of quadriplegia and Multiple Sclerosis (MS). -Brief Interview of Mental Status (BIMS) was scored as 12. According to the MDS Manual a score of 8 to 12 indicates moderate cognitive impairment. -required total assistance with eating, dressing, bathing, hygiene, bed mobility and transfers. -was at risk of developing a pressure ulcer. - had a stage 4 pressure ulcer. According to the MDS Manual a stage 4 pressure ulcer is full thickness tissue loss with exposed bone, tendon or muscle and often includes undermining (the destruction of tissue or ulceration extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface) and tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound). Record review of Resident 3's Nursing admission Screening/History (NASH) dated 05-09-2025 revealed Resident 3's skin was intact upon admission. Record review of Resident 3's Electronic Health Record (EHR) revealed a Braden Scale (a pressure ulcer risk tool) dated 05-09-2025 revealed Resident 3 scored a 13, indicating moderate risk of developing a pressure ulcer. Record review of Resident 3's Baseline Care Plan (BCP) dated 05-21-2025 revealed Resident 3 was at risk for skin breakdown/issues due to impaired mobility, dependence on team for all cares and to keep skin clean and dry. - Encourage adequate nutritional intake. - Encourage and assist to reposition in chair and in bed at routine intervals for pressure relief. - Notify PCP of any changes noted in skin condition.Further review of the BCP revealed there was no indication that pressure-reducing surfaces were provided to the bed or the wheelchair. Record review of Resident 3's Comprehensive Care Plan (CCP) printed on 01-20-2026 revealed Resident 3 had a potential or actual impairment to skin integrity due to dependence on the team for all activities of daily living (ADLS), mobility, catheter use, colostomy use, feeding tube in place but not currently and had a stage 2 pressure ulcer (According to the MDS Manual a Stage 2 pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising and may also be an intact or open/ruptured blister) to the left buttock. Date initiated 05-21-2025. The goal was Resident 3 will maintain or develop clean and intact skin by the review date. Interventions in reaching this goal were:-encourage and assist to reposition in bed and in the chair at routine intervals for pressure relief.-encourage good nutrition and hydration in order to promote healthier skin.-keep skin clean and dry. Use lotion on dry skin. Do not apply on any site of injury. -monitor and document location, size and treatment of any skin injury, issue or change when noted, then weekly thereafter until healed. Report abnormalities, failure to heal, signs and symptoms of infection to the physician.-pressure reduction mattress on bed and pressure reduction cushion in w/c. Record review of Resident 3's Skin Only Evaluations ([NAME]) revealed no skin evaluation from 05-09-2025 to 5-23-2025, a 14 day span of time. Record review of Resident 3's Treatment Administration Record (TAR) for May 2025 revealed an order dated 05-21-2025 to remove old dressing, cleanse area place xeroform to size of area, cover with mepilex (a type of wound dressing) and change the dressing on Monday, Wednesday and Friday. The order did not identify where the location of the wound was. Record review of Resident 3's [NAME] dated 05-23-2025 revealed Resident 3 had no skin issues. Record review of Resident 3's [NAME] dated 05-31-2025 revealed Resident 3 had a stage 2 pressure ulcer to the left buttock without measurements or a description of the wound. An interview conducted with the Director of Nursing (DON) on 01-20-2026 at 3:00 PM confirmed Resident 3 should have had an [NAME] on 05-16-2025 and hadn't and confirmed interventions to prevent pressure ulcer development were not implemented until 05-21-2025 after Resident 3 developed a pressure ulcer to the left buttock and confirmed an initial evaluation of the wound was not conducted. Record review of Resident 3's Progress Notes (PN) revealed wound documentation for the following dates:-06-13-2025 Skin issue: Pressure ulcer to the left buttock stage 2 without measurements. -07-18-2025 Skin issue: Pressure ulcer to the left buttock stage 2 and pressure ulcer to left heel without measurements. Record review of Resident 3's PN revealed wound documentation for the following dates:-07-25-2025 Skin issue: Pressure ulcer to the right buttock stage 3 with full thickness skin loss and tunneling present. -07-28-2025 Resident 3 had a pressure ulcer stage 3 to the right buttocks measuring 2.5 centimeters (cm) by 1.8 cm x 1.2 cm with tunneling at 10 o'clock measuring 3.5 cm and the wounds to the left heel and left great toe are healed. Record review of Resident 3's CCP printed on 01-20-2026 revealed no new interventions were implemented for Resident 3's stage 3 pressure ulcer to the right buttock. An observation conducted on 01-20-2026 at 8:00 AM of Licensed Practical Nurse (LPN) D and the Assistant Director of Nursing (ADON) performing wound care for Resident 3 revealed an oval shaped wound approximately 2 cm in length by 3 cm width by 1 cm depth and a tunnel at 1 o'clock to the right gluteal fold, there was a moderate amount of red and brown drainage on the old dressing, the wound bed was pink and the skin around the wound was pink. An interview conducted with the ADON on 01-20-2026 at 3:10 PM revealed orders were obtained for the treatment of the right buttock and causal factors for Resident 3's pressure ulcer to the right buttock had not been identified. An interview conducted with the DON on 01-20-2026 at 3:50 PM confirmed Resident 3 had 2 separate pressure ulcers one on the right buttock and one on the left buttock. C. Record review of the Operation Manual for the Protekt Aire 4000DX/5000DX air mattress revealed the mattress can be adjusted to the desired firmness according to user's weight or the suggestion from a health care professional. Record review of Resident 3's EHR under the section weights and vitals revealed Resident 3's the most recent weight was 178.0 lbs. on 01-09-2026. An observation conducted on 01-15-2026 at 9:20 AM revealed Resident 3 had an air mattress on the bed set at 240 pounds (lbs). An observation conducted on 01-15-2026 at 11:15 AM revealed Resident 3 had an air mattress on the bed set at 240 lbs. An observation conducted on 01-20-2026 at 6:05 AM revealed Resident 3 was in bed and the air mattress was on and set at 270 lbs. An observation conducted on 01-20-2026 at 12:30 PM with Nursing Assistant (NA) A confirmed Resident 3's air mattress was set at 270 lbs. Record review of Resident 3's EHR revealed no order for an air mattress or air mattress settings.An interview conducted with the DON on 01-20-2026 at 3:00 PM confirmed having the air mattress set for a person that weighs 270 lbs. would cause increased pressure for a person weighing 178 lbs. An interview with the Director Of Compliance on 01-20-2026 at 3:55 PM confirmed the air mattresses should be set according to the resident's weight or according to practitioner ordered settings. D. Record review of Resident 1's MDS dated [DATE] revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE]-BIMS was scored as 14. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact. -required limited assistance with bed mobility.-required extensive assistance with dressing and bathing.-required total assistance with toileting and transfers.-was always incontinent of bladder.-was frequently incontinent of bowel.-was at risk of developing a pressure ulcer.-had a stage 2 pressure ulcer. Record review of Resident 1's EHR revealed a Braden scale evaluation conducted on 11-21-2025 revealed Resident 1 scored a 13, indicating moderate risk of pressure ulcer development. Record review of Resident 1's CCP printed on 01-20-2026 dated 12-09-2024 revealed the following for Resident 1:-was at risk for the potential or actual impairment of skin integrity due to incontinence, decreased mobility, at risk per Braden risk assessment, previous issues with Moisture Associated Skin Damage (MASD) to groin and abdominal folds and excoriation to the buttocks. -on 04-22-2025 unstageable pressure ulcer to the right heel.- The goal was Resident 1 will maintain clean and intact skin by the review date. -Interventions to reach the goal were:-encourage and assist to reposition when in bed and in chair at routine intervals throughout each shift for pressure relief. -encourage good nutrition and hydration in order to promote healthier skin. -keep skin clean and dry. Use lotion on dry skin. Do not apply on any site of injury. -monitor and document location, size and treatment of any skin injury, issue or change when noted, then weekly thereafter until healed. Report abnormalities, failure to heal, signs and symptoms of infection to the physician.-pressure reduction mattress on bed and pressure reduction cushion in w/c. Record review of Resident 1's PN revealed on 04-22-2025 Resident 1 had an unstageable pressure ulcer to the right heel; orders were received for treatment of the wound and for a protective boot. Record review of Resident 1's CCP revealed new interventions for skin integrity dated 04-22-2025:-heel protectors on at all times as resident will allow-treatment to skin areas as ordered see Medication and Treatment Administration Records and notify physician of any changes as needed. Record review of Resident 1's PN dated 12-01-2025 revealed Resident 1 had a stage 2 pressure ulcer to the right heel measuring 2.2 cm by 1.3 cm. Record review of Resident 1's [NAME] dated 12-04-2025 revealed Resident 1 had a diabetic foot ulcer and redness to the buttocks. Record review of Resident 1's EHR revealed no [NAME] on or around 12-11-2025. Record review of Resident 1's PN dated 12-08-2025 revealed Resident 1 had a stage 2 pressure ulcer to the right heel measuring 1.8 cm by 1 cm and a large fluid filled blister to the top of the right foot measuring 4.5 cm by 4.5 cm. Record review of Resident 1's PN dated 12-15-2025 revealed Resident 1 had a stage 2 pressure ulcer to the right heel measuring 1 cm by 1 cm and the large fluid filled blister, now open due to resident having telfa (a type of wound dressing) on the blister to the top of the right foot measuring 5.5 cm by 6.5 cm. Record review of Resident 1's PN dated 12-15-2025 at 8:04 PM revealed Resident 1 had slurred speech and was behaving abnormally and had been sent to the emergency room (ER). Record review of Resident 1's Emergency Department Provider Notes (EDPN) dated 12-15-2025 at 8:08 PM revealed Resident 1 had a wound to the right posterior thigh with surrounding redness, foul rotting fruit odor, mild drainage and additional skin breakdown was identified to the right posterior heel, and a large fluid-filled blister to the lateral aspect of the right foot without abnormal drainage or surrounding redness. Record review of Resident 1's Hospital History and Physical (H&P) dated 12-16-2025 at 5:02 AM revealed Resident 1 presented to the ER on [DATE] with encephalopathy (a broad term for any disease, damage, or malfunction that alters brain function or structure, leading to an altered mental state, confusion, memory loss, or personality changes, with potential causes including infections, toxins, metabolic issues, lack of oxygen, or head trauma, and it can range from temporary to permanent) from a skilled nursing facility. Resident 1 had lab work that was suggestive of a urinary tract infection and possible cellulitis from a pressure sores. Resident 1 was started on an antibiotic and was admitted to the hospital. Record review of Resident 1's Hospital Wound Ostomy Care Consult note dated 12-16-2025 at 4:25 PM revealed Resident 1 had 3 wounds identified with the descriptions as follows:- wound characteristic of unknown etiology located to the right posterior thigh measuring 6 cm by 6.8 cm by unknown depth. The wound was described as a full-thickness wound, extending through the top 2 layers of skin. The wound had a boggy center, dark purple/maroon discolorations, pink granular, red granular, slough and eschar. The skin around the wound was indurated around the edges and reddened. There was a moderate amount of purulent and malodorous exudate draining from the wound. -wound was characterized as a chronic pressure ulcer stage 2 located on the right posterior heel measuring 2.0 cm by 1 cm x 0.1 cm.-wound is characterized as a pressure ulcer stage 2 to the top of the right foot measuring 6.8 cm by 7.0 cm. Record review of Resident 1's Hospital Progress note dated 12-17-2025 revealed Resident 1 had a soft tissue infection of the pressure ulcer to the hip. Record review of Resident 1's Hospital Operative Note dated 12-18-2026 revealed Resident 1 had an operative procedure for the debridement of the wound to the right posterior thigh and for placement of a wound vac to the wound. The note also revealed the surgeon had to remove a 7 cm by 4 cm area of necrotic (dead) skin, the subcutaneous fat was absent exposing the thigh fascia (connective tissue) and the depth of the wound was 2 cm. An interview conducted on 01-20-2026 at 2:00 PM with NA B revealed NA B was aware of Resident 1 having a skin issue to the right thigh near buttocks and the area was covered with a square bandage, prior to discharge to the hospital on [DATE]. An interview conducted on 01-20-2026 at 2:10 PM with Registered Nurse (RN) C revealed RN C knew Resident 1 was starting to get a pressure ulcer to the thigh but could not recall whether a treatment was in place prior to discharge to the hospital on [DATE]. An interview conducted with the ADON on 01-20-2026 at 8:50 AM revealed the floor nurses perform the [NAME] every week and the ADON performs wound evaluations weekly with measurements. An interview conducted with the DON on 1-20-2026 at 3:00 PM revealed Resident 1 should have received an [NAME] on 12-11-2026 and confirmed Resident 1's last [NAME] prior to discharge to the hospital was on 12-4-2026, a span of 11 days. An interview conducted with the ADON on 01-20-2026 at 3:10 PM revealed causal factors for the wound to the top of Resident 1's right foot had not been identified. An interview with the Director of Compliance (DOC) on 01-20-2026 at 3:45 PM confirmed [NAME] are to be conducted weekly. The facility staff were not able to provide additional information regarding the wounds for Resident 3 or Resident 1 prior to exiting the facility on 01-20-2026.

Licensure Reference Number 175 NAC 12-009.06 (H)(iii). Based on observation, interview and record review the facility failed to ensure vascular wounds were monitored to promote healing for 1 (Resident 2) of 1 residents sampled. The facility census was 95. Findings are:Record review of the facility policy titled Skin integrity, Wound, Ulcer Assessment Prevention Treatment Documentation Policy dated 02-11-2021 revealed all team members are responsible for preventing, caring for, and providing treatment to any guest that has altered skin integrity. A licensed nurse/physician/therapist may stage a wound and determine etiology. Measurement of the wound must be completed upon identification. For admissions, wounds must be measured when completing the admission skin assessment. Wounds are measured in 3 dimensions: length, width, and depth. Measurements must be completed routinely and documented on a wound progress assessment form on all identified impaired skin integrity issues.Record review of Resident 2's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 12-11-2025 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-Brief Interview of Mental Status (BIMS) was scored as a 15. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact. -required extensive assistance with upper body dressing.-required total assistance with lower body dressing, hygiene, toileting, bathing, bed mobility and transfers.-had 2 venous and or arterial wounds. Record review of Resident 2's Comprehensive Care Plan (CCP) dated 12-12-2023 revised on 12-19-2024 revealed Resident 2 was at risk of an alteration in skin integrity related to poor nutritional intake related to gastric bypass surgery, intolerance to nutritional supplements, and Resident 2's preference to stay in bed most of the time. The CCP also identified on 12-24 Resident 2 had venous ulcers to both lower extremities and the right lower extremity ulcers were worse than the left. The goal was Resident 2's venous ulcers to both lower extremities would show progression or be healed by the review date. The interventions were as follows:-encourage and assist to reposition in bed and in the chair at routine intervals for pressure relief.-encourage good nutrition and hydration in order to promote healthier skin.-keep skin clean and dry. Use lotion on dry skin. Do not apply on any site of injury. -monitor and document location, size and treatment of any skin injury, issue or change when noted, then weekly thereafter until healed. Report abnormalities, failure to heal, signs and symptoms of infection to the physician.-pressure reduction mattress on bed and pressure reduction cushion in w/c when up in wheelchair.-provide treatments to venous ulcers as ordered. Notify the physician of changes when noted. Record review of Resident 2's Electronic Health Record under the assessments section revealed the absence of wound evaluations with a description and measurements of Resident 2's venous ulcers. Record review of Resident 2's Progress Notes (PN) from 10-01-2025 to 01-20-2026 revealed the absence of wound evaluations with a description and measurements of Resident 2's venous ulcers. Record review of Resident 2's EHR under the section documents revealed a document from the vascular clinic dated 12-05-2025 with orders for continued treatment of Resident 2's venous ulcers, orders to return to the vascular clinic on 01-09-2026. The document did not include any wound descriptions or measurements. Record review of Resident 2's EHR under the document section revealed an After Visit Summary (AVS) dated 01-09-2026 from the vascular clinic with orders for continued care of Resident 2's venous ulcers and to return to the clinic on 03-06-2026. The AVS did not include a description or measurements of Resident 2's venous ulcers. An interview with Resident 2 on 01-15-2026 at 9:50 AM revealed Resident 2 had been going to a vascular clinic for management of (gender) venous ulcers. An observation conducted on 01-15-2026 at 2:00 PM revealed Resident 2 was sitting in the wheelchair and both lower legs had gauze bandages from the ankles to the knees. An interview conducted with the Assistant Director of Nursing (ADON) on 01-20-2026 at 8:50 AM revealed Resident 2 had declined the wound care treatment for today and confirmed the absence of wound evaluations in Resident 2's EHR was because (gender) venous ulcers are measured and assessed at the vascular clinic. An interview conducted with the Director of Nursing on 01-20-2026 at 3:00 PM confirmed Resident 2 went to the vascular clinic on 12-05-2025 and 01-09-2026 and the facility had not obtained a description or measurements of Resident 2's venous ulcers from either appointment. An interview conducted on 01-20-2026 at 3:50 PM with the Director of Compliance (DOC) confirmed Resident 2's venous ulcers should have been evaluated weekly and confirmed monitoring of the wound needed to be done in between appointments at the vascular clinic. The facility staff were unable to provide additional information on Resident 2's venous ulcers prior to exiting the facility on 01-20-2026.

Licensure Reference Number 175 NAC 12-006.18(B)(D)Based on observation, interview, and record review the facility failed to ensure staff utilized infection control practices to prevent cross contamination of wounds during wound care for 2 of 2 residents sampled (Resident 1 and 2). The facility had a census of 44.A.A record review of the facility's Hand Hygiene Policy, dated 3/1/2022 revealed the following:Hand Hygiene GuidanceHealthcare personnel should use an alcohol-base hand rub or wash with soap and water for the following clinical indications:Before moving from work on a soiled body site to a clean body site on the same patient.After touching a patient or the patient's immediate environmentAfter contact with blood, body fluids, or contaminated surfacesImmediately after glove removalGloves and Hand HygieneIf your task requires gloves, perform hand hygiene prior to donning (put on) gloves, before touching the patient or the patient environment.Change gloves and perform hand hygiene during patient care, if moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs.B.A record review of Resident 1's Clinical Resident Profile sheet revealed Resident 1 was admitted to the facility on [DATE].A record review of Resident 1's undated Care Plan (a comprehensive written document developed by healthcare professionals with the individual and outlining specific, personalized health and social care needs, goals and actions to be taken) revealed Resident 1 had the following diagnoses: Dementia (a decline in cognitive function severe enough to interfere with daily life), Hemiplegia (total or partial paralysis of one side of the body), and hemiparesis (mild to moderate numbness or reduced control on one side of the body) following cerebral infarction (stroke) affecting left side and Morbid Obesity ( a chronic disease defined by a body mass index of 35 or higher).A record review of Resident 1's Minimum Data Set (MDS - a federally mandated assessment tool used in Medicare/Medicaid-certified nursing homes to evaluate a resident's functional, medical, psychosocial and cognitive status) dated 12/30/2025, revealed Resident 1 had a Brief Interview for Mental Status (BIMS - a mandatory 0-15 point tool used to screen and identify the cognitive condition of residents upon admission to a long-term care facility) of 3, indicating Resident 1 was severely cognitively impaired. A record review of Resident 1's Progress Note (essential documentation in a patient's record that tracks their status, treatment and response to care) dated 3/10/2026 revealed Resident 1 had a Stage II Pressure Injury (a partial-thickness skin loss which looks like a shallow open wound with a red-pink wound bed or an intact/ruptured blister) to the right gluteal fold (the horizontal crease that defines the boundary between the lower part of the buttocks and the upper back thigh).A record review of Resident 1's wound care order, dated 2/23/2026 by a Wound Care Advanced Practice Nurse Practitioner (APRN - a licensed Registered Nurse with graduate level education and specialized clinical training) revealed the following instructions:Remove dressings to right gluteal crease.Clean area with wound spray and apply Calcium Alginate to area and skin prep to surrounding skin. Cover with bordered gauze.Sign and dated dressings daily and as needed (PRN).An observation on 3/12/2026 at 9:45 AM of wound care provided to Resident 1 by Licensed Practical Nurse A (LPN) revealed that LPN A failed to perform hand hygiene between glove changes and failed to discard the Calcium Alginate dressing (a highly absorbent dressing derived from seaweed) after it had fallen from Resident 1's wound site and become contaminated by touching Resident 1's bed linen.An interview on 3/12/2026 at 10:00am with LPN A confirmed the Calcium Alginate dressing should have been discarded and a new one placed on the wound. LPN A confirmed they should have performed hand hygiene in between glove changes. LPN A confirmed these two occurrences were breaches of infection control.An interview on 3/12/2026 at 10:00 AM with the Assistant Director of Nursing (ADON) confirmed LPN A should have performed hand hygiene between glove changes and should have discarded the dressing after it had become contaminated. The ADON confirmed these were breaches of infection control.C.A record review of Resident 2's Clinical Resident Profile Sheet revealed Resident 2 was admitted to the facility on [DATE].A record review of Resident 2's undated Care Plan revealed Resident 2 had the following diagnoses: Peripheral Vascular Disease (a slow progressive circulation disorder which commonly causes non-healing wounds to the legs), Carrier or suspected carrier of Methicillin Resistant Staphylococcus Aureus ( a person with MRSA bacteria living on their skin or nose with displaying symptoms or falling ill), protein calorie malnutrition ( a clinical condition caused by inadequate intake of protein and calories), and Post Bariatric Surgery (a medical surgical procedure to modify the stomach and promote significant weight loss).A record review of Resident 2's MDS dated [DATE] revealed Resident 2 had a BIMS of 15 indicating Resident 2 was cognitively intact.A record review of Resident 2's wound care order, dated 3/11/2026 by the Wound Care APRN revealed the following information:Gently wash the bilateral lower extremities (both lower legs) with foam soap and water, Gently pat dry.Apply Calcium Alginate covered with small amount of Vaseline to open areas on right leg cover with Vaseline gauze to prevent sticking to wounds.Cover legs with ABD pads (highly absorbent, sterile, multi-layer and breathable bandage used for covering large, heavily draining wounds) with small amount of Vaseline to back of the pads to prevent sticking to the wounds.Continue betadine to BOTH legs to the scattered superficial open areas no need to put on crusting.Sign and date all dressings.An observation on 3/12/2026 at 10:45 AM of LPN A during wound care to Resident 2 revealed LPN A failed to change gloves and use hand sanitizer in between cleaning the wounds on Resident 2's right and left legs and failed to change gloves and use hand sanitizer in between applying betadine (a brown-colored broad spectrum antiseptic agent) to both legs and applying dressings to both legs.An interview on 3/12/2026 at 11:00 AM with LPN A confirmed they did not change their gloves and did not use hand sanitizer between moving from one body site to the other. LPN A confirmed this was a breach of infection control.An interview on 3/12/2026 at 11:00 AM with the ADON confirmed moving from one wounded body site to another body site without changing gloves or without using hand sanitizer was a breach of infection control.

Licensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview, the facility failed to ensure that monitoring was in place for diuretic medication (a medication that increases the amount of urine produced by the kidneys and helps to remove excess fluid and salt from the body) administered to 3 of 6 residents surveyed (Residents 2, 3, and 4). The facility claimed a census of 109. Findings are: A. A record review of Resident 2's medical diagnoses (the nature and cause of a disease or condition) revealed Resident 2 had Chronic Kidney Disease (a disease characterized by progressive damage and loss of function in the kidneys). A record review of Resident 2's medication orders revealed an order dated 3/3/2025 for Furosemide (a diuretic medication used to treat excess fluid held in the body) 20 mg (mg - milligram - a unit of measurement) daily for edema (excess fluid retained in the body). A record review of Resident 2's physician orders revealed there were no laboratory orders to monitor the effect of the medication Furosemide on Resident 2. A record review of Resident 2's Care Plan (a document that provides directions on the type of nursing care the individual may need) revealed it did not include any interventions (an act to prevent harm or improve functioning) to monitor the resident for the use of Furosemide. An interview on 5/21/2025 at 2:00 PM with RN (Registered Nurse) A confirmed Resident 2 had an order for Furosemide 20 mg daily in March 2025. RN-A confirmed Resident 2 did not have an order to monitor the effects of the medication. B. A record review of Resident 3's medical diagnoses revealed the resident has chronic kidney disease and Congestive Heart Failure (a chronic condition where the heart cannot pump blood effectively, leading to fluid buildup in the lungs and other tissues). A record review of Resident 3's MAR (Medication Administration Record - a standardized record that includes medication names, the dose taken, any special instructions, the date and time the medication was given or withheld, the reasons why, the dates the order was received and discontinued) revealed an order dated 9/25/2024 for Torsemide (a diuretic medication used to treat excess fluid held in the body) 10 mg once daily for edema. A record review of Resident 3's care plan revealed an intervention dated 10/03/2024 which stated: Monitor Lab work as ordered. Ensure results reported to PCP (Primary Care Provider) as needed. A record review of Resident 3's care plan revealed an intervention dated 10/03/2024 which stated: Monitor/document PRN (As needed) any signs or symptoms of hypokalemia (a low blood level of potassium) in residents receiving diuretic therapy: Fatigue, muscle weakness, diminished appetite, nausea and vomiting and dysrhythmias (abnormal heart rhythms). Monitor potassium levels. Notify PCO (physician contracting organization) of these changes as needed. A record review of Resident 3's MRR's (Medication Regimen Review - a thorough monthly evaluation of a patient's medication regimen by a pharmacist to identify, prevent and resolve medication related issues) revealed there were no pharmacy recommendations to monitor the use of the medication Torsemide. A record review of Resident 3's order summary revealed there were no orders to monitor the resident for the use of the medication Torsemide. An interview on 5/21/2025 at 2:25 PM with Resident 3 revealed the resident did not have any blood tests while in the facility. An interview on 5/21/2025 at 2:15 PM with RN-A confirmed Resident 3 did not have an order to monitor the effects of Torsemide. C. A record review of Resident 4's medication orders revealed Resident 4 had an order for Spironolactone (a diuretic medication used to treat excess fluid held in the body) 25 mg. Half of a tablet one time a day for CHF (Congestive Heart Failure - a chronic condition where the heart cannot pump blood effectively, leading to fluid buildup in the lungs and other tissues). A record review of Resident 4's Care Plan revealed the following interventions dated 2/14/2025 which stated: Monitor/document PRN (As needed) any signs or symptoms of hypokalemia (a low blood level of potassium) in residents receiving diuretic therapy: Fatigue, muscle weakness, diminished appetite, nausea and vomiting and dysrhythmias (abnormal heart rhythms). Monitor potassium levels. Monitor Lab work: K+ (potassium), NA (Sodium), BUN (Blood Urea Nitrogen - a test to assess how well the kidneys are functioning), Creatinine (a test to assess kidney function). Report results to PCP. A record review of Resident 4's MAR revealed there is no documentation indicating Resident 4 was monitored for diuretic use. An interview on 5/21/2025 at 2:25 PM with RN-A confirmed Resident 4 did not have an order to monitor the effects of Spironolactone. A record review of an undated sheet provided by the Director of Nursing and titled Medication Monitoring revealed the following information: The following are medication classes that are candidates for routine monitoring, frequency of labs is often provider preference based on the residents' health. Diuretics (CMP or BMP -Comprehensive Metabolic Panel or Basic Metabolic Panel - tests that measure the levels of various substances in the blood). An interview on 5/21/2025 at 11:50 AM with the DON confirmed the pharmacy will make recommendations to the primary care provider to monitor the effects of specific medications. The DON confirmed it is up to the provider to order monitoring for medications.

Licensure Reference Number 175 NAC 12.006.11(E) Nebraska 2017 Food Code 2-301.14 Nebraska Food Code 2017 3-302.11(4) Based on observations, record review and interview; the facility staff failed to utilize handwashing and gloving techneques during meal service and failed to serve foods in a manor to prevent potentail contamination. This had the potential to affect 44 residents. the facility census was 103. Findings are: Record review of a facility policy entitled Meal Tray Delivery Related to Infection Control dated 10/27/2017 revealed: -2. After a tray has been delivered, the server will exit the room and apply hand sanitizer that is provided in the service hallways (Per the hand sanitizing gel policy) prior to entering the next resident's room. -3. Once the server has returned to the kitchen, he/she will repeat the handwashing procedures (Per the handwashing policy) prior to the delivery of the next meal tray. Continuous observation in the assisted dining room and the Evergreen Hall on 04/17/2025 from 12:15 PM to 12:43 PM revealed Nurse Tech (NA)-K, with gloved hands, obtained a meal tray from the enclosed meal tray cart which stored multiple resident trays and delivered the tray to room E12. NA-K knocked on the door and entered the room. The resident declined the tray, without doffing (removing) gloves and without the benefit of hand hygiene, NA-K returned the tray to the meal tray cart, obtained another meal tray and delivered to room E8. NA-K knocked on the door and entered the room. The resident declined the tray. Without doffing gloves and without the benefit of hand hygiene, NA-K returned the tray to the meal tray cart and doffed gloves. Without the benefit of hand hygiene, NA-K donned (applied) gloves, obtained a meal tray from the enclosed meal tray cart and delivered the tray to room E1. The resident declined the meal tray. NA-K Without doffing gloves and without the benefit of hand hygiene, NA-K returned the tray to the tray cart. NA-K obtained a large tray of dishes that contained sliced cinnamon apples. Half of the dishes of cinnamon apples were covered with plastic wrap while the remaining dishes were uncovered. NA-K carried the tray and entered room E4 and delivered the cinnamon apples and exited the room. An interview on 04/17/2025 at 12:46 PM with NA-K confirmed that [gender] did not doff gloves and perform hand hygiene between resident rooms and should have. NA-K further confirmed that [gender] carried the entire tray of cinnamon apples into resident rooms and should not have. An interview on 04/22/2025 at 2:48 PM with the Clinical Care Coordinator (CCC) revealed that 44 residents received foods from the assisted dining room tray cart.

Licensure Reference Number 175 NAC 12-006.02(H) Based on interview and record reviews; the facility failed to report an allegation of abuse to the required State Agency (SA) within the required timeframe for 1 (Resident 15) of 1 sampled resident. The facility staff identified a census of 103. The findings are: Record review of a facility policy entitled Reporting Allegations of Abuse/Neglect/Exploitation dated revised 03/05/2025 revealed: -The facility must develop and operationalize policies and procedures for screening and training team members, protection of guest and for the prevention, identification, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control prevent occurrences. -7. Reporting/Response: The facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective action depending on the results of the investigation. -Procedure for Response and Reporting Abuse/Neglect/Exploitation, including allegations: -2. The Director of Clinical Services and Administrator, or Designee will: -a. Notify the appropriate agencies of all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, not later than 2 hours after the allegation is made, if the evens that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if events that cause the allegation do not involve abuse and do not result in serious bodily injury. -i. Call Nebraska Department of Health and Human Services, Adult Protective Services (HHSS/APS) local office to file the report. Record review of Resident 15's Admission Record revealed the facility admitted the resident on 09/21/2023 with diagnoses of fibromyalgia, other specified depressive episodes, cognitive social or emotional deficit following cerebral infarction (stroke), and insomnia. Record review of Resident 15's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14/15. According to the MDS Manual, a score of 14 indicated the resident was cognitively intact. Further review of the MDS revealed the resident displayed physical and verbal behavioral symptoms on 1-3 days and the resident rejected care on 1-3 days. An observation on 4/16/25 at 3:33 PM of Resident 15's medial aspect of the right upper arm revealed an oval-shaped purple discolored area. An interview on 4/16/25 at 3:33 PM with Resident 15 revealed an allegation that the resident was grabbed, held down, and made me take a shot at the end of March. Resident 15 was unaware of the exact date. Resident 15 revealed that facility staff were aware of the allegation. Resident 15 further revealed that [gender] felt safe at the facility at the time of the interview. The facility Administrator (ADM) and Director of Nursing (DON) were notified by the surveyor of Resident 15's allegation on 04/16/2025 at 3:58 PM. Record review of Resident 15's Progress Notes revealed a note on 03/31/2025 that showed the resident called the police and stated that she had been beaten by a nurse two days ago, and tied up with blue rope, and had blood drawn. Record review of an Abuse, Neglect or Misappropriation document dated 04/01/2025 revealed that the ADM or DON were notified of Resident 15's allegation on 04/01/2025 at 9:30 AM. The document did not show that the SA had been notified. An interview on 04/22/2025 at 7:08 AM revealed that the facility staff reported Resident 15's allegation to the State Agency on 4/16/25 and completed an investigation. The ADM further revealed that the allegation was not reported as required at the time the resident reported the allegation on 03/31/2025.

Nebraska Licensure Reference Number 175 NAC 12-006.09(h)(vi)(3)(g) Based on interview and record review; the facility failed to measure and record pulse rates before and after a breathing treatment was administered for 1 (Resident 42) of 1 sampled resident. The facility staff identified a census of 103. The findings are: Record review of a facility provided, undated Nebulizer Competency revealed: -Procedure: -3. Take client's pulse prior to treatment. -10. Take client's pulse rate at completion of treatment. Record review of Resident 42's Admission Record revealed the facility admitted the resident on 03/11/2025. Further review of the admission record revealed Resident 42 had diagnoses which included congestive heart failure, atrial fibrillation (irregular heartbeat), and chronic kidney disease. Record review of Resident 42's Order Summary Report printed 04/17/2025 revealed an order dated 04/14/2025 for albuterol sulfate inhalation nebulization solution to be administered by nebulizer twice daily for seven days. Record review of Resident 42's medical record revealed that the resident's pulse was measured and recorded one time daily for each day from 04/14/2025 through 04/21/2025. An interview on 04/22/2025 at 9:05 AM with the Director of Nursing (DON) revealed the facility did not have a policy for nebulized medication adminisration and the facility followed the Nebulizer Competency. The DON further confirmed that pulse rates were not measured and recorded before and after the administration of a nebulizer treatment and should have been.

Licensure Reference Number 175 NAC 12.006.18 (D) Based on record review, observation and interview, the facility staff failed to perform hand hygiene before and after using gloves during medication administration for 2 (Residents 33 and 66) of 4 residents observed during medication pass. The facility census was 103. Findings are: A. An observation on 4/17/2025 at 7:10AM of medication administration by Medication Aide (MA) I to Resident 33 revealed MA I donned gloves to assist Resident 33 to sit up, handed them their medication and a glass of water. MA I administered nasal spray and assisted Resident 33 to lie down on their bed. MA I applied powder to Resident 33's skin and covered the resident with a blanket. MA I removed their gloves and left the residents room to return to the medication cart and chart the medication administration. MA I did not wash their hands or use hand sanitizer before putting the gloves on, taking them off or when they exited the room. An interview with MA I on 4/17/2025 at 7:10AM confirmed they should have used hand sanitizer before and after using gloves, but they forgot to do so. B. An observation on 4/17/2025 at 7:30 AM of medication administration by Registered Nurse J (RN J) to Resident 66 revealed RN-J donned gloves in Resident 66's room to administer eye drops to Resident 66. RN-J did not wash their hands or use hand sanitizer prior to donning gloves. An interview on 4/17/2025 at 7:30 AM with RN J confirmed they should have used hand sanitizer or washed their hands before donning gloves and they had not done so. A record review of the facility Hand Hygiene Policy dated 3/1/2022 revealed the following: A. Hand Hygiene Guidance. 1. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: a).Immediately before touching a patient. b).After touching a patient or the patients immediate environment. f). Immediately after glove removal. - Gloves and Hand Hygiene. 1. Wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potential infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment occur. 2. Gloves are not a substitute for hand hygiene. a). If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment.

Licensure reference: 175 NAC 12-006.09(H) Based on observation, interview, and record review, the facility failed to ensure positioning to maintain body alignment for 1 [Resident 1] of 3 sampled residents. The facility had a total census of 103 residents. Findings are: A review of Resident 1's Admission Record revealed Resident 1 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease [a progressive disease that destroys memory and other important mental functions]. A review of Resident 1's Care Plan revealed a focus area for being at risk for falls with an intervention dated 11/2/24 of staff being educated on ensuring Resident 1 is in a tilt position in wheelchair at all times except when eating meals. A review of facility investigation dated 11/6/24 revealed Resident 1 was being wheeled to communal area after dinner when Resident 1 put feet down on the floor, leaned forward and fell out of Resident 1's wheelchair. Resident 1 was transferred to the hospital and diagnosed with a nose fracture. As follow-up, staff education was provided regarding resident's wheelchair being in the tilt position at all times except during meals. Observations on 11/20/24 at 8:46 AM, 9:28 AM, 9:40 AM revealed Resident 1 seated in tilting wheelchair at dining room table with chair in upright position. Resident 1's legs/feet were in dependent position without leg rests or foot pedals to support Resident 1's legs. Resident 1's feet did not reach the floor. Observations on 11/20/24 at 10:06 AM, 10:50 AM, and 11:32 AM revealed Resident 1 seated in common area, with activities going on, with wheelchair tilted back and feet/legs dangling from wheelchair seat. The wheelchair did not have any leg rests or foot pedals to support Resident 1's legs. Observations on 11/20/24 at 11:36 AM revealed Resident 1 pushed from common area to dining room table in with wheelchair in reclined position with feet/legs dangling from wheelchair seat. No leg rests or foot pedals were placed on wheelchair while wheelchair was being moved. Resident 1 wheelchair was placed in an upright position while at dining room table. Resident 1 feet did not touch the floor while in the upright position. Observations on 11/20/24 at 1:14 PM revealed Resident 1 being pushed from dining room table to spa in reclined position with feet/legs dangling and no leg rests or foot pedals on wheelchair. In an interview on 11/20/24 at 1:14 PM, Nurse Aide A confirmed staff had been educated to tilt Resident 1 back when transporting in wheelchair. In an interview on 11/20/24 at 2:19 PM, Occupational Therapist G reported Resident 1 had been evaluated for a new wheelchair but it had not been approved by Resident 1's insurance. Occupational Therapist G confirmed leg rests/foot pedals should be utilized when Resident 1 is tilted back in wheelchair or when wheelchair is being pushed. In an interview on 11/20/24 at 3:18 PM, the Director of Nursing reported Resident 1's wheelchair pedals had been removed from the wheelchair due to Resident 1 scooting self-back in the wheelchair. The Director of Nursing confirmed that wheelchair pedals should be used when pushing a resident in the wheelchair.

Licensure reference: 175 NAC 12-006.09(l) Based observation, interview, and record review, the facility failed to ensure residents were transferred in accordance with plan of care for 2 [Residents 1 and 3] of 3 sampled residents. The facility had a total census of 103 residents. Findings are: A. A review of Resident 3's Admission Record revealed Resident 3 was admitted to the facility on [DATE] with Parkinson's Disease [a disorder of the central nervous system that affects movement] and unspecified dementia. A review of Resident 3's Care Plan revealed a focus area related needing assist with activities of daily living with an intervention dated 11/15/24 of Resident 3 requiring a Hoyer lift [full body lift] transfer with 2-assist. Observations on 11/20/24 at 11:51 AM revealed Resident 3 being transferred from recliner to wheelchair by Director of Nursing and Nurse Aide A with gait belt and utilizing a pivot transfer. Resident 3 was taken by wheelchair to the spa and transferred to toilet by Nurse Aide A and Nurse Aide B to toilet with gait belt utilizing a pivot transfer. Observations on 11/20/24 at 1:25 PM revealed Nurse Aide C and Nurse Aide D transfering Resident 3 from wheelchair to bed utilizing a Hoyer lift [full body weight lift]. A review of Shoe Color Change assessment dated 11.14.24 identified Resident 3 being a red shoe transfer which is identified as requiring assist of 2 and/or mechanical lift. A review of Physical Therapy Note dated 11/14/24 revealed Resident 3 had decreased weight bearing, decreased upright posture and no maneuvering of bilateral feet during pivot transfer. A trial of transfer with sit to stand lift revealed Resident 3 with decrease in upright posture and heavy leaning into axillary. Physical Therapy note stated that due to concerns identified and concern for patient/staff safety Resident 3 was being downgraded to Hoyer lift transfer with assist of 2. A review of undated Shift Report revealed Resident 3 was identified as a 2 assist stand pivot, hoyer lift. In an interview on 11/20/24 at 1:35 PM, Nurse Aide A reported being unaware that Resident 3's transfer status had been changed to a Hoyer Lift. In an interview on 11/202/4 at 2:41 PM, Physical Therapy Assistant E confirmed Resident 3 transfer status had been downgrade to a Hoyer lift transfer due to difficulty with a pivot transfer, ability to bare weight, and inconsistency with ability to use sit to stand lift. Physical Therapy Assistant E reported completing shoe color change form and care profile. In an interview on 11/20/24 at 3:07 PM, the Director of Nursing reported that being aware of Resident 3 transfer status change to Hoyer lift. The Director of Nursing reported Resident 3 can do a pivot transfer when alert and staff can use their discretion for making transfer decisions. B. A review of Resident 1's Admission Record revealed Resident 1 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease [a progressive disease that destroys memory and other important mental functions]. A review of Resident 1's Care Plan revealed a focus area related having a deficit with activities of daily living and needing moderate to maximum assist with activities of daily living with an intervention dated 9/23/24 of Resident 1 requiring Hoyer lift transfer with 2-assist. Observations on 11/20/24 at 1:14 PM revealed Resident 1 being transferred out of wheelchair by Nurse Aide A and Nurse Aide F utilizing a sit to stand lift. A review of Resident 1's Therapy Screening Note dated 8/23/24 revealed Resident 1 remains a Hoyer lift with 2-assist. A review of undated Shift Report revealed Resident 1 was a 2 assist-sit 2 stand-hoyer. In an interview on 11/20/24 at 2:54 PM, Physical Therapy Assistant E reported that Resident 1 has not been on case load for a period of time. Physical Therapy Assistant E reported that nursing may down grade a resident's transfer status based on resident and staff safety. In an interview on 11/20/24 at 3:18 PM, the Director of Nursing reported Resident 1 may be a Hoyer lift transfer or a sit to stand transfer depending on behaviors.

Licensure Reference Number 175 NAC 12-006.09D7a Based on interview and record review, the facility failed to ensure 1 (Resident 48) of 8 sampled resident's safety belt remain secured during the bathing process and implement interventions to prevent a fall with fracture for 1 (Resident 94) of 8 sampled residents. The facility census was 92. Findings are: A. Record review of the facility's Bathing Procedure dated 05/23/2024 revealed the spa tub procedure was to assist residents out of their clothing and onto the tub chair utilizing appropriate transfer device and ensure the safety belt was on the resident. NEVER leave guest unattended during bath. A record review of Resident 48's Medical Diagnosis dated 04/04/2024 revealed the resident had diagnoses of Vascular Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety (confusion), Other Sequelae of Cerebral Infarction (altered sensation following a stroke), Memory Deficit Following Cerebral Infarction (poor memory following a stroke), Epilepsy, Unspecified, Not Intractable, Without Status Epilepticus (uncontrolled seizure disorder), Long Term (Current) Use of Opiate Analgesic (long term use of a pain patch), and Essential (Primary) Hypertension, (high blood pressure). A record review of Resident 48's Minimum Data Set (MDS, a comprehensive assessment used to develop a resident's care plan) dated 02/14/2024 revealed the resident had a Brief Interview for Mental Status (BIMS, a score of a residents cognitive abilities) that was blank. The resident was dependent for all activities of daily living (ADL), transfers, and rolling left to right. The MDS revealed Resident 48 was on Hospice (end of life care). A record review of Resident 48's Care Plan with an admitted [DATE] revealed the resident was admitted to the facility on [DATE]. The resident had a Focus area of at risk for falls due to a history of falls, balance issues, at risk for falls per fall risk assessment, incontinence, use of PRN opioid meds (medications), impulsive and does not recognize her limitations due to dementia and multiple interventions for falls. The Care Plan revealed the residents would require 2-person assist with ADLs for safety and was a mechanical lift for transfer with 2 staff assistance. A record review of Resident 48's Progress Note dated 03/22/2024 at 1:32 PM revealed the Hillcrest Hospice Bath Aide (HHBA)-X finished giving Resident 48 a bath and was about to start dressing the resident when HHBA-X saw the resident leaning forward. HHBA-X went to stop the resident from falling and ended up falling on the spa floor and Resident 48 fell on top of HHBA-X. The resident hit the resident's head, needed stitches, and was sent to the Emergency Department (ED). A record review of the Abuse, Neglect or Misappropriation (stealing) reportable sheet dated 03/26/2024 revealed on 03/22/2024 at about 12:20 PM, the HHBA-X was getting Resident 48 out of bath and drying resident off. HHBA-X lowered the shower chair and removed bath strap and reached for resident's shirt and the resident fell out of the chair onto staff member that slipped trying to stop the fall. The resident fell on HHBA-X and hit the resident's head on floor that required sutures. The resident was a Hoyer lift (mechanical lift for transfers) for all transfers. The resident was alert and oriented to the resident's name only. The resident was assessed and sent to ED. Permanent measures to prevent reoccurrence were that Hospice was to increase their presence with the resident, continue comfort meds, and the resident would require 2 staff assist when bathing, transferring, and dressing. A record review of the Hillcrest Hospice Patient Fall dated 3/22/2024 revealed Resident 48 was sitting in the bath chair and was finished with bathing. HHBA-X was present and stared to dress the resident. HHBA-X turned to grab the resident's shirt and the resident was leaning forward when HHBA-X reached to catch the resident. HHBA-X slipped on water and fell and the resident fell over HHBA-X. Resident 48 hit the resident's head on the bath chair leg. There was a large laceration on top of the resident's head and a moderate amount of bleeding. The wound measured 6.5 centimeter (cm) long, 0.7 cm wide, and 0.4 cm deep but it was an approximate measurement because the resident's hair and bleeding interrupted the view. A record review of the Hospice Nursing Clinical Note dated 03/22/2024 revealed the same information as the Hillcrest Hospice Patient Fall dated 3/22/2024 and also revealed Resident 48 was moaning occasionally, the wound was on the crown of the head, and the wound appeared deeper in some areas than what was measured. The Hospice Nurse, Case Manager (HNCM)-Y, notified the Emergency Medical Services (EMS) that the resident was a Hospice patient, and they only wanted the head laceration addressed, no other tests, procedures, or treatments. The HNCM-Y then spoke with the ED and notified the ED that the HNCM-Y only wanted the resident's head assessed with no other treatments, assessments, or procedures and then send the resident back to the facility. A record review of Resident 48's Progress Note dated 03/22/2024 at 06:00 PM revealed the resident returned from the ED with the head laceration (cut) was repaired with dissolving sutures (stitches) and that the resident had no signs of pain at that time. A record review of Resident 48's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated March 2024 revealed the resident had an order for Morphine Sulfate (concentrate)(a liquid pain medication) Oral Solution 100 milligrams (mg)/5 Milliliters (ml). Give .025 ml every 6 hours for pain and every 1 hour for pain as needed. The order for as needed has only administered (given) on 03/01/2024 and 03/04/2024 prior to the resident's fall and the last dose of that order was administered 03/22/2024 at 12:00 PM. After the fall the Morphine Sulfate (concentrate) Oral Solution 100 mg/5 ml was changed to: Give .5 ml every 4 hours for pain and every 1 hour for pain as needed which was last administered 03/23/2024 at 12:00 PM Give .5 ml every 4 hours for pain and every 30 minutes for pain as needed which was last administered 03/23/2024 at 12:17 PM Give .5 ml every 2 hours for pain and every 1 hour for pain as needed which was last administered 03/24/2024 at 04:00 AM Give .75 ml every 4 hours for pain and every 1 hour for pain as needed which was last administered 03/25/2024 at 08:00 AM Give 1.25 ml every 2 hours for pain and every 1 hour for pain as needed which was last administered 03/25/2024 at 10:00 PM Give 1.75 ml every 2 hours for pain and every 1 hour for pain as needed which was last administered 03/29/2024 at 10:00 AM AT 2:00 PM at 2:00 PM Oxycodone HCL (a pain medication) Oral Tablet 10 mg, Give 2 tablets under the tongue every 2 hours and every 1 hour as needed for pain or shortness of breath, crush tabs and dissolve in a small amount of liquid was last administered 03/31/2024 at 6:00 AM. In a telephone interview on 04/04/2024 at 3:26 PM, HHBA-X confirmed HHBA-X got Resident 48 out of the bath and resident was still in shower chair. HHBA-X took the safety strap off and went to reach for the resident's clothing and it was out of reach, so HHBA-X had to take a step away from the resident. HHBA-X noticed the resident start to fall so HHBA-X stepped to put a hand in front of the resident, the HHBA-X slipped, and the resident fell on top of HHBA-X and smacked the resident's head on shower chair leg. My biggest mistake was I took the strap off too soon. In a telephone interview on 04/04/2024 at 1:43 PM, HNCM-Y confirmed Resident 48 fell , hit the resident's head, was bleeding, and sent to the ED. HNCM-Y confirmed HHBA-X told HNCM-Y that HHBA-X got the resident out of the whirlpool and the resident was in the chair, the chair was in the normal sitting position. HHBA-X started drying the resident, took the safety belt off and threw it in the corner, went to reach for Resident 48's clothing but it was out of reach, so HHBA-X had to take a couple of steps away and the resident started leaning forward so HHBA-X lunged back toward the resident and slipped in water, and resident 48 fell over HHBA-X and hit the resident's head. HNCM-Y confirmed the safety belt should have been left on the resident anytime the resident was in the bath chair unless another staff member was there to assist. HNCM-B confirmed the resident did have increased pain following the fall. In an interview on 04/04/2024 at 11:26 AM with Regional Nurse Consultant (RNC)-A confirmed HHBA-X should not have taken the safety belt off the resident prior to getting the resident dressed and transferred. 50106 B. Record review of Resident 94's census sheet printed on 4-02-2024 revealed Resident 94 was admitted to the facility on [DATE] and was discharged on [DATE]. Record review of Resident 94 Medical Diagnosis sheet printed on 4-02-2024 revealed the following diagnosis: Attention and concentration deficit following cerebral infarction, cognitive social or emotional deficit following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, cerebral infarction, and vascular dementia. Record review of Resident 94's annual Minimum Data Set (MDS, federally mandated assessment tool used for care planning), dated 6/29/2023 revealed Resident 94 had a Brief Interview for Mental Status (BIMs) score of 3. According to the MDS [NAME] a score of 0 to 7 indicates a person has severe cognitive impairment. Further review of Resident 94's MDS revealed Resident 94 had rejection of care issues 4-6 times during the look-back period. According to Resident 94's MDS dated [DATE] Resident 94's functional status revealed Resident 94 required extensive assist with bed mobility, limited assistance with transfers, supervision with eating, and limited assistance with toileting. Mobility devices used by Resident 94 were a walker and a wheelchair. Bowel and bladder status of Resident 94 revealed occasionally incontinent of urine and frequently incontinent of bowel. Record Review of Resident 94's Comprehensive Care Plan (CCP) revealed the following information: -Fall Problem: Falls-at risk due to history of falls, need for assist with Activities of Daily Living (ADLs) mobility due to balance issues, incontinence of bowel and bladder, does not recognize limitations due to dementia, non-compliant with calling for assist or waiting for assistance with transfers related to cognition and dementia, at risk per fall risk assessment. -Goals: Resident 94 will have no falls with injury thru next review. -Interventions: -Fall risk assessment completed. Fall score is 18. A score of 18 revealed Resident 94 is a high risk for falls. (No date). -Falling prevention program as indicated. Date identified as Status active and current. -Encourage to use the call light. (No date). -5/18/23-Physical therapy to evaluate and treat. -6/13/23-Request for Miralax (Laxative to treat constipation) to be changed to as needed (PRN). -6/26/23-X-ray done; sent to hospital due to inconclusive X-ray results. -3/8/23- Call don't fall sign in resident's bathroom. -7/27/23-Encourage resident to use the bathroom. 5/18/23-red tape to call light for visual acuity. -Transfer to stronger side-left side- (no date). -Keep assistive device within reach. -9/15/22-Call don't fall sign. -11/6/22-red tape to call light for visual acuity. -4/16/23-Physical therapy to evaluate and treat due to recent falls. -5/15/23-soft touch call light. Record review of a Huddle Report sheet dated 6/13/2023 revealed Resident 94 fell in the bathroom. In the section titled immediate interventions to be taken the following interventions were: Do not leave alone (Resident 94) with wheelchair in room, please rise slowly to prevent dizziness, non-slip socks, and staff to assist to bathroom on a schedule. Record review of a Huddle Report sheet dated 6/26/2023 revealed Resident 94 fell in the dinning area. Further review of the Huddle Report sheet dated 6/26/2023 revealed Resident 94 had complaints of left hip pain after being assisted back to Resident 94's room. According to the information in the Huddle Report sheet dated 6/26/2023 Resident 94 was sent to the emergency room (ER). Record review of a Fall with Injury sheet dated 6/28/2023 revealed Resident 94 had fallen while ambulating in the dinning room. Resident 94 complained of pain and was assisted back to Resident 94's room in a wheelchair. Resident 94 was sent to ER for an evaluation with the results being Resident 94 sustained a fracture of the left femur. Interview with MDS coordinator on 4/3/23 at 7:55 AM confirmed the intervention added to the care plan for fall dated 6/26/23 was X-ray done; sent to the hospital due to inconclusive X-ray results. MDS coordinator confirmed no further interventions are found nor implemented on the care plan. Interview on 4/4/24 at 4:31 PM with MDS Coordinator revealed the following interventions were never added to the care plan or implemented: Do not leave alone (Resident 94) with wheelchair in room, please rise slowly to prevent dizziness, non-slip socks, and staff to assist to bathroom on a schedule. Record review of Hillcrest Health Services, Fall Risk Management Program, with effective date 4/18/22, revealed: Determining Appropriate Interventions: 1. Nurse/Therapist reviews medical and personal history and completes additional screens/assessments as needed to assist in determining additional risk factors for falls. 2. After completion of additional assessments, admitting nurse or therapist determines what factors could contribute to fall risk. a. Based on these factors, the admitting nurse and/or therapist determines appropriate interventions to implement within the baseline care plan/nurse tech care plan. 3. Selected interventions will be updated to the Care plan and/or Nurse Tech Care plan by the clinical care coordinator, therapist and/or designees. Therapy selected interventions will be communicated to the nurse on shift and initially implemented by therapist of designee. 4. Fall Risk interventions should be reviewed by the interdisciplinary team as needed and can be included in the Quality assurance, Huddle, Risk, and All Team Meetings. 5. Care plan interventions are reviewed during interdisciplinary team meetings assuring interventions continue to be appropriate for the resident/patient. a. Care Plan Interventions should be monitored and/or audited for consistent application in the care of the patient. Care plan interventions should be monitored and/or audited for consistent application in the care of the patient. Care plan interventions can be listed on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) and/or nurse tech care plan according to the Plan of Care policy. 6. Nursing/Therapy leadership will educate the nursing/IDT (Interdisciplinary Team) on a regular basis regarding care plan interventions for all risk reduction efforts, changes in care, etcetera.

Licensure Reference Number 175 NAC 12-006.11E Based on observation, interview, and record review, the facility failed to perform hand washing after touching potentially contaminated items during meal prep, place the blade in the puree blender in a sanitary manner, ensure staff did not touch the drinking surfaces of the cups of 12 residents in the E hall dining room to prevent cross-contamination. The facility failed to ensure the main kitchen and the Evergreen/Memory unit kitchen floors and equipment were cleaned and failed to ensure all items in the Evergreen/Memory Care unit refrigerator and freezer were labeled and dated to prevent the potential for food-borne illness. This had the potential to affect all 92 residents in the facility. The facility census was 92. Findings are: A. An observation on 04/02/2024 at 7:04 AM revealed the facility's Chef went to dry storage in the food preparation (prep) process and got 3 cans of green beans, the Chef opened a box of frozen beans and opened the plastic bag inside the box and dumped them into a saucepan with the other green beans. The Chef did not perform hand hygiene after returning from the dry storage area. The Chef got a strainer, dumped a can of green beans in a steamer pan, opened another can of green beans and dumped the beans into a large saucepan. The Chef covered both steam pans, and left the food prep area to go to the walk-in refrigerator and placed the green beans in walk-in. The Chef then returned to the food prep area and took large saucepan, added an unmeasured amount of water, placed the saucepan on the stove without having performed hand hygiene. The Chef put a pot of measured water on stove, got a rag from sanitizer bucket and rung it out, refilled the sanitizer bucket, tested the sanitizer revealing the sanitizer was in range. The Chef got a new towel from the bin, went to walk-in freezer got a box of chicken, gloved, without performing hand hygiene, realized the box of chicken was bad so the Chef threw it away, went back to the walk-in freezer and got a box of frozen sausage patties, and re-gloved, all with no hand hygiene. The Chef opened the box by touching the box and the bag inside and grabbed the sausage patties and placed them on a baking sheet, removed the gloves and placed the baking sheet of sausage patties into oven, all without hand hygiene. The Chef closed the bag, dated it, covered it with plastic wrap, and went back to the walk-in freezer. The Chef then opened a box, re-gloved, opened a bag of chicken breast, grabbed the chicken breasts with the gloved right hand and placed the chicken in a medium warmer pan, added unmeasured amt of water, removed the gloves and handwashed for greater than 20 seconds. The Chef prepped the potatoes and took the box of unused potatoes to walk-in refrigerator, returned to the food prep area, stirred the gravy with the right hand, got 6 small steam pans and put plastic bags in them without gloved hands. The Chef went to walk-in and got 2 boxes of diced chicken, added unmeasured amount of water to the gravy, got a bag of diced chicken from the box, opened and dumped the chicken into the gravy, whisked in, and added basil leaves without hand hygiene. The Chef got bread loafs, set the oven to 45 minutes, and put the baking trays of potatoes in the oven. The Chef got a knife, gloved both hands, halved bread slices and them placed the bread in a steamer pan with paper, returned to the food prep area and covered the bread with plastic wrap removed gloves and did not complete hand hygiene. The Chef whisked the chicken supreme, got a spoon and stirred the beans with right hand, then took the green beans to blender and used the Chef's bare hand to put the blade in the blender. The Chef then scooped in servings of green beans and pureed the beans. The Chef dumped the beans into the warmer pans, covered with plastic wrap and repeated the process 2 more times. The Chef put the 3 pans of green beans on the griddle, stirred the chicken supreme mixture, pureed more green beans, took the blender parts to the sink and sprayed them off, and ran blender parts through the sanitizer. The Chef took the blender bowl back to blender and placed the blade in using right bare hand without having performed hand hygiene. In an interview on 04/04/2024 at 8:55 AM, the facility's Dietary Manager (DM) confirmed the Chef should have washed hands when the Chef returned to the food prep area after going to the dry storage, walk-in refrigerator and freezer, and after touching the boxes. The DM confirmed the Chef should not have inserted the blade into the blender with a potentially contaminated bare hand. B. An observation on 04/02/2024 at 12:18 PM revealed Dietary Aide (DA)-HH delivered beverages in cups to Residents 62, 84, 47, 76, 34, 21, 20, 33, 36, 69, 86, and 35 in E hall dining room by touching the drinking surface of the cups and the drinking surface of the straw for Resident 34. In an interview on 04/02/2024 at 12:53 PM, The Registered Dietician (RD) confirmed the RD observed DA-HH delivered beverages in cups by touching the drinking surfaces of the cups for the above listed residents and the straw for Resident 34. The RD reported DA-HH should not have touched the drinking surfaces. C. A record review of the Culinary (cooking or kitchen) Equipment Cleaning Policy dated 02/22/2022 revealed each piece of equipment would have a cleaning procedure and weekly schedule for cleaning. The cleaning checklist forms were to be signed off by the team member that completed the task. It was the responsibility of the culinary team to maintain the sanitization of all pieces of equipment and the kitchen. A record review of the facility's undated Chef's Daily Cleaning List revealed the morning chef was to sweep and mop the entire kitchen and clean under the prep and steam tables. A record review of the undated Chef Weekly Cleaning List revealed the morning and evening shift chefs were to work together to clean the walls behind the equipment, sides of the equipment, and the floors under the equipment on Wednesdays. An observation on 04/01/2024 at 7:05 AM revealed the floor throughout the main kitchen contained scattered food debris and white flakes, a black substance, and were sticky by reach-in refrigerator with glass doors. Both the walk-in refrigerator and walk-in freezer floors contained scattered food debris. The inside of the walk-in refrigerator door had smeared substance and handprints on it. Oven 001's horizontal and vertical surfaces were scattered with splashes from the waste can and food debris. The vertical surfaces of the stove contained a brown crusty substance and food debris. The stainless-steel wall behind the griddle was splattered with a white substance. The top of the steamer had gray fuzzy substance and food debris on it. The dish sanitizer had a white crusty and brown crusty substance on the top. The warmer carts doors contained smears of food and the bottoms contained food debris. An observation on 04/02/2024 at 7:04 AM revealed the floor throughout the main kitchen contained scattered food debris and white flakes, and a black substance. Both the walk-in refrigerator and walk-in freezer floors contained scattered food debris. The inside of the walk-in refrigerator door had smeared substance and handprints on it. Oven 001's horizontal and vertical surfaces were scattered with splashes from the waste can and food debris. The vertical surfaces of the stove contained a brown crusty substance and food debris. The stainless-steel wall behind the griddle was splattered with a white substance. The top of the steamer had gray fuzzy substance and food debris on it. The dish sanitizer had a white crusty and brown crusty substance on the top. The warmer carts doors contained smears of food and the bottoms contained food debris. An observation on 04/01/2024 at 7:05 AM with the DM revealed the floor throughout the main kitchen contained scattered food debris and white flakes, a black substance, and were sticky by reach-in refrigerator with glass doors. Both the walk-in refrigerator and walk-in freezer floors contained scattered food debris. The inside of the walk-in refrigerator door had smeared substance and handprints on it. Oven 001's horizontal and vertical surfaces were scattered with splashes from the waste can and food debris. The vertical surfaces of the stove contained a brown crusty substance and food debris. The stainless-steel wall behind the griddle was splattered with a white substance. The top of the steamer had gray fuzzy substance and food debris on it. The dish sanitizer had a white crusty and brown crusty substance on the top. The warmer carts doors contained smears of food and the bottoms contained food debris. In an interview on 04/01/2024 at 11:50 AM, the DM confirmed the DM observed all of the above concerns and that all of the items should have been cleaned and were not. D. A record review of the Culinary (cooking or kitchen) Equipment Cleaning Policy dated 02/22/2022 revealed each piece of equipment would have a cleaning procedure and weekly schedule for cleaning. The cleaning checklist forms were to be signed off by the team member that completed the task. It was the responsibility of the culinary team to maintain the sanitization of all pieces of equipment and the kitchen. A record review of the undated Evergreen/Memory Kitchen Daily Cleaning End of Shift Check List revealed the refrigerator and freezer was to be cleaned daily on the morning and afternoon shift. It did not reveal a cleaning schedule for the floors and microwave. An observation on 04/01/2024 at 7:42 AM of the Evergreen/Memory Care unit's refrigerator revealed the handles had white crusty substance on them, the floors had a dark gray substance and scattered drippings. The horizontal surfaces and pull-out tray of the refrigerator were sticky and contained food debris throughout. All surfaces of the freezer were sticky and contained food debris. The microwave had red and brown food debris on bottom. An observation with the DM on 04/01/2024 at 11:50 AM of the Evergreen/Memory Care unit's refrigerator revealed the handles had white crusty substance on them, the floors had a dark gray substance and scattered drippings. The horizontal surfaces and pull-out tray of the refrigerator were sticky and contained food debris throughout. All surfaces of the freezer were sticky and contained food debris. The microwave had red and brown food debris on bottom. In an interview on 04/01/2024 at 11:50 AM, the DM confirmed the DM observed all the concerns from above and confirmed the refrigerator, freezer, floors, and microwave should have been clean and they were not. E. A record review of the facility's Proper Food Storage policy dated 02/22/2022 revealed the staff should label all foods removed from their original container. The label should contain the item name, preparation date, use by date, expiration date, and prepared by name. An observation on 04/01/2024 at 7:42 AM of the Evergreen/Memory Care unit's refrigerator revealed 1 great value Blue Cheese Dressing opened, not dated. 1 Mr. C's Italian dressing opened, not dated. a plastic bag with a Styrofoam container, what appeared to be lunch meat and a banana was not labeled and dated. The freezer contained 1 white plastic bag assorted meats, 2 bags of brats, 2 bags of jerky were not labeled or dated, 1 black container with clear lid and brown and white substance inside was not labeled and dated. An observation with the DM on 04/01/2024 at 11:50 AM of the Evergreen/Memory Care unit's refrigerator revealed 1 great value Blue Cheese Dressing opened, not dated. 1 Mr. C's Italian dressing opened, not dated. a plastic bag with a Styrofoam container, what appeared to be lunch meat and a banana was not labeled and dated. The freezer contained 1 white plastic bag assorted meats, 2 bags of brats, 2 bags of jerky were not labeled or dated, 1 black container with clear lid and brown and white substance inside was not labeled and dated. In an interview on 04/01/2024 at 11:50 AM, the DM confirmed the DM observed the items listed above and all the items should have been labeled and dated.

Licensure Reference Number 175 NAC 12-006.17B Licensure Reference Number 175 NAC 12-006.17D Based on observation, interview, and record review, the facility failed ensure the facility staff wore surgical masks above the nose and below the chin while in resident care areas, failed to perform hand hygiene when going between 2 residents while assisting with meal, failed to ensure that hand hygiene was performed before and after glove changes during medication administration for Resident 74, and failed to glove and do hand hygiene to prevent cross-contamination during wound care for resident 81 and catheter care for Resident 88 and Resident 1. This had the potential to affect all 92 residents in the facility. The facility census was 92. Findings are: A. A record review of the facility's Infection Prevention and Control Program dated 01/04/2024 revealed health care workers were recommended to wear masks during routine care for residents who were thought to be contagious. Observation on 4-01-2024 at 8:06 AM revealed a sign was posted directing when entering the unit everyone must wear a mask. An observation on 04/01/2024 at 10:19 AM revealed Medication Aide (MA)-M was working with Resident 84 within 1 foot of the resident with the MA-FF's surgical mask below the nose. An observation on 04/01/2024 at 11:43 AM revealed MA-M was walking down the hall between resident rooms C8 - C13 with the surgical mask off. An observation on 04/01/2024 at 10:22 AM revealed Registered Nurse (RN)-W was working within 2 feet or Resident 69 with the surgical mask below the nose. An observation on 04/01/2024 at 11:45 AM revealed MA-FF walked down the hall between resident rooms C2 - C6 with the surgical mask below the mouth. MA-FF then walled into the nurse's station where there was a resident taking a breathing treatment and MA-FF sat down within 2 feet of the resident. An observation on 04/02/2024 at 11:55 AM revealed Licensed Practical Nurse (LPN)-AA pushed a resident North from the dining room past the main entrance leaning on the handles of the resident's wheelchair with the surgical mask below the nose. LPN-AA face was within 1 foot of the resident's face. An observation on 04/02/2024 at 12:05 PM revealed MA-K had the surgical mask below the nose as 3 resident past by to enter the assisted dining room. All 3 residents were within 3 feet of MA-K. An observation on 04/02/2024 at 12:09 PM revealed MA-K was in a resident's room working with the resident with the surgical mask below the nose. An observation on 04/02/2024 at 2:09 PM revealed Administrative Assistant (AA)-GG sat at the reception desk at the entrance to the facility within 2 feet of a visitor without a mask, and within 6 feet of a resident with the surgical mask below the nose. In an interview on 04/02/2024 at 12:09 PM, the Regional Nurse Consultant (RNC)-A confirmed there were COVID-19 positive residents in the facility and all the staff should have worn a surgical mask at all times while in the facility above the nose and below the chin. B. A record review of the facility's Infection Prevention and Control Program dated 01/04/2024 revealed hand hygiene (cleaning) should have been completed before and after direct contact with each resident and before donning (putting on) and after removing gloves. In an observation on 04/02/2024 at 12:32 PM revealed Nursing Assistant (NA)-II touched Resident 20's clothing and arm then assisted Resident 33 with the meal without removing gloves and performing hand hygiene. NA-II kept touching Resident 20's clothing protector and then would go back to assisting Resident 33 with bite of food. NA-II continued to go back and forth between assisting Residents 20 and 33 with bites of food. An observation on 04/02/2024 at 12:37 PM revealed Activities Director (AA)-JJ went back and forth between Resident 34 and Resident 21 assisting with bites of food and adjusting the resident's clothing. AA-JJ did not perform hand hygiene at any time between contacts with the residents. AA-JJ then got up, touched Resident 35's clothing and wheelchair and then went back to assisting Residents 34 and 21 with bites of food. AA-JJ touched Resident 34's lap with AA-JJ's right hand then assisted Resident 21 with a bite of food with the same right hand. AA-JJ touched Resident 34's clothing on back with AA-JJ's right hand, assisted with drink, then assisted Resident 21 with a bite of food with the same right hand. AA-JJ got up and got Resident 34 a cup of ice water gave the resident a drink while touching straw with right hand. AA-JJ the assisted Resident 21 with a bite of food with the same right hand. AA-JJ touched Resident 34's spoon and then assisted Resident 21 with a bite with the same right hand. The entire observation did not reveal AA-JJ performed hand hygiene. In an interview on 04/02/2024 at 12:53 PM, The Registered Dietician (RD) confirmed the RD observed AA-JJ and NA-II going back and forth assisting residents with dining without having performed hand hygiene and should have. In an interview on 04/02/2024 at 12:53 PM RNC-A confirmed AA-JJ and NA-II should not have went back and forth between residents while assisting with dining without having performed hand hygiene between resident contacts. 45614 C. An observation on 04/03/2024 at 7:15 AM of Certified Medication Assistant K (CMA)-K performing blood glucose testing and insulin administration for Resident 74 revealed CMA-K gathered Resident 74's individual glucose monitor, a test strip, a cotton ball, a lancet and a pair of gloves. CMA-K also had 2 insulin flex pens, one of Lantus with 22 units of insulin and one of Humalog 5 units of insulin, both pens were prepared for administration with a safety needle attached. CMA-K entered the resident room and informed Resident 74 that CMA-K was there to test the residents blood glucose and administer insulin. Resident 74 agreed and CMA-K donned gloves without washing their hands or using hand sanitizer. CMA-K opened the alcohol wipe and wiped the forefinger on the right hand. CMA-K used the lancet to [NAME] the skin producing a drop of blood , placed the test strip in the glucometer and collected the blood drop. CMA-K used the cotton ball to blot the blood on the resident's finger and then gathered the trash and removed their gloves. CMA-K did not wash or sanitize their hands after removing the soiled gloves. An observation on 04/03/2024 at 7:40 AM Revealed CMA-K returned to Resident 74's room with an alcohol wipe, donned clean gloves and did not washing or sanitizing their hands CMA-K wiped Resident 74's upper right arm with the alcohol wipe and administered the insulin Humalog, 5 units to the front of the arm and Lantus 22 units to the back of the arm. Record review of the facility's Infection Prevention and Control Program dated 01/04/2024 revealed hand hygiene (cleaning) should have been completed before and after direct contact with each resident and before donning (putting on) and after removing gloves. 50106 D. Record Review of Minimum data Set (MDS, a federally mandated assessment tool used for care planning) dated 3/4/2024 revealed Resident 87 had a BIMS of 12. According to the MDS [NAME] a BIMS score of 8 to 12 indicates a person has moderately impaired cognition. Record review of Physician Orders dated 3/6/2024 for Resident 87 revealed an order for Triad Hydrophilic Wound Dress External Paste (Wound Dressings) to be apply to coccyx wound two times a day after cleansing area until healed. Observation on 04/02/24 at 9:37 AM revealed LPN-P gathered supplies from the nurse's station. LPN-P knocked on Resident 87's door and got permission for observation of the wound care. LPN-P laid the supplies on the bedside table without a barrier. LPN-P closed the blinds, did Hand Hygiene (HH) and applied clean gloves. Resident 87 slid their pants down to knees and to perform the wound care Resident 87 bended over the bed to expose the coccyx area. LPN-P sprayed the wound with wound cleaner and wiped with a new gauze each swipe down the coccyx. LPN-P with the same soiled gloves applied the cream to the open area on Resident 87's coccyx. A interview on 04/02/24 at 9:45 AM with LPN-P confirmed HH should have been done between cleaning the wound and application of the cream. LPN-P further confirmed a barrier should have been used when laying supplies on the bedside table. Policy Hand Hygiene policy Effective: 4.11.18; Updated 2.23.22 revealed the following: Policy: All members of the healthcare team will comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. Purpose: Effective hand hygiene reduces the incidence of healthcare-associated infections. Hand Hygiene Guidance/Procedure: 1. Healthcare Personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: a. Immediately before touching a patient. b. Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices. c. Before moving from work on a soiled body site to a clean body site on the same patient. d. After touching a patient or the patient's immediate environment e. After contact with blood, body fluids, or contaminated surfaces. f. Immediately after glove removal 2. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and, in the absence of a sink, are an effective method of cleaning hands. E. Record Review of Resident 88's MDS dated [DATE] revealed Resident 88 was admitted on [DATE]. Review of the Bowel and Bladder section of the MDS revealed Resident 88 had an indwelling catheter and was always incontinent of bowel. Record Review of the Order Summary printed on 4-01-2024 for Resident 88 revealed Resident 88 has an order for Foley Catheter (type a tube placed into the bladder to drain urine). Observation on 4-02-2024 at 7:38 AM of catheter care for Resident 88 revealed certified Medication Assistant (CMA)-M completed HH and donned gloves. CMA-M using a wipe cleansed Resident 88's front peri area revealing the wipe had a brownish stain, similar to bowel movement. CMA-M without changing the soiled gloves and completing HH retrieved a bag of wipes. CMA-M with out changing the soiled gloves and completing HH pulled wipes from the container and wiped each buttocks. CMA-M with the same soiled gloves took another wipe from the package and wiped Resident 88's coccyx/rectal area. CMA-M removed the soiled gloves and did not complete HH. CMA-M picked up garbage of dirty wipes and paper towel from the floor with bare hands. Then CMA-M did HH with soap and water for 20 seconds and applied clean gloves. CMA-M assisted Resident 88's roommate with getting a sweatshirt from the closet. CMA-M with out changing the gloves and completing HH returned to Resident 88 to complete cares. CMA-M obtained wipes from the package and wiped Resident 88's catheter tubing up and down the tubing repeatedly with the same wipe. CMA-M disconnected the catheter bag and cleaned the tubing with an alcohol wipe, spilled urine on the floor, then connected the leg bag. CMA-M placed a paper towel over the spilled urine on the floor, took catheter bag to the bathroom and emptied the urine from the bag. CMA-M put the catheter bag in a gray open container and reported (gender) would clean the catheter bag later as there was not time right now. 4/20/24 8:10 AM an interview was conducted with CMA-M. CMA-M confirmed the bag of wipes became contaminated when getting wipes out with dirty gloves. CMA-M confirmed no HH was done when moving from doing peri-care/catheter care on the front then moving to the buttocks and rectal area. CMA-M confirmed after assisting the roommate, HH should have been done before returning to complete care for Resident 88. CMA-M confirmed the catheter tubing should be wiped going from the resident and down the tubing, using a new wipe each time and not in an up and down motion repeatedly. F. Record review of Resident 1's Order Summary Sheet printed on 4-02-2024 revealed Resident 1 had a Foley Catheter. Observation on 4-02-2024 at 11:00 AM of catheter care for Resident 1 revealed CMA-M completed HH and donned clean gloves. CMA-M using a wipe cleansed the catheter tubing using 3 swiping motions with the same wipe. CMA-M obtained another wiped and wiped down each side of the front peri-area. CMA-M removed the soiled gloves and did not complete HH. CMA-M applied gloves and assisted Resident 1 onto the left laying position. CMA-M obtained a wipe and cleansed the buttock and rectal area. CMA-M removed the soiled gloves, did not complete HH, applies gloves and applied a clean brief to Resident 1. A interview on 04/02/24 at 11:31 AM was conducted with CMA-M. CMA-M confirmed (gender) did not do HH with each glove change. CMA-M confirmed getting a clean wipe from the wipe package with soiled gloves contaminated the wipe package. CMA-M confirmed that wiping with the same wipe on catheter tubing is incorrect. CMA-M reported a clean wipe should have been obtained each time before (gender) wiped the catheter tubing. Record review: Policy Hand Hygiene policy effective 4.11.18; Updated 2.23.22 revealed the following: -Policy: All members of the healthcare team will comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. -Purpose: Effective hand hygiene reduces the incidence of healthcare-associated infections. -Hand Hygiene Guidance/Procedure: -1. Healthcare Personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: -a. Immediately before touching a patient. -b. Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices. -c. Before moving from work on a soiled body site to a clean body site on the same patient. -d. After touching a patient or the patient's immediate environment. -e. After contact with blood, body fluids, or contaminated surfaces. -f. Immediately after glove removal. -2. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and, in the absence of a sink, are an effective method of cleaning hands.

Licensure Reference Number 175 NAC 12-006.18B3 Based on observations and interviews; the facility staff failed to ensure the venting system was functional in 4 (B-004, C-010, C-015 and C-017) room effecting 7 residents who resided in those rooms and failed to ensure the Heating and Cooling unit (commonly called PTAC) was maintained in good repair. This effected 7 of 92 residents. The facility staff identified a census of 92. Findings are: An observation on 04/01/24 at 9:30 AM revealed the vent were not fuctioning in the bathroom of rooms B-004, C-010, C-015, and C-017. An observation on 04/01/2024 at 10:00 AM revealed the front cover of the PTAC has missing pieces in room C-011. On 4/04/2024 at 12:26 PM during a tour of the facility with the Maintenance Director (MD) confirmed the vents in rooms B-004, C-010, C-010, and C-017 were not functional and the PTAC front cover needed replaced in C-011.

Licensure Reference Number 175 NAC ,d+[DATE].05(9) Based on record review and interview; the facility staff failed to protect 4 (Resident 32, 92, 342 and 33) residents from abuse. The survey sample was 19 and the facility staff identified a census of 92. Findings are: A. Record review of a Order Summary report sheet printed on [DATE] revealed Resient 32 was admitted to the facility on [DATE]. Record review of Resident 32 Minimum Data Set (MDS, a federally mandated assessment tool used for care-planning) dated [DATE] revealed Resident 32 had Brief Interview for Mental Status (BIMS) score of 15. According to the MDS [NAME] a score of 13 to 15 indicates a person is cognitively intact. On [DATE] at 11:00 AM the facility Administrator identified Resident 32 had reported of being verbally abused by Nursing Assistant (NA)-EE. On [DATE] at 1:14 PM an interview was conducted with Resident 32. During the interview Resident 32 reported the incident of verbal abuse occurred on [DATE]. According to Resident 32 NA-EE was informed of the need to use the bathroom. Resident 32 reported NA-EE stated there's the door. Resident 32 further reported telling NA-EE having been married a long time and had 4 children and that Resient 32's husband had died . According to Resident 32 report, NA-EE stated you know what that makes you? An old widow. During the interview Resident 32 reported no one else in the facility treated Resident 32 like that. Resident 32 reported reported not being able to sleep after that incident and stated I was so upset. I prayed to God to help me sleep. Resident 32 reported not having any problems sleeping currently. Resident 32 further reported requesting the family not be notified of the incident as the family would worry about Resident 32. On [DATE] at 9:08 AM a follow up interview was conducted with Resident 32. During the interview Resident 32 identified not reporting NA-EE right ways as Resident 32 did not know who to tell. According to Resident 32 the Ombudsman had been in the facility and Resident knew the Ombudsman was someone Resident 32 could report the incident to. Resident 32 reported feeling like NA-EE didn't like resident 32. Resident 32 reported being fearful of NA-EE as NA-EE has a strong personality. On [DATE] at 2:13 PM an interview was conducted with the facility Administrator. During the interview the Administrator reported calling NA-EE. According to the Administrator NA-EE immediately knew about the incident that occurred on [DATE] and had not been rude to Resident 32. B. Record review of a facility Staff to Resident Allegation of Abuse (SRAA) sheet dated [DATE] revealed Licensed Practical Nurse (LPN) QQ reported Nursing Assistant (NA) -PP was verbally inappropriate and rough with Residents, 92, 33 and 342 on [DATE]. According to the SRAA dated [DATE] the Director of Nursing/Administrator was notified on [DATE] at 1:24 PM. Under the section identified as What immediate steps were taken to protect the resident? revealed the facility Administrator seen a email at 10:40 PM, approximately 9 hours and 16 miniutes later. Record review of a interview sheet identified as a conversation with LPN QQ dated [DATE] and times as 8:11 AM revealed LPN QQ identified the resident in an email about the alleged verbal abuse as Resident 92,33 and 342. Further review of the interview sheet identified as a conversation with LPN QQ dated [DATE] revealed there was no discussion of how Resident 92, 33 and 342 were protected or what actions LPN QQ took to protect the residents. Record review of the facility for Report Allegations of Abuse/neglect/Exploitation Reporting with an effective date of [DATE] revealed the following information: -Policy: -It is the policy to report all allegations of abuse/neglect/exploitation to the appropriate agencies in accordance with current state and federal regulations. -Responsibility: All team members. -Compliance Guideline: -3. The facility will provide residents, families and team member information on how and to whom they may report concerns,incidents,and grievances without fear of retribution. -4. Verbal abuse means the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to resident or their families, or within hearing distance regardless of their age, ability to comprehend or disability. -6. Protection; The facility will protect residents from harm during the investigation. -Procedure for Response and Reporting Allegations of Abuse/Neglect/Exploitation: -When suspicion of abuse/neglect/exploitation of reports of abuse/neglect/exploitation occur, the following procedure(s) will be initiated: -The licensed nurse or designee will: -a. Remove the accused team member from resident care. -f. Initiate an investigation.

Licensure Reference Number 175 NAC 12-006.04B2b Based on interview and record review, the facility staff failed to ensure competencies in insulin administration were completed for 5 Certified Medication Assistant (CMA) and 3 licensed nurses surveyed. This had the ability to affect 13 residents (Residents 6, 15, 19, 21, 25, 30, 38, 50, 60, 62, 74, 194 and 196) who receive insulin in the facility. The facility claimed a census of 92. Findings are: An interview on 04/03/2024 at 10:32 AM with CMA-K revealed they had not been assessed for competency in administering insulin by the facility. An interview on 04/03/2024 at 1:37 PM with the Director of Nursing (DON) confirmed CMA's have to be assessed for competency before they are allowed to administer insulin in the facility. The DON confirmed they were not aware that MA-K had not been assessed for competency to administer insulin by the facility. An interview with on 04/03/2024 at 1:39 PM with Registered Nurse (RN) B confirmed facility staff are assessed for competency through the facility on boarding and education process. RN-B confirmed staffing agencies supply the facility with their completed assessment/competency requirements for the staff they send to work in the facility. An interview on 04/03/2024 at 1:44 PM with the facility Administrator (ADM) confirmed the staffing agencies send completed competency information on each employee they send to the facility. The Administrator was unable to find the competency information on MA-K. A record review of the facility CMA competency checklists, revealed the following CMA did not receive a competency assessment in insulin administration when they completed their annual competency assessments: CMA -L, CMA-M , CMA, and CMA-O. An interview with CMA-L on 04/04/2024 at 11:00AM confirmed they had not been assessed for competency in insulin administration. CMA-L confirmed they had administered insulin to residents in the facility when working as a CMA. CMA-L confirmed they were not aware they needed to be assessed for competency before administering insulin to residents. A record review of the facility nurse competency checklists, dated 2/2/2024 and 2/7/2024 revealed the following nurses did not receive an assessment in competency to administer insulin to residents, Licensed Practical Nurse (LPN) -P,LPN-Q, and LPN-R. An interview on 04/04/2024 at 11:16 AM with the facility ADM confirmed the competency checklists for CMA-L, CMA-M, CMA-N, CMA-O, LPN-P, LPN-Q and LPN-R did not reveal an insulin administration competency completion sheet. The ADM confirmed they were unable to provide evidence of competency assessment for insulin administration for these employees. A record review of the undated facility Medication Administration and Provision Policy from the website \\fs1\Redirected Folders\drice\Documents\Clinical Policies--Revised\Medication adm.policy.doc Final: revealed the following information: -Number 26 in the procedure directions: Only licensed nurses/certified may administer injections. (Other than insulin which may be administered by competent medication tech using insulin pens only) Vials must be administered by the nurse.

Licensure Reference Number 175 NAC 12-006.12B Based on record review and interview; the facility staff failed to have rationale for the continued use of an antianxiety medication for 3( Resident 1,21 and 25), failed to complete behavioral monitoring for 1(Resident 57) and failed to identify the need for a increase in dosage of a antidepressant medication for 1 (Resident) 1 of 5 residents sample size for the medication review. The facility staff identified a census of 92. Findings are: A. A record review of Resident 21's Minimum Data Set (MDS- a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) dated 1/1/2024 revealed Resident 21 is [AGE] years old and had a Brief Interview of Mental Status (BIMS - a mandatory tool used to screen and identify the cognitive condition of residents) of 5 indicating Resident 21 is severely cognitively impaired. Resident 21 had the following diagnoses: Unspecified dementia, severe with other behavioral disturbance, depression, unspecified, Type 2 Diabetes, COPD, Heart Failure, Acute and chronic Respiratory failure with hypoxia, hypothyroidism, Vitamin D deficiency, anxiety disorder, unspecified, Neurogenic bladder, neuromuscular dysfunction of bladder, osteoarthritis, insomnia due to medical condition, slow transit constipation. A record review Resident 21's annual MDS dated [DATE] revealed Resident 21 is taking an antipsychotic, antidepressant, antianxiety and hypoglycemic medication. The MDS indicated the physician stated a Gradual Dose Reduction (GDR) of the antipsychotic was contraindicated (a symptom or medical condition that is a reason for a person to not receive a particular treatment or procedure because it may be harmful) and verbal behavior symptoms were present. Record review of Resident 21's Order Summary Report with active orders as of 4-02-2024 revealed Resident 21's practitioner order Lorazepam (an antianxiety medication) started on 2-02-2024 and had an end date to the order of 2-01-2025. An interview on 04/04/2024 at 3:51 PM with the Director of Nursing (DON) confirmed that they are unable to find any documentation of rational from the pharmacy to the facility and physician in relation to the as needed (PRN) lorazepam order for 365 days. A record review of the Medication Regimen Review Policy (Policies and Procedures - Pharmacy Services for Nursing Facilities - Copyright 2006 American Society of Consultant Pharmacists and MED-PASS, Inc. revealed the following under Procedures: The consultant pharmacist's evaluation includes, but is not limited to reviewing and/or evaluating the following: -C.9) The duration of therapy is indicated and is appropriate for the resident. A record review of undated Rely Pharmacy Admission Medication Regimen Review (MRR) contains the following statement in the section titled Provider Review: Resident has a PRN psychotropic medication which will DC (discontinue) in 14 days, if physician does not want to DC in 14 days, please provide both rationale and duration for continued use. 45641 B. A record review of the facility's Psychotropic Medication Policy dated 01/01/23 revealed Residents are not prescribed psychotropic medications unless they are necessary to treat a specific condition, as diagnosed and documented in the medical record, and the medication is beneficial to the patient, as evidenced by monitoring and documentation of the patient's response to the medications. The indications for use of psychotropic medications should be documented in the medical record. The indications for use of psychotropic medications should be documented in the medical record. Non-pharmacological interventions that have been attempted and the target symptoms for monitoring shall be included in the documentation. A record review of Resident 57's Medical Diagnosis dated 04/03/2024 revealed the resident had diagnoses of Unspecified Mood (Affective) Disorder and Dysthymic Disorder (a milder, but long-lasting form of depression). A record review of Resident 57's Minimum Data Set (MDS, a comprehensive assessment used to develop a resident's care plan) dated 01/10/2024 revealed the resident had a Brief Interview for Mental Status (BIMS, a score of a residents cognitive abilities) 13 of 15 which indicated the resident was cognitively aware. The resident was dependent or needed substantial/maximal assistance for most activities of daily living (ADL). The MDS revealed Resident 57 never felt down, depressed, or hopeless during the look back period. The resident did exhibit verbal behavioral symptoms directed towards others and rejection of care. The MDS revealed the resident was on a antipsychotic and antidepressant medication. A record review of Resident 57's Care Plan with an admitted [DATE] revealed the resident was admitted to the facility on [DATE]. Resident 57's Care Plan had a Focus area of Psychiatric (Psych) medication use- uses antidepressant and an intervention of document behaviors as scheduled and when behaviors occur. A record review of Resident 57's Order Summary Report of current active medications dated 04/03/2024 revealed the resident had orders of Mirtazapine (an antidepressant medication) Oral Tablet 7.5 milligram (mg), Give 1 tablet by mouth at bedtime for mood disorder. In addition the Order Summary Report sheet dated 04/03/2024 revealed the following additional orders: -Antidepressant Behavior Monitoring - Monitor for signs/symptoms of target Behaviors. Notify the Physician of increased behaviors or ineffective antidepressant medication, monitor every shift the targeted behaviors related to depression. The Order Summary Report did not reveal the specific mood disorder for Mirtazapine or what behaviors the staff were to monitor for. A record review of the Medication Administration Record and Treatment Administration Record (MAR & TAR) dated February 2024, March 2024, and April 2024 revealed the resident had orders of Mirtazapine Oral Tablet 7.5 mg (Mirtazapine) Give 1 tablet by mouth at bedtime for mood disorder. The MARs & TARs did not reveal the specific mood disorder for Mirtazapine or what behaviors the staff were to monitor for. A record review of Resident 57's University of Nebraska Medical Center (UNMC) Geriatric Psychiatry note dated 09/19/202 revealed the resident had a history of depression, hallucinations, and suicidal statements, but did not reveal the indication or targeted behaviors for the Mirtazapine. A record review of Resident 57's Progress Notes dated 04/03/2024 revealed 1 on documented behavior in the last 3 months and that was yelling at the staff on 01/24/2024. In an interview on 04/03/2024 at 11:29 AM, Nursing Assistant (NA)-BB was unsure what Resident 57's target behaviors were and was not sure what the target behaviors for depression would be. NA-BB confirmed the only behaviors from Resident 57 was the resident liked the room dark and liked to stay in the room due the resident's eyes. In an interview on 04/03/2024 at 11:31 AM, NA-CC confirmed Resident 57 don't have any signs or symptoms of depression other than stays in the resident's room due to the resident's eyes. In an interview on 04/03/2024 at 11:33 AM, Licensed Practical Nurse (LPN)-AA reported Resident 57 sometimes got tearful and angry but now is on Tramadol (a medication for pain) routinely and anger is better. LPN-AA reviewed the MARs & TARs for March 2024 and April 2024 and confirmed there was not targeted behaviors listed for Resident 57's Mirtazapine or what specific behaviors were related to the resident's depression. In an interview on 04/03/2024 at 11:48 AM, DON confirmed there were no specific target behaviors on the orders, MARs & TARs, or the Care Plan. The DON confirmed that the provider was not specific in his documentation for the reason for ordering Mirtazapine or the behaviors that were being exhibited by Resident 57, and there should have been. 47733 Record review of the facility's policy dated 1/1/2023 and titled Hillcrest Health Services, Psychotropic Medication Policy revealed the following: - The Policy: - Patients are not to be prescribed psychotropic medications unless they are necessary to treat a specific condition, as diagnosed and documented in the medical record, and the medication is beneficial to the patient, as evidence by monitoring and documentation of the patient's response to the medication. -A psychotropic drug is any drug that affects the brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: -Antipsychotics -Antidepressants -Anti-anxiety medications -Hypnotics -Policy and explanation and compliance guidelines: -8) PRN (As Needed) orders for any psychotropic medication shall be used only when medication is necessary to treat a diagnosed specific condition that is documented in the medical record and for a limited duration (i.e., 14 days). If the prescribing provider believes that it is appropriate for the PRN order to be extended beyond the order duration, they shall document the rationale in the patient's medical record and indicate the new duration for the PRN order. Record review of Resident 25's Medication Administration Record (MAR) for March 2024 revealed Resident 25 had orders for Lorazepam 0.5 mg every 6 hours as needed for anxiety ordered on 1/29/2024. Further review of Resident 25's MAR for March 2024 revealed Resident 25 was administered the as needed Lorazepam on the 1st, 2nd, 3rd, 7th, 9th in the AM and 11th, 15th, 17th, and the 23rd on the PM. Record review of Resident 25's Care plan initiated on 2/07/2024 revealed Resident 25 resists Care at times, yells out at team members and peers frequently, has delusions/hallucinations once in a while and can become verbally aggressive at times. The goal for Resident 25 was Resident 25 would cooperate with a target date: 05/10/2024. -Interventions listed on Resident 25's care plan are as follows: -Encourage as much participation/interaction by Resident 25 as possible during care, activities. - Give clear explanation of all care activities prior to and as they occur during each contact. - If Resident 25 resists with ADLs, reassure Resident 25 safety, leave and return 5-10 minutes later and try again. -Praise Resident 25 when behavior is appropriate. -Provide Resident 25 with opportunities for choice during care provision. -Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, caregivers, and routine, as much as possible. A interview on 4/03/24 12:00 PM was conducted with Regional Nurse Consultant (RNC)-A. During the interview RNC-A confirmed non-pharmacological interventions had been implemented prior to administering the as needed Lorazepam. 50106 D. Record review of Resident 1's Order Summary Report sheet printed on 4-02-2024 revealed Resident 1 had orders for Lorazepam 0.25 milliliters (ml) every 4 hours as needed with a order date of 2/24/2023 and end date of the order being 6/09/2024. In addition Resident 1 had an order for Sertraline (a antidepressant medication) 50 mg give 1.5 tabs (75 mg) at bed time. Record review of a Census sheet printed on 4/02/2024 revealed Resident 1 was discharged from hospice care on 12/19/2022. Record review of Note to Attending Physician/Prescribers dated 6/9/2023 from the consultant pharmacist revealed the following note: Centers for Medicare and Medicaid Services (CMS) rules now limit PRN psychotropic orders to 14 days unless rationale and duration are clearly stated. This resident is enrolled in Hospice Care and therefore requires the following PRN psychotropic order as a comfort medication to manage anxiety and/or agitation. In signing below, it is acknowledged that this medication should be continued for at least 6 months from date signed unless otherwise noted. Medication and Directions: Lorazepam 2 mg/ml solution give 0.25 mg sublingually every 4 hours as needed anxiety/agitation. Resident 1's Advance Registered Nurse Practitioner (ARNP) signed the note to continue for 365 days. Record review of Note to Attending Physician/Prescribers dated 10/13/2023 per behavior meeting, nursing staff reported resident is showing increased signs/symptoms of depression. Would you like to increase her order for Sertraline 50 mg every day at this time? New order was received to increase Sertraline to 75 mg every day orally. Observation of the resident were 4/1/2024 at 9:00 AM, 10:13 AM, and 1:15 PM with no behaviors noted. Observation of Resident 1 were 4/2/2024 at 11:15 AM and 12:35 PM with no behaviors noted. Observation of Resident 1 were 4/3/2024 at 12:16 PM with no behaviors noted. Observation of Resident 1 on 4/4/2024 at 12:35 PM with no behaviors noted. A interview was conducted with DON on 4/4/2024 at 11:45 AM revealing there was no documentation why Resident 1 required an increase of Sertraline. A interview was conducted with DON on 4/4/2024 at 11:45 AM. During the interview the DON reported there was not documentation found to indicate a rationale for the as needed Lorazepam to extend past 14 days.

Licensure Reference Number 175 NAC 12-006.12E1 Licensure Reference Number 175 NAC 12-006.12E7 Based on observation and interview;the facility staff failed to ensure 2 medications in medication cart E were labeled for use, failed to ensure 2 medication carts and medications were secured and failed to ensure the medication refrigerator was secured in the memory care unit. This had the ability to affect 9 ambulatory residents of 22 residents who live on the memory care unit. The facility claimed a census of 92. Findings are: A. An observation on 04/04/2024 at 7:30 AM of the drawers in the medication cart on hall E revealed an open undated, unlabeled generic brand of a 8 oz bottle of Cough DM and a bottle of Neomycin and Polymyxin B Sulfates and Dexamethasone Ophthalmic Suspension On 04/04/2024 at 7:30 AM an interview was conducted with Certified Medication Assistant (CMA). During the interview CMA-K reported not knowing who the medication belonged to or how long the medications had been in the cart. B. An observation on 04/04/24 at 12:45 PM revealed the medication refrigerator on memory care unit did not have a lock. An interview on 04/04/2024 at 12:50 PM with Registered Nurse (RN)-W confirmed the office door should be locked at all times and the fridge should have a lock. RN-W further confirmed there were ambulatory residents in the memory care unit. An interview on 04/04/2024 at 2:14 PM with the Regional Nurse Consultant (RNC) confirmed having an undated, unlabeled generic bottle of Cough DM and an unlabeled prescription medication in the medication cart does not meet the expectations of the facility. The RNC confirmed having the nurse's office door open and an unlocked medication refrigerator in that office on the memory care unit is a danger to ambulatory residents. 47733 C. Observation on 04/2/24 10:47 AM revealed LPN-T laid a Resident's blood pressure medication on top of the medication cart and walked away from leaving the medication unsecured and unsupervised in the memory care unit. An interview on 04/2/24 10:49 AM with LPN T confirmed that the medication should not have been left on top of the medication cart unsupervised. Observation on 04/03/24 8:24 AM revealed the medication cart on the secured memory care unit, across from room D6 was unlocked, unsupervised and had Metoprolol ( medication used to help control blood pressure) 100 mg tablets was left on top of the cart. in addition the medication cart An interview on 04/03/24 8:27 AM with LPN-U confirmed that the cart should not have been unlocked and the card of Metoprolol should have not been on the top of the cart. Record review of the facility policy Hillcrest Shadow Lake Medication Administration And Provision. Policy: It is the policy of the facility to ensure that each guest receives medications as prescribed by their physician. Procedure: 29) During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication team member. No medications can be left on top of the medicaiton cart or in the medication cabinet in rooms without team member that is administering the medications within the sight of the medications.

Licensure Reference Number 175 NAC 12-006.09C1c Based on observation, interview, and record review, the facility failed review and revise 1 (Resident 77) of 1 resident's Care Plan related to the oxygen order. The facility census was 92. Findings are: A record review of the facility's undated Comprehensive Care Planning policy revealed assessments of residents were ongoing and the care plans were revised as information about the resident and the resident's condition changed. A record of Resident 77's Clinical Census dated 04/02/2024 revealed the resident was admitted to the facility 02/17/2024. A record review of Resident 77's Medical Diagnosis dated 04/02/2024 revealed the resident had diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Pulmonary Hypertension, Unspecified (high pressure in the blood vessels that supply the lungs), Dependance on Supplemental Oxygen, and Solitary Pulmonary Nodule (single mass in lungs). A record review of Resident 77's Minimum Data Set (MDS,a comprehensive assessment used to develop a resident's care plan) dated 02/23/2024 revealed the resident had a Brief Interview for Mental Status (BIMS,a score of a residents cognitive abilities) 4 of 15 which indicated the resident was severely cognitively impaired. The resident was dependent on staff for toileting, bathing and needed substantial/maximal assistance with personal hygiene (cleaning), and upper and lower body dressing. The MDS revealed Resident 77 was on oxygen while a resident. An observation on 04/01/2024 at 10:01 AM revealed Resident 77 was in the room with the oxygen nasal cannula (a tube that goes in the nose to delive oxygen) on and the oxygen concentrator (a machine that purifies oxygen) set at 5 liters per minute (l/m). An observation on 04/01/2024 at 3:22 PM revealed Resident 77 was in the room with the oxygen on and the concentrator was set at 5 l/m. A record review of the Order Summary Report dated 04/01/2024 revealed Resident 77 had an order: Oxygen: Oxygen at 2 L (liters) per nasal cannula every shift Check Oxygen Saturation. Notify Physician if less than 90%. A record review of the Medication Administration Record and Treatment Administration Record (MAR & TAR) dated [DATE] and March 2024 revealed Resident 77 had the order: Oxygen: Oxygen at 2 L (liters) per nasal cannula every shift Check Oxygen Saturation. Notify Physician if less than 90%. A record review of Resident 77's Progress Notes dated 03/22/2024 revealed the resident was having low oxygen levels on oxygen at 2 l/m. The Nurse Practioner was contacted, and a verbal order was given to increase the oxygen to 5 l/m. A record review of Resident 77's Radiology Report dated 03/22/2024 revealed a telephone order of oxygen at 2-5 L per nasal cannula to keep saturations above 88%. A record review with Regional Nurse Consultant (RNC)-A of Resident 77's Care Plan with an admitted [DATE] revealed the resident had a Focus area of altered respiratory status/difficulty breathing related to the COPD diagnosis. The Care Plan had an intervention of oxygen settings: Oxygen (o2) via nasal cannula at 2 l/m continuously. In an interview on 04/02/2024at 10:52 AM, RNC-A confirmed the Care Plan still showed an intervention of o2 via nasal cannula at 2 l/m continuously and it should have been changed with the new telephone order from 03/22/2024.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3(5) Based on record review and interview; the facility staff failed to evaluate risk factors and implement interventions to prevent fecal impaction ([NAME] stool that is stuck in the large intestine) for 1( Resident 3) of 1 sampled residents. The facility staff identified a census of 85. Findings are: Record review of Resident 3's Minimum Data Set (MDS: a federally mandate assessment tool use for care planning ) dated 1-3-2022 revealed the facility assessed the following about the resident: -Brief interview of mental status was assessed as a 4. According to the MDS Manuel, a score of 0 to 7 indicates severe impairment. -Required extensive assistance with bed mobility, dressing and toilet use. -Totally dependent for transfers. -Frequently incontinent of bowel. Further review of Resident 3's MDS dated [DATE] revealed Resident 3 had admitted on [DATE] to the facility. Record review of a Hospice Nursing Initial Comprehensive Admission Assessment (HNICAA) revealed Resident 3 transitioned to hospice services on 12-27-2021. Further review of Resident 3's HNICAA dated 12-27-2021 revealed opioid medications were in use or started as well as a bowel regimen that included the use of senna (medication used to treat constipation). Record review of Resident 3's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . According to rxlist.com side effects of [MEDICATION(S)] include constipation. Further review of Resident 3's MAR for January 2022 revealed Resident 3's senna was not administered on 1-01-2022, 1-02-2022, 1-03-2022 for the day shift and once on 1-03-2022 on the evening shift. Record review of a Hospice Nursing Comprehensive Reassessment sheet for Resident 3 dated 12-28-2021 revealed Resident 3's last Bowel Movement (BM) was identified as 12-27-2021. Record review of a Hospice Nursing Comprehensive Reassessment sheet for Resident 3 dated 1-06-2020 revealed Resident 3's Hospice nurse documented Resident 3 had not had a BM in 60 shift or 20 days. The Hospice nurse entered Resident 3's room and identifies Resident 3 is lying in bed, moaning and in the fetal position yelling for help. Resident 3 reports to the Hospice Nurse (gender) is having pain in the stomach and needs to poop. The Hospice digitally checks with a large amount of soft sticky stool noted. Record review of Resident 3's Progress Notes (PN) revealed on 1-06-2022 the Hospice Nurse was seeing Resident 3. Resident 3's PN dated 1-06-2022 identified Resident 3 had no BM in 20 days and that a small soft semi liquid stool was manually removed by the hospice nurse. Record review of a Telephone Orders sheet signed on 1-06-22 revealed the practitioner was notified Resident 3 did not have a BM in 20 days and was compacted. Record review of a Hospice Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Physician Communication section of the Hospice Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 3's BM report printed on 2-10-2022 revealed there was not any BM's documented 12-18-2021 through 1-06-2022 ( a 20 day time frame). Record review of Resident 3's medical record revealed there was no information that identified Resident 3 had been evaluated for potential bowel issues or what interventions had been implemented in an attempt to prevent the impaction such as the use of as needed medications for BM difficulties. On 2-10-2022 at 3:44 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON reported there was not an evaluation of Resident 3's bowel function and no additional interventions had been implemented to prevent a bowel impaction for Resident 3. Record review of the of the facility Bowel Management Protocol dated 5-23-2017 revealed the following information: -Policy: -All guest will be monitored and staff will intervene when necessary to prevent constipation. -Procedure: -Review guest orders,typical bowel patterns, and verify the absence of contraindications to initiating bowel management protocol. -Upon report of or sign and symptoms of constipation and/or following 2 days without a bowel movement, the following protocol may be initiate per standing orders: -Milk of Magnesia 30 milliliters (ml) by mouth every 8 hours times 2. -If no relief and physicians orders, administer Dulcolax 10 milligrams (mg) suppository rectally. -If suppository is not effective, you may administer Fleets Enema rectally daily as needed. Notify the provider and/if no results. -Additional Interventions to promote bowel health for consideration: -Review guest medications such as narcotics that may be contributing to constipation. According to information at medlineplus.gov common symptoms of fecal impaction include Abdominal cramping, bloating, leakage of stool, small semi-formed stool and rectal bleeding. The facility was not able to provide additional information prior to exiting the building.

Licensure Reference Number 12-006.09D2b Based on observation, interviews and record reviews, the facility failed to monitor pressure ulcers for 2 residents (Residents 111 and 118) of 2 residents sampled. The facility staff identified the census at 102. The findings are: A. Record review of a Weekly Skin Assessment sheet dated 11 25 2016 revealed Resident 118 was admitted to the facility with wound ulcers to the right toe, shin, foot and on top of the left foot and left 2nd toe. Record review of a Wound Tracking Tool (WTT) sheet dated 12 1 2016 revealed Resident 118 had excoriation to the buttocks with barrier cream applied. Record review of a WTT sheet dated 12 06 2016 revealed Resident 118 had developed a pressure ulcer to the right buttock that measured 3 centimeters (cm) by 3 cm with a depth of 0.10 cm. No staging of the pressure ulcer was completed. Record review of a WWT dated 12 08 2016 revealed Resident 118's pressure ulcer measured 3.0 cm by 3.0 cm by 0.20 cm. No staging of the pressure ulcer was identified. Also identified on the WTT dated 12 08 2017 was that Resident 118 had also developed a pressure ulcer to the left lower gluteal fold and right lower gluteal fold. No measurements were identified for the left lower gluteal fold and right lower fold. No staging of the pressure ulcer was identified. Record review of a WTT dated 1 5 2017 revealed Resident 118's pressure ulcer to the left buttocks measured 1.0 cm by 0.70 cm, with the left lower gluteal fold measured 4.0 cm by 5.0 cm and the right lower gluteal fold measured 4.0 cm by 6.0 cm. No staging of the pressure ulcer was completed. Record review of a WTT dated 2 13 2017 revealed Resident 118's left buttocks pressure area measured 10.00 cm by 2.0 cm, the right buttocks pressure ulcer measured 5.0 cm by 2.0 cm. In addition, a pressure ulcer to the left lower scrotum measured 6 cm by 7 cm's. No staging of the pressure ulcers were completed. Record review of a WTT dated 3 06 2017 revealed Resident 118 continued to have pressure ulcers to the left buttocks, right buttocks and left lower scrotum. No measurements or staging of the pressure ulcers were completed. Record review of a WTT dated 3 15 2017 revealed Resident 118's pressure ulcer to the left buttocks measured 5.0 cm by 1.0 cm and the pressure ulcer to the right buttocks measured 8.0 cm by 3.0 cm. There was no indication for the status of the pressure ulcer to the left lower scrotum. Observation on 8 9 17 at 9:20 AM of the left buttock pressure ulcer treatment revealed it to be approximately quarter sized roundish with an unmeasured deep looking hole. The DON (Director of Nursing) applied a wound vac (device that assist in increasing the blood flow to a wound area and removes drainage) to the pressure ulcer. On 8 10 2017 at 12:35 PM, an interview was conducted with the DON. The DON reported during the interview that Resident 118 did have pressure ulcers on admission, however, there were no measurements of the pressure ulcer. During the interview, the DON confirmed Resident 118's pressure ulcers were not consistently monitored and that Resident 118 started going to the wound clinic on 3 07 2017. The DON reported the pressure ulcer to the left buttock was a stage 4 ( Stage 4 Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). B. A review of Resident 111's Face Sheet dated 8/10/17 revealed that Resident 111 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A review of Resident 111's medical record revealed Wound Tracking Tools were completed on 6/16/17, 7/3/17, 7/17/17, 7/28/17, 8/4/17, and 8/10/17. An interview conducted on 8/10/17 at 2:23 PM with the Director of Nursing (DON) revealed that Wound Tracking Tools were to be completed weekly.