Every finding on record at Imperial Manor Nursing Home

Licensure Reference Number 175 NAC 12-006.18(D) Based on observation, interview and record review the facility failed to perform hand hygiene to prevent the potential for cross contamination during meal preparation. This had the potential to affect all residents. The facility census was 30.Findings are:An observation on 10/01/2025 at 9:17 AM revealed three bags of half frozen potatoes in the sink defrosting. Cook-B while wearing gloves opened the bags with a knife and poured the potatoes into a colander. Cook-B then grabbed a bowl and a spoon and began spooning the frozen chunks into the bowl and chopping at the potatoes to separate them. Cook-B grabbed a large chunk of potatoes and used hands to break the pieces apart. Cook-B rinsed their gloved hands in the sink the potatoes were sitting in. While still wearing the same gloves Cook-B poured the potatoes into the pan on the stove. An observation of kitchen on 10/01/2025 at 10:49 AM revealed while wearing gloves, Cook-B moved two bowls of raw chicken from the refrigerator to the counter. Cook-B gathered three large baking pans and placed the pans on the counter, still wearing the same gloves, grabbed a can of cooking oil and sprayed each pan. Cook-B walked to counter grabbing three baking sheets without changing gloves and placed the sheets on top of cooking oil. Cook-B tried to pull up the gloves on their hands, but both gloves were torn along the cuff line. Cook-B noticed the gloves were torn and promptly took off the torn gloves, placing the gloves in the trash. [NAME] B obtained new gloves and put them on without first performing hand hygiene. Cook-B walked over to the chicken and started to bread the chicken with breadcrumbs. Cook-Bs gloves were visibly dirty and cook-B removed soiled gloves. Cook-B left the pans of chicken on the counter. Cook-B began cleaning counters and collecting dishes to take to the dishwasher side to be washed. An observation on 10/01/2025 at 11:40 AM Cook-B removed three baking pans of chicken from the convection oven and placed the pans with chicken on a rolling cart pulling it over to the counter. Cook-B pulled down three steam table pans and began spraying each pan with cooking oil, grabbed three sheets of baking paper Cook-B used tongs to press the baking paper into the corner of the baking pans and used their bare hand to smooth the rest of the paper into the pan. Cook-B then used tongs to place the chicken into the steam table pans. An interview on 10/01/2025 at 11:55 AM with the Dietary manager in the dietary manager's office confirmed hands were to be washed each time gloves are removed and before putting new gloves on hands.An interview on 10/01/2025 at 2:45 PM with Administrator confirmed gloves are not to be washed off, hand washing is to be done before putting on gloves and after taking them off. Acknowledging this has the potential to affect everyone with cross contamination.A record review of facility policy last revised on 04/11/2023 states Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses. Dietary employees shall clean their hands in a handwashing sink or approved automatic handwashing facility and may not clean hands in a sink used for food preparation, warewashing, or in a service sink that is used for disposal of mop water or similar waste.

Licensure Reference Number 175 NAC 12-006.18(B) & (D)Based on Observation, interviews and record review the facility failed to prevent the potential for cross contamination while scooping ice into resident drinking cups. The facility also failed to perform hand hygiene to prevent the potential for cross contamination during hydration preparation in the dining room This had the potential to affect all residents. The facility census was 30.Findings are:An observation on 9/29/2025 at 12:19 PM revealed Dietary Aide (DA)-A serving juice out of the cart with bins sitting on ice in the dining room. DA-A observed a soiled spot on the counter, grabbed a rag and began to wipe down the counter while wearing gloves. DA-A then resumed serving drinks to residents while still wearing the same gloves and without performing hand hygiene. An observation on 9/29/2025 at 12:20 PM revealed DA-A wearing the same gloves while they resumed serving drinks. DA-A picked up an empty glass off the cart and without using an ice scoop, used the glass to scoop ice out of the blue ice chest sitting on a chair in the dining room. DA-A then poured juice into the glass and served it to a resident. DA-A went back to the drinking cart, picked up two small drinking cups, scooped ice out of the ice chest using the cups, poured juice and served to the residents while continuing to wear the same gloves. A record review of facility policy titled Hand Washing Guidelines for Dietary Employees last revised on 04/11/2023 stated Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses. Dietary employees shall clean their hands in a handwashing sink or approved automatic handwashing facility and may not clean hands in a sink used for food preparation, warewashing, or in a service sink that is used for disposal of mop water or similar waste.A record review of an undated facility policy titled Passing Water in the dining room states that the water shall be passed in a consistent sanitary manner that promotes resident hydration, dignity and choice. Under the procedures section of the policy ice must be handled only with a clean scoop: scoops may not be stored in ice. An interview on 9/29/2025 at 3:00 PM with Dietary Manager (DM) confirmed that the staff was to use an ice scoop and glasses should not be used to scoop ice from ice bucket. DM confirmed gloves should have been changed and hands washed after touching cleaning rag.

Based on record review and interview, the facility failed to employ a qualified infection preventionist. This had the potential to affect all residents residing within the facility. The facility census was 30.Findings Are: An interview on 9/29/2025 at 10:25 AM with the administrator revealed Licensed Practical Nurse (LPN)-C was the facility's Infection Preventionist. A record review of facility provided documents revealed no evidence that LPN-C had completed specialized training for infection control and prevention. An interview on 9/29/2025 at 11:36 AM with the administrator confirmed LPN-C had not completed specialized training for infection control and prevention and that the facility's Director of Nursing (DON) had been covering the duties of the Infection Preventionist in addition to their DON job duties.

Based on record review and interview, the facility failed to notify the ombudsman of 1 (Resident 35) of 1 sample resident's discharge from the facility. The facility census was 30. Findings Are: A record review of Resident 35's admission Record revealed the resident was admitted to the facility on [DATE]. The record also revealed the resident discharged to another nursing facility on 8/19/2025. A record review of Resident 35's electronic medical records revealed no evidence of the Ombudsman being notified of the resident's discharge from the facility. An interview on 9/30/2025 at 2:32 PM with the Director of Nursing (DON) confirmed the resident was discharged from the facility. The DON stated that the Social Services Director (SSD) was responsible for notifications to the ombudsman. An interview on 9/30/2025 at 2:35 PM with SSD revealed the SSD was only aware of the requirement to notify the Ombudsman of emergency transfers therefore, no notification had been sent regarding Resident 35's discharge from the facility.

Licensure Reference Number 175 NAC 12-006.09(E) Based on record review and interview, the facility failed to ensure the care plans were comprehensive for 2 (Residents 17 and 26) of 12 sampled residents. The facility census was 30. Findings Are: A record review of the facility's Comprehensive Care Plans policy with revision date of 9/12/2024 revealed it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment. A.A record review of Resident 17's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses of migraine and polyneuropathy. An interview on 9/29/2025 at 4:38 PM with Resident 17 revealed the resident had chronic pain and suffered from near constant migraines. A record review of Resident 17's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 6/11/2025 revealed the resident had a Brief Interview for Mental Status (BIMS, a brief screener used to determine cognitive status) score of 14/15, indicating the resident was cognitively intact. In the Pain Assessment Interview section, the resident attested to frequent pain that frequently affected their sleep, rehabilitation therapy sessions, and day to day activities. A record review of Resident 17's Quarterly MDS dated [DATE], the resident had a BIMS score of 14/15. In the Pain Assessment Interview section, the resident attested to almost constant pain that almost constantly affected their sleep and day to day activities. The resident rated the intensity of their pain as severe. A record review of Resident 17's physician's orders revealed the following:-Ibuprofen (an over-the-counter pain medication) Oral Tablet 400 milligrams (MG), give 400 mg by mouth every 24 hours as needed for pain/headaches. This order had a start date of 8/29/2025. -Pregabalin (a medication used to treat nerve pain) Oral Capsule 150 MG, give 1 capsule by mouth in the morning for neuropathy. This order had a start date of 6/5/2025.-Tylenol (an over-the-counter pain medication) Extra Strength Oral Tablet 500 MG, give 2 tablets by mouth every 6 hours as needed for mild pain or fever greater than 38.5 Celsius (101.3 Fahrenheit). This order had a start date of 6/4/2025. A record review of Resident 17's undated Care Plan revealed no evidence of care planning related to the resident's chronic pain. An interview on 10/1/2025 at 11:30 AM with the Director of Nursing (DON) confirmed that Resident 17's care plan did not reflect their chronic pain or the interventions in place to address it. B. A record review of Resident 26's admission Record revealed the resident was admitted to the facility on [DATE] with a diagnosis of Myasthenia Gravis without (acute) exacerbation (Myasthenia Gravis is a chronic neuromuscular autoimmune disease that causes weakness in the voluntary muscles. Voluntary muscles include muscles that connect to a person's bones, muscles in the face, throat, and diaphragm.) A record review of Resident 26's Annual MDS dated [DATE] revealed documentation of diagnoses of Myasthenia Gravis, weakness, history of falling, and unspecified abnormalities of gait and mobility. A record review of Resident 26's Quarterly MDS dated [DATE] revealed documentation of diagnoses of Myasthenia Gravis, weakness, history of falling, and unspecified abnormalities of gait and mobility. A record review of Resident 26's Physician's Orders revealed the following:-azaTHIOprine (an immunosuppressant medication) tablet 50 MG, give 0.5 tablet by mouth one time a day related to Myasthenia Gravis and other Myoneural Disorders. This order had a start date of 8/2/2023. -Pyridostigmine Bromide (a reversible cholinesterase inhibitor medication used primarily to improve muscle strength in people with Myasthenia Gravis) tablet 60 MG, give 1 tablet by mouth four times a day related to Myasthenia Gravis and other Myoneural Disorders. This order had a start date of 8/1/2023. A record review of Resident 26's undated Care Plan revealed no evidence of care planning related to the resident's Myasthenia Gravis condition, potential risks, or interventions related to the condition. An interview on 10/1/25 at 8:00 AM with the DON confirmed Resident 26 had a diagnosis of Myasthenia Gravis and the resident's care plan did not address the disease process, or medications and interventions required to treat it.

Licensure Reference Number 175 NAC 12-006.11(E) Based on observations, interviews, and record reviews, the facility failed to ensure foods were not stored on the floor and meats were not thawed above fresh vegetables. This had the potential to affect all residents. The facility census was 36. Findings are: Record review of the policy and procedure Food Receiving and Storage with a revised date of 10/1/2024 revealed the policy is so food shall be received and stored in a manner that complies with safe food handling practices. The purpose is to ensure the quality of food and ensure it is stored and handled properly. Refrigerated foods will be stored in such a way that promotes adequate air circulation around food storage containers. The freezer must keep foods frozen solid. Uncooked and raw animal products and fish will be stored separately in drip proof containers and below fruits, vegetables, and other ready to eat foods. An observation on 2/4/2025 at 10:45 AM revealed in the walk-in refrigerator two boxes of lettuce stored on the floor, one non-drip container of chicken thawing on a shelf above another box with ready to consume lettuce, and a bowl of ground meat stored in a bowl above a bowl of potato salad. The walk-in freezer door was open into the refrigeration area. In the walk-in freezer several boxes of food were stored on the floor. These boxes were label desserts, ice cream, fine ground beef, potato triangles, dinner roll dough, among other items where label couldn't be read. A plastic bag of sliced apples was laying on the floor, and a 2-3 gallon container of ice cream was on the floor. There were also two non-drip containers of frozen produce on the floor both holding numerous plastic bags filled with sliced apples. The black plastic floor mats in the freezer area had small bits of yellow and brown debris. Interview on 2/4/2025 at 11:10 AM with Dietary Aide (DA-B) who stated that the delivery truck had come and all of the food in the freezer would be put away before the end of the shift but at the time because of cooking meals, there was no time to do it. Observation on 2/4/2025 at 11:15 with the Dietary Supervisor (DS) as a second tour of the walk-in refrigerator and walk-in freezer are done. Two boxes of fresh vegetables, including lettuce remain on the floor and chicken continues to thaw above the lettuce in the refrigerator. In the walk-in freezer the boxes remained on the floor, the frozen apples remained on the floor, and the ice cream remained on the floor. Interview on 2/4/2025 at 11:20 AM with the Dietary Supervisor (DS) who stated that food is delivered on Mondays, Thursday and Fridays. We haven't had anything delivered since last Friday (1/31/2025). Confirmed there is food stored on the floor that has been sitting on the floor over the past 5 days.

Licensure Reference Number 175 NAC ,d+[DATE].11(E) Based on observations, interviews and record review, the facility failed to ensure that outdated food items were not available for use, failed to ensure clean and sanitary surfaces were maintained throughout the kitchen, and failed to do proper hand hygiene to prevent cross contamination and prevent the spread of foodborne illness. The facility also failed to use pasteurized eggs when serving over-easy eggs to prevent foodborne illness and failed to follow package directions while preparing stuffing. This had the potential to affect all 32 residents served food out of the kitchen. Findings are: During the initial kitchen tour on [DATE] from 10:30 AM to 11:24 AM revealed the following concerns: A cart with pots and pans on the bottom shelf had dust and food particles on it. Two shelves above the serving area had seven plastic canisters with cereal, no dates on the canisters. Dust, grime and food particles were also on this shelf that could fall into food being prepped in this area. The shelves below this prep area had bowls and plate covers' with old food particles on shelf. The oven had dried fried food substances on the top of the stove and the front of the oven. The backsplash had brown oily substance on it and other yellow/brown splatters. There were two plastic containers of oil and soybean oil that were open with no dates. A sanitizer dispenser above the prep sink with a sign that reads out of order. A bucket of sanitizer on the prep sink shelf with four wet rags lying the sink shelf. Seven containers used to store greater than 10 pounds of flour, sugar, powdered sugar, oatmeal and rice in them, were found on the floor below the prep sink and prep counter. One container with breadcrumbs had a soiled blue bag on it. None of these canisters had dates and all of the canister outer surfaces were covered with dried food particles and dust. Foil lined trays stored on the bottom shelf of the prep cart containing one undated box of baking soda with an expiration date of [DATE], one open bag of granola with no date, one open bag of baking powder with no date, an undated open bag of vanilla pudding, and a pint sized plastic container of oregano leaves with an expiration date of [DATE]. All trays were soiled with old food particles, a sticky substance and other dark liquids. An upright refrigerator with one carton of cottage cheese with an expiration date of [DATE], that was available for use. The area near the office had 1 box of sweet potatoes stored on the floor with regular potatoes stacked on top of it. The walk in refrigerator had leaves and old food particles on the floor. The cartons of eggs did not have a P on them, indicating they were pasteurized. The walk in freezer had no less that six boxes of steak fries/pork/Brussel sprouts and sherbet stored on the floor. There was also one bag of hot dogs open and unsealed with no date, one bag of stir fry open and unsealed with no date, one bag of chicken breasts in a Ziploc bag with no date. The large dry storage room with shelf storage contained four boxes of baking soda with expiration dates of [DATE], one open and unsealed bag of egg noodles with no date, one bag of spaghetti rolled up but open and no date, one bag of penne noodles open and unsealed with no date. One open bag of rice crispy cereal with no date, one open bag of tortilla chips with no date and two bags expired on [DATE]. A 35 pound bag of powdered sugar that was open and unsealed with no date. Two boxes of corn and one box of cherry pie filling stored on the floor. An interview on [DATE] at 11:15 AM with the Dietary Supervisor (DS) confirmed the cleanliness concerns and outdated food items in the kitchen. An interview with on [DATE] at 10:35 AM with Dietary Aide (DA)-M revealed that the DA was uncertain if the dishwasher sanitized the dishes by chemical or hot water. Interview also revealed that they had a 3 compartment sink: the first one was used with dish soap to wash the dishes, the second one had water to rinse and the third sink they filled to the crate line and put some chemicals in, not measured because it is really strong. An observation on [DATE] at 10:38 AM revealed Cook-K obtaining a green bucket half full with the sanitizer solution. No test strips seen or observed being used to test sanitizer solution. An interview on [DATE] at 10:32 AM with DA-L about sanitizing solution revealed DA-L verbalized that the solution is changed after every meal. When asked how the solution is tested to ensure adequate sanitization of surfaces is occurring, DA-L was unsure. When asked how the cook obtained sanitizer solution, the cook verbalized that it comes from the wall mount and the cook adds water because it is too strong. DA-L confirmed that (gender) does not test the solution. An interview with the DS at 9:36 AM on [DATE] confirmed the chemicals for the dishwasher are not tested as they ran out of test strips a week ago. Interview also confirmed the sanitizer solution for cleaning surfaces test strips are out as well. An observation on [DATE] at 8:45 AM revealed Resident 1 and Resident 29 were both served over easy eggs and 100% was eaten. An interview with the DS on [DATE] at 9:35 AM confirmed that there were no pasteurized eggs available and that the cooks were instructed to only use those for hard fried eggs. An observation on [DATE] for meal prep from 10:07 AM to 10:53 AM of DA-L preparing lunch revealed DA-L removed foil from turkey pans and placed in trash. DA-L completed hand hygiene for 5 seconds under running water, applied new gloves and picked up turkey from pan and placed on a cutting board in a pan, removed string around turkey and sliced turkey with clean knife. Removed gloves and poured juice over the slices. Obtained sanitizer bag and wiped prep counter with rag. DA-L completed hand hygiene for 11 seconds under running water and applied new gloves then picked up the turkey and placed on a cutting board, removed string and threw in trash, sliced turkey, removed gloves, purred juice on turkey. Obtained foil. Placed pans in oven at 350 degrees. Observation of meal prep continued: DA-L obtained 2 pans and sprayed them with non-stick spray, then obtained a bag of stuffing, read the directions, dumped one bag of dry breadcrumbs in the large pan, then obtained 2 and ,d+[DATE] quarts of water per directions and poured over the dry crumbs. DA-L then poured ,d+[DATE] of another bag of breadcrumbs into the small pan, no measurement. DA-L applied gloves without the benefit of hand hygiene and stirred the crumbs and water with gloved hands. DA-L removed gloves, obtained and undetermined amount of water and poured over the ,d+[DATE] pan of crumbs, applied clean gloves without the benefit of hand hygiene and stirred the mixture with gloved hands. DA-L then added a packet of seasoning to the large pan and part of the other package to the half pan. (no measurement completed) It is to note that the directions on the package said to boil the water and add the seasonings and bring to a boil prior to pouring over the breadcrumbs. DA-L then took and unmeasured amount of used butter from the refrigerator and placed in the microwave to melt. There was a line on the container that the butter was in that read 1 pound. The recipe called for 1 pound of butter per package. The butter was less than ,d+[DATE] way to the 1 pound line and it was divided between the two pans of crumbs. Pans covered and placed in oven at 350 degrees. It is to note that when the dressing was served, it was very dry. An interview with the DS on [DATE] at 10:55 AM confirmed that the cook should have followed directions on the package, and that the DS would expect staff to do hand hygiene for ,d+[DATE] seconds, per facility policy. 51122 A record review of a facility policy titled, Hand Hygiene, last revised [DATE], revealed hand hygiene using soap and water or alcohol-based hand rub should be performed, between resident contacts, and after handling contaminated objects. The policy also stated, The use of gloves does not replace hand hygiene. On [DATE] between 12:14 and 12:54 PM, Dietary Aide (DA)-A was continually observed wearing the same pair of disposable gloves. During this time, DA-A: -delivered lunch plates to all residents in the dining room -walked from dining room across a hall to retrieve resident plates from the kitchen service window -carried lunch plates back to the dining room -removed and reapplied lids from multiple used resident cups -poured drinks into cups for multiple residents -retrieved sugar packets from the secondary kitchen area then delivered them to a resident in the dining room -touched their face with their gloved hand -delivered dessert plates to the residents in the dining room from a rolling cart -wrapped clean silverware in a napkin -retrieved a water pitcher from the secondary kitchen area. An interview with DA-A on [DATE] at 1:08 PM confirmed that they should have changed their gloves and performed hand hygiene during meal service between resident contacts and after touching contaminated objects.

Licensure Reference 175 NAC 12-00604(B)(ii) Licensure Reference 175 NAC 12-006.04(B)(ii)(1) Based on record reviews and interview, the facility failed to ensure nurse aides had completed at least 12 hours of continuing education, including Dementia and Abuse training, as required for 4 (Nurse Aide G, F, D, and H) of 5 sampled employees. This had the potential to affect all 32 residents who reside within the facility. Findings are: A record review of the Imperial Manor Facility Assessment with a date of 8/5/2024, under Training and Education Section, indicated nurse aides must complete no less than 12 hours per year of continuing education, including Dementia and abuse. A record review of Nurse Aide (NA)-G's Relias Transcript with a date of 10/8/2024 revealed a hire date of 7/23/2021. It also revealed 0 hours of training for the year and no evidence of Dementia or abuse training. A record review of an undated list of in-services for NA-G revealed no in-services had been completed for the year and no evidence of Dementia or abuse training. A record review of NA-F's Relias Transcript, with a date of 10/8/2024, revealed a hire date of 7/10/2023 and a total training hours of 4.05. A record review of an undated list of in-services for NA-F revealed a total of 5 hours. NA-F had a total of 9.05 training hours for the year. A record review of NA-D's Relias Transcript, with a date of 10/8/2024, revealed a hire date of 11/23/2021 and a total of 8.3 training hours completed for the year. A record review of an undated list of in-services for NA-D revealed a total of 3 hours. NA-D had a total of 11.3 training hours for the year. A record review of NA-H's Relias Transcript, with a date of 10/8/2024, revealed a hire date of 4/12/2021 and a total of 7.55 training hours completed. A record review of an undated list of in-services for NA-H revealed a total of 4 hours. NA-H had a total of 11.55 training hours for the year. An interview on 10/9/2024 at 3:00 PM with the Administrator confirmed NA-D, NA-G, NA-F, and NA-H did not meet the required 12 hours of continuing education.

Licensure Reference 175 NAC 12-006.09(I)(i)(3) Based on observations, interviews, and record reviews; the facility failed to implement interventions to prevent elopement for 1 resident (Resident 26), ensure fall interventions were in place for 2 residents (Resident 3 and 22), and ensure a call light was within reach for 1 resident (Resident 15). The sample size was 4 out of 4 residents. The facility identified a census of 32. Findings are: A. A record review of a facility policy Elopements and Wandering Residents with a date of 5/9/2023 indicated the facility's approach to monitoring and management of residents at risk for elopement included implementing interventions to reduce the hazard and risk of elopement. A record review of an Admission Record indicated the facility admitted Resident 26 on 12/28/2023 with diagnoses of dementia with agitation and anxiety. A record review of Resident 26's significant change Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning,) with a date of 9/18/2024 indicated Resident 26 had a Brief Interview for Mental Status (BIMS) of 2/15, which indicated severe cognitive impairment. It also revealed Resident 26 had behaviors of having delusions and wandering into unsafe spaces. A record review of Resident 26's Progress Notes with a date of 1/27/2024, written by Registered Nurse (RN) - E revealed Resident 26 had eloped out the front door of the facility after breakfast. Staff were able to catch up to Resident 26 and redirect. Resident 26 attempted to leave the facility again about an hour later. A record review of Resident 26's Care Plan with a date initiated of 12/29/2024 indicated Resident 26 was an elopement risk with history of attempts to leave the facility unattended and wandered throughout the facility. Interventions included the following: - Document if wandering behavior and attempted diversional interventions with an initial date of implementation of 12/29/2023. - Monitor for fatigue and weight loss with a date initiated of 1/18/2024. - Provide structured activities toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes with a date of implementation of 1/18/2024. - Resident able to sit in front entry way with frequent visual checks by staff with a date of implementation of 6/5/2024. - Resident has Wander Guard with a date of implementation of 12/29/2023. An interview on 10/10/2024 at 10:15 AM with RN-E confirmed Resident 26 had eloped through the front door and an hour later had exited through a rear door on 1/27/2024. RN-E confirmed no new interventions were implemented after Resident 26's elopements. B. A record review of the facility's policy Fall Prevention Program with a date of 6/28/2024 indicated the facility would implement interventions to decrease the risk of resident's falling. A record review of an Admission Record indicated the facility admitted Resident 3 on 8/1/2023 with diagnoses of dementia, weakness, and history of falls. A record review of Resident 3's quarterly MDS, with a date of 8/12/2024, indicated Resident 3 had a BIMS score of 6/15, which indicated Resident 3 had severe cognitive impairment. It also indicated Resident 3 used a walker and wheelchair, required extensive assistance for transfers, and required moderate assistance for walking. It also indicated Resident 3 had one fall without injury since the last MDS completion. A record review of Resident 3's Care Plan, with a last revised date of 8/15/2024, indicated Resident 3 was at risk for fall due to history of falls and weakness. The care plan included an intervention of ensuring Resident 3's walker was always in reach. An observation on 10/8/2024 at 2:16 PM revealed Resident 3 had been sitting in their recliner. Resident 3's walker had been positioned across the room near the window and was not within Resident 3's reach. An observation on 10/9/2024 at 10:31 AM revealed Resident 3 had been sitting in their recliner. Their walker was positioned across the room near the window and was not within Resident 3's reach. An interview on 10/9/2024 at 10:41 AM with Nurse Aide (NA)-D confirmed Resident 3's walker was not within reach and NA-D was not aware of the care plan intervention of keeping the walker within Resident 3's reach. C. A record review of the facility's policy Fall Prevention Program with a date of 6/28/2024 indicated the facility would implement interventions to decrease the risk of resident's falling. A record review of an Admission Record indicated the facility admitted Resident 22 on 5/22/2023 with a diagnosis of spinal stenosis (a condition where the spine narrows causing pressure on the spinal cord and nerves) and macular degeneration (a disease that causes central vision loss). A record review of Resident 3's quarterly MDS, with a date of 8/29/2024, indicated Resident 3 had a BIMS of 3/15, which indicated Resident 3 had severe cognitive impairment. It also indicated Resident 3 required extensive assistance with transfers. A record review of Resident 22's Care Plan, with a last revision date of 12/12/2023 revealed Resident 3 was at risk for falls. The care plan included an intervention to remind Resident 3 to use their call light when needing to transfer. An observation on 10/9/2024 at 9:27 AM revealed Resident 3 had been sitting in their wheelchair. Resident 3's call light was positioned on the floor behind the bed, inaccessible to Resident 3. An interview on 10/9/2024 at 9:28 AM with NA-C confirmed Resident 3's call light was inaccessible to Resident 3 and should have been within Resident 3's reach. 51560 D. Record review of Resident 15's Admission Record revealed the Resident admitted on [DATE] and subsequent diagnosis were listed: Hypotension, Unspecified Dementia, Anxiety, Cervical Disk Disorder with Myelopathy, Pain and Constipation. Record review of Resident 15's quarterly MDS dated [DATE] revealed under Section C a Brief Interview for Mental Status (BIMS, an interview to determine a residents cognition) a score 3 out of 10 indicating severe cognitive impairment. An observation of Resident 15 on 10/07/24 at 1:41 PM revealed Resident 15's call light was across the room attached to the wall with the cord draped over the call box, not within reach of the resident. An observation of Resident 15 on 10/08/24 at 7:50 AM revealed the Resident resting in bed with both shoes on, the call light across the room on wall. An observation of Resident 15 on 10/08/24 at 1:43 PM revealed Resident up in room with shoes on getting ready to go out to activities. Call light across the room on wall. An interview with Resident 15 on 10/08/24 at 1:43 PM revealed that staff do not leave the call light within reach and if the Resident needed to call for help, the Resident would get up and walk over to the wall. An interview with Nurse Aide (NA)-J at 9:30 AM on 10/09/24 revealed that call lights are detachable from wall down the 300 hall. They also have a cord if it will reach to the resident, or they also use a pendant (necklace). When asked what type of call light Resident 15 uses NA-J states Resident 15 has a pendant. No pendant was noted to be found with Resident 15 or in the room. NA-J confirmed that if a resident does not have a pendant and the cord will not reach them that they are supposed to be detached and placed by the resident. NA-J then removed the box from wall and set it next to Resident 15 on the bed. An interview with the MDS Coordinator at 9:58 AM on 10/09/24 revealed Resident 15 does not have order for pendant and should be utilizing either the cord or the box for a call light. An interview on 10/09/24 at 2:49 PM with the Director of Nursing (DON) confirmed that call lights are expected to be near wherever the resident is located for instance if they were in their recliner, we would have it next to recliner. Or we also keep it in one place so residents won't forget where it is located The DON confirmed that the call light for Resident 15 should not be left on the wall while in bed and should be by resident, within reach. Record review of the facility Fall Prevention Policy implemented 6/28/24 revealed the call light and frequently used itmes are to be within reach. Record review of the facility Call Light Policy last revised 6/28/24 revealed staff will ensure the call light is within reach of residents and secured, if needed.

Licensure Reference 175 NAC 1-005.01(G) Based on record reviews and interview, the facility failed to report to the State Agency and submit an investigation within 5 working days of an elopement for 1 (Resident 26) of 1 sampled resident. The facility identified a census of 32. Findings are: A record review of a facility policy Reporting Alleged Violations with a date of 2/22/2023 revealed alleged violations must be reported to the administrator of the facility and to the State Survey Agency in accordance with state law. The policy did not include a timeframe. A record review of Resident 26's Progress Notes with a date of 1/27/2024, written by Registered Nurse (RN) - E revealed Resident 26 had eloped out the front door of the facility after breakfast. Staff were able to catch up to Resident 26 and redirect. Resident 26 attempted to leave the facility again about an hour later. An interview on 10/10/2024 at 11:00 AM with the Administrator confirmed a report to the State Agency within 5 working days regarding Resident 26's elopement had not completed.

Licensure Reference 175 NAC 12-006.09(c)(ii) Based on interviews and record review, the facility failed to complete a significant change in status 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) within the required 14 days assessment within 14 days of the determination of a significant change for 1 (Resident 11) of 1 sampled resident. The facility identified a census of 32. Findings are: A record review of the Long-Term Care Facility Resident Assessment Instrument Manual (RAI Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities), Chapter 2.6 revealed, A significant change of status assessment (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program. The record also revealed that the Assessment Reference Date (ARD) of an SCSA must be no later than, the 14th calendar day after determination that significant change in resident's status occurred. A record review of Resident 11's face sheet revealed the resident was admitted to the facility on [DATE]. A record review of Resident 11's active physician's orders revealed an order dated 6/5/24 stating, Admit to hospice services. A record review of Resident 11's Minimum Data Set (MDS) assessment, a data tool used by nursing homes to report resident information to the federal government, dated 7/4/24, indicated the type of assessment was, significant change in status (SCSA). Section O of the record also revealed resident was receiving hospice care. An interview on 10/09/24 at 1:46 PM with the MDS Coordinator revealed that the facility followed the RAI Manual's guidelines when completing and submitting MDS assessments. The MDS coordinator confirmed that the SCSA for Resident 11 was completed beyond the required 14-day timeframe set forth by the RAI Manual.

Based on observation, interview and record review; the facility failed to ensure an accurate Preadmission Screening and Resident Review (PASRR) was completed prior to admission for one (Resident 15) of one sampled resident. The facility identified a census of 32. Findings are: Record review of Residents 15's face sheet revealed a diagnosis of schizoaffective disorder (a chronic mental illness that combines symptoms of schizophrenia and a mood disorder, such as bipolar disorder or depression) dated the day of admission 12/15/21. Record review of Resident 15's PASSR dated 12/15/21 on page two under section three where the form asks if the Resident has a suspected mental illness, the facility answered the question no and the Resident had a diagnosis of schizoaffective disorder. On page four of the PASRR form where the facility would write in any suspicion of a mental illness, this was also marked no. Record review of Resident 15's care plan dated 9/26/24 revealed an additional diagnosis of psychotic disturbance, mood disturbance, and schizoaffective disorder. Record review of Resident 15's physicians orders revealed Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour 37.5 MG (Venlafaxine HCl) for depression, prescribed on 2/11/23. Quetiapine Fumarate Tablet Give 50 mg by mouth in the evening related to schizoaffective disorder, prescribed on 2/25/22, this was decreased to 25 mg on 2/10/23. Interview with Social Service Director (SSD) on 10/8/24 at 12:48 PM confirmed if a resident admits from home the facility is responsible for completing the PASRR. The SSD also confirmed that the diagnosis of schizoaffective disorder should have triggered a level two PASRR. The additional diagnosis of psychotic disturbance and mood disturbance along with psychotropic medications also failed to prompt the facility to complete a new PASRR.

Licensure Reference 175 NAC 12-006.09(F)(i) Based on record review and interview, the facility failed to develop a baseline care plan (a written strategy for how nursing home staff will help a resident receive the care they need) with the required information for 1 (Resident 30) of 1 sampled resident. The facility identified a census of 32. Findings are: A record review of a facility policy Baseline Care Plan with a date implemented of 10/7/2022 indicated baseline care plans would, at minimum, include initial goals, physician's orders, dietary order, therapy services, and social services. A record review of an Admission Record indicated the facility admitted Resident 30 on 3/29/2024 with diagnoses of Chronic Obstructive Pulmonary Disease and dementia. A record review of Resident 30's Interim Care Plan with a date of 3/29/2024 revealed no evidence of physician's orders, dietary orders, or social services. An interview on 10/8/2024 at 12:40 PM with the Minimum Data Set (MDS) Coordinator confirmed the required information was not included on Resident 30's baseline care plan and should have been included.

Licensure Reference 175 NAC 12-006.09(H)(vi)(3)(g) Based on observations, interviews, and record review; the facility failed to ensure that nasal cannula tubing was stored in a sanitary condition and failed to ensure oxygen settings were set at the prescribed rate for 2 (Resident 8 and 30) of 2 sampled residents. The facility identified a census of 32. Findings are: A. A record review of a facility policy Oxygen Administration with a date implemented of 5/31/2023 indicated oxygen delivery devices are to be kept covered in plastic bags when not in use and oxygen is to be administered under orders of a physician. A record review on an Admission Record indicated the facility admitted Resident 30 on 3/29/2024 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD.) A record review of Resident 30's Order Summary with a date of 10/8/2024 revealed an order for oxygen at 2 Liters Per Minute (LPM) at bedtime and as needed. An observation on 10/8/2024 at 11:50 AM revealed Resident 30's oxygen tubing had been wrapped through the handle of the oxygen concentrator with the nasal cannula resting on the floor. An interview on 10/8/2024 at 11:58 AM with Registered Nurse (RN) - B confirmed the nasal cannula was on the floor and should have been stored in a bag. An observation on 10/8/2024 at 2:00 PM revealed Resident 30's oxygen concentrator was set at 4 LPM. An interview on 10/8/2024 at 2:05 PM with Licensed Practical Nurse (LPN) - I confirmed Resident 30's oxygen concentrator was set at 4 LPM and should have been set at 2 LPM. 51560 B. Record review of Resident 8's Face sheet revealed the resident admitted on [DATE] with the following diagnosis: COPD, Unspecified, Essential Hypertension, Obstructive Sleep Apnea, Shortness of Breath, Chronic Systolic Heart Failure, Hypoxemia. Record review of Resident 8's Physicians Orders dated 2/27/22 revealed oxygen at 2 liters per nasal cannula to keep oxygen saturations greater than 90%. Check oxygen saturations every shift. An observation on 10/08/24 at 01:30 PM of Resident 8 sitting in electric recliner in room with head elevated to the highest postion. Continuous Positive Airway Pressure (CPAP) device in place on Resident's face with oxygen attached to the device. No sound was audible from CPAP machine and it was discovered to be unplugged. Resident was not receiving oxygen. Resident cued to turn machine on after plugging it in and the oxygen concentrator was noted to be at .5 liters. An interview on 10/8/24 at 2:07 PM with Registered Nurse (RN)- B revealed that the person on the medication cart should be monitoring the oxygen machine and oxygen saturations. RN-B accompanied the surveryor to room to look at oxygen concentrator dial and confirmed that the order is for 2 liters and the concentrator is on .5 liters. Record review of the facility Oxygen Administration Policy dated 5-31-23 under number 4; The care plan shall identify equipment setting for prescibed flow rates and monitoringand c. monitoring of SpO2 and equipment setting for the prescribed flow rates.

Licensure Reference 175 NAC 12- 006.09(H) Based on record reviews and interview, the facility failed to have a stop date for an antibiotic for 1 (Resident 3) of 5 sampled residents. The facility identified a census of 32. Findings are: A record review of the facility's policy Antibiotic Stewardship Program with a last review/revised date of 10/8/2024 revealed all prescriptions for antibiotics shall specify the dose, duration, and indication for use. Antibiotic orders obtained upon admission to the facility shall be reviewed for appropriateness. A record review of an Admission Record revealed the facility admitted Resident 3 on 8/1/2023. A record review of Resident 3's Order Summary with a date of 10/9/2024 revealed an order for Doxycycline (an antibiotic) once a day for chronic knee infection. The order had a beginning date of 8/1/2023 and no evidence of a stop date. An interview on 10/9/2024 at 1:00 PM with the Infection Preventionist (IP) confirmed Resident 3's antibiotic had no stop date and no attempts to discontinue the antibiotic had been made.

Liscensure Reference Number 175 NAC 12-006.10 (D) Based on observation, interview, and record review; the facility failed to ensure that 1 (Resident 6) of 7 sampled residents received an extended-release medication per manufacturer directions. This resulted in a significant medication error. The facility identified a census of 32. Findings are: Record review of Resident 6's Minimum Data Set (MDS, a federally mandated assessment that helps determine a plan of care) dated 8/20/24, under Section C the Brief Mental Interview (BIMS) (an interview to determine a resident's cognition) a score of 7 out of 15 indicating the resident has moderate cognitive impairment. Section I indicates a diagnosis of non-Alzheimer's dementia and dysphagia (a swallowing disorder). Record Review of Resident 6's Medication Administration Record (MAR) revealed the following medications were ordered: -Magnesium 400 milligram (mg) orally every day for dietary supplement. -Vitamin B12 1000 micrograms (mcg) orally every day for dietary supplement -Zinc 50 mg orally every day for dietary supplement -Calcium + D3 600-400 mg orally every day for osteoporosis -Metoprolol Succinate extended-release 25 mg orally every day- for hypertension -Miralax 17 grams orally in 8 ounces of water for constipation -Sertraline 25 mg orally every day for depression -Vitamin D 1000 units gel capsule orally every day for osteoporosis -Metformin 500 mg give 2 tabs orally twice a day for diabetes -Voltaren gel 1% topically to right knee every 6 hours as needed for pain A medication administration observation of Registered Nurse (RN) E on 10/9/24 at 8:30 AM of prepping mediations for Resident 6 revealed RN- E placing all oral medications in a plastic envelope to be crushed. This included Metoprolol Succinate Extended-Release. RN-E mixed the crushed the medications with applesauce in a small cup and administered to Resident 6, Resident 6 swallowed all the medications. Interview with RN-E on 10/10/24 at 08:59 AM confirmed metoprolol ER should not be crushed and that there is no special order from doctor or instructions from pharmacy specifying that it was ok to crush metoprolol. Record Review of manufacturer recommendations for metoprolol extended release revealed metoprolol succinate extended-release tablets are scored and can be divided; however, the whole or half tablet should be swallowed whole and not chewed or crushed. https://www.accessdata.fda.gov/drugsatfda_docs/label/2006/019962s032lbl.pdf NDA 19-962 /S-032 Page 16 Interview with Director of Nursing (DON) on 10/10/24 at 09:18 AM revealed that the expectation for crushed medications is that there are some medications that cannot be crushed, however for some residents that refuse to swallow a whole pill they will continue to crush. The DON stated the Medical Director agreed that it is better for them to get it than for them not to get it however there is no documentation in the Resident 6's medical record to support that.

Licensure Reference 175 NAC 12-006.18(B) Licensure Reference 175 NAC 12-006.18(D) Based on observations, interview, and record reviews; the facility failed to don (put on) Personal Protective Equipment (PPE) of a gown during catheter cares and completed hand hygiene between glove use as required for 1 (Resident 26) of 1 sampled resident. The facility identified a census of 32. Findings are: A record review of Enhanced Barrier Precautions with a date of 5/3/2024 revealed initiation of enhanced barrier precaution will be implemented for those with indwelling medical devices (urinary catheters) during high-contact resident care activities of transferring, providing hygiene, changing briefs, or urinary device care. A record review of a facility policy Hand Hygiene with a date last revised of 6/12/2023 revealed if a task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. A record review of Resident 26's Care Plan with a date of 8/14/2024 revealed Resident 26 had a urinary tract infection, Methicillin-resistant Staphylococcus aureus (MRSA, an infection caused by a type of staph bacteria that's resistant to many antibiotics,) and had a urinary catheter. An intervention included to wear gowns and gloves during physical contact with the resident. An observation on 10/9/2024 at 12:16 PM revealed Nurse Aide (NA) - D had began to pull Resident 30's pants down to provide a brief change and peri-care. NA-D had not donned a gown before starting. An interview on 10/9/2024 at 12:18 PM with NA-D confirmed NA-D had not donned a gown and should have before beginning Resident 30's care. An observation on 10/9/2024 at 12:19 PM revealed NA-D had changed gloves without the benefit of performing hand hygiene prior to the application of new gloves. An observation on 10/9/2024 at 12:23 PM revealed NA-F, who had been assisting NA-D with Resident 30's care, had removed their gloves and applied new gloves without the benefit of hand hygiene prior to the application of the new pair of gloves. An interview on 10/9/2024 at 12:28 PM with NA-F confirmed NA-F did not perform hand hygiene between glove changes and should have. An interview on 10/9/2024 at 12:30 PM with NA-D confirmed NA-D did not perform hand hygiene between glove changes and should have.

Based on record reviews and interview, the facility failed to submit data for the third quarter of 2024 for the Payroll Based Journal (PBJ, a collection of staffing information and a requirement of all long-term care facilities.) This had the potential to affect all resident residing within the facility. The facility identified a census of 32. Findings are: A record review of a facility policy Payroll Based Journal with a last reviewed/revised date of 8/31/2024 revealed the facility shall submit information as per Centers for Medicare and Medicaid Services (CMS) requirements and no later than the deadline specified for the specific quarter in which the data is to be reported. The policy states the deadline for submission for quarter three is August 14th. A record review of the PBJ report from CMS revealed the facility had failed to submit data for the third quarter (April 1 - June 30) in 2024. An interview on 10/10/24 at 08:20 AM with the Administrator confirmed the third quarter PBJ was not reported on time by the business manager as required.

Licensure Reference Number 175 NAC 12-006.11E Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in a manner that prevents the potential for foodborne illness in residents who consume food from the kitchen. This had the potential to affect all residents residing in the facility who ate from the kitchen. The facility census was 39. The findings are: A. An initial observation on 10/2/23 from 10:20 AM through 10:50 AM in the kitchen revealed the following: -The refrigerator contained two bowls of lettuce covered with plastic wrap with no dates on them - A clear plastic bag of cooked bacon with no date on it - A clear plastic bag of an unknown food with no label or date on it -Three flat metal pans were sitting on racks under the prep counter that had a significant amount of food debris on them -The Walk-in fridge contained the following items: an open bottle of prune juice that was not dated, and open bottle of Thirs-Tea that was not dated, and a large, opened Chipotle Ranch dressing container that was not dated. A record review of Nebraska Food Code, Section 81-2,272.24(3)A food specified under this section shall be discarded if such food: (b)Is in a container or package that does not bear a date or day. An observation on 10/4/23 from 9:15 AM through 10:40 AM in the kitchen revealed Cook-A preparing to make the lunch meal, which included Salmon Patties. Cook-A could not find a recipe for the Salmon Patties in the Week 2 Recipe Binder and was observed asking DM for a recipe. DM provided a handwritten recipe to Cook-A but did not identify where the recipe came from. The recipe was written for 5 servings, so it was then altered for 35 servings. Cook-A sprinkled Lemon Pepper from container into bowl containing recipe ingredients without measuring. The recipe did not have Lemon Pepper on it. Cook-A stated the [NAME] residents don't like Black Pepper, so Cook-A planned to leave out the Black Pepper and that is why the Lemon Pepper was added. Cook-A continued to measure the ingredients into the bowl per the recipe. There was no measurement on the recipe for salt, the recipe only said, Kosher Salt, Cook-A poured some salt into their gloved and sprinkled the unmeasured salt over the bowl using their other gloved hand three times. After Cook-A had mixed all the ingredients in the bowl, Cook-A used a 1/4 cup scoop to form the salmon patties. The recipe did not say how much salmon mixture to put into each of the patties. The recipe said to fry the patties in oil, but Cook-A stated they were going to bake the patties to save time. DM approached while the patties were being formed and confirmed Cook-A was going to bake the patties instead of fry them despite the recipe instructions. An interview on 10/4/23 at 10:30 AM with Cook-A revealed the facility had recently changed to the fall/winter menus and the facility was currently on week two of the menus. Cook-A stated the DM was still reviewing to make sure they have all the recipes in the binder. Cook-A stated it is not very often that they do not have the necessary recipe available. An interview on 10/4/23 at 10:32 AM with DM confirmed DM was still reviewing the fall/winter menus to ensure all the recipes were in the recipe binder. A record review of myplate.gov Salmon Patties recipe revealed a serving size of 1/3 cup. A record review of the facility Salmon Pattie recipe did not reveal a serving size of the Salmon Pattie. B. An observation on 10/4/23 from 9:15 AM through 10:40 AM in the kitchen revealed Cook-A took out a flat pan and covered it with wax paper, then sprayed the wax paper with PAM. Cook-A opened the refrigerator with gloves on, took out a bag of broccoli and sat it on the prep counter. Cook-A took the gloves off, performed hand hygiene (HH) with soap and water for 8 seconds, and applied new gloves. Cook-A then plated two breakfast plates, threw away gloves their gloves, and performed HH with soap and water for 9 seconds. Cook-A put on a new pair of gloves and served another breakfast plate. Cook-A obtained one 4-inch-deep pan and filled it partially with water, put a 2-inch slotted pan inside the other pan, and left them on prep counter while they went to serve another breakfast plate. Cook-A then took off their gloves, performed HH with soap and water for 7 seconds, and put on a new pair of gloves. Cook-A then opened a bag of broccoli and put it in the slotted pan, covered it with foil and put it on the stove. Cook-A got out more broccoli, removed their gloves, performed HH with soap and water for 9 seconds, and then put on new gloves. Cook-A opened the broccoli and poured it into the pan, covered the pan with foil, and put it on the stove. Cook-A took off their gloves and performed HH with soap and water for 9 seconds. Cook-A took 3 packages of roast beef out of the refrigerator, put two of the bags into two 2-inch pans, and put the third bag in blender. Cook-A used their gloved hand to remove the roast beef from blender and push into the pan. Cook-A then removed the gloves, performed HH with soap and water for 7 seconds, covered the pans with foil and labeled them. Cook-A put on new gloves, made several breakfast plates, took all the breakfast food from the serving warmer and took it to the dishwasher area. Cook-A used a rag soaked from the sanitizer bin and wiped down the counters, warmer, and toaster. Cook-A removed their gloves and performed HH with soap and water for 11 seconds. Cook-A obtained the ingredients for the salmon patties and applied new gloves. Cook-A then broke up the salmon in a bowl, broke eggs into the salmon, threw away the shells, removed their gloves and performed HH with soap and water for 8 seconds. Cook-A put on new gloves, added the remaining ingredients into the bowl, then mixed the ingredients using the same gloved hands they had used to touch the containers for all the ingredients. Cook-A removed their gloves, took the dishes to the dishwasher area, and threw away the trash. Cook-A then performed HH with soap and water for 10 seconds. An observation on 10/4/23 at 11:55 in the kitchenette revealed Cook-A perform hand hygiene with soap and water for 14 seconds prior to putting on gloves and serving resident meal plates. A record review of the facility's Hand Hygiene policy, last review/revised on 6/28/23 revealed Policy Explanation and Compliance Guideline 5.a Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers.

Licensure Reference Number 175 NAC 12-006.09C1c Based on interviews, and record review, the facility failed to review and revise 4 (Residents 26, 27, 33, and 38) of 4 sampled resident's care plans after a fall. The facility census was 39. The findings are: A. A record review of Resident 26's Facesheet revealed Resident 26 was admitted to the facility on [DATE] with a primary diagnosis of Chronic Kidney Disease, Unspecified. A record review of Resident 26's Minimum Data Set (MDS) (an assessment completed to determine cares needed for the resident) dated 9/14/2023, Section C revealed Resident 26's Brief Interview for Mental Status (BIMS) score was 9 out of 15 which indicates the resident had moderately impaired cognition. Resident 26's MDS Section G revealed Resident 26 required extensive assist from one staff for transferring, toilet use, and walking. A record review of an Event Report dated 7/6/23 at 7:15 PM revealed Resident 26 had an unwitnessed fall in their room. A record review of an Event Report dated 7/22/23 at 8:30 PM revealed Resident 26 had an unwitnessed fall in their room. A record review of an Event Report dated 7/29/23 at 7:45 PM revealed Resident 26 had an unwitnessed fall in their room. A record review of an Event Report dated 8/12/23 at 8:59 PM revealed Resident 26 had an unwitnessed fall in their room. A record review of an Event Report dated 8/24/23 at 7:45 PM revealed Resident 26 had an unwitnessed fall in their room. A record review of an Event Report dated 9/6/23 at 7:30 PM revealed Resident 26 had an unwitnessed fall in their room. A record review of an Event Report dated 9/12/23 at 6:44 AM revealed Resident 26 had a witnessed fall in their room. A record review of Resident 26's Care Plan, initiated on 1/26/2023 revealed no new interventions for the falls occurring on 7/22/23, 8/12/23, 8/24/23, 9/6/23, and 9/12/23. An interview on 10/4/23 at 2:50 PM with the facility MDS Coordinator confirmed that new interventions were not put into place each time Resident 26 fell . The MDS Coordinator stated the facility has had a hard time coming up with interventions despite discussing at Risk meetings and discussing with Resident 26's son/POA. B. A record review of Resident 27's Facesheet revealed Resident 27 was admitted to the facility on [DATE] with a primary diagnosis of Unspecified fracture of shaft of left tibia, initial encounter for closed fracture. A record review of Resident 27's MDS dated [DATE], section C revealed Resident 27's BIMS score was 15 out of 15 which indicated the resident was cognitively intact. Section G of the MDS revealed Resident 27 required extensive assist from one staff for transferring, toilet use, and walking. A record review of Resident 27's Care Plan, date initiated 5/27/22 revealed Special Instructions on page one that Resident 27 required a Sit to stand lift. An interview on 10/4/23 at 3:00 PM with nursing staff Medication Aide (MA)-F confirmed Resident 27 required stand by assist with a gait belt and can walk with walker from their bed to their bathroom and then the resident will pivot transfer from the toilet to the wheelchair. MA-F reported they did not use the Sit to Stand (STS) lift on Resident 27 and has never seen or heard about anyone using the STS lift with this resident. An interview on 10/4/23 at 3:15 PM with the MDS Coordinator confirmed the STS lift use was added to the Care Plan Special Instructions upon Resident 27's admission and was never removed. The MDS Coordinator confirmed the STS lift should not have been on the Care Plan as Resident 27 no longer required a STS lift for transfers. 48765 C. Record review of Resident 33's Face Sheet revealed resident was admitted on [DATE] with the diagnosis of Wedge Compression Fracture of T7-T-8 Vertebra, Initial Encounter for Closed Fracture. Record review of Resident 33's MDS dated [DATE] revealed in Section C: the Brief Interview for Mental Status (BIMS) showed a score of 5 out of 15 which indicated the resident was cognitively impaired. In Section G: Functional Status showed Resident 33 needed extensive assistance and one-person physical assist for bed mobility, limited assistance and one-person physical assist for transfer, independent and set up help for eating and extensive assistance and one-person physical assist for toileting. Record review of Incident Reports revealed Resident 33 had falls on 7/2/2023, 8/26/2023 and 9/22/2023. Record review of Resident 33's Care Plan dated 5/23/2023 revealed Resident 33's Care Plan had the 9/22/2023 fall on the care plan but no intervention was listed for the 9/22/2023 fall. An interview on 10/6/2023 at 9:54 AM with the facility MDS Coordinator confirmed that the 9/22/2023 fall for Resident 33 had no interventions in place. D. Record review of Resident 38's Face Sheet revealed resident was admitted on [DATE] with the diagnosis of History of Falling and Muscle Weakness. Record review of Resident 38's MDS dated [DATE] revealed in Section C: the Brief Interview for Mental Status (BIMS) showed a score of 15 out of 15 which indicated the resident was cognitively intact. In Section G: Functional Status showed Resident 38 independent with set help only for bed mobility, extensive assistance and one-person physical assist for transfer, independent and set up help for eating and extensive assistance and one-person physical assist for toileting. Record Review of Incident Reports revealed Resident 38 had falls on 8/23/2023, 9/4/2023 and 9/14/2023. Record Review of Resident 38's Care Plan dated 8/24/2023 and revised on 9/25/2023 revealed Resident 38's Care Plan did not have an intervention in place for the 9/4/2023 and the 9/14/2023 falls. An interview on 10/6/2023 at 9:54 AM with the MDS Coordinator confirmed that there were no interventions in place for the 9/4/2023 and the 9/14/2023 falls for Resident 38.