Every finding on record at Kimball County Manor

Licensure Reference Number 175 NAC 12-006.11(E)Based on observation, record review, and interview, the facility failed to date stored foods, and failed to ensure proper hand hygiene was performed to prevent the potential for cross contamination and food borne illness. Findings are: Observations made at 8:00 AM on 6/22/26 during the initial kitchen tour revealed the following:-A container of chicken base with no open, use by, or expiration date.-10 ceiling panels with water damage and staining and 1 ceiling tile with a hole in it-1 box baking soda w/o open date in a sealed Ziploc bag-4 boxes of krusteaz cornbread mix with no best by date, received date or expiration date.-1 box buttermilk biscuit mix open without an opened date marked-8 bottles of ketchup with no receive date or expiration date. -1 box of individual [NAME] mayo packets with no open, use-by, or expiration date-1 gallon of dill pickle relish with no open, use-by, or expiration date-1 gallon of miracle whip with a best-by date listed at 5/18/26-Four, 7-pound cans of banana pudding with open, use-by, or expiration dates-Two, 104-ounce cans apricot halves with open, use-by, or expiration dates-Five, 6.63-pound cans of apples with no open, use-by, or expiration dates-Four, 116-ounce cans of cherry pie filling with no open, use-by, or expiration date-4 loaves of bread in a white freezer with no use-by, or expiration date- 1 loaf of bread, opened with no opened, use-by, or expiration date.-1 Ziploc bag with 4 rolls/buns inside with no open, use-by, or expiration date-1 bag of long rolls with no open, use-by, or expiration date-2 separate half gallons of almond milk with expiration dates of 4/13/26-1 full unopened gallon and 1 partially used gallon of ice cream mix with best by dates of 6/18/26An interview with the Dietary Manager (DM) at 8:48 AM on 6/22/26 confirmed the expiration dates on the items listed above and discarded them. Continuous observations made on 6/23/26 from 9:14 AM to 10:30 AM revealed the following:-At 9:19AM the DM performed hand hygiene for 3 seconds with soap and water and then stated they were going to grab soap because they were out of it at the hand-washing sink. At 9:20 AM an observation of the soap dispenser at the hand-washing sink revealed there was no soap in it. The DM returned with new bag of soap and refilled the dispenser and then performed hand hygiene for 15 seconds. At this time the Dietary Aid (DA)-F performed hand hygiene with soap and water for 12 seconds.-At 9:26 the DM prepared 3 basins of vegetables and then performed hand hygiene with soap and water for 10 seconds. The DM then donned gloves and cut through butter with the wrapper still on, then removed the wrapper and cut the butter into smaller chunks with the same knife and added the pieces of butter to each basin of vegetables. The DM put the remaining butter away, removed their gloves and performed hang hygiene with soap and water for 13 seconds.-At 10:16 AM the DM walked into the bathroom with their kitchen apron on. An interview at 9:31 AM on 6/23/26 with the DM confirmed they should wash their hands for probably 30 seconds.Record review of a facility policy dates 2/27/23 and labeled 'Handwashing/hand hygiene' revealed information about when to wash hands using either 62% alcohol-based hand rub or soap and water. This includes washing hands before and after the use of gloves and before and after handling foods. This policy also revealed that hands should be washed for a minimum of 15 seconds when using soap and water.

Licensure Reference Number 175 NAC 12-006.05(E) Based on record review and interview, the facility failed to obtain informed consents from the resident or their representative prior to the use of psychotropic medication for 5 (Residents 1, 6, 7, 8, & 31) of 5 sampled residents. The facility identified a census of 39. Findings Are: An interview on 6/23/26 at 1:20 PM with the facility Administrator revealed the facility did not have any policies specific to psychotropic medications and confirmed that the facility had not obtained informed consents prior to the administration of psychotropic medications for any residents who were currently prescribed psychotropic medications. A. A record review of Resident 1's Continuity of Care Document dated 6/24/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 1's Medication Order revealed the resident had an order for mirtazapine (an antidepressant medication) 7.5 milligrams (mg) daily for a diagnosis of depression. The order had a start date of 3/3/2026. A record review of Resident 1's medical records revealed no evidence of the resident or their representative being informed in advance of the risks, benefits, and alternative treatment options for the mirtazapine medication. B. A record review of Resident 31's Continuity of Care Document dated 6/24/2026 revealed the resident was admitted to the facility on [DATE]. The document also revealed the resident had an order for Paxil (an antidepressant medication) 20mg to be taken at bedtime for a diagnosis of depression. The order had a start date of 6/6/2025. A record review of Resident 31's medical records revealed no evidence of the resident or their representative being informed in advance of the risks, benefits, and alternative treatment options for the Paxil medication. C. Record review of Resident 6's face sheet, dated 6/24/26, revealed an original admission date of 9/12/25 and the following relevant diagnoses: -Depression, unspecified Record review of Resident 6's undated Continuity of Care Document dated 6/24/25 revealed an order for Seroquel (atypical antipsychotic prescription medication used to treat schizophrenia, bipolar disorder (both manic and depressive episodes), and as an add-on treatment for major depressive disorder) 100milligram (mg) tablet, take twice a day for: Depression, unspecified, with a start date of 2/1/2026, and Duloxetine(a prescription medication used to treat depression, anxiety, and various forms of chronic pain) 30mg capsule delayed release, take twice a day for: Depression, unspecified, with a start date of 2/5/26. Record review of Resident 6's care plan with a last conference care date of 6/8/26, revealed a problem start date of 9/12/25 for: Category: Psychotropic Drug Use Resident has Depression and takes Duloxetine 30 mg twice a day (bid) and Seroquel 100mg bid. The following relevant approaches were listed with a start date of 9/12/25: - Assess for mood/behavior problems. - Attempt non-pharmacological interventions such as music, repositioning, new environment, pet therapy, take resident outdoors. - Convey an attitude of acceptance toward the Resident. - Report emergence of signs of isolation (e.g., sad, dull affect; non-communicative; withdrawn; lack of eye contact; expressions of loneliness/rejection; hostile, irritable behavior; lack of awareness of surroundings; inattention to self-care; etc.). The following approaches were listed with a start date of 2/10/26 - Acknowledge to the Resident that the current situation must be difficult. - Closely supervise resident. - Restrict access to potentially harmful items (e.g., glass, scissors, needles, razors, plastic bags, lighters, hangers, knives, medications, call light cords, electrical appliances, etc.). Continued record review of Resident 6's Electronic Medical Record (EMR) revealed there was no consent for the use of psychotropic medications or documentation of alternative treatment options and education. On 6/23/2026 at 1:20 PM an interview was conducted with the facility administrator. During the interview the facility Administrator reported having consent forms, however, the consent forms were not implemented for the use of psychotropic medications. D. Record review of Resident 7's face sheet, dated 6/25/26, revealed an original admission date of 6/14/17 and the following relevant diagnoses: - Dementia in other diseases classified elsewhere, unspecified severity, with agitation - Depression, unspecified Record review of Resident 7's undated Continuity of Care Document revealed an order for Mirtazapine (a prescription antidepressant primarily used to treat major depressive disorder) 15 mg, 1 tablet at bedtime, with a start date of 10/8/2023. Record review of Resident 7's care plan with a last care conference date of 4/9/26 revealed the following problems: -a problem start date of 6/22/17 for: Category: Psychosocial well-being, Level II PASRR as evidenced by Depression, Parkinsons with Dementia/Psychosis. Mirtazapine 15mg at bedtime (hs) for depression. -a problem star date of 6/22/17 for: Category: Psychotropic Drug Use Resident has potential for adverse consequences while receiving antidepressant medication R/T DX: Depression, Parkinsons with Dementia/Psychosis. Currently takes Mirtazapine 15 mg at HS. This listed problem also revealed the following relevant approaches: - Approach Start Date: 06/27/2025 Assess/record effectiveness of drug treatment. Monitor and report signs of sedation, hypotension, or anticholinergic symptoms. - Approach Start Date: 06/27/2025 Attempt non-pharmacological interventions such as: music, repositioning, new environment, pet therapy and taking resident outdoors. - Approach Start Date: 06/27/2025 Pharmacy consultant review. - Approach Start Date: 03/28/2018 Observe for and report S/S of worsening depression (increased irritability, anxiousness, sadness, restlessness, tearfulness, frustration, anxiety, agitation, anger, difficulty sleeping, decreased energy, difficulty concentrating, remembering, making decisions, angry outbursts, increased aches/pain, appetite and/or weight changes) - Approach Start Date: 06/22/2017 Administer/record/adjust for depression medications as ordered by physician. Evaluate/record/report effectiveness and any adverse side effects. - Approach Start Date: 06/22/2017 Assess/record effectiveness of drug treatment. Observe for and report signs of sedation, hypotension, or anticholinergic symptoms (constipation, blurred vision, drowsiness, increased confusion, tremors, lip-smacking, involuntary tongue movement, shuffling gait ). Continued record review of Resident 7's EMR revealed there was no consent for the use of psychotropic medications or documentation of alternative treatment options and education. On 6/23/2026 at 1:20 PM an interview was conducted with the facility administrator. During the interview the facility Administrator reported having consent forms, however, the consent forms were not implemented for the use of psychotropic medications. E. Record review of Resident 8's face sheet, dated 6/23/26 revealed an original admission date of: 12/9/22, with the following relevant diagnosis: - Schizophrenia, unspecified Record review of Resident 8's undated Continuity of Care Document revealed the following relevant orders; - Risperidone (atypical (second-generation) antipsychotic medication used to help stabilize thinking, mood, and behavior.) 0.5 mg tablet Twice A Day for Schizophrenia, unspecified - Lexapro (escitalopram oxalate; a widely prescribed prescription antidepressant belonging to the selective serotonin reuptake inhibitor (SSRI) class used to treat major depressive disorder (MDD) and generalized anxiety disorder (GAD)) 10 mg tablet. Record review of Resident 8's care plan with a last care conference date of 5/21/26 revealed a problem start date of 12/19/22 Category: Psychotropic Drug Use Resident receives antipsychotic medication Risperidone 0.5 mg BID for DX of Schizophrenia. Also receives Lexapro 10 mg daily. This problem has the following listed approaches: - Approach Start Date: 08/08/2025 Attempt non-pharmacological interventions such as music, repositioning, new environment, pet therapy, taking resident outdoors. - Approach Start Date: 04/21/2025 If resident appears to be overstimulated, move resident to a new environment that is not as busy and is quieter. - Approach Start Date: 12/19/2022 Assess if the resident's behavioral symptoms present a danger to the resident and/or others. Intervene as needed. - Approach Start Date: 12/19/2022 Attempt yearly GDR thereafter unless clinically contraindicated. - Approach Start Date: 12/19/2022 Pharmacy consultant review Continued record review of Resident 8's EMR revealed there was no consent for the use of psychotropic medications or documentation of alternative treatment options and education. On 6/23/2026 at 1:20 PM an interview was conducted with the facility administrator. During the interview the facility Administrator reported having consent forms, however, the consent forms were not implemented for the use of psychotropic medications.

Licensure reference number 175 NAC 12-006.09Based on record review and interview the facility failed to notify the provider of blood pressures being outside the set parameters per their order for 3 (Residents 5,6, and 31) of 5 sampled. The facility showed a census of 39Findings are: A. Record review of a facility policy with a revision date of 2/28/25 and a subject label of ' Notification of Physicians' revealed the following statements:The nurse will notify the resident's attending physician or physician on call when there has been:- specific instruction to notify the physician of changes in the residents condition-A significant change of condition is a major decline or improvement in the resident's status that: a.) will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting)b.) impact more than one area of the residents healthc.) requires interdisciplinary review and/or revision to the care plan,. -The nurse will record in the resident's medical record information relative to changes in the residents medical/mental condition or statusThe nursing personnel at this facility are responsible for notification of the physician of the above information. All attempts to notify physicians will be noted in the residents' health record including the time and method of communication. If the physician is not contacted, the individual acknowledging contact, if any, will be documented. If the attending physician or his designee is not readily available, emergency medical care will be provided and emergency physicians contacted. Record review of Resident 6's face sheet, dated 6/24/2026, revealed an original admission date of 9/12/2025 with the following relevant diagnoses: -Hyperlipidemia, unspecified (high cholesterol) -Essential (primary) hypertension (High blood pressure with an unknown cause) -Cerebral infarction, unspecified (stroke caused by a clot in the brain) -Pain in left shoulder -Other abnormalities of gait and mobility -Repeated falls -Weakness -Dizziness -Abnormal results of thyroid function studies A Record review of Resident 6's care plan with a 'last review' date of 6/8/26 revealed a problem of: 'Category: Medical Condition; Resident is at risk for unstable blood pressure related to hypertension' with a problem start date f 9/12/25. The Goal listed for this problem revealed the following: - 'Resident's Systolic pressure will not be greater than 180 or lower than 90 and her Diastolic pressure will not be greater than 100 or lower than 60' with a start date of 9/10/26. The relevent approaches listed for this goal revealed the following: -Administer medications as ordered by provider- Hydrochlorothiazide 25mg daily and Clopidogrel 75 mg daily. Evaluate/record/report effectiveness/adverse side effects with a start date of 9/12/25. Resident 6's care plan also revealed a problem of: 'Category: Falls Resident at risk for falling R/T dizziness and giddiness, unsteadiness on feet, Osteoarthritis, low back pain, Abnormalities of gait and mobility, Spondylosis with Myelopathy of lumbar region and weakness and repeated falls. High fall risk' with a problem start date of 9/12/25. Record review of a progress note dated 2/20/26 revealed: .It was reported that the resident has always had very high blood pressure and that (gender) is very high fall risk with 'normal' blood pressure range-(gender) gets lethargic and behaves not within normal limits (WNL). Record review of a 'Doctors order sheet' dated 9/12/26 revealed a note: Patient (Pt) has been severely hypertensive. Rapid correction is hazardous. Be permissive of Hypertension (HTN). Primary care provider (PCP) to slowly correct. Record review of Resident 6's order report dated 6/25/2025 revealed the following relevant orders and changes since their admission on [DATE]: Start date 9/11/25, Contact provider if Systolic blood pressure (the top number in a blood pressure reading,) is greater than 180 or less than 90 OR Diastolic blood pressure (the bottom number in a blood pressure reading) is greater than 100 or less than 60. Start date 2/20/26, Hydrochlorothiazide tablet, 25mg oral, HOLD if systolic is under 140 and had no end date when the order would be discontinued. Start date 9/13/25, Lisinopril (a blood pressure medication that works by blocking a substance that causes blood vessels to tighten) tablet, 5mg oral, once a day 7:00 AM. Discontinued on 10/28/25. Start date, 2/23/26, Lisinopril tablet, 20mg oral, once a date 7:00 AM. HOLD if systolic is less than 140. Discontinued 2/23/26 Start date 2/24/26, Lisinopril tablet, 20mg oral, once a day 7:00 AM. HOLD if systolic is under 140. There is no end date on this order Record review of Resident 6's administration records and vitals since admission on [DATE] in the electronic medical record (EMR) revealed the following blood pressures outside the ordered parameters set by the provider on the following dates: -09/27/25 3:57 PM Blood Pressure: 181 (systolic) / 90 (diastolic) -10/2/25 5:40 PM Blood Pressure: 185 / 85 -10/4/25 4:26 PM Blood Pressure: 187 / 80 -10/13/25 9:06 AM Blood Pressure: 189 / 88 -10/14/25 7:00 AM Blood Pressure: 186 / 78 -10/15/25 4:16 PM Blood Pressure: 183 / 95 -10/16/25 5:42 PM Blood Pressure: 184 / 95 -10/17/25 4:29 PM Blood Pressure: 188 / 97 -10/20/25 5:43 PM Blood Pressure: 189 / 90 -10/21/25 7:00 AM Blood Pressure: 188 / 98 -10/22/25 7:00 AM Blood Pressure: 192 / 75 -10/22/25 5:28 PM Blood Pressure: 180 / 109 -10/23/25 7:00 AM Blood Pressure: 196 / 92 -10/23/25 4:42 PM Blood Pressure: 185 / 90 -10/25/25 10:36 AM Blood Pressure: 181 / 98 -10/25/25 11:45 AM Blood Pressure: 192 / 84 -10/27/25 7:00 AM Blood Pressure: 194 / 72 -10/27/25 8:45 AM Blood Pressure: 194 / 72 -10/27/25 4:04 PM Blood Pressure: 196 / 90 -10/30/25 11:35 AM Blood Pressure: 181 / 83 -10/30/25 6:44 PM Blood Pressure: 194 / 96 -11/5/25 4:23 PM Blood Pressure: 198 / 100 -11/9/25 6:46 AM Blood Pressure: 195 / 83 -11/10/25 7:00 AM Blood Pressure: 183 / 76 -11/12/25 4:12 PM Blood Pressure: 199 / 105 -11/18/25 7:00 AM Blood Pressure: 189 / 97 -11/19/25 7:00 AM Blood Pressure: 190 / 100 -11/19/25 10:16 AM Blood Pressure: 190 / 100 -11/20/25 7:00 AM Blood Pressure: 192/110 -11/22/25 7:00 AM Blood Pressure: 197 / 93 -11/23/25 7:00 AM Blood Pressure: 187 / 95 -11/25/25 7:00 AM Blood Pressure: 189 / 97 -11/26/25 3:53 PM Blood Pressure: 200 / 98 -12/2/25 3:00 PM Blood Pressure: 189 / 93 -12/3/25 5:39 PM Blood Pressure: 144 / 58 -12/13/25 4:00 PM Blood Pressure: 195 / 94 -12/14/25 4:21 PM Blood Pressure: 188 / 91 -12/17/25 4:09 PM Blood Pressure: 184 / 83 -12/18/25 4:05 PM Blood Pressure: 186 / 79 -12/19/25 10:19 AM Blood Pressure: 190 / 76 -12/20/25 3:00 PM Blood Pressure: 183 / 78 -12/21/25 5:39 PM Blood Pressure: 187 / 104 -12/23/25 7:00 AM Blood Pressure: 182 / 81 -12/23/25 10:53 AM Blood Pressure: 206 / 94 -12/23/25 3:58 PM Blood Pressure: 199 / 93 -12/24/25 6:10 PM Blood Pressure: 221 / 99 -12/25/25 7:00 AM Blood Pressure: 182 / 93 -12/25/25 6:12 PM Blood Pressure: 201 / 98 -12/29/25 11:34 AM Blood Pressure: 190 / 82 -12/29/2025 5:30 PM Blood Pressure: 184 / 86 -12/30/25 4:26 PM Blood Pressure: 190 / 96 -12/31/25 5:40 PM Blood Pressure: 187 / 95 -1/4/26 5:28PM Blood Pressure: 179 / 102 -1/7/26 9:30 AM Blood Pressure: 188 / 84 -1/14/26 4:31 PM Blood Pressure: 185 / 88 -1/15/2026 9:50 AM Blood Pressure: 183 / 95 -1/15/26 5:51 PM Blood Pressure: 188 / 77 -1/17/26 5:54 PM Blood Pressure: 185 / 83 -1/19/26 7:00 AM Blood Pressure: 207 / 94 -1/19/26 4:03 PM Blood Pressure: 189 / 91 -1/20/26 5:41 PM Blood Pressure: 182 / 94 -1/21/26 8:01 AM Blood Pressure: 204 / 102 -1/23/26 7:00 AM Blood Pressure: 187/104 -1/23/26 9:42 AM Blood Pressure: 193 / 87 -1/24/26 4:26 PM Blood Pressure: 180 / 105 -1/25/26 9:03 AM Blood Pressure: 184 / 100 -1/25/26 4:38 PM Blood Pressure: 194 / 100 -1/27/26 10:09 AM Blood Pressure: 182 / 83 -1/27/26 4:16 PM Blood Pressure: 190 / 90 -1/29/26 7:00 AM Blood Pressure: 193 / 106 -1/31/26 7:00 AM Blood Pressure: 205/111 -2/2/26 7:00 AM Blood Pressure: 183 / 83 -2/3/26 10:01 AM Blood Pressure: 209 / 114 -2/3/26 10:17 AM Blood Pressure: 183 / 89 -2/4/26 9:44 AM Blood Pressure: 194 / 83 -2/4/26 3:53 PM Blood Pressure: 191 / 102 -2/5/26 7:00 AM Blood Pressure: 196 / 85 -2/5/26 10:53 AM Blood Pressure: 197 / 70 -0/12/26 1:31 PM Blood Pressure: 184 / 77 -2/14/26 9:26 AM Blood Pressure: 150 / 103 -2/15/26 11:24 AM Blood Pressure: 184 / 83 -2/15/26 5:43 PM Blood Pressure: 185 / 87 -3/4/26 7:30 AM Blood Pressure: 191 / 91 -3/6/26 7:30 AM Blood Pressure: 190 / 95 -3/7/26 7:30 AM Blood Pressure: 182 / 90 -3/9/26 7:30 AM Blood Pressure: 192 / 103 -3/10/26 7:30 AM Blood Pressure: 201 / 93 -3/10/26 5:46 PM Blood Pressure: 186 / 89 -3/11/26 7:30 AM Blood Pressure: 203 / 74 -3/12/26 7:30 AM Blood Pressure: 185 / 88 -3/14/26 7:30 AM Blood Pressure: 197 / 100 -3/15/26 7:30 AM Blood Pressure: 201 / 84 -3/19/26 7:30 AM Blood Pressure: 201 / 76 -3/20/26 7:30 AM Blood Pressure: 198 / 76 -3/23/26 7:30 AM Blood Pressure: 186 / 105 -3/25/26 7:30 AM Blood Pressure: 189 / 78 -3/26/26 7:18 AM Blood Pressure: 208 / 75 -3/27/26 7:30 AM Blood Pressure: 191 / 93 -3/28/26 9:26 AM Blood Pressure: 182 / 74 -4/1/26 7:30 AM Blood Pressure: 209 / 99 -4/5/26 7:30 AM Blood Pressure: 194 / 109 -4/8/26 4:41 PM Blood Pressure: 189 / 89 -4/9/26 7:30 AM Blood Pressure: 188 / 102 -4/13/26 12:30 PM Blood Pressure: 100 / 59 -4/14/26 7:30 AM Blood Pressure: 189 / 81 -4/15/26 3:51 PM Blood Pressure: 182 / 91 -4/20/26 7:30 AM Blood Pressure: 188 / 79 -4/22/26 10:23 AM Blood Pressure: 181 / 80 -4/25/26 7:30 AM Blood Pressure: 192 / 96 -4/27/26 7:30 AM Blood Pressure: 185 / 94 -5/4/26 7:30 AM Blood Pressure: 183 / 101 -5/5/26 7:30 AM Blood Pressure: 194 / 84 -5/6/26 7:30 AM Blood Pressure: 196 / 97 -5/8/26 7:30 AM Blood Pressure: 193 / 92 -5/9/26 7:30 AM Blood Pressure: 182 / 78 -5/9/26 9:34 AM Blood Pressure: 183 / 77 -5/11/26 7:30 AM Blood Pressure: 181 / 84 -5/12/26 7:30 AM Blood Pressure: 188 / 74 -5/13/26 7:30 AM Blood Pressure: 199 / 80 -5/15/26 7:30 AM Blood Pressure: 205 / 89 -5/17/26 10:07 AM Blood Pressure: 187 / 72 -5/18/26 10:08 AM Blood Pressure: 170 / 104 -5/19/26 7:30 AM Blood Pressure: 189 / 83 -5/22/26 7:30 AM Blood Pressure: 215 / 96 -5/23/26 7:30 AM Blood Pressure: 188 / 96 -5/23/26 2:08 PM Blood Pressure: 183 / 82 -5/30/26 9:16 AM Blood Pressure: 203 / 104 -6/3/26 4:25 PM Blood Pressure: 182 / 93 -6/4/26 7:30 AM Blood Pressure: 183 / 101 -6/5/26 7:30 AM Blood Pressure: 194 / 84 -6/6/26 7:30 AM Blood Pressure: 196 / 97 -6/8/267:30 AM Blood Pressure: 193 / 92 -6/9/26 7:30 AM Blood Pressure: 182 / 78 -6/11/26 7:30 AM Blood Pressure: 181 / 84 -6/12/26 7:30 AM Blood Pressure: 188 / 74 -6/13/26 7:30 AM Blood Pressure: 199 / 80 -6/15/26 7:30 AM Blood Pressure: 205 / 89 -6/17/26 7:30 AM Blood Pressure: 160 / 123 -6/17/26 4:18 PM Blood Pressure: 182 / 81 -6/19/26 7:30 AM Blood Pressure: 189 / 83 -6/22/26 7:30 AM Blood Pressure: 215 / 96 -6/23/26 7:30 AM Blood Pressure: 188 / 96 Record review of a fax sheet dated 2/3/26 revealed: 'Message: Resident 6, DOB; Post fall with neuro x72 hors. Responding WNL.BP 201/109.No current concerns Record review of Resident 6's medical record from 9/11/25 to 6/25/26 revealed no evidence of a provider being notified of their abnormal blood pressures per their provider order. An interview with the Administrator at 2:00 PM on 6/24/25 confirmed there was not notification to the physician per the order every time that Residet 6's blood pressure was outside the set parameters. B. A record review of Resident 5's Continuity of Care Document dated 6/23/2026 revealed the resident was admitted to the facility on [DATE] and had a diagnosis of Essential (primary) Hypertension (elevated blood pressure). A record review of Resident 5's Active Orders revealed the following orders: -losartan (a prescription angiotensin II receptor blocker (ARB) medication primarily used to treat high blood pressure) 100 milligrams (mg) daily, with a start date of 12/1/2025. -metoprolol succinate (an extended-release, once-daily beta-blocker medication used to treat high blood pressure) 25 mg daily, with a start date of 12/3/2025. -Contact provider if systolic (the top number of a blood pressure) blood pressure is greater than 180 or less than 90 or diastolic (the bottom number of a blood pressure) blood pressure is greater than 100 or less than 60. This order had a start date of 10/16/2024. -Document vital signs (essential clinical measurements that indicate the state of a body's basic functions. The four primary vital signs routinely monitored to assess overall physical health are body temperature, pulse (heart rate), respiration rate, and blood pressure) once a day on Mondays and Thursdays. This order had a start date of 12/13/2025. A record review of Resident 5's Vital Signs documentation revealed the following: -On 4/30/2026 at 11:44 AM the resident had a blood pressure of 93/56. -On 6/8/2026 at 5:50 PM the resident had a blood pressure of 96/58. -On 6/11/2026 at 9:10 AM the resident had a blood pressure of 106/59. A record review of Resident 5's medical records from 4/30/2026 through 6/23/2026 revealed no evidence of a provider being notified of their abnormal blood pressures per their provider order. An interview on 6/24/26 at 7:30 AM with the facility Administrator confirmed the facility did not notify the provider of Resident 5's blood pressures being outside of the set parameters. C. A record review of Resident 31's Continuity of Care Document dated 6/24/2026 revealed the resident was admitted to the facility on [DATE] and had diagnoses of Essential (primary) Hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris (a condition where plaque builds up in the heart's original arteries without causing the classic chest pain known as angina. Also known as silent coronary artery disease, it requires careful management to prevent sudden heart attacks or disease progression), pulmonary heart disease (the enlargement and failure of the right side of the heart. It is caused by underlying lung diseases or high blood pressure in the lungs (pulmonary hypertension), which forces the right ventricle to overwork itself), peripheral vascular disease (a slow, progressive circulation disorder characterized by narrowing, blockage, or spasms in blood vessels outside the heart), and other nonrheumatic pulmonary valve disorders (refers to conditions affecting the heart's pulmonic valve that are unrelated to rheumatic fever). A record review of Resident 31's Active Orders revealed the following: -Contact provider if systolic blood pressure is greater than 180 or less than 90 or diastolic blood pressure is greater than 100 or less than 60. This order had a start date of 4/30/2024. -lisinopril 2.5 mg to be given twice a day with a start date of 2/16/2026. The order had instructions to hold the medication (don't give it) if the resident's systolic blood pressure was less than 90. A record review of Resident 31's Vital Signs documentation revealed the following: -On 3/4/2026 at 10:43 AM the resident's blood pressure was 106/59. -On 4/25/2026 at 3:29 PM the resident's blood pressure was 101/58. -On 5/6/2026 at 11:03 AM the resident's blood pressure was 110/54. -On 6/17/2026 at 10:04 AM the resident's blood pressure was 90/54. A record review of Resident 31's May 2026 Medication Administration Record (MAR) revealed the following: -On 5/8/2026 during the 7:00 AM medication administration time, the resident's blood pressure was 85/50. -On 5/16/2026 during the 7:00 AM medication administration time, the resident's blood pressure was 90/56. -On 5/30/2026 during the 7:00 AM medication administration time, the resident's blood pressure was 85/52. A record review of Resident 31's June MAR revealed the following: -On 6/18/2026 during the 7:00 AM medication administration time, the resident's blood pressure was 93/57. -On 6/20/2026 during the 6:00 PM medication administration time, the resident's blood pressure was 100/57. A record review of Resident 31's medical records from March 2026 through 6/23/2026 revealed no evidence of a provider being notified of their abnormal blood pressures per their provider order.

Licensure reference number 175 NAC 12-006.18 & (B) & 1-005.06 The facility failed to ensure hand hygiene was performed to prevent the potential for cross contamination during medication administration for 7 Residents (5, 25, 26, 32, 39, 40, and 43) of 7 residents medications administered. The facility showed a census of 39.Findings areRecord review of a facility policy 'Hand Hygiene' dated 2/27/23 revealed information that reads: Use alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . The relevant situations are as follows:-Before and after coming into direct contact with residents-Before preparing or handling mediations- After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident-After removing glovesContinuous observations made from 7:13 AM until 8:30 AM on 6/24/26 with Medication Aid (MA)B revealed the following:-At 7:13 AM MA-B began preparing medications for Resident 43, then grabbed a spoon and a pulse oximeter from the cart, locked the cart and their computer and walked to the residents room. After knocking, MA-B walked into Resident 43's room and did not perform hand hygiene before walking in. MA-B grabbed the residents water jug and handed it to the resident, then used a spoon to help give the resident their medications. MA-B [NAME] attempted to use a pulse oximeter to measure the residents pulse, which was not working and then took the residents radial pulse manually. MA-B stated the residents pulse, returned to the medication cart to grab one more medication for the resident, then returned to the residents room to give them the last medication. The MA-B then assisted the resident with their foot petals on their wheelchair, and finally left Resident 43's room. MA-B then performed hand hygiene with alcohol-based hand rub at the medication cart. -At 7:31 AM, MA-B began preparing one medication for Resident 5. MA-B brought this resident their medication to their room, watched the resident take it and then returned to the medication cart. MA-B did not perform hand hygiene before entering or leaving the residents room, or when returning to the medication cart to prepare medications for the next resident.-At 7:40 AM, MA-B began preparing one medication for Resident 40. Ma-B brought Resident 40 their medication to their room, knocked on the door and made their presence known while entering Resident 40's room. MA-B assisted this resident with their inhaled medication, holding it to the resident's mouth and giving warning of the medication being administered both times. MA-B then asked the Resident if they needed anything before leaving the room. MA-B did not perform hand hygiene after leaving this residents room or after returning to the medication cart.-At 7:43 AM, MA-B began preparing one medication for Resident 32. MA-B stated this resident refused this medication regularly. MA-B grabbed a bottle of MiraLAX powder from the cart, mixing it with water, and then bringing it to the Resident in the dining area. Resident 32 did refuse this medication. Then MA-B discarded this medication in the medication room. MA-B did not perform hand hygiene after leaving the residents room, discarding the medication, or after returning to the medication cart.At 7:45 AM, MA-B began preparing medications for Resident 25. Once medications were prepared, MA-B brought the medication to the dining hall. MA-B recorded a pulse on this resident using a pulse oximeter, and then gave this resident their medications with a spoon, while Resident 25 drank water to swallow their medications. Once Resident 25 was finished taking all medications, MA-B returned to the medication cart and did not perform hand hygiene.-At 8:17 AM, MA-B began preparing medications for Resident 39. Ma-B grabbed 2 creams out of the cart, and one donned a pair of gloved without performing hand hygiene. MA-B then mixed the 2 creams and then placed cream on Resident 39's back and chest. MA-B then removed their gloves, did not perform hand hygiene and then donned new gloves. MA-B helped hold open Resident 39's eyes while administering eye drops to the resident. Ma-B then removed their gloves and returned to the medication cart and did not perform hand hygiene.-At 8:22 AM, MA-D stated the resident they were giving medications too was in the bathroom and was waiting for the resident to finish. At 8:24 AM MA-D grabbed a pair of gloved and the resident's medications and proceeded to Resident 26's room. MA-D knocked on the resident's door, making their presence aware and then entered the resident's room, closing the door behind them to provide privacy to the residents. MA-D then [NAME] gloves without performing hand hygiene first, grabbed a Kleenex tissue for the resident, and then placed two eye drops in the bottom lid of the resident's eyes with their gloved hands holding the resident's eyes open.An interview with MA-B at 8:18 AM on 6/24/26 confirmed they were not washing their hands during their medication passes in between residents.An interview with the Administrator at 3:45 PM on 6/24/26 confirmed that staff frequently failed to perform hand hygiene due to not having hand sanitizer readily available at residents' rooms.

Licensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview, the facility failed to ensure 1 (Resident 1) of 5 sampled residents did not suffer adverse consequences from their psychotropic medication as evidenced by increasing Abnormal Involuntary Movement Scale (AIMS, a brief, 12-item clinician-rated examination used to detect and measure the severity of tardive dyskinesia (TD, a neurological movement disorder that causes uncontrollable, repetitive muscle movements, usually in the face, lips, jaw, and tongue)) assessment scores. The facility census was 39.Findings Are: An interview on 6/23/26 at 1:20 PM with the facility administrator revealed the facility did not have any policies specific to the use or monitoring of psychotropic medications. The administrator also revealed the facility performed AIMS assessments on all residents that were taking psychotropic medications. A record review of Resident 1's Continuity of Care Document dated 6/24/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 1's AIMS assessment dated [DATE] revealed a total score of 0, indicating the resident had no abnormal involuntary movements. A record review of Resident 1's Medication Order revealed the resident had an order for mirtazapine (an antidepressant medication) 7.5 milligrams daily, with a start date of 3/3/2026. A record review of Resident 1's AIMS assessment dated [DATE] revealed a total score of 2 and a severity judgement of minimal. The evaluation section revealed this score was an increase in symptoms compared to the prior assessment. The facility indicated there were no referrals necessary and they would continue the resident's current plan of care. A record review of Resident 1's AIMS assessment dated [DATE] revealed a total score of 4 and a severity judgement of mild. The evaluation section revealed this score was an increase in symptoms compared to the prior assessment. The facility indicated there were no referrals necessary and they would continue the resident's current plan of care. A record review of Resident 1's medical records revealed no evidence of the facility notifying the resident's provider or otherwise addressing the resident's increasing AIMS assessment scores. An interview on 6/24/26 at 7:30 AM with the facility Administrator revealed the nurse conducting the AIMS assessments on Resident 1 had not been aware they needed to do anything with the information gathered during the assessments. The administrator confirmed Resident 1 had been started on mirtazapine on 3/3/2026 and that the resident's provider had not been notified of their increasing AIMS assessment scores.

Based on record review and interview, the facility failed to notify the Ombudsman (a state official who works with nursing home and assisted living residents who helps answer resident concerns and complaints and advocates for resident rights and their well-being) of 1 (Resident 47) of 1 sampled resident's discharge from the facility. The facility census was 39.Findings Are: A record review of Resident 47's Interdisciplinary Discharge Summary revealed the resident was admitted to the facility on [DATE] following a right hip fracture. The document revealed the resident was later discharged from the facility on 4/1/2026 to their family home. A record review of Resident 47's medical records revealed no evidence of the Ombudsman being notified of their discharge from the facility. An interview on 6/24/26 at 2:45 PM with the facility Administrator confirmed the facility had not notified the Ombudsman of Resident 47's discharge. Per the administrator, the facility only notified the Ombudsman of facility-initiated discharges.

Licensure Reference Number 175 NAC 12-006.05(S) Based on observations, interview, and record review; the facility failed to preserve 1 (Resident 27) of 1 sampled resident's dignity by ensuring their catheter bag was concealed when in view of other residents. The facility identified a census of 39.Findings Are: A record review of facility policy Resident Dignity Policy with a review date of 5/15/26 revealed the facility would maintain an environment that preserved each resident's dignity. A record review of Resident 27's Continuity of Care Document dated 6/23/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 27's undated Care Plan revealed the resident required an indwelling urinary catheter related to urinary retention. This section of the Care Plan contained an intervention stating, store collection bag inside a protective, dignity pouch. An observation on 06/23/2026 at 8:15 AM revealed Resident 27 walking out of the dining room and down the 100 hallway. Their catheter bag was hooked to their walker with no dignity bag concealing it. An observation on 06/23/2026 at 8:31 AM revealed Resident 27 in the therapy room sitting in a chair with their walker beside them. Their catheter bag was hanging from the walker without a covering on it and the bag was situated in a manner that the other resident in the room could see the urine in the bag. An observation on 06/23/2026 at 9:54 AM revealed Resident 27 sitting in a recliner in their room with their catheter bag hooked to a trash can. There was no dignity bag on the catheter bag, and the bag was visible from the hallway. An observation on 06/23/2026 at 12:00 PM revealed Resident 27 sitting at a table in the dining room with their catheter hanging from their walker without a dignity bag concealing it. There were several other residents present in the dining room. An observation on 06/24/2026 7:30 AM revealed Resident 27 walking with their walker up the 200 hallway and into the dining room. Their catheter bag was hanging from their walker without a covering on it and there was yellow urine visible in the bag from across the hallway. An observation on 06/24/2026 at 11:25 AM revealed Resident 27 walking from their room to the dining room with their walker. Their catheter bag was hanging from their walker without a cover on it and urine was visible from several feet away. An observation on 6/24/26 at 1:15 PM revealed Resident 27 sitting in their recliner with their catheter bag hooked to the side of their trash can. The bag was visible from the hallway and was not concealed within a dignity bag. An interview on 6/24/26 at 1:58 PM with Nurse Aide (NA)-A confirmed there was no dignity bag concealing Resident 27's catheter bag.

Based on record review and interview, the facility failed to ensure an antibiotic was clinically indicated for 1 (Resident 42) of 1 sampled resident. The facility identified a census of 39.Findings Are: A record review of facility policy Antibiotic Stewardship Program with a review date of 2/14/19 revealed the facility's antibiotic stewardship program promotes the appropriate use of antibiotics and a system of monitoring to improve resident outcomes and reduce antibiotic resistance. Antibiotics will be prescribed for the correct indication, dose, and duration to appropriately treat the resident while attempting to reduce the development of antibiotic-resistant organisms or other adverse consequences or outcomes. In the procedure section it states that the physician will be notified of results of diagnostics to ensure resident is taking the appropriate antibiotic or if antibiotic needs to be discontinued or changed. A record review of Resident 42's Continuity of Care Document dated 6/24/2026 revealed the resident was admitted to the facility on [DATE]. The resident had a diagnosis of Overactive Bladder with an effective date of 3/3/2026. A record review of Resident 42's Provider Visit dated 4/21/2026 revealed the resident was being seen for their 60-day recertification visit. The provider documented that the resident was having urinary frequency and urgency despite being on Myrbetriq (a medication used to treat overactive bladder symptoms) 25 milligrams (mg). The provider increased Resident 42's Myrbetriq dose to 50 mg during this appointment. A record review of Resident 42's Progress Notes from 6/1/2026 through 6/16/2026 revealed no evidence of the resident having urinary frequency, urgency, or painful urination. A record review of Resident 42's Provider Visit dated 6/16/2026 revealed the resident was being seen for their 60-day recertification visit. The provider documented that during the resident's last evaluation, their Myrbetriq had been increased to 50 mg, the resident was presently having frequency and burning sensations, and a urinalysis (UA, a test that evaluates the physical, chemical, and microscopic properties of urine) had not been ordered. The provider wrote in the assessment section Dysuria (pain, burning, or discomfort during urination)- urinalysis with reflex culture ordered and pending. Further record review of Resident 42's Progress Notes from 6/16/2026 through 6/18/2026 revealed no evidence of the resident having any symptoms indicative of a urinary tract infection. On 6/17/2026 there was documentation that a urine sample had been obtained and taken to the laboratory. On 6/19/2026 the facility received a call from the medical clinic and were notified the resident's urinalysis was positive for infection and had been sent to the provider. Later that same day, the facility documented they had received an order for Macrobid (an antibiotic medication) 100 mg twice a day for 7 days for a diagnosis of urinary tract infection. A record review of a Centers for Disease Control (CDC) document titled NHSN Long-term Care Facility Component-Urinary Tract Infection and dated January 2025 revealed in Figure 1: Criteria for Defining Non-Catheter Associated Symptomatic Urinary Tract Infection (SUTI) that one of the required criteria for a urinary tract infection was a positive urine culture with no more than 2 species of microorganisms, at least one of which is a bacterium of greater than or equal to 100,000 CFU/ml (colony-forming units per milliliter, a unit of measurement used in microbiology to estimate the number of viable (living and reproducing) bacteria or fungal cells in a liquid sample). A record review of Resident 42's Urine Culture for the urinalysis obtained on 6/17/2026, revealed the final culture result was dated 6/19/2026 and that the urine grew 10,000-50,000 CFU/ml of Escerichia Coli (a bacteria commonly found in human feces). This is less than the amount of growth required to constitute a urinary tract infection. Further record review of Resident 42's Progress Notes revealed the following:-On 6/19/26 at 11:37 PM staff documented the resident had started their antibiotic that evening, the resident denied burning or painful urination, and their frequency had subsided.-On 6/20/2026 at 2:15 PM staff documented the resident continued to have frequency and went to the bathroom often.-On 6/21/2026 at 10:39 AM staff documented the resident was having less frequency to the restroom and denied any pelvic pain or issues with urination.-On 6/22/2026 at 12:51 AM staff documented the resident denied burning or painful urination and their symptoms were improved. Observations of Resident 42 on 6/23/2026 revealed the following:-At 8:23 AM the resident was sitting on the toilet in their bathroom, and their urine had a foul odor. The resident exited the bathroom at 8:24 AM.-At 8:26 AM the resident stands up from their recliner and goes into the bathroom and sits on the toilet. The resident exited the bathroom at 8:27 AM.-At 10:44 AM the resident walked from the hallway and went into the bathroom and sat on the toilet. The resident exited their bathroom at 10:45 AM and walked into the hallway.-At 10:46 AM the resident went back into their bathroom and sat on the toilet. The resident exited their bathroom at 10:47 AM. Urine was observed in the toilet bowl; there was no toilet paper in the toilet or in the trashcan. Observations of Resident 42 on 6/24/2026 revealed the following: -At 11:14 AM the resident was sitting in their recliner; the resident then stood up and went into the bathroom. At 11:16 AM the resident exited the bathroom and sat back in their recliner.-At 11:24 AM the resident stood up from their recliner and went into the bathroom. Staff entered the resident's room and went into the bathroom with the resident, assisting them to change their incontinence brief. After the toilet use was completed, the resident was assisted to go to the dining room. -At 1:14 PM the resident went into their bathroom and sat on the toilet. The resident exited the bathroom at 1:16 PM and sat in their recliner.-At 1:29 PM the resident went into their bathroom and sat on the toilet. The resident exited the bathroom at 1:30 PM and sat in their recliner.-At 1:32 PM the resident went into their bathroom and then returned to their recliner within the same minute.-At 1:36 PM the resident went into their bathroom and sat on the toilet. The resident exited the bathroom at 1:37 PM and sat in their recliner.- At 1:38 PM the resident went into their bathroom and sat on the toilet. The resident exited the bathroom at 1:39 PM and sat in their recliner.- At 1:43 PM the resident went into their bathroom and sat on the toilet. The resident exited the bathroom at 1:44 PM and sat in their recliner.- At 1:45 PM the resident went into their bathroom and sat on the toilet. The resident exited the bathroom at 1:46 PM and sat in their recliner.- At 1:46 PM the resident went into their bathroom and sat on the toilet just seconds after sitting down in their recliner. The resident exited the bathroom at 1:47 PM and sat in their recliner.- At 1:48 PM the resident went into their bathroom and sat on the toilet. The resident exited the bathroom at 1:49 PM and sat in their recliner.- At 1:50 PM the resident went into their bathroom and then returned to their recliner within the same minute.- At 1:54 PM the resident went into their bathroom and sat on the toilet. The resident exited the bathroom at 1:55 PM and was walking in their room. An interview on 6/15/2026 beginning at 8:45 AM with the facility Administrator and Infection Preventionist (IP) revealed facility staff had reported to them prior to the provider visit rounds on 6/16/2026 that Resident 42 had been more confused, having dysuria, and having increased urination. The IP stated this had then been reported to the provider on 6/16/2026, which then led to the provider ordering the urinalysis to be completed. The administrator and IP confirmed that Resident 42's urine culture grew less than the required 100,000 CFU/mL of bacteria to constitute an infection and necessitate antibiotic use.

Licensure Reference Number 175 NAC 12-006.02(G) Licensure Reference Number 175 NAC 12-006.09(I) Based on record reviews and interviews, the facility failed to determine the root cause of every fall incident, implement interventions that prevented recurrence of falls related to the identified causes, and develop and implement new interventions after subsequent falls occurred for 3 (Residents 1, 2, and 3) of 3 sampled residents. The facility identified a census of 38. Findings are: An interview on 8/27/2025 at 10:25 AM with the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed that the facility's process following a resident fall includes the nurse completing an incident report, noting what was happening before the fall. The facility holds a Utilization Review (UR) meeting daily (except Thursdays and weekends) to discuss falls and assign interventions. The interdisciplinary team (IDT) determines if interventions are appropriate based on the cause of the fall. The DON gave an example that if a resident falls while reaching for a remote on a dresser, an appropriate intervention would be to move the remote closer, not lower the bed, to prevent the fall from recurring. The DON revealed the facility utilizes the following polices for falls: Fall Prevention Program (Angel Watch), Incident Report, Protocol for Neurological Assessment, and Possible Injury After a Fall. A record review of the facility's Fall Prevention Program (Angel Watch) policy dated 1/2013, revealed the policy states residents with two falls in one week or three in a month should be placed on the Angel Watch program, identified by an angel marker on their assistive devices and door. The policy did not include conducting root cause analysis or specifying development of fall-prevention interventions. A record review of the facility's Possible Injury After a Fall policy dated 4/2024, revealed that falls with injury must be reported to Adult Protective Services (APS) within two hours, and a five-day investigation submitted to the state. The policy did not include requirements for conducting a root cause analysis or implementing fall-prevention interventions. A. A record review of Resident 3's Face Sheet revealed the facility admitted the resident on 2/3/2022. Resident 3 had a diagnosis of dementia (a usually progressive condition marked by the development of multiple cognitive deficits such as memory impairment, aphasia, and the inability to plan and initiate complex behavior). A record review of Resident 3's quarterly 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 7/3/2025 revealed the resident had a Brief Interview for Mental Status (BIMS, a brief screening that aids in detecting cognitive impairment) score of 6/15, which indicated Resident 3 had severe cognitive impairment. Additionally, it revealed the resident had one-sided lower extremity impairment and utilized a walker for mobility. The resident required partial assistance with toileting and dressing, and was independent with bed mobility, ambulation, and transfers. A record review of Resident 3's Event Reports dated 5/31/2025 revealed the resident was found naked on the floor beside their spouse's bed. The resident stated they had been engaging in sexual activity with their spouse when they fell. There was no documented evidence that a root cause analysis had been conducted following this fall, nor were interventions identified to reduce the risk of recurrence. A record review of Resident 3's Event Reports dated 6/23/2025 revealed the resident was found on the floor beside their spouse's bed. On 6/24/2025, a UR meeting was held and an intervention of no sense of safety due to resident failing to ask for assistance for intimacy had been implemented. There was no evidence that the root cause had been identified and no specific intervention to prevent recurring falls during intimacy was developed. A record review of Resident 3's Event Reports dated 7/3/2025 revealed the resident was found sitting on the floor in their room with back against the bed. Resident 3 was sitting with their pants and brief around their ankles with regular socks on. The resident reported they were attempting to get in their spouse's bed to engage in sexual activity. The resident's fall root-cause was identified as slipping from regular socks. An intervention for physical therapy (PT) and occupational therapy (OT) evaluation for balance was placed, however, no intervention was put in place to mitigate the specific slipping hazard. An interview on 8/27/2025 at 10:50 AM with the NHA and DON revealed the following:- Confirmed there was no documented evidence a root cause had been identified in the resident's medical record for the 5/31/2025 fall. However, it was determined the root cause to be from losing balance. An intervention for gripper socks had been added. The DON confirmed the gripper socks was not related to the cause or prevention of that fall.- Confirmed no root cause or intervention for prevention had been placed for the 6/23/2025 fall.- The DON confirmed the cause of the 7/3/2025 fall was slipping on the floor in regular socks, and acknowledged that a PT/OT evaluation would not mitigate slipping in inappropriate footwear. B.A record review of Resident 1's Face Sheet revealed the facility admitted the resident on 8/26/2024. Resident 1 had a diagnosis of Lewy Body Dementia (LBD, a progressive disease caused by abnormal protein clumps, Lewy bodies, in the brain cells that leads to decline in thinking, movement, sleep, and behavior. Key symptoms include fluctuating alertness, visual hallucinations, and acting out dreams during sleep). Additionally, Resident 1 had a diagnosis of repeated falls. A record review of Resident 1's MDS dated [DATE] revealed the resident had a BIMS score of 11/15, which indicated the resident had moderate cognitive impairment. Additionally, the MDS revealed Resident 1 was independent with bed mobility, transfers, and ambulation of 10 feet. A record review of an Event Report for Resident 1 with a date of 6/7/2025 revealed the resident was found on the floor in a pool of blood, having hit their head on a nightstand after reportedly rolling out of bed during a bad dream. The resident required six staples at the Emergency Room. An intervention was added on 6/9/2025 to lower the bed and place a fall mat. There was no evidence of a root cause analysis or additional interventions to prevent the recurrence of the fall. A record review of an Event Report for Resident 1 with a date of 8/16/2025 revealed the resident reported falling out of bed during the night, sustaining a bruise to the right wrist. The resident could not give an exact time but stated they had been roaming early in the morning. The intervention section had none of the above marked. There was no evidence an intervention was developed or root cause identified. A record review of Resident 1's Fall Care Plan, with a last reviewed/revised date of 8/18/2025, listed the interventions of lowering the bed and moving nightstand away from the head of the bed for the 6/7/2025 but did not include any additional interventions for that fall nor any interventions for the 8/16/2025 fall. An interview on 8/27/2025 at 10:30 AM with the NHA and DON revealed the facility had identified Resident 1 had rolled out of bed due to having bad dreams on 6/7/2025. They confirmed no further root cause analysis of the dream-related behavior had been completed and no additional intervention had been developed to prevent the fall from recurring. Regarding the fall on 8/16/2025, the NHA and DON confirmed no root cause or intervention had been identified or implemented, stating they did not believe the fall occurred because the resident would not have been able to get off the floor without assistance. C. A record review of Resident 2's Face Sheet revealed the resident was admitted to the facility on [DATE]. Resident 2 had diagnoses of dementia, hemiplegia (one-side paralysis), and weakness. A record review of Resident 2's MDS, dated [DATE], revealed the resident had a BIMS score of 5/15, which indicated sever cognitive impairment. Resident 2 required full assistance with toileting and dressing. Resident 2 also required moderate assistance with bed mobility and transfers. A record review of an Event Report for Resident 2 with a date of 7/8/2025 revealed the resident was self-ambulating to the bathroom when they bent down to retrieve a tissue from the floor and lost their balance, resulting in a fall. The intervention implemented was the application of gripper socks while ambulating. There was no evidence of a root cause analysis beyond balance was conducted or additional fall prevention interventions were developed to address the mobility deficit. An interview on 8/27/2025 at 10:45 AM with the NHA and DON revealed that the root cause of Resident 2's fall on 7/8/2025 was identified as a loss of balance and underlying weakness. The NHA and DON confirmed the fall was unwitnessed, and since it was unclear whether the loss of balance was related to the resident's foot slipping, no additional interventions beyond gripper socks were developed or implemented.

Licensure Reference Number 175 NAC 12-006.05 (H) Based on observation, record reviews, and interviews, the facility failed to protect 1 (Resident 39) of 1 sample resident after receiving an allegation of staff-to-resident abuse. The facility identified a census of 39. The facility was notified on 4/15/2025 at 5:00 PM of an Immediate Jeopardy (IJ) which began on 4/11/2025. The IJ was removed on 4/15/2025, as confirmed by the surveyor's onsite verification. Findings are: A record review of the facility's policy Abuse Prohibition Polices and Procedures, with a date of 1/11/2017, revealed the following: - The purpose of the policy is to ensure all residents in the facility are free from verbal, physical, sexual and mental abuse, involuntary seclusion, neglect or mistreatment. - The policy defined abuse as a willful infliction of injury resulting physical harm, pain or mental anguish by an individual, including a caretaker. - The section Procedure for Training revealed the following: o Any staff member who suspects abuse or neglect of a resident is to report the alleged incident to their immediate supervisor. o All written or oral reports of suspected abuse or neglect shall be given to the Administrator. o An immediate investigation will be conducted by the Nursing Home Administrator (NHA), Director of Nursing (DON), Social Service Director (SSD), or a designated staff member. o During the investigation process, appropriate measures will be initiated for the protection of the residents and to prevent possible further abuse/neglect during this time. - The section Procedure for Investigation revealed all incidents/situations/concerns will be investigated. A record review of Resident 39's Face Sheet revealed Resident 39 was admitted to the facility on [DATE]. Resident 39 had diagnoses of dementia without behavioral, mood, or psychotic disturbances (a usually progressive condition marked by the development of multiple cognitive deficits such as memory impairment, aphasia, and the inability to plan and initiate complex behavior), epilepsy (a neurological condition characterized by recurrent seizures), and an anxiety disorder (mental health conditions characterized by excessive worry, fear, and anxiety that interfere with daily life). A record review of Resident 39's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) with an Assessment Reference Date (ARD) of 3/19/2025 revealed Resident 39 had a Brief Interview for Mental Status (BIMS, a brief screening that aids in detecting cognitive impairment) score of 10/15, which indicated Resident 39 had moderate cognitive impairment. The MDS also revealed Resident 39 had not exhibited any behaviors of hallucinations or delusions within the past 7 days of the ARD. A record review of Resident 39's Comprehensive Care Plan (a detailed, personalized document that outlines how staff will meet a resident's medical, nursing, mental and psychosocial needs) revealed, as of 3/19/2025, Resident 39 has difficulty making self-understood due to difficulty expressing what they are trying to say. Approaches were to allow Resident 39 time to speak and avoid interrupting; ask Resident 39 questions requiring 1-2 word answers; ask Resident 39 to repeat any slurred, mumbled words; ask simple yes/no questions; encourage verbalization; provide a quiet, non-hurried environment, free of background noises and distractions; remind Resident 39 to speak slowly and clearly; repeat what Resident 39 has said to validate; and when Resident 39 becomes frustrated, provide the word/phase for the resident. Additional record review of Resident 39's Comprehensive Care Plan revealed no problem areas identified for Resident 39 having delusions, altered sense of reality, or other related psychological impairments. A record review of Resident 39's Progress Note from 4/11/2025 at 9:24 AM written by Licensed Practical Nurse (LPN) - A revealed Resident 39 had been upset when LPN-A was assessing the resident. Resident 39 kept repeating that the guy/girls from last night were hitting them. LPN-A explained to Resident 39 that it was a new day; fresh start and those people are gone. The note revealed Resident 39 appeared to be receptive to the conversation and appeared to be in a happier mood. There was no evidence LPN-A had reported the allegation to the NHA (Nursing Home Administrator) or initiated an investigation regarding the allegation. An interview on 4/15/2025 at 1:40 PM with Resident 39 revealed on Friday the resident had been deliberately hit between their shoulders by a nurse aide (NA). Resident 39 revealed they had been sitting in their wheelchair when the NA had forcefully hit the vinyl backrest of their wheelchair between their shoulders. Resident 39 stated the hit had hurt but the resident had not felt it because they were scared. Resident 39 also revealed they are unable to communicate the best but does know right from wrong and when someone is deliberately hitting them versus an accident. Resident 39 provided three unique characteristics and descriptions of the nurse aide and stated Resident 39 did not know the NA's name but would recognize them due to the unique characteristics. Resident 39 stated the NA was here now and stated, I'm scared of [gender]. Resident 39 had been tearful throughout the interview. An observation on 4/15/2025 at 1:52 PM revealed there was a NA that was currently working and had matched the unique description provided by Resident 39. A follow-up interview on 4/15/2025 at 3:40 PM with Resident 39 revealed Resident 39 was sure the hit had been deliberate as the force of the hit could be heard down the hall. Resident 39 reiterated the unique characteristics of the NA and stated they were scared. Resident 39 confirmed the resident had reported the incident to the nurse. An interview on 4/15/2025 at 3:35 PM with LPN-A revealed LPN-A had been told by Resident 39 about allegations of staff hitting them the night before. LPN-A stated there wasn't any guys or girls overnight so if it had been a more realistic situation of abuse, LPN-A would have reported it and done something about it. LPN-A had determined the situation was not serious as it was a dream or misconception of reality but was unsure of how they had determined it was a misconception of reality or a dream. An interview on 4/15/2025 at 4:55 PM with the NHA and DON (Director of Nursing) identified NA-H as matching the unique characteristics and description provided by Resident 39. An interview on 4/15/2025 at 2:52 PM with NA-M revealed NA-M had concerns regarding agency aides, especially NA-H and NA-E. The interview revealed NA-H and NA-E [NAME] together when working and NA-E initiates instances and NA-H follows their lead. NA-M revealed instances of the NAs yelling at the residents, not feeding or forcefully feeding the residents, taking the residents walkers away, and kicking walkers out of the resident's hands. NA-M stated they have reported instances of concerns to the charge nurses and DON, but their concerns seemed to have been dismissed. A record review of a facility-provided copy of their staffing schedule revealed NA-H and NA-E had worked on 4/11/2025 from 5:00 AM - 5:00 PM. A record review of a Staff Assignment Sheet from 4/11/2025 confirmed NA-E had been assigned to Resident 39's hall and NA-H had also been working the floor on a nearby hall. An interview on 4/15/2025 at 4:00 PM with the DON revealed the DON had denied any knowledge of staff concerns regarding care provided by other staff. An interview on 4/15/2025 at 4:58 PM with the NHA revealed NHA had been unaware of Resident 39's allegations as LPN-A had not reported it. The NHA confirmed LPN-A should have reported the allegation of abuse to the NHA, so an investigation could have been conducted and actions implemented to protect Resident 39 in the meantime. The following is the facility's abatement statement: DON will do a full head to toe skin assessment on Resident #39, noting any discolorations, bruises, or visible markings on body. DON and NHA will place phone call to resident family to inform them of the allegation of abuse and share with the them the steps we are taking and findings from skin assessment. Alleged perpetrator will not be allowed to return to work until investigation is complete. DON will begin investigation into allegation by interviewing staff, residents, and speaking to family members. A report with the findings of the investigation will be provided to the State Agency within 5 days. NHA will provide a copy of the Abuse Prohibition Policies and Procedures to all staff currently at facility to review and sign. Copies of this will be provided to all oncoming staff at the start of next shift to be reviewed and signed. An all staff Inservice is scheduled for Friday 4/18/25 to educate staff on the importance of adhering to the Abuse Prohibition Policies and Procedures. DON and NHA upon arriving at facility, will read through progress notes for all residents on a daily basis, and immediately investigate any allegation of abuse or neglect. DON and NHA will alternate reading through progress notes on Saturday and Sunday for a period of 1 year. NHA will continue to ensure that all staff are compliant with their mandatory, annual Abuse/Neglect Inservice. SSD will conduct spot interviews with residents 1x weekly to ensure residents they feel they are receiving adequate care. At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observations, interviews and record reviews completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level.

Licensure Reference Number 175 NAC 12-006.04(B)(ii) Based on record reviews and interview, the facility failed to ensure nurse aides had completed at least 4 hours of dementia training annually as required for 5 [Nurse Aide (NA) - K, NA-O, NA-P, NA-L, and NA-N] of 5 sample employees. This had the potential to affect all residents who reside within the facility. The facility identified a census of 39. Findings are: A record review of a Facility Assessment with a date of 4/1/2025 revealed all staff would have training on dementia. There was no evidence that nurse aides would complete at least 4 hours of dementia training as required. A record review of an undated facility-provided list of staff names, dates of hire, their department, and job title revealed the following: - NA-K was hired on 1/15/2015. - NA-O was hired on 3/31/2021. - NA-P was hired on 3/19/2024. - NA-L was hired on 12/8/2023. - NA-N was hired on 5/23/2023. A record review of NA-K's Relias Transcript as of 4/15/2025 revealed no evidence NA-K had completed any dementia training between 1/15/2024 and 1/15/2025. A record review of NA-O's Relias Transcript as of 4/15/2025 revealed no evidence that NA-O had completed any dementia training between 3/31/2024 and 3/31/2025. A record review of NA-P's Relias Transcript as of 4/15/2025 revealed no evidence that NA-P had completed any dementia training between 3/19/2024 and 3/19/2025. A record review of NA-L's Relias Transcript as of 4/15/2025 revealed NA-L had completed 1 hour of dementia training between 12/8/2023 and 12/8/2024. A record review of NA-N's Relias Transcript as of 4/15/2025 revealed NA-N had completed 1 hour of dementia training between 5/23/2023 and 5/23/2024. An interview on 4/15/2025 at 12:00 PM with the Nursing Home Administrator (NHA) revealed they were not aware of the requirement for nurse aides to complete at least 4 hours of ongoing training on dementia yearly. The NHA confirmed NA- K, NA-O, NA-P, NA-L, and NA-N had not met this requirement.

Licensure Reference Number 175 NAC 12-006.04(B)(i) Based on record reviews and interviews, the facility failed to ensure each employee received initial orientation within 2 weeks after beginning employment on topics of resident rights, emergency procedures, adult abuse/neglect and training on medical emergency directives and dementia for nursing staff as required for 11 [Nurse Aide (NA) - Q, NA-R, Housekeeper (HSKPG) - U, Activities Supervisor (AS) - S, NA-D, NA-E, NA-F, NA-G, NA-H, and NA-I] of 12 sample employees. This had the potential to affect all residents residing within the facility. The facility identified a census of 39. Findings are: A record review of the facility's Facility Assessment with a date of 4/1/2025 revealed all staff would have training on Emergency Preparedness, Resident Rights, and Abuse and Neglect. There was no evidence that the facility provides training on medical emergency directives. A record review of the Fusion Workforce Solutions Compliance Requirements with a date of 11/20/2024 revealed the facility required training on Elder Abuse. A record review of a facility provided list of staff names, dates of hire, their department, and job title revealed the following: - NA- Q was hired on 4/3/2025. - NA-R was hired on 3/18/2025. - HSKPG - U was hired on 9/14/2024. - AS - S was hired on 3/31/2025. A record review of an agency contracts list that provided the agency staff's name and date of contract revealed the following: - NA-D began employment with the facility on 3/24/2025. - NA-E began employment with the facility on 1/18/2025. - NA-F began employment with the facility on 2/24/2025. - NA-G began employment with the facility on 1/29/2025. - NA-H began employment with the facility on 3/3/2025. - NA-I began employment with the facility on 1/27/2025. A record review of Dietary Aide (DA) - T personnel file revealed DA-T had been rehired on 2/2/2025. There was no evidence DA-T had completed training on resident rights, emergency procedures, or adult abuse and neglect within 2 weeks of re-starting employment. A record review of NA-Q's personnel file revealed no evidence that NA-Q had completed training on emergency procedures, medical directives, or dementia within 2 weeks of beginning employment. A record review of NA-R's personnel file revealed no evidence that NA-R had completed training on emergency procedures, medical directives, or dementia within 2 weeks of beginning employment. A record review of HSKPG-U's personnel file revealed no evidence that HSKPG-U had completed training on emergency procedures within 2 weeks of beginning employment. A record review of AS-S's personnel file revealed no evidence that AS-S had completed training on emergency procedures within 2 weeks of beginning employment. A record review of NA-D's Core Mandatory Attestation (a record of the agency staff's mandatory training topics) with a completion date of 12/20/2024 revealed no evidence that NA-D had completed training on adult abuse and neglect within 2 weeks of beginning employment with the facility. A record review of NA-E's Core Mandatory Attestation with a completion date of 8/30/2024 revealed no evidence that NA-E had completed training on adult abuse and neglect within 2 weeks of beginning employment with the facility. A record review of NA-F's Core Mandatory Attestation with a completion date of 2/13/2025 revealed no evidence that NA-F had completed training on adult abuse and neglect within 2 weeks of beginning employment with the facility. A record review of NA-G's Core Mandatory Attestation with a completion date of 6/6/2024 revealed no evidence that NA-G had completed training on adult abuse and neglect within 2 weeks of beginning employment with the facility. A record review of NA-H's Core Mandatory Attestation with a completion date of 2/17/2025 revealed no evidence that NA-H had completed training on adult abuse and neglect within 2 weeks of beginning employment with the facility. A record review of NA-I's Core Mandatory Attestation with a completion date of 1/15/2025 revealed no evidence that NA-I had completed training on adult abuse and neglect within 2 weeks of beginning employment with the facility. An interview on 4/21/2025 at 9:55 AM with Human Resources (HR) confirmed DA-T had been rehired on 2/2/2025 and had not completed initial orientation upon rehire. The interview also confirmed NA-Q, NA-R, HSKP-U, and AS-S had not completed all required initial orientation training as the facility does not provide initial orientation training on emergency procedures, medical emergency directives, or dementia. An interview on 4/21/2025 at 8:35 AM with the Director of Nursing confirmed the facility had no evidence NA-D, NA-E, NA-F, NA-G, NA-H, and NA-I had completed adult abuse and neglect training within two weeks of beginning employment with the facility.

Licensure Reference Number NAC 175 12.006.18 Based on observations and interviews the facility failed to develop Enhanced Barrier Precautions (EBP) policies and procedures and implement EBP for Residents 10, 21, and 27. The facility identified a census of 39. Findings are: A record review of Resident 21's Minimum Data Set (MDS- a federally mandated assessment tool used in Long Term Care) dated 4/10/25 revealed in Section H that Resident 21 had an indwelling catheter. A record review of Resident 27's MDS dated [DATE] revealed in Section M that Resident 27 had unresolved wounds. A record review of Resident 10's MDS dated [DATE] revealed in Section M that Resident 10 had one unresolved stage III pressure ulcer. An observation on 4/14/25 at 9:45 AM in the hallway outside Resident 21's room revealed no sign on Resident 21's door or any other indicator to staff that Resident 21 required the use of personal protective equipment (PPE) for high-contact care. An observation on 4/14/25 at 11:00 AM in the hallway outside Resident 27's room revealed no sign on Resident 27's door or any other indicator to staff that Resident 27 required the use of personal protective equipment (PPE) for high-contact care. An observation on 4/14/25 at 2:15 PM in the hallway outside Resident 10's room revealed no sign on Resident 10's door or any other indicator to staff that Resident 10 required the use of personal protective equipment (PPE) for high-contact care. An interview with Nurse Aide (NA)- A.S on 4/14/25 at 10:15 AM regarding Enhanced Barrier Precautions (EBP-an infection control intervention that uses gowns and gloves during high-contact resident care activities to reduce the spread of Multi Drug-Resistant Organisms (MDROs), NA-A.S stated the facility uses EBP on everyone. An interview with NA-A.B on 4/14/25 at 10:20 AM revealed no one is on enhanced barrier precautions at this time and if they start to get sick with something contagious, we gown up and the resident stays in their room. NA-A.B denies receiving training on the need to apply PPE in the presence of wounds and catheters. An interview on 4/14/25 at 12:56 PM with the Director of nursing (DON) confirmed the facility had not implemented enhanced barrier precautions and were unaware of the regulation or recommendation from the Center of Disease Control (CDC). The DON revealed that it is usually the Administrator that monitors for new regulations and will alert the DON to what they are and when they need to be implemented. An interview on 4/14/25 at 3:00 PM with the Administrator (NHA) revealed that they monitor and alert the facility to new regulations and recommendations. The NHA denied being aware of the regulation and confirmed that the facility had not enacted that regulation. The NHA stated they would look at the regulation with the DON and begin development, implementation, and staff education of the regulation immediately.

Licensure Reference Number 175 NAC 12-006.04(B)(ii)(1) Based on record reviews and interviews, the facility failed to ensure 5 [Nurse Aide (NA) - P, NA-L, NA-O, NA-N, and NA-K] of 5 sampled nurse aides (NA) had completed at least 12 hours of ongoing training annually based upon their employment date as required. This had the potential to affect all residents who reside within the facility. The facility identified a census of 39. Findings are: A record review of the facility's Facility Assessment with a date of 4/1/2025 revealed all staff would have training on resident transfers, infection control, disaster/emergency preparedness, resident rights, abuse and neglect, dementia, oxygen, Activities of Daily Living, and Hospice/Comfort Care. There was no evidence that nurse aides would complete at least 12 hours of ongoing education based upon their employment date. A record review of an undated facility-provided list of staff names, dates of hire, their department, and job title revealed the following: - NA-P was hired on 3/19/2024. - NA-L was hired on 12/8/2023. - NA-O was hired on 3/31/2021. - NA-N was hired on 5/23/2023. - NA-K was hired on 1/15/2015. A record review of NA-P's Relias Transcript as of 4/15/2025 revealed NA-P had completed a total of 3.82 hours of ongoing training between 3/19/2024 and 3/19/2025. A record review of NA-L's Relias Transcript as of 4/15/2025 revealed NA-L had completed 7 hours of ongoing training between 12/8/2023 and 12/8/2024. A record review of NA-O's Relias Transcript as of 4/15/2025 revealed NA-O had completed a total of 8.07 hours of ongoing training between 3/31/2024 and 3/31/2025. A record review of NA-N's Relias Transcript as of 4/15/2025 revealed NA-N had completed a total of 9.5 hours of ongoing training between 5/23/2023 and 5/23/2024. A record review of NA-K's Relias Transcript as of 4/15/2025 revealed NA-K had repeated courses of Documenting Medications, Basics of Medication Management, and Avoiding Common Medications Errors during their year between 1/15/2024-1/15/2025. After deducting duplicate courses, NA-K had completed 10.82 hours of ongoing training between 1/15/2024 and 1/15/2025. An interview on 4/15/2025 at 12:00 PM with the Nursing Home Administrator (NHA) confirmed NA-P, NA-L, NA-O, NA-N, and NA-K had not completed at least 12 hours of ongoing training based upon their employment date.

Licensure Reference Number 175 NAC 12-006.04(A)(iii) Based on record reviews and interviews, the facility failed to implement their policies and procedures related to screening potential employees prior to employment for 3 [Housekeeper (HSKPG) - U, Actvities Supervisor (AS) - S, and Dietary Aide (DA) - T] of 5 sampled employees. This had the potential to affect all residents who reside within the facility. The facility identified a census of 39. Findings are: A record review of a facility policy Abuse Prohibition Policies and Procedures with a last revised date of 1/11/2017 revealed all potential employees will be screened for a history of abuse, neglect or mistreatment of residents by checking criminal prosecution history by: 1) reviewing the Nebraska License Information System for Disciplinary Action and License Status - for all nursing staff holding licenses or certifications, 2) checking the Nebraska Adult Abuse Registry and Child Abuse Registry (APS/CAN), 3) checking a criminal history and 4) checking the Nebraska State Patrol Sex Offender Registry. There was no evidence of the requirement to ensure a nurse aide registry check is completed on any staff members who have direct and unsupervised access to or who provide care and treatment to residents. A record review of an undated facility-provided list of staff names, dates of hire, their department, and their job title revealed HSKPG - U was hired on 9/14/2024 and AS - S was hired on 3/31/2025. A record review of DA-T's personnel file revealed DA-T was re-hired on 2/2/2025. There was no evidence that a criminal background, nurse aide registry, APS/CAN registry, or sex offender registry checks had been completed upon re-hire. A record review of HSKPG-U's personnel file revealed no evidence that a Nurse Aide registry check had been completed prior to hire. A record review of AS-S's personnel file revealed no evidence that a Nurse Aide registry check had been completed prior to hire. An interview on 4/21/2025 at 9:55 AM with Human Resources (HR) confirmed there was potential for DA-T, HSKPG-U, and AS-S to have direct and unsupervised access to the residents. HR also confirmed DA-T was rehired on 2/2/2025 and no background or registry checks had been completed upon their rehire. Additionally, HR confirmed HSKPG-U and AS-S did not have a nurse aide registry check completed prior to their hire as HR was unaware of the requirement of any staff with direct and unsupervised access to the residents required a nurse aide registry check to be completed prior to hire.

Licensure Reference Number 175 NAC 12-006.09(H) Based on record reviews and interviews, the facility failed to attempt the use of appropriate alternatives prior to the installation of bed rails (adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Synonymous terms are side rails, bed side rails, and safety rails) as required for 1 (Resident 39) of 1 sample resident. The facility identified a census of 39. Findings are: A record review of a facility policy Side Rails with a date of 2/27/2023 revealed bed rails may be used by a resident if a bed rail request form and a bed rail decision making tree has been filled out. This will be reviewed quarterly. There was no evidence that the use of appropriate alternatives prior to the installation of bed rails was required. A record review of the Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings with a date of April 2023 revealed the following: - Automatic use of bed rails of any size or shape should be avoided. - If a resident, family member, or authorized representative requests the inappropriate use of side rails, then the interdisciplinary care team has a responsibility to discuss the risks involved, as well as the benefits of any clinical and/or environmental interventions that may be safer in meeting the patient's assessed needs, individual circumstances, and environment. - Nursing/medical and environmental interventions, such as the use of a trapeze bar (a transfer aid that's suspended over the bed) affixed to the bed to increase the resident's mobility, should be considered. - The patient's chart should include a risk-benefit assessment that identifies why other care interventions are not appropriate or not effective if they were previously attempted and determined not to be the treatment of choice for the patient. A record review of Resident 39's Face Sheet revealed Resident 39 was admitted to the facility on [DATE]. Resident 39 had diagnoses of dementia (a usually progressive condition marked by the development of multiple cognitive deficits such as memory impairment, aphasia, and the inability to plan and initiate complex behavior), epilepsy (a neurological condition characterized by recurrent seizures), and an anxiety disorder (mental health conditions characterized by excessive worry, fear, and anxiety that interfere with daily life). A record review of Resident 39's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) with an Assessment Reference Date (ARD) of 3/19/2025 revealed Resident 39 had a Brief Interview for Mental Status (BIMS, a brief screening that aids in detecting cognitive impairment) score of 10/15, which indicated Resident 39 had moderate cognitive impairment. Additionally, it revealed Resident 39 required maximum assistance with bed mobility and transfers. A record review of Resident 39's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) with a start date of 3/20/2025 revealed Resident 39 required a positioning device to assist with getting in/out of bed and with repositioning. Approaches listed were to complete a positioning device assessment before applying and quarterly thereafter, complete a position device assessment monthly, and the Power of Attorney (POA) to sign the consent for the positioning device. There was no evidence that appropriate alternatives to the bed rails had been attempted or contraindications to alternatives had been identified. A record review of Resident 39's Side Rail Request/Authorization with a date of 3/20/2025 revealed the POA had requested bilateral half-side bed rails be placed on Resident 39's bed to enhance independent bed mobility. A potential risk of entrapment had been identified. However, there was no evidence that the POA had been informed of alternatives that had been considered or attempted, or the benefits of the bed rails and the likelihood of the benefits had been reviewed with the POA. A record review of a Bed Side Rails Decision Tree with a date of 3/20/2025 revealed a signature and date from the Director of Nursing (DON). There was no resident's name included, or evidence of what pathway had been taken to determine the decision to proceed with the implementation of bed rails. An interview on 4/16/2025 at 3:00 PM with the Director of Nursing (DON) and concurrent record review of the provided Bed Side Rails Decision Tree revealed the DON had followed the left side steps of the following: 1) Wants bed side rails , 2) Is there is a risk to the resident if bed side rail is used? and 3) If no, obtain reason and document. Note bedside rail per resident/family choice on plan of care. Bed side rail is not a restraint. The DON explained Resident 39's family had requested the bed rails. The DON had then determined Resident 39 to have no risk if the bed rails were implemented but had not documented the reason. The DON confirmed no alternatives were considered or attempted prior to implementing Resident 39's bed rails.

LICENSURE REFERENCE NUMBER 175-12 006.09(G)(i) Based on record review and interviews, the facility failed to document a recapitulation (a complete summary of resident stay in nursing facility from admittance to discharge) for a resident-initiated discharge for one (Resident 40) of one sampled resident. The facility identified a census of 39. Findings are: A record review on 04/14/2025 of a Discharge and Transfer Policy last revised on 02/27/2023 revealed no documented evidence requiring a recapitulation of stay as part of the discharge process. A record review of a progress note dated 02/21/2025 at 2:30 PM revealed a summary of care conference meeting note and detailed that Resident 40's goals to be discharged home had been met. No other documentation of a complete summary of the residents stay noted in the residents' chart. An interview with the Social Service Director (SSD) on 04/14/2025 at 2:30 PM revealed the facility has not ever done a recapitulation upon discharge, only an Interdisciplinary discharge planning summary which just indicates the Resident met their goals to return home.

Licensure Reference 175 NAC 12-006.09(E) The facility failed to develop a Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment (CCP) regarding Resident 16's primary diagnoses and high-risk medications and develop and implement a Comprehensive Care Plan including non-pharmacological interventions related to Resident 25's behavioral and emotional well-being. This affected 2 of 12 sampled residents. The facility identified a census of 39. Findings are: A. Record review of Resident 25's electronic medical record revealed Resident 25 had medical diagnoses including Parkinson's disease (a movement disorder that affects the nervous system and worsens over time), dementia (a usually progressive condition marked by the development of multiple cognitive deficits), and anxiety disorder (anxiety is an abnormal and overwhelming sense of apprehension and fear often marked by physical signs, by doubt concerning the reality and nature of the threat, and by self-doubt about one's capacity to cope with it). Record review of a Brief Interview for Mental Status (BIMS, a brief screening tool that aids in detecting cognitive impairment) completed on 2/4/25 revealed Resident 25 had a score of 0 out of 15, which indicated the resident had severely impaired cognition. Record review of Resident 25's Comprehensive Care Plan (CCP) revealed a Problem titled, Psychotropic drug use, with a start date of 11/5/24, and stated Resident receives antianxiety medication buspirone and Xanax (alprazolam) r/t anxiety diagnosis. The stated goal was that the resident will be prescribed the lowest effective dose of medication, and two approaches were listed. The approaches were to attempt a gradual dose reduction if ordered by the physician, and the second approach was to have pharmacy consultant reviews. Record review of Resident 25's quarterly 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 2/6/25 revealed the following: -Section C revealed Resident 25 had severely impaired cognition. -Section D revealed a Staff Assessment of Resident 25's Mood (PHQ-09-OV, a questionnaire used to measure frequency and severity of depression symptoms) with a total severity score of 6, indicating mild depression. -Section E revealed no indicators of psychosis for Resident 25. -Section N revealed Resident 25 was taking anti-anxiety and anti-depressant medications. Record review of Resident 25's Medication Administration Records dated 1/1/2025 through 4/20/25 revealed the resident was taking the following psychotropic medications: -alprazolam, one 0.5 milligram (mg) tablet by mouth scheduled to be given at 1:30 PM daily, starting on 1/11/24. -buspirone, one 10 mg tablet by mouth scheduled three times a day (7:00 AM, 1:00 PM, and 7:30 PM), starting on 10/27/2023. -trazodone, one 50 mg tablet by mouth scheduled to be given at bedtime daily, starting on 1/10/24, and updated on 3/5/25 to include the direction to administer between 7:00 PM and 8:00 PM. A record review of Resident 25's orders revealed that the diagnosis listed for all three psychotropic medications was anxiety disorder. A record review of Resident 25's CCP revealed no evidence of non-pharmaceutical interventions for anxiety disorder, moods, or behavior. An interview on 4/16/25 at 3:24 PM with DON confirmed trazodone was not mentioned on Resident 25's CCP, and that there were no non-pharmaceutical interventions for anxiety disorder, moods, or behavior on the CCP. 49766 B. A record review of a facility policy Care Plans with a date of 2/29/2023 revealed care plans address problem areas identified as conditions that fall outside or have the potential to fall outside of normal parameters of biopsychosocial and spiritual well-being. Each identified problem area will be developed into a format on the care plan with a statement to the reason it is a problem, evidence or factors by which it is determined to be a problem, measurable time limited goals, and approaches to achieve the stated goal. Problem areas are identified after a review of the resident's medical and physical history, physician's orders, and other assessment tools. A record review of Resident 16's Face Sheet revealed the facility admitted Resident 16 on 7/28/2022. Resident 16 had diagnoses of Alzheimer's disease (a progressive brain disorder that primarily affects memory, thinking, and behavioral abilities that leads to a decline in cognitive function, ultimately affecting a person's ability to perform daily tasks), Congestive Heart Failure (CHF - a condition where the heart can't pump enough blood to meet the body's needs, leading to fluid buildup in the body), atrial fibrillation (AFib - a heart rhythm problem where the heart beats irregularly and fast), diabetes, and a history of a stroke. A record review of Resident 16's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) with an Assessment Reference Date (ARD) of 2/1/2025 revealed Resident 16 was taking a high-risk medication of an antiplatelet (a medication that prevent blood cells called platelets from sticking together and forming clots) and a diuretic (a water pill). A record review of Resident 16's Care Plan with a last reviewed/revised date of 2/7/2025 revealed no evidence of problem areas for Resident 16's diabetes, CHF, use of an antiplatelet, or use of a diuretic medication. An interview on 4/15/2025 at 12:00 PM with the Nursing Home Administrator and Director of Nursing confirmed Resident 16's care plan did not include problem areas of their diabetes, CHF, use of an antiplatelet, or use of a diuretic medication and would have expected these areas to have been included.

Licensure Reference 175 NAC 12-006.09(H) Based on interviews and record reviews, the facility failed to ensure a gradual dose reduction was attempted for psychotropic medications for 1 (Resident 25) of 5 sampled residents. The facility identified a census of 39. Findings are: Record review of Resident 25's electronic medical record revealed Resident 25 had medical diagnoses including Parkinson's disease (a movement disorder that affects the nervous system and worsens over time), dementia (a usually progressive condition marked by the development of multiple cognitive deficits), and anxiety disorder (anxiety is an abnormal and overwhelming sense of apprehension and fear often marked by physical signs, by doubt concerning the reality and nature of the threat, and by self-doubt about one's capacity to cope with it). Record review of a Brief Interview for Mental Status (BIMS, a brief screening tool that aids in detecting cognitive impairment) completed on 2/4/25 revealed Resident 25 had a score of 0 out of 15, which indicated the resident had severely impaired cognition. Record review of Resident 25's Medication Administration Records dated 1/1/2025 through 4/20/25 revealed the resident was taking the following psychotropic medications: -alprazolam, one 0.5 milligram (mg) tablet by mouth scheduled to be given at 1:30 PM daily, starting on 1/11/24. -buspirone, one 10 mg tablet by mouth scheduled three times a day (7:00 AM, 1:00 PM, and 7:30 PM), starting on 10/27/2023. -trazodone, one 50 mg tablet by mouth scheduled to be given at bedtime daily, starting on 1/10/24, and updated on 3/5/25 to include the direction to administer between 7:00 PM and 8:00 PM. Record review of Resident 25's medication orders revealed that the diagnosis for all three psychotropic medications was anxiety disorder. An interview with the Nursing Home Administrator (NHA) on 4/16/25 at 1:10 PM revealed they were unable to locate a policy for the use of psychotropic medications. A record review of a facility document titled Kimball County Manor Psychoactive Drug Recertification, dated 3/5/24, revealed Resident 25 was receiving trazodone 50 mg once daily for anxiety. The document also revealed the doctor did not change the dosage at that time. Review of Resident 25's medical record revealed no evidence of gradual dose reduction (GDR) attempted for Resident 25's buspirone or alprazolam, and no evidence of a GDR attempted for trazadone since 3/5/24. An interview on 4/21/25 at 12:55 PM with the Director of Nursing (DON) confirmed that no gradual dose reduction had been attempted for Resident 25's buspirone or alprazolam, and that no GDR had been attempted for Resident 25's trazodone since 3/5/24.

Licensure Reference Number 175 NAC 12-006.02(H) Nebraska Revised Statute 28-372 Based on record review and interview, the facility failed to A) immediately investigate and report an allegation of staff-to-resident abuse within 24 hours of the allegation being made and B) submit an investigation to the State Agency (SA) within 5 working days of the incident for 1 (Resident 39) of 1 sample resident. The facility identified a census of 39. Findings are: A record review of a facility policy Abuse Prohibition Policies and Procedures, with a last revised date of 1/11/2017, revealed an allegation of abuse will be reported within 24 hours to the SA and a copy of the written investigation report will be submitted to the SA within five working days of the alleged incident. A. A record review of Resident 39's Progress Note from 4/11/2025 at 9:24 AM written by Licensed Practical Nurse (LPN) - A revealed Resident 39 had been upset when LPN-A was assessing the resident. Resident 39 kept repeating that the guy/girls from last night were hitting them. LPN-A explained to Resident 39 that it was a new day; fresh start and those people are gone. The note revealed Resident 39 appeared to be receptive to the conversation and appeared to be in a happier mood. There was no evidence that LPN-A had reported the allegation to the Nursing Home Administrator (NHA) or SA or had begun an investigation. An interview on 4/15/2025 at 3:35 PM with LPN-A revealed LPN-A had been told by Resident 39 about allegations of staff hitting them the night before. LPN-A stated there wasn't any guys or girls overnight so if it had been a more realistic situation of abuse, LPN-A would have reported it and done something about it. LPN-A had determined the situation was not serious as it was a dream or misconception of reality but was unsure of how they had determined it was a misconception of reality or a dream. An interview on 4/15/2025 at 4:58 PM with the NHA revealed NHA had been unaware of Resident 39's allegations as LPN-A had not reported it to them. The NHA confirmed LPN-A should have reported the allegation of abuse to the NHA, so an investigation could have been conducted immediately and an initial report made to the SA within 24 hours. B. A record review of a sent e-mail revealed the NHA had sent the investigation to the SA on 4/21/2025 at 6:29 AM (7 working days from the date of the incident.) An interview on 4/21/2025 at 9:55 AM with the NHA confirmed the report had not been submitted to the SA until today (4/21/2025.)

Licensure Reference Number 175 NAC ,d+[DATE].09D7 Based on record reviews and interviews, the facility failed to ensure that 1) a safety belt was used on the whirlpool bath chair to reduce the risk of falls and injuries for one sampled resident (Resident 1) and 2) the facility bathing procedure included specific instructions on the use of a safety belt on the bath chair to ensure consistent and safe bathing. The facility census was 46 with seven sampled residents. Findings are: Review of Resident 1's Care Plan, goal date [DATE], revealed that the resident required extensive assistance on two staff for transfers and extensive assistance of one staff for bathing. Further review revealed that the resident had diagnoses including Dementia, Diabetes and [CONDITION(S)]. The resident had severely impaired cognition (thinking skills, awareness, judgement, language use and perception), was on prescribed blood thinning medication and was at risk for falls due to muscle weakness and difficulty walking. Review of the Resident Progress Notes revealed that on [DATE] at 10:50 AM, RN (Registered Nurse) - A, Charge Nurse, answered call for help from NA (Nursing Assistant) - B in the bathing room and observed the resident on the floor on right side. The resident hit the right side of the face and noted a laceration and swelling. NA - B stated that the resident was on the bath chair, leaned forward and fell . The resident was transferred to the hospital per ambulance. At 6:31 PM, RN - A phoned the resident's family member to report that the resident was transferred to a hospital in Denver. Further review revealed that on [DATE], the Denver hospital reported that the resident passed away. Review of the facility Internal Investigation Report, dated [DATE], revealed that upon assessment RN - A observed that the resident fell forward out of the bath chair, hit right side of head and face and observed blood. Review of the facility policy and procedure Tub Bathing, dated [DATE], revealed the following including: 1. Purpose 1. To ensure client safety and comfort while bathing . 2. Policy . 8. Use bath chair seatbelt as needed. Observations on [DATE] at 9:05 AM in the west bathing room revealed NA - B prepared Resident 8 for a whirlpool bath. Further observations revealed the resident seated on the bath chair, undressed, with safety straps placed around the waist and the chest. NA - B was ready to lift the resident into the whirlpool bath. Interview with NA - B on [DATE] at 9:30 AM revealed that on [DATE] the resident was transferred to the whirlpool chair and undressed. NA - B stated that the resident was restless and didn't want to sit so NA - E assisted positioning the resident back further into the chair. Further interview revealed that the resident was seated in the whirlpool chair with feet a few inches off of the floor, stood behind the resident to untangle the safety strap and prepared to place it on the resident, the resident leaned forward and fell off of the chair before was able to reach the resident to prevent the fall. NA - E called for assistance and staff responded right away to help. NA - E stated that the whirlpool safety belt was only used when a resident was restless or uncooperative with the bath. Interview with RN - A on [DATE] at 9:20 AM revealed responded to the call for help in the bathing room on [DATE], found the resident undressed on the floor in the bathing room, bleeding from laceration on the head. Further interview revealed no safety strap was used on the bath chair. Interview with MA (Medication Aide) - F on [DATE] at 9:50 AM revealed responded to the emergency call light in the bathing room on [DATE] and found the resident on the floor, undressed and no safety strap was on the bath chair. Further interview revealed that the safety straps were available in the bathing rooms and the staff used them at their own discretion. Interview with LPN (Licensed Practical Nurse) - G revealed was not on duty on [DATE]. Further interview revealed that the safety straps were available for use in the bathing rooms. LPN - G stated that the safety belt was used when the nursing assistant determined that it was needed. Interview with NA - E on [DATE] at 11:30 AM confirmed had assisted NA - B on [DATE] to position the resident further back on the whirlpool bath chair as the resident was restless. Interview with Resident 4 on [DATE] at 10:25 AM revealed did not use a safety strap when on the whirlpool bath chair. Interview with Resident 5 on [DATE] at 10:40 AM revealed not sure if the staff placed a safety strap on when seated on the whirlpool bath chair don't think so. Interview with Resident 6 on [DATE] at 10:45 AM revealed that sometimes they put a safety strap on when seated on the the whirlpool bath chair and sometimes they don't. Interview with the Director of Nursing on [DATE] at 11:15 AM revealed that the staff don't use a safety belt in the whirlpool unless it is needed for a confused resident. The bath aide would decide whether or not it was needed. Interview with the Administrator on [DATE] at 12:00 PM confirmed that safety interventions were not in place to ensure safe bathing and to reduce the risk for falls and injuries. Further interview confirmed that the bathing procedure did not include specific instructions for the use of the safety belt on the whirlpool chair and nursing assistants should not determine whether or not a safety belt was needed for safe bathing for each resident. On [DATE] at 2:11 PM Program Manager reviewed with Supervisor and both agreed this deficiency rose to the level of Immediate Jeopardy. First- non compliance by the facilities failure to provide a safe whirlpool bath for resident #1 on [DATE] at 10:50 AM. Staff were providing a bath to a severely cognitively impaired resident, with Dementia, on blood thinners, at risk for falls, with muscle weakness and difficulty walking and required extensive assist of 2 staff for transfers and extensive assist of one staff member for bathing, The resident was in the whirlpool chair, was restless, did not have a safety strap on and fell forward striking the residents head, Staff stated they were preparing the safety strap to put on the resident, who fell before it was placed. Second the resident sustained serious harm and expired shortly after this event. Third there was a need for an immediate action to prevent other potential harm as evidenced by interviews with other residents that revealed the whirlpool safety belts were not used consistently. On [DATE] at 1:30 PM Program Manager Reviewed Potential IJ concerns with Regional Office Staff. Regional Office staff confirmed evidence supported changing the scope and severity of the survey to an IJ and to notify the facility Administrator and send the facility an Immediate Jeopardy Template. On [DATE] at 2:04 PM telephone interview with Administrator revealed the Administrator was not aware of the make/model of the [NAME] pool tub, but that it was made by the [NAME] Manufacturing Corporation. When asked the tub required a mechanical lift the Administrator stated 'Yes.' When asked if the residents entered the whirlpool tub via mechanical lift from the side or over the top of the tub, the Administrator stated Over the top. The Administrator confirmed that prior to the survey the bath aide or NA assessed/determined if a resident required a safety belt or not and safety belts were only used when residents were confused. When asked what the manufactures recommendations are regarding the safety strap and resident bathing the Administrator stated I don't know. During the interview I notified the Administrator that after the State Agency received the investigation and reviewed it, we determined the violation to be immediate jeopardy and reviewed the findings with our Regional Office Staff who confirmed the Immediate Jeopardy. As such we will send out an Immediate Jeopardy Template for the deficiency. I asked the Administrator to provide me with the make and model of the tub. The tub is a [NAME] tub Model # 0-x, lift chair model number #,d+[DATE]. The Administrator stated an abatement had been put in place on [DATE] that included safety belts were affixed to each bath chair. The policy was updated on [DATE] all residents are required to wear a seat belt when bathing. Nursing staff was educated on [DATE] about the bathing policy change. On [DATE] a record review of the [NAME] Manufacturing website revealed training videos for staff the content of the video includes All [NAME] lifts come with a lift belt that is mandatory to place and It is important that whenever in the chair the resident remain belted at all times. On [DATE] during the survey the facility abated the immediacy of the deficiency, lowering the scope and severity to a G after the immediate jeopardy.

Licensure Reference Number 175 NAC 12-006.09D8b Based on record reviews and interviews; the facility failed to ensure that nutritional interventions were in place to maintain residents weights and reduce the risk of further weight loss for one sampled residents (Resident 52). Facility census was 41. Finding are: Review of the "Resident Profile" for Resident 52 revealed current [DIAGNOSES REDACTED]. Review of the "Nutrition Risk Assessment" for Resident 52, dated 11/7/13, with the admission date of [DATE], revealed documentation by the DM (Dietary Manager) of a height of 63 inches, weight 122, usual body weight range unknown, and BMI (Body Mass Index) of 21 for this resident. Further review revealed that this resident was identified with relevant conditions and [DIAGNOSES REDACTED]. Score of this assessment was"15" which placed this resident at "High risk" with a moderate risk being anything over "8". Continued review revealed that the RD (Registered Dietician) reviewed and signed the assessment form on 11/12/13. Review of an RD (Registered Dietary Recommendation) fax dated and signed by the RD on 11/5/13 revealed, with the recommendations of milk for more nutrients, Med Pass if resident doesn't like milk and instant breakfast shakes might also be tried. Review of the facility's "Bathing Record" for the month of November 2013 revealed a weight on 11/5/13 of 119.5, on 11/12 of 119 (weight loss of 8 ounces), 11/19/13 113.5 (weight loss of 6 pounds), 11/26/13 a weight of 108.5 (weight loss of 11 pounds), and on 12/3/13 a weight of 107 (weight loss of10 percent or 12.5 pounds in less than a 28 day period. Review of the "physician's orders [REDACTED]. Review of the "Medication Flowsheet" for Resident 52 revealed that there was no documentation of an order dated 11/1/13 for Med Pass, two ounces three times a day. Further review revealed that the Med Pass was not administered for the Month of November 2013. Review of the "Care Plan" for Resident 52 dated 11/28/13, revealed a problem identified at at "Risk for nutritional intake of less than body requirements related to presence of pressure ulcers, [MEDICAL CONDITION] and [MEDICAL CONDITION]". Interventions dated 11/28/13 were to complete nutritional risk assessment, provide diet per Doctor's orders, encourage fluids, extra small servings per request, instant breakfast shakes with meals, extra small servings per request, Med Pass three times a day, weigh once weekly or per Doctor's order, weight to be monitored on a weekly basis by the care plan team, monitor and document food intake at meals with an additional intervention dated 12/12/13 to protein power pack meals. Review of the "Dietary Percentage Sheet" for the month of November 2013 for Resident 52 revealed that during the month fortified drinks were administered on 3 occasions. Further review revealed that on 22 occasions during the month this resident ate less than 50 percent of his/her meals and it was not clear if resident had received extra small portions. Interview on 1/23/14 at 11:00 AM with the (Dietary Manager) - DM revealed that Resident 52 was not on a physician ordered weight loss plan. Interview on 1/27/14 at 9:00 AM with the Administrator and the Director of Nursing confirmed that Resident 52 was at risk for malnutrition and weight loss and interventions were not in place to meet the orders/nutritional recommendations for this resident. Further interview confined that this resident did have a 10 percent loss in weight in a 28 day period and this should have been recognized and intervention put into place to prevent further decline in weight.