Every finding on record at Linden Court

Licensure Reference Number 175 NAC 12-006.11(E) Based on observations, interviews and record review, the facility failed to ensure outdated food items were not available for use, opened items were dated, and failed to do to complete hand hygiene and change gloves while preparing food to prevent potential cross contamination and food-borne illness. The facility identified a census of 113. This had the potential to affect all residents who ate out of the kitchen.Findings are: A. During the initial tour on 4/13/2026 from 11:21 AM until 12:00 PM, the following concerns were identified: -Walk-in refrigerated was found to have a half gallon bottle of buttermilk dated best by 4/11/2026. A tray of hamburger on the top shelf with a pan of cheesecake below it that had saran wrap loosely on top of it, not sealed.-Walk-in freezer was found to have box of hamburger patties opened in package and not sealed.-In dry storage, a bottle Coffee Mate hazelnut liquid creamer found with the lid caved in and available for use.-Opened package of penne and rotini pasta opened, resealed, but no date indicating date it was opened. A interview on 4/13/2026 at 11:55 AM with Culinary and Dining Coordinator (CDC)-N confirmed the expired buttermilk, the meat above the cheesecake, opened package of hamburger patties, concaved lid of creamer, and undated, opened pasta bags. B. During an observation of meal preparation on 4/14/2026 from 7:30 AM to 7:50 AM revealed Culinary Lead (CL)-P obtained two 10 pound tubes of raw hamburger meat from the refrigerator and placed them on to counter. CL-P completed hand hygiene for 10 seconds under running water and applied a new pair of gloves. CL-P cut open a package of the meat and dumped the meat into pan, and with same soiled gloves on, broke up the meat in the pot. CL-P removed the soiled gloves and performs hand hygiene for 12 seconds under running water and applies new gloves. CL-P cut open the second package of meat and dumped half the package into the pot and sets the other half of the package on the counter. Using the same soiled gloves to grab the meat from inside the package and set it into pot. CL-P removed the gloves and washes hands for 10 seconds. Observation of food preparation on 4/14/2026 from 8:20 AM until 8:45 AM revealed CL-P stirred a pan of casserole with spoon and without gloves. CL-P after finishing stirring pan 1, sat the soiled spoon on top of the casserole on pan 2. CL-P took the spoon sitting on top of pan 2 and wiped the handle with a paper towel and used that to stir pan 3. CL-P washed their hands for 20 seconds, puts on gloves on and stirs additional meat into the pans. CL-P grabbed a bag of parmesan cheese out of refrigerator, dumped parmesan cheese into measuring cup and used the same soiled gloves to sprinkle parmesan cheese with the casserole in 2 pans. Cl-P sat the measuring cup down and stirred pan 3 with same gloves and spoon.CL-P picked up cup with parmesan cheese and sprinkles pan 3 casserole with cheese using same soiled gloves. A interview with Chef-O, on 4/14/2026 at 8:40 AM confirmed hands need to be washed for 20 seconds and gloves should have been changed before touching meat and cheese. An observation during meal cart preparation inside the main kitchen on 4/15/2026 at 11:21 AM revealed CA-T reaching over clothing protectors on food transport cart and touches them with uncovered arms. Observation of meal service in Dogwood satellite kitchen on 4/15/2026 from 11:25 until 12:33 revealed Culinary Assistant (CA)-T grab different sized scoops for each food item based on kitchen spreadsheet reference scoop size for meal items. CA-T placed the scoops into steam table pans and washes hands for 10 seconds then grabs dessert out of refrigerator. An interview with Chef-O on 4/16/2026 at 8:00 AM confirmed the concerns with initial kitchen tour storage and hand hygiene. Chef-O will begin working on correcting these concerns.Record review revealed a poster above every sink in the main kitchen and satellite kitchens to ensure proper hand hygiene referencing steps for hand washing with pictures. The poster referenced the World Health Organization and stated All it takes is 20 seconds.

Licensure Reference Number 175 NAC 1-005.06(E&F), 12-006.18(B), and 1-005.06(D) Based on record review, interview, and observation, the facility failed to change their personal protective equipment when transitioning from infectious rooms to non-infectious rooms, failed to perform hand hygiene, and failed to ensure housekeeping services were provided to non-infectious rooms prior to infectious rooms. This had the potential to affect all residents residing within the facility. The facility census was 113. Findings Are: A. A record review of the Nebraska Infection Control Assessment and Promotion Program (ICAP) Nebraska Medicine 2026 website revealed a hyperlink in the COVID-19 Resources for Healthcare Settings section. The hyperlink was https://www.cdc.gov/covid/hcp/infection-control/. A record review of the CDC Infection Control Guidance: SARS-CoV-2 (COVID-19) document found at https://www.cdc.gov/covid/hcp/infection-control/ and dated 6/24/2024 revealed the guidance applied to all United States settings where healthcare is delivered, including nursing homes. In the section titled Implement Source Control Measures the document states a respirator with N95 filters or higher should be worn during the care of a patient with SARS-CoV-2 infection and states the respirator should be removed and discarded after the patient care encounter and a new one should be donned (put on). Further record review of the Nebraska ICAP website under the COVID-19 Resources for Long Term Care Settings section revealed a link to Zones PPE (Personal Protective Equipment, includes clothing, gloves, face shields, goggles, facemasks, respirators, and other equipment to protect front-line workers from injury, infection, or illness) and Testing. This link revealed the following guidance: -Red Zone Isolation (residents with a positive COVID-19 test), Staff PPE: COVID-19 full PPE is a respirator, eye protection, isolation gown, and gloves before entering resident room. Respirator and eye protection may be used according to extended use guidance if they are not touched. -Light Red Zone Isolation (symptomatic residents with a COVID-19 test pending), Staff PPE: COVID-19 full PPE is a respirator, eye protection, isolation gown, and gloves. Respirator and eye protection may be used according to extended use guidance if they are not touched. A record review of the Nebraska Medicine COVID-19 PPE Guidance: Extended Use and Reuse of Facemasks, KN95s, Respirators (PAPR, N95) and Protective Eyewear for Healthcare Personnel updated 1/14/2022 revealed the recommendations in the guidance are temporary while there are national and international shortages of personal protective equipment. An observation on 4/13/2026 at 12:00 PM revealed the following residents with signage on their room doors: -Resident 101 in room [ROOM NUMBER] had a sign stating Red Zone on their door. -Resident 99 in room [ROOM NUMBER] had a sign stating Red Zone on their door. -Resident 11 in room [ROOM NUMBER] had a sign stating Red Zone on their door. -Resident 12 in room [ROOM NUMBER] had a sign stating Red Zone on their door. -Resident 42 in room [ROOM NUMBER] had a sign stating Red Zone on their door. -Resident 86 in room [ROOM NUMBER] had a sign stating Light Red Zone on their door. -Resident 49 in room [ROOM NUMBER] had a sign stating Red Zone on their door. -Resident 22 in room [ROOM NUMBER] had a sign stating Red Zone on their door. -Resident 34 in room [ROOM NUMBER] had a sign stating Red Zone on their door. -Resident 87 in room [ROOM NUMBER] had a sign stating Red Zone on their door. -Resident 38 in room [ROOM NUMBER] had a sign stating Red Zone on their door. An observation on 4/13/2026 at 1:01 PM revealed Nurse Aide (NA)-G was exiting resident room [ROOM NUMBER] wearing full PPE (gown, gloves, eyewear, and an N95 mask) and carried dishes to a rolling cart that was parked outside room [ROOM NUMBER]. NA-G placed the dishes on the cart, applied Alcohol Based Hand Rub (ABHR) to their gloved hands and then entered Resident 49's room while wearing the same PPE, obtained dishes from this room and handed them to another staff. NA-G applied ABHR to their gloved hands and entered room [ROOM NUMBER] wearing the same PPE, turned off the resident's light switch, then exited the room closing the door behind them. NA-G applied ABHR to their gloved hands, then entered room [ROOM NUMBER] while continuing to wear the same PPE, obtained the resident's dishes and handed them to NA-E. NA-G then entered room [ROOM NUMBER] wearing the same PPE, obtained the resident's dishes and handed them to NA-E upon exiting the room. NA-G applied ABHR to their gloved hands, then entered room [ROOM NUMBER], obtained dishes, exited the room and handed the dishes to NA-E. While continuing to wear the same PPE, NA-G stood in the hallway talking to another staff who was less than 2 feet away from them, then removed their gown and gloves and discarded them in room [ROOM NUMBER]. NA-G touched their eyewear with their bare hand and then performed hand hygiene (HH) via ABHR. A continuous observation on 4/14/2026 from 7:43 AM until 8:18 AM revealed the following: -At 7:43 AM NA-C entering room [ROOM NUMBER] wearing full PPE and closing the door. NA-C exited room [ROOM NUMBER] at 8:01 AM after removing their gown and gloves. NA-C entered the nurse's station, removed their eyewear and set it on the desk, then picked it back up and walked to the PPE cabinet near room [ROOM NUMBER]. NA-C put on a gown, put their eyewear back on, performed HH via ABHR, and put on gloves. NA-C then entered room [ROOM NUMBER] without first disinfecting their eyewear or changing their mask. -At 7:58 AM the Director of Nursing (DON) and the Infection Preventionist (IP) were observed pushing a rolling cart containing covered dishes with food on them onto the 100 hallway. -At 8:11 AM, NA-D entered room [ROOM NUMBER] with a plate of food while wearing full PPE. NA-D then leaned out of the room and obtained a cup of fluids from other staff and requested condiments then went back into the room. At 8:12 AM, NA-D exited room [ROOM NUMBER] in full PPE and stood in the hallway with their gloved hand holding the handrail outside the room and talked to the DON. IP approached NA-D in the hallway and put condiments into NA-D's gloved hand. NA-D re-entered room [ROOM NUMBER] with the condiments. NA-D exited the room at 8:13 AM, removed their gown and gloves, and performed HH via ABHR. NA-D then pushed the rolling cart around the corner and down the other part of the 100 hallway without changing their mask or disinfecting their eyewear. At 8:15 AM, Assistant Director of Nursing (ADON)-A entered the 100 hallway, spoke with another staff while grabbing the same handrail outside room [ROOM NUMBER] that NA-D had their gloved hand on, then continued walking down the 100 hallway. An observation on 4/14/2026 at 10:08 AM revealed NA-C entering the 100 hallway wearing a mask and eyewear. NA-C put on a gown and gloves and then entered room [ROOM NUMBER]. NA-C exited room [ROOM NUMBER] carrying bags with laundry and trash at 10:21 AM after removing their gown and gloves, opened the unmarked door of a room and put the bags in the room. Next, NA-C performed HH via ABHR and entered the nurse's station to talk to another staff without changing their mask or disinfecting their eyewear. NA-C then went to a cupboard, put on a gown and gloves and entered room [ROOM NUMBER]. B. A record review of the ICAP Summary of Recommendations for COVID-19 in a Long-Term Care Facility dated 3/11/2026 revealed if environmental services (EVS) staff is performing cleaning in the red zone, they should also be dedicated to this unit (or if unable to dedicate, may plan daily activity in a way that they enter the red zone towards the end of their shift after they are done with rest of the facility). An observation on 4/14/2026 at 8:19 AM revealed Housekeeper (Hskp)-F exiting room [ROOM NUMBER] carrying housekeeping supplies and wearing full PPE. Hskp-F placed the cleaning supplies in their housekeeping cart without first disinfecting them, then removed their gown and gloves and performed HH via ABHR. Hskp-F put on a new gown and gloves, obtained cleaning supplies from their cart, and entered room [ROOM NUMBER] without first changing their mask or disinfecting their eyewear. An observation on 4/14/26 at 10:24 AM revealed Hskp-F putting on a gown and gloves, obtaining cloths, spray bottles, and a scrub brush out of their housekeeping cart, and entering room [ROOM NUMBER]. At 10:27 AM, Hskp-F exited room [ROOM NUMBER], put their spray bottles back in their cart, obtained a mop, and went back into room [ROOM NUMBER]. The resident residing in room [ROOM NUMBER] was not on transmission-based precautions (additional infection control measures used in healthcare settings beyond standard precautions to prevent the spread of known or suspected highly transmissible pathogens, such as COVID-19). An interview on 4/15/2026 at 8:24 AM with Hskp-F revealed they were to change their gown and gloves between cleaning each resident's room. Hskp-F stated that when there were only 1 or 2 rooms containing residents with infections, housekeepers were to clean these rooms at the end of the day, but when there were a large number of residents with infections there was not enough time to go back and forth in the building so the rooms were cleaned in order on the hallway. Hskp-F confirmed that by doing this, they cleaned rooms in the Red Zone or Light Red Zone interspersed with rooms that were not on transmission-based precautions. C. A record review of a facility document dated 4/13/2024 revealed the following Covid positive Resident rooms/locations: -100,102,103,104,105,109,110,112,114,115,125,201,204,205A,205B,208,300B,310A,401A,500,506,514A,700,713. A record review of an undated facility document labeled 'Standard and Transmission based precautions' revealed a small paragraph on the bottom that read: Hang hygiene is the single most important practice for preventing the transmission of potentially infectious microorganisms from one person to another. Studies have found that hand hygiene reduces the incidence of healthcare-associated infections. This document revealed references to CDC guidelines on hand hygiene procedures and when to clean hands with soap and water vs alcohol-based hand rubs, and provides examples that reference certain infections. During an interview with the Infection Preventionist (IP) and DON at 7:50 AM on 4/14/2026, the IP confirmed that hang hygiene is to be performed before and after resident contact, before and after using Personal Protective Equipment (PPE), after toileting, and before eating, and in between resident rooms. An observation made at 8:57 AM on 4/14/2026 revealed a staff member entering room [ROOM NUMBER], with a gown, mask, goggles, and gloves. The unidentified staff member left room [ROOM NUMBER] at 8:59AM and did not change their mask or clean their eye protection. That same staff member then entered another resident room at 8:59 AM wearing the same mask and eye protection. An observation made on 4/14/2026 at 11:40 AM revealed Nurse Aide (NA)-U leaving room [ROOM NUMBER] and not performing hand hygiene. An observation made at 12:05 PM on 4/15/2026 revealed Licensed Practical Nurse (LPN)-H walking out of a red zone room without cleaning eye protection or changing mask. An observation made at 12:09 PM on 4/15/2026 revealed a NA walking out of room [ROOM NUMBER] and not performing hand hygiene.

Based on record review and interview, the facility failed to notify the ombudsman of 2 (Residents 116 and 118) of 3 sampled residents' discharge from the facility. The facility census was 113.Findings Are: A. A record review of Resident 116's admission Record dated 4/15/2026 revealed the resident was admitted to the facility on [DATE]. The document revealed the resident was discharged from the facility on 3/17/2026. A record review of a fax sent to the ombudsman by the Social Services Supervisor (SSS) on 4/1/2026 revealed no evidence of the ombudsman being notified of Resident 116's discharge from the facility. An interview on 04/14/2026 at 2:22 PM with the Administrator confirmed the ombudsman had not been notified of Resident 116's discharge from the facility. B.A record review of Resident 118's admission Record dated 4/15/2026 revealed the resident was admitted to the facility on [DATE]. The document revealed the resident was discharged from the facility 3/13/2026. A record review of a fax sent to the ombudsman by SSS on 4/1/2026 revealed no evidence of the ombudsman being notified of Resident 118's discharge from the facility. An interview on 04/14/2026 at 2:22 PM with the Administrator confirmed the ombudsman had not been notified of Resident 118's discharge from the facility. An interview on 4/15/2026 at 2:00 PM with the DON confirmed the facility did not have a policy related to discharge of a resident. The DON revealed the nursing department utilized a checklist for discharges, but the checklist did not encompass the duties for resident discharge for departments outside of nursing.

Licensure Reference Number 175 NAC 12-006.09(B) Based on record review and interview, the facility failed to ensure the 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) was coded accurately for Resident 3's medication and Resident 5's Pre-admission Screening and Resident Review (PASRR, a process which requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have Serious Mental Illness or Intellectual Disability). The sample size was 23 and the facility census was 113.Findings Are: A.A record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities) dated October 2025 revealed in Chapter 3, Section N that the line item Antiplatelet should be coded as Yes if the resident received antiplatelet medications during the 7-day lookback period. A record review of Davis's Drug Guide for Nurses, 19th edition dated 2026 revealed the medication Plavix (clopidogrel) was in the antiplatelet agent therapeutic class. A record review of Resident 3's admission Record dated 4/15/2026 revealed the resident was admitted to the facility on [DATE] with a diagnosis of non-ST elevation (NSTEMI) myocardial infarction (a type of heart attack caused by a partial blockage of a coronary artery, leading to reduced blood flow and damage to the heart muscle). A record review of Resident 3's Medication Administration Record for March 2026 revealed an order for clopidogrel bisulfate tablet, 75 milligrams to be given once a day for NSTEMI myocardial infarction. The medication was documented as administered daily from March 4th through March 29th, 2026. A record review of Resident 3's MDS dated [DATE] revealed in Section N the line item for Antiplatelet was marked as No, indicating the resident had not received this medication during the 7-day lookback period. An interview on 4/15/2026 at 3:18 PM with MDS-L confirmed Resident 3's antiplatelet medication, clopidogrel should have been marked as Yes on their MDS dated [DATE] and was not. B. A record review of the CMS's Resident Assessment Instrument Version 3.0 Manual dated October 2025 revealed that on page A-30 to A-32 in Chapter 3, Section A that the line A1500. Preadmission Screening and Resident Review (PASRR) should be coded as 1. Yes if the resident is currently considered by the state level II PASRR process to have serous mental illness and/or intellectual disability or a related condition and to continue to A1510, Level II PASRR Conditions. Section A1510: Level II PASRR Conditions revealed to check all that apply: serious mental illness, intellectual disability, or other related conditions. Record review of Resident 5's census data revealed the resident was admitted on [DATE]. A record review of Resident 5's diagnoses list revealed a diagnosis of Bipolar Disorder (a condition characterized by dramatic shifts in mood, energy, and activity levels that affect a person's ability to carry out day-to-day tasks. These shifts in mood and energy levels are more severe than the normal ups and downs that are experienced by everyone) was added on 10/24/2025. Record review of Resident 5's annual MDS completed on 11/26/2025 revealed in Section A1500 the code was marked as 1. Yes. Section A1510 revealed that the line serious mental illness was marked. A record review of Resident 5's medical record revealed a Preadmission Screening and Resident Review (PASRR) Level II Determination Notification completed on 12/5/2025. The resident was approved of 180 days at a nursing home without any additional services. The facility will need to complete another Level II on or before 6/30/2025 per the PASRR Level II report. A record review of Resident 5's medical record revealed a significant change MDS completed on 2/24/206. In Section A1500 the code was marked as 0. No skip to A15550, indicating that the resident is not currently considered by the state level II PASRR process, to have serious mental illness, revealing that section A1510 was skipped. An interview with MDS nurse-K, on 4/15/206 at 7:58 AM, confirmed MDS nurse-K did not think that Resident 5 was a PASRR Level II. MDS nurse -K also confirmed that the social work handles the PASRR section of the MDS, but if social work was busy, MDS nurse-K would just mark things on the PASRR section. An interview with Social Service Staff, on 4/15/2026 at 9:13 AM confirmed that the PASRR sections on the annual MDS dated [DATE] and the significant change MDS dated [DATE] should have been marked as yes, indicating Resident 5 as PASRR Level II. An interview with Director of Social Services-Consultant on 4/15/2026 at 9:20 AM confirmed that Resident 5 is a Level II and that it needed to be marked on the MDS until not approved, but it was missed on the significant change MDS dated [DATE]. An interview with the Director of Nursing on 4/15/2026 at 2:00 PM revealed the facility does not have an MDS policy as they follow the Resident Assessment Instrument (RAI) Manual to complete the MDS's.

Licensure Reference Number 175 NAC 1-009.02(F)Based on observation, interview, and record review the facility failed to provide an environment free of accident hazards related to chemicals in the resident bathrooms for 3 residents (Resident 18, 92, 113) of 8 residents sampled. The facility census was 113. Findings are:An observation on 4/13/26 at 3:08 PM in the bathroom for Resident 92 revealed a cylindrical container titled, Micro-Kill D1 Germicidal Wipes sitting on the toilet tank. The container had a wipe hanging out of the lid of the container at the time.An interview with Resident 92 on 4/13/26 at 3:08 PM about the Micro-Kill D1 Germicidal Wipes in the bathroom revealed the resident smiling stating not knowing anything about it.An interview on 4/13/26 at 3:10 PM with Registered Nurse (RN)-V revealed the Micro-Kill D1 Germicidal Wipes are used for residents that occupy bathrooms with transmissible bacteria. RN-V further revealed Resident 92 has Extended-Spectrum Beta-Lactamase (ESBL; an enzyme produced by certain bacteria, that make them resistant to many common antibiotics with a high transmissible rate often found on contaminated hands, surfaces, or medical equipment often causing urinary tract infections (UTI; a bacterial infection of the urinary system causing pain and frequent urges to urinate)).A record review of Resident 92's admission Record dated 4/16/26 revealed diagnosis information of ESBL.A record review of Resident 92's Care Plan Report dated 4/14/26 revealed a focus on paralysis, unaware of safety needs; and an intervention to maintain an environment free of clutter and safety hazards.An observation on 4/13/26 at 3:15 PM in the bathroom for Resident 18 and Resident 113 revealed a cylindrical container titled, Micro-Kill D1 Germicidal Wipes sitting on the toilet tank.An interview with Resident 18 on 4/13/26 at 3:15 PM about the Micro-Kill D1 Germicidal Wipes in the bathroom revealed the resident not knowing anything about it.An interview with Resident 113 on 4/13/26 at 3:15 PM about the Micro-Kill D1 Germicidal Wipes in the bathroom revealed the resident was sleeping, unable to be aroused.A record review of Resident 18's admission Record dated 4/16/26 revealed diagnosis information of ESBL and dementia (a decline in mental ability such as memory, reasoning, and communication severe enough to interfere with daily life).A record review of Resident 18's Care Plan Report dated 4/16/26 revealed interventions to maintain environment free of clutter and safety hazards.A record review of Resident 113's admission Record dated 4/16/26 revealed diagnosis information of macular degeneration (cause of vision loss in people 60 years and older, destroying vision through damage to the retina).A record review of Resident 113's Care Plan Report dated 4/14/26 revealed a focus that the resident has the potential for impaired visual function related to untreated macular degeneration with an intervention to maintain an uncluttered environment free of obstacles and safety hazardsAn observation with Maintenance (Maint)-I on 4/16/26 at 8:20 AM confirmed a cylindrical container titled, Micro-Kill D1 Germicidal Wipes sitting on the toilet tank in the bathroom for Resident 18, 113 and 92.An interview with Maint-I on 4/16/26 at 8:20 revealed not knowing if the Micro-Kill D1 Germicidal Wipes were acceptable to keep in the bathroom with residents who have memory or vision issues.A record review of a Safety Data Sheet (SDS; a standardized document that provides comprehensive information about a hazardous substance or mixture), for Micro-Kill D1 Germicidal Wipes revealing:Section 1: Identification; recommended use: disinfectantSection 2: Hazardous Identification; classification: eye irritationSection 3: Ingredients; Benzyl alcohol (a solvent, preservative, and fragrance ingredient); Dodecyl benzenesulfonic Acid (a powerful detergent)Section 4: First Aide Measures; rinse with water, tret symptomaticallySection 7: Handling and Storage; advice on safe handling: wash hands thoroughly, keep out of reach of childrenSection 11: Toxicological Information; Potential Health Effects: Eyes: cause eye irritation, Skin: health injuries are not known or expected under normal use.Section 15: Regulatory Information; Caution: causes moderate eye irritation. Avoid contact with eyes or clothing. Wash thoroughly with soap and water after handling and before eating, drinking, chewing gum, tobacco, or using the toilet.During an interview with Administrator on 4/16/26 at 8:45 AM, the administrator agreed that a confused or visually impaired resident could inadvertently mistaken the container of Micro-Kill D1 Germicidal Wipes with personal cleansing wipes when accessible and in plain view.

Licensure Reference Number 175 NAC 1-005.06(C)Based on record review and interviews, the facility failed to ensure a stop date for the use of antibiotics medication. This affected 1 (Residents 15) ) of 5 sampled residents. The facility census was 113. Findings are: Record review of Resident 15's undated care plan revealed an admission date of 4/12/2021 with the following diagnoses: -FREQUENCY OF MICTURITION-AUDITORY HALLUCINATIONS-UNSPECIFIED URINARY INCONTINENCE -COGNITIVE COMMUNICATION DEFICIT-LONG TERM (CURRENT) USE OF ANTIBIOTICS -UNSPECIFIED DEMENTIA, SEVERE, WITH OTHER BEHAVIORAL DISTURBANCE-UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL -DISTURBANCEA record review of Resident 15's orders revealed an order dated 1/24/2025 with an order summary stating Bactrim Tablet 400-80 Milligrams (mg). Give 1 tablet by mouth one time a day related to long term use of antibiotics, continue this order. Leave as prescribed. There was no stop date identified for the use of the antibiotic medication. A record review of a document The core elements of Antibiotic Stewardship for Nursing Homes from the CDC revealed information recommending a reduction in antibiotic use in asymptomatic bacteriuria (ASB) (The presence of bacteria in the urine without UTI. It is common in older adults and usually doesn't require treatment). Antibiotic use for ASB does not confer any long-term benefits in preventing symptomatic UTI or improving mortality, and may actually increase the incidence of adverse drug events and result in subsequent infections with antibiotic-resistant pathogens.Very few studies support antibiotic use for UTI prophylaxis, especially in older adults, and many studies have shown this antibiotic exposure increases risk of side effects and resistant organisms. Therefore, efforts to educate providers on the potential harm of antibiotics for UTI prophylaxis could reduce unnecessary antibiotic exposure and improve resident outcomes'. An interview at 1:35 PM on 4/14/2026 with the Director of Nursing (DON) confirmed that Resident 15 was admitted to the facility with an antibiotic for UTI prophylaxis, which was changed to Bactrim after admission. The DON confirmed there has not been a stop trial on the Antibiotic since Resident 15's admission. The DON also confirmed that there has been no attempt at alternatives recommended by the Pharmacist for other medications as listed on the MRR. An interview at 7:50 AM on 4/15/2026 with the Infection Preventionist (IP) and the DON confirmed that when an antibiotic order is placed for a resident, a case is opened and tracked in Point Click Care (The charting system used in this facility). The IP looks at progress notes and reviews the reason for the antibiotic prescription. The IP nurse confirmed they follow the case until signs and symptoms for the resident's infection are no longer present. The IP confirmed there is not continuous observation or tracking of antibiotics for residents on long term antibiotic therapy. During the same interview, the DON confirmed there was no additional follow up for medication reviews, or trials off the antibiotic for Resident 15.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record reviews and interviews, the facility failed to conduct and document a thorough investigation of misappropriation of resident property for 1 (Resident 3) of 3 sampled residents. The facility identified a census of 104. Findings are:A record review of the facility's policy, Abuse and Neglect Prevention Standard dated 3/2017, under Section V. Investigation, revealed all allegations of abuse or neglect would be investigated and interview investigations would be completed and documented. All investigation results would be maintained in a confidential file by the Administrator. A record review of an admission Record revealed the facility admitted Resident 3 on 7/12/2022. A record review of Resident 3's Inventory of Personal Effects (dated 9/10/2022), under Items of Specific Value revealed a wedding ring, a mother's ring, and a [NAME] ring. A record review of an Investigation Report (dated 10/8/2025) revealed on 10/3/2025, the facility received an email for Resident 3's family member sharing they had noticed Resident 3 was not wearing their wedding ring. The family member informed the facility Resident 3 had been wearing their wedding ring during their last visit in July 2025. During their visit, the family member conducted a partial search and was unable to find it, therefore, had reported it missing to the nurse on duty. Additionally, the report revealed the facility searched on, behind, and under Resident 3's furniture and other areas. This report was completed by the Social Services Coordinator (SSC). There were no evidence interviews with all staff who had potential access had been conducted. An interview on 11/25/2025 at 10:35 AM with the SSC confirmed Resident 3's family member had reported their wedding ring being missing but had been present during their last visit in July 2025. The SSC confirmed Resident 3's wedding ring was added to their personal inventory. The SSC and Nursing Home Administrator (NHA) had conducted an investigation including searching Resident 3's room and the entire unit. Interviews with residents had not been completed due to their impaired cognition. Additionally, the SSC revealed they had interviewed the roommate's daughter of Resident 3 as well. An interview on 11/25/2025 at 12:30 PM with the SSC and NHA confirmed the facility had not interviewed all staff who had access to Resident 3's wedding ring or narrowed down a timeline of when the ring had been last noted to be present. The facility had interviewed the nurse and aide on duty at the time of the report as well as the Assistant Director of Nursing (ADON) but had not documented the findings of these interviews. Additionally, the NHA confirmed the facility had not ruled out the potential misappropriation had occurred.

Licensure Reference Number 175 NAC 12.006.09(I) Based on observations, interviews and record reviews, the facility failed to provide a safe environment when residents have been identified at risk for elopement. This affected 10 (Residents 1, 4, 5, 7, 8, 9, 10, 11, 12, and 13) of 12 sampled residents. The facility census was 105. The facility Administrator (ADM) was notified on 04/30/2025 at 6:00 PM of an Immediate Jeopardy (IJ) which began on 04/20/2025. The IJ was removed on 04/30/2025, as confirmed by surveyor onsite verification. Findings are: A record review of a policy titled Elopement Prevention and Management dated 3/2024 revealed: Key elements: -Every building must have a current Elopement Risk Manual, located at the nurse's station. It includes the Missing Resident Identification Form for those at risk for elopement. -Every facility should be doing elopement drills quarterly and as needed. -Elopement Prevention Audit per the QAPI Audit schedule Resident Risk Assessment: -All residents will be evaluated prior to admission for concerns related to elopement risk and resident safety. Appropriate placement of the resident is of utmost importance. Ongoing review will occur with all residents to ensure proper placement and a safe environment. Pre-Admission/Admission and ongoing review: -Social Services or Nursing will complete the Elopement Risk Review as a component of admission paperwork utilizing the Elopement/Wandering Review in PCC. All residents at risk are care planned for elopement risk by Social Services or Nursing and approaches are implemented and maintained. Elopement risk should be care planned separately on the care plan. -The Elopement Risk Manual includes resident identified at risk for elopement. The Administrator is ultimately responsible for ensuring this manual is current and accessible. -Discontinuation of residents from the Elopement Risk Manual (If the IDT feels the resident no longer poses a risk for elopement, the determination would be documented on an in the resident's medical record and the corresponding resident's Missing Resident Identification information would be removed from the Elopement Risk Manual as well as discontinuing the elopement risk problem from the care plan.) -If a resident is identified at risk an admission photograph is taken and the Missing Resident Identification Form is completed, including resident photo, and placed in the Elopement Risk Manual at the nurses' station for easy access during an emergency. The Missing Resident Identification form will be reviewed during weekly risk meetings, with every care plan conference and prn (as needed) to ensure all information is current and accurate. Education/Preparedness: -New team members are oriented to elopement prevention policies. The facility will also conduct in-services for all team members regarding elopement prevention and management procedures annually and as needed. An observation on 04/30/2025 at 8:00 AM revealed at the front door, the doors opening on their own by sensor, then a second door also opening by sensor. A front desk was observed at the opening of the front entrance and a greeter. An interview on 04/30/2025 at 8:05 AM with Guest Relations (GR)-J revealed they are at the desk from 8:00 AM until 4:00 PM and then someone relieves them and works until 7:00 PM. When asked about the front doors, who is staffing or watching, GR-J stated they just started working at the facility and were not entirely sure who or how it is maintained. An observation on 04/30/2025 at 8:30 AM revealed an area for residents identified as high risk for elopement located in a secure unit, accessible through keypad entry. On the west section of the building, the unit was titled [NAME] Street and included 12 residents. An observation on 04/30/2025 at 8:40 AM revealed an area for residents identified as high risk for elopement located in a secure unit, accessible through keypad entry. On the west section of the building, the unit was titled Pine Street and included 15 residents. An observation on 04/30/2025 at 8:45 AM revealed an area for residents identified as high risk for elopement located in a unit, accessible through an open door. On the west section of the building, the unit was titled [NAME] Street and included 8 residents. An observation on 04/30/2025 at 9:00 AM revealed an open area in the East side of the building where residents reside in areas of the facility easily accessible to all residents, families, and staff. These areas are called: Birch Street, containing 11 Residents, Ash Street, containing 21 Residents, Chestnut Street, containing 20 Residents, and Dogwood Street, containing 18 Residents. A record review of an undated list titled, Resident at Risk for Elopement revealed 28 Residents on the list from various areas of the building and 1 resident no longer residing in the building. A record review of an Elopement Risk Manual on [NAME] Street revealed 9 residents identified on the Resident at Risk for Elopement List and 7 Missing Resident Identification Forms for those identified as an elopement risk were in the Elopement Risk Manual. Of those 7 Missing Resident Identification Forms in the Elopement Risk Manual, several were identified as missing from the binder. Resident 9 resides on [NAME] Street and is identified on the Resident at Risk for Elopement; however, no form is found in the manual. Resident 10 resides on [NAME] Street and is identified on the Resident at Risk for Elopement; however, no form is found in the manual. Resident 11 resides on [NAME] Street and is identified on the Resident at Risk for Elopement; however, no form is found in the manual. A record review of Resident 9's Elopement/Wandering Review assessment dated [DATE] revealed a score of 26 with a category of High Risk. A record review of Resident 10's Elopement/Wandering Review assessment dated [DATE] revealed a score of 25 with a category of High Risk. A record review of Resident 11's Elopement/Wandering Review assessment dated [DATE] revealed a score of 41 with a category of High Risk. A record review of an Elopement Risk Manual on Pine Street revealed 8 residents identified on the Resident at Risk for Elopement List and 6 Missing Resident Identification Forms for those identified as an elopement risk were in the Elopement Risk Manual. Of those 6 Missing Resident Identification Forms in the Elopement Risk Manual, several were identified as missing from the binder. Resident 7 resides on Pine Street and is identified on the Resident at Risk for Elopement, however no form is found in the manual. Resident 12 resides on Pine Street and is identified on the Resident at Risk for Elopement, however no form is found in the manual. A record review of Resident 7's Elopement/Wandering Review assessment dated [DATE] revealed a score of 11 with a category of High Risk. A record review of Resident 12's Elopement/Wandering Review assessment dated [DATE] revealed a score of 15 with a category of High Risk. A record review of an Elopement Risk Manual on [NAME] Street revealed 5 residents identified on the Resident at Risk for Elopement List and 3 Missing Resident Identification Forms for those identified as an elopement risk were in the Elopement Risk Manual. Of those 3 Missing Resident Identification Forms in the Elopement Risk Manual, several were identified as missing from the binder. Resident 8 resides on [NAME] Street and is identified on the Resident at Risk for Elopement, however no form is found in the manual. Resident 13 resides on [NAME] Street and is identified on the Resident at Risk for Elopement, however no form is found in the manual. Resident 4 resides on [NAME] Street and is identified on the Resident at Risk for Elopement, however no form is found in the manual. A record review of Resident 8's Elopement/Wandering Review assessment dated [DATE] revealed a score of 25 with a category of High Risk. A record review of Resident 13's Elopement/Wandering Review assessment dated [DATE] revealed a score of 15 with a category of High Risk. A record review of Resident 4's Elopement/Wandering Review assessment dated [DATE] revealed a score of 10 with a category of High Risk. A record review of an Elopement Risk Manual on Birch Street revealed 2 Missing Resident Identification Forms for those identified on the Resident at Risk for Elopement List and 2 Missing Resident Identification Forms for those identified as an elopement risk were in the Elopement Risk Manual. A record review of an Elopement Risk Manual on Ash Street revealed 2 residents identified on the Resident at Risk for Elopement List and 2 Missing Resident Identification Forms for those identified as an elopement risk were in the Elopement Risk Manual. A record review of an Elopement Risk Manual on Chestnut Street revealed no residents identified on the Resident at Risk for Elopement List and no Missing Resident Identification Forms for those identified as an elopement risk were in the Elopement Risk Manual. A record review of an Elopement Risk Manual on Dogwood Street revealed 1 resident identified on the Resident at Risk for Elopement List and no Missing Resident Identification Forms for those identified as an elopement risk were found in the Elopement Risk Manual. Resident 5 resides on Dogwood Street and is identified on the Resident at Risk for Elopement, however no form is found in the manual. A record review of Resident 5's Elopement/Wandering Review assessment dated [DATE] revealed a score of 15 with a category of High Risk. An interview on 04/30/2025 at 2:00 PM with Nursing Assistant (NA)-C and NA-D on Chestnut and Ash Street revealed they were unaware of who was an elopement risk and where to locate the Elopement Risk Manual. An interview on 04/30/2025 at 2:10 PM with Registered Nurse (RN)-E on Chestnut and Ash Street revealed they were aware of who was at risk for elopement and elaborated on the process of why they were at risk and how to keep them safe. RN-E further revealed they completed an elopement risk assessment for Resident 5 who was located on Dogwood Street several weeks ago. An interview on 04/30/2025 at 2:15 PM with Licensed Practical Nurse (LPN)-G on Dogwood Street revealed LPN-G knew who was at risk for elopement and where the Elopement Risk Manual was located. When looking through the manual, no one was identified for being at risk for elopement. When interviewed, LPN-G revealed an assessment was due that day for Resident 5 and the resident was not at risk because they used oxygen services. A record review of Resident 5's elopement assessment completed by LPN-G on 04/03/2025 revealed that the resident scored a 15, which was a category of High Risk. The resident was also identified on the Resident at Risk for Elopement list previously provided. An interview on 04/30/2025 at 2:35 PM with Medication Aide (MA)-F on [NAME] Street revealed all residents except 1 resident; due to an inability to walk or self-propel in their wheelchair were at risk for elopement. When interviewed, MA-F revealed they were not responsible for updating the Elopement Risk Manual, this would be completed by the Social Services Department. An interview on 04/30/2025 at 3:25 PM with Social Services (SS)-H and SS-I revealed they were responsible for updating the list of Resident at Risk for Elopement and all Elopement Risk Manuals within the facility. When asked about the process of determining who was at risk for elopement, SS-H revealed this was determined at the risk meeting (IDT-Inter-Disciplinary Team-a working meeting between team leaders to identify those at risk for medical complications or matters) amongst all facility department leader staff. An interview on 04/30/2025 at 3:30 PM with the Director of Nursing (DON) revealed there was no wander guard system to prevent residents that wander from exiting the front door. During the interview, the DON stated that the front doors were unlocked around 5:00 AM to 6:00 AM when the Maintenance Directors arrive every morning, and locked by the Charge Nurse after the last pharmacy drop off occurred around 10:00 PM every evening. The DON also revealed the front desk schedule was for it to be staffed from 8:00 AM until 7:00 PM Monday through Friday and 9:00 AM through 4:00 PM on Saturday and Sunday, leaving the front doors unstaffed and unlocked for several hours daily. An interview on 04/30/2025 at 4:15 PM with facility staff member Guest Relations (GR)-K revealed their workstation was at the front desk, but that they were not at the front desk throughout their entire shift. GR-K also revealed not knowing who was at risk for elopement and not knowing how to locate or identify this information if needed. GR-K was asked about education on elopement, to which they revealed not receiving, but still needing to complete online. A record review of education provided on March 27, 2025 revealed instruction on wandering, types of wandering, elopement, and the elopement process including identified risks. Of the 192 staff listed, 45 facility staff attended the education event, leaving the remaining staff to receive and review the education at another time through an offsite education platform available online. GR-K was identified as not attending this education event. A record review of the facility's most recent elopement drill revealed it was conducted on 04/15/2025 at 4:15 PM due to a potential elopement of Resident 10 while attempting to pry a window open. The drill signature sheet revealed 6 staff members being educated at the event. A record review of facility Incidents dated 01/30/2025 through 04/30/2025 revealed one elopement incident concerning Resident 1 on 04/20/2025 at 11:00 AM when GR-K was working the front desk that day. An interview on 04/30/2025 at 4:15 PM with GR-K on the elopement of Resident 1 revealed GR-K seeing Resident 1 leave through the front doors and not being alarmed because the resident stopped right out front. The interview further revealed GR-K left the front desk area to assist another resident and family, however upon returning, Resident 1 was no longer in view. GR-K stated after looking for Resident 1, the resident could be seen being assisted back to the facility by way of an off-duty facility staff member. An interview on 04/30/2025 at 4:30 PM with the DON revealed education was not provided to facility staff after the incident of the elopement that occurred on 04/20/2025 with Resident 1. The facility implemented the following plan on 4/30/2025 to remove the immediacy: Immediate plan of correction [NAME] Court 04/30/2025: -All elopement binders have been updated as of 04/30/2025 with current resident that are identified as being at risk for elopement. -Care plans for those identified as being at risk have been updated as of 04/30/2025. -Front desk team member educated on elopement standard 04/30/2025 -Front door will be locked when staff is not present at front desk to monitor. -Elopement standard education will be provided to all staff currently working as well as all staff prior to start of shift beginning 04/30/2025 to be completed with all staff by 05/02/2025. -Elopement binders will be reviewed weekly by IDT and updated as needed. -Process will be reviewed in QAPI. At the time of the survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review 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 E level.

Licensure Reference Number: 175 NAC 12-006.09(D) Based on record review, and interview, the facility failed to accurately code comprehensive assessments for 2 of 4 sampled residents (Resident #7 and Resident #14) and failed to accurately complete care area assessment summaries for 2 of 4 sampled residents (Resident #5 and Resident #14). The facility census was 105. Findings are: A. Record review of Resident #7's Quarterly Minimum Data Set (MDS - a federally mandated assessment used to develop resident care plans) dated 04/23/2025 revealed an anticoagulant medication (medication used to prevent blood clots) and antidepressant medication (medication used to treat symptoms of depression) was used during the last 7 days. Record review of Resident #7's MAR (medication administration record) showed no anticoagulant or antidepressant medication in use during the MDS observation period. An interview on 05/01/2025 at 1:45 PM with MDS Coordinator RN-A and MDS Coordinator LPN-B revealed that medications anticoagulant and antidepressant should not have been on the MDS because Resident #7 is no longer taking the medications and has not been taking the medications since the look back period. 49382 B. A record review of a facility document titled Admission Record revealed the facility admitted Resident #14 on 04/08/2025 with diagnoses that included 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), and Type 2 Diabetes (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production). The Comprehensive Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) with an Assessment Reference Dated (ARD) of 04/09/2025 revealed the resident was coded to have received an Anticonvulsant medication during the look back period for obtaining MDS data (the ARD plus 13 days). A record review of Resident #14 Physician orders revealed no physician order present for resident to receive an anticonvulsant medication from 03/27/2025 through 04/09/2025. A record review of Resident #14 Electronic Medication Administration Record from 03/27/2025 through 04/09/2025 (the MDS look back period) revealed no documentation reflecting Resident #14 received a anticonvulsant medication. In an interview completed on 05/01/2025 at 1:15 PM with MDS-B, MDS-B confirmed that the MDS was coded incorrectly and that Resident #14 was not prescribed and did not receive a anticonvulsant medication during the look back period for the MDS. C. A record review of a facility document titled Admission Record revealed the facility admitted Resident #5 on 03/31/2025 with diagnoses that included Pulmonary Fibrosis (a thickening of the tissue around and between the air sacks in the lungs causing difficulties breathing) and Congestive Heart Failure (when the heart can not pump enough blood to meet the body's needs). The Comprehensive Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) with an Assessment Reference Dated (ARD) of 04/06/2025 revealed the resident had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 8 indicating the resident was moderately cognitively impaired. The resident was also coded as occasionally incontinent of bladder and staff provided supervision or touching assistance with toilet use and set up or clean up assistance with toileting hygiene. A record review of the Care Area Assessment(CAA) (which is a systematic process used to analyze data collected through the MDS to identify resident needs and guide care planning for triggered care areas (CAA) for the comprehensive MDS revealed Resident #5's cognitive impairment and incontinence to triggered CAA areas. Review of the Cognitive Loss/Dementia CAA revealed documentation that this area was a potential problem. Further documentation revealed in the area that cognitive loss or dementia will be addressed in the care plan with an answer of no. In the area indicated to describe the impact of this problem on the resident and the rational for the care plan decision area was left blank and no documentation present explaining the rational for the care plan decision to not address the residents' cognitive impairment on the care plan. Review of the Urinary Incontinence CAA revealed documentation that this was an actual problem for the residents. Further documentation revealed in the area will Urinary Incontinence be addressed in the care plan with an answer of no. In the area indicated to describe the impact of this problem on the resident and the rational for the care plan decision area was left blank and no documentation present explaining the rational for the care plan decision to not address the resident's urinary incontinence. In an interview completed on 05/01/2025 at 1:15 PM with MDS-A, MDS-A confirmed that the CAA's for Resident #5 addressing the cognitive impairment and urinary incontinence were not completed correctly. The MDS-A confirmed that both areas should have been marked yes to be addressed on the resident's care plan and the rational for the decision area should have been completed for each area and was not. D. A record review of a facility document titled Admission Record revealed the facility admitted Resident #14 on 04/08/2025 with diagnoses that included 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), and Type 2 Diabetes (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production). The Comprehensive Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) with an Assessment Reference Dated (ARD) of 04/09/2025 revealed the resident was coded to always be incontinent of bladder and the resident to be independent with toileting hygiene and toilet use. A record review of the CAA for the comprehensive MDS revealed Resident #14's Urinary Incontinence CAA documentation that this was an actual problem for the residents. Further documentation revealed in the area will Urinary Incontinence be addressed in the care plan with an answer of yes. In the area indicated to describe the impact of this problem on the resident and the rational for the care plan decision area was left blank and no documentation present explaining the rational for the care plan decision. In an interview completed on 05/01/2025 at 1:15 PM with MDS-A, MDS-A confirmed that the CAA for Resident #14 addressing the urinary incontinence was not completed correctly. The MDS-A confirmed that the rational for the decision area should have been completed and was not.

Licensure Reference Number: 175 NAC 12-006.09(F) Based on record review and interview, the facility failed to update resident care plans to reflect resident care needs for 1 resident (Resident #7). The facility census was 105. Findings are: A record review of Resident #7's Care Plan (CP - an individual plan for caring for each resident that can be updated daily, and as needed between quarterly care plan assessments) last updated on 04/30/2025 revealed Resident #7 is taking an anticoagulant medication (medication used to prevent blood clots) and psychoactive medications; an antianxiety (medication used to treat symptoms of anxiety) and an antidepressant (medication used to treat symptoms of depression). Record review of Resident #7's MAR (medication administration record) showed no anticoagulant or antidepressant medication in use during the MDS observation period. Record review of Resident #7's last Quarterly Minimum Data Set (MDS - a federally mandated assessment used to develop resident care plans) was dated 04/23/2025. A record review of a Comprehensive Care Plan Policy dated 11/28/2016 revealed that the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive, quarterly MDS (MDS- a Federally mandated tool for implementing standardized assessment and facilitating care management in nursing homes) assessment, and as needed. An interview on 05/01/2025 at 1:45 PM with MDS Coordinator RN-A and MDS Coordinator LPN-B revealed that medications anticoagulant and antidepressant should not have been on the CP because Resident #7 is no longer taking the medications and has not been taking the medications since the look back period.

Licensure Reference Number NAC 175 12-006.11E Based on observations, interviews, and record review, the facility failed to perform hand hygiene as required after handling uncooked meat and failed to wear hair restraints in the kitchen as required to prevent the potential for food-borne illness. This had the potential to affect all 104 residents who resided within the facility and were served out of the kitchen. Findings are: A. Record review of an undated facility policy titled, Hand Washing Importance and Technique, revealed that hand washing was indicated after handling uncooked foods including raw meat, fish, poultry, and produce. An observation on 1/28/25 at 7:37 AM revealed Culinary Lead-B (CL-B) was preparing the ingredients for meat loaf. The observation revealed CL-B performed the following: -CL-B completed hand hygiene prior to food preparation using soap and water. -CL-B opened a 10-pound tube of uncooked ground beef while wearing gloves and emptied it into a bowl. -CL-B removed their gloves, then discarded their gloves and packaging at the same time. -CL-B entered the walk-in cooler and returned with a carton of eggs. CL-B then cracked 6 eggs into the bowl containing the meat. -CL-B measured additional ingredients, including breadcrumbs, salt, spices, Worcestershire sauce, and chopped onion, handling all packages with their bare hands. CL-B used a ladle to measure and remove tomato sauce from a plastic bulk container. -CL-B then mixed the ingredients, dumped the mixture into a pan and formed it into loaves. -CL-B completed hand hygiene using soap and water. An observation on 1/28/25 at 7:52 AM revealed CL-B entered the walk-in cooler and returned with one and a half 10-pound tubes of uncooked ground beef. The observation revealed CL-B was not wearing gloves. CL-B opened the tubes with a knife, then emptied the meat into a mixing bowl. CL-B added the additional ingredients, touching eggs, containers, and utensils with their ungloved hands. The CL-B completed hand hygiene using soap and water at the end of meat loaf preparation. An interview on 1/28/25 at 8:10 AM with CL-B confirmed they did not complete hand hygiene after handling uncooked meat and should have. An interview on 1/28/25 at 8:25 AM with the Culinary Director (CD) confirmed CL-B should have completed hand hygiene after handling uncooked meat and before handling other items. B. A record review of an undated, facility-provided excerpt from the 2017 Nebraska Food Code revealed that food employees were required to wear hair restraints. This document was provided in lieu of a facility-specific policy for hair restraints in the kitchen. An interview on 1/30/25 at 10:30 AM with the Administrator confirmed that the 2017 Nebraska Food Code was what the facility utilized for hair restraint guidance and that the facility did not have a policy for this topic. An observation on 1/29/25 at 11:30 AM revealed Culinary Assistant-C (CA-C) walked through the food preparation area of the kitchen without wearing a hair restraint. An interview on 1/29/25 at 11:31 AM with CD confirmed that they were also present to observe CA-C not wearing a hair restraint while in the food preparation area and that CA-C should have been wearing one.

Licensure Reference Number 1-005.06(D) Based on observations and interviews, the facility failed to follow infection control practices during environmental cleaning, disinfection, and with the application of Personal Protection Equipment (PPE). This had the potential to affect all the residents. The facility identified a census of 104. Findings Are: A continuous observation on 1/28/25 from 10:20 AM to 10:45 AM of the 100 Hall revealed at 10:22 AM a housekeeping staff (HSK-H) coming out of a residents' room with gloves on both hands. HSK-H was then observed renewing supplies at the housekeeping cart and returning to a different room with the same gloves on. HSK-H was observed using this technique to clean three resident rooms. At 10:40 AM a Nurses Assistant (NA-I) was observed applying PPE to enter an Enhanced Barrier Precautions room (EBP). NA-I was observed applying gown to shoulder length without tying it up to the neck before entering the room. An interview on 1/28/25 at 10:35 AM with HSK-H confirmed that the observed technique was not the facility policy and that HSK-H should have removed the gloves and washed hands. An interview on 1/28/25 at 10:45 AM with NA-I confirmed was it was not policy to wear gown in that fashion and stated I didn't think I'd be in there that long. NA-I confirmed that was not how the facility trained regarding the application of PPE. Interview with Infection Preventionist (IP) nurse on 1/29/25 at 3:00 PM confirmed that HSK-H was to perform hand hygiene and new glove application between cleaning rooms. IP further confirmed that NA-I should have tied gown around the neck and not allowed to drape around shoulders.

Licensure Reference 175 NAC 12-006.09(E)(iii) Based on record reviews and interviews, the facility failed to develop comprehensive care plans (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) that reflected Resident 97's dialysis treatment and Resident 99's anticoagulant use. This affected 2 (Resident 97 and 99) of 21 sampled residents. The facility identified a census of 104. Findings are: A record review of a facility policy, Comprehensive Care Plans with a date implemented of 11/28/2016, indicated that is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that includes measurable objectives and timeframes to meet each resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The CCP will include services that are to be furnished and any specialized services the nursing facility will provide to maintain the resident's highest practicable physical, mental and psychosocial well-being. A. A record review of an Admission Record revealed the facility admitted Resident 99 on 11/18/2024 with diagnoses of cardiac arrythmia (an abnormal heart rhythm, characterized by an irregular, too fast, or too slow heartbeat), a history of blood clots, and long term (current) use of anticoagulants (blood thinners.) A record review of Resident 99's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) with an Assessment Reference Date (ARD) of 11/24/2024 revealed Resident 99 was taking an anticoagulant. A record review of Resident 99's undated Care Plan revealed no focus care area for anticoagulant use. An interview on 1/29/2025 at 3:44 PM with MDS-A confirmed Resident 99's care plan did not include a care focus area for their anticoagulant use and should be included. 51560 B. A record review of Resident 97's admission face sheet revealed an admitted [DATE]. A record review of an MDS dated [DATE] revealed in Section C a BIMS score of 15; indicating that Resident 97 is cognitively intact. Section GG revealed Resident 97 uses a walker for ambulation and is independent with most cares and activities apart from toileting, for which Resident 97 is dependent. Section 0 reveals Resident 97 to be on hemodialysis (a treatment that removes waste products and excess fluid from the blood when the kidneys are no longer able to do so). A record review of Resident 97's current pertinent diagnoses include: -Discitis (an inflammation of the intervertebral discs). -End stage renal disease (a condition where the kidneys have permanently lost most of their function and can no longer adequately filter waste products from the blood). -Moderate protein-calorie malnutrition (a condition where a person is not consuming enough protein and calories). -Type 2 Diabetes Mellitus (a chronic condition that affects how the body uses sugar (glucose) for energy). -Malignant Neoplasm of the Bladder (a type of cancer that develops in the bladder, the organ that stores urine). A record review of Resident 97's Care Plan dated 1/27/25 revealed no evidence of hemodialysis being a focus area with subsequent interventions or monitoring. An observation and interview with Resident 97 on 1/27/25 at 2:05 PM in Resident 97's room revealed Resident 97 is scheduled for dialysis every Monday, Wednesday, and Friday and had been on dialysis since admission to the facility. An Interview with the Minimum Data Set Nurse (MDS-A) on 1/28/24 at 10:00 A.M confirmed that Resident 97 was on dialysis and that it was not on the care plan as an area of focus. MDS-A confirmed that the MDS-A was responsible for ensuring the comprehensive care plan was complete and confirmed that dialysis would fall under the role of Nursing to complete. An interview with the Director of Nursing (DON) on 1/28/25 at 3:00 PM confirmed Resident 97 was on dialysis, which has many side effects and potential complications to monitor for. The DON confirmed that dialysis was not listed in the care plan as a focus area and that it should have been.

Licensure Reference Number 12.006.04(F) Based on observation, interview, and record review; the facility failed to ensure that 1 (Resident 94) of 21 sampled residents care plan was reviewed and revised to reflect significant weight loss. The facility identified a census of 104. The findings are: A record review of a Comprehensive Care Plan Policy dated 11/28/2016 revealed that the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive, quarterly MDS (MDS- a Federally mandated tool for implementing standardized assessment and for facilitating care management in nursing homes) assessment, and as needed. A record review of Resident 94's admission face sheet revealed an admitted [DATE]. A record review of Resident 94's diagnoses included pneumonia (an inflammation of the lungs that causes the air sacs (alveoli) to fill with fluid or pus), altered mental status (a change in a person's level of consciousness, awareness, and cognitive function), and functional diarrhea (a chronic condition characterized by frequent, loose, and watery stools without an underlying structural or biochemical abnormality). A record review of a MDS dated [DATE] revealed in Section C that Resident 94 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool that helps identify cognitive impairment in patients and residents) score of 7; indicating moderate to severe cognitive impairment. Section D revealed a Patient Health Questionnaire 2-9 (PHQ 2-9-a tool used to screen for and diagnose depression) score of 0, indicating that Resident 94 was likely not experiencing symptoms of depression. Section GG revealed Resident 94 needed some help with self-care and was independent with eating. Section K revealed no evidence of swallowing concerns. Section K revealed Resident 94's height was 67 inches and weight was 135 pounds (lbs.). Section K recorded no weight loss. Record review of a Physician Notification Communication Form dated 12/18/24 revealed that Resident 94's weight was 126 pounds (lbs) that day and that Resident 94 was triggering for a 9.5 lbs. or 7% weight loss in 30 days. The communication stated that Resident 94's food intake was poor and that Resident 94 was currently being offered an oral house supplement twice a day. The communication further stated that Resident 94 was continuing to have loose to liquid stools. There was a request attached to the communication requesting to add Metamucil to aid with stools and to change oral nutritional supplement to 237 milliliters of Ensure Plus twice a day to prevent further weight loss. The physician was noted to have agreed to the request. A record review of a Physician Notification Communication Form dated 1/7/25 revealed a request to change Resident 94 to a mechanical soft and thin liquid diet as Resident 94 was having difficulty chewing regular texture diet due to no teeth. The request was agreed to by the physician. A record review of Resident 94's care plan dated 1/27/25 revealed a Focus area dated 10/7/24 stating at risk for potential impaired nutritional status related to pneumonia and altered mental status. Interventions for risk for impaired nutritional status included: -Notify Doctor with significant weight loss as needed- date initiated 10/7/24. -Dietician to evaluate for nutritional needs as needed- date initiated 10/7/24. -Monitor and document food intake- date initiated 10/7/24. -Lab work as ordered by physician- date initiated 10/7/24. -Allow adequate time to ingest meal and offer assistance as needed- date initiated 10/7/24. -Provide diet as ordered- regular diet with texture and fluids- date initiated 10/7/24. -Provide supplement as ordered- date initiated 10/24/24. -Review pharmacological regiment and note any medications that may interfere with food intake. Document and report findings to physician- date initiated 10/7/24. -Weigh per facility protocol and as needed- date initiated 10/7/24. A record review of Resident 94's care plan dated 1/27/25 revealed no evidence of revision or updating of the care plan to reflect Resident 94's weight loss or any subsequent interventions and strategies developed by the interdisciplinary team related to that weight loss. An interview with the Minimum Data Set (MDS-A) Nurse on 1/28/24 at 10:00 A.M revealed that they are responsible for the oversight of the entire care plan, however, each department is responsible for entering their own data and interventions. MDS-A is responsible for ensuring the entirety of the care plan is complete and reminding departments when a specific portion of the care plan is missing. MDS-A nurse stated they do this during the MDS documentation period. MDS-A stated that revisions were done at the facilities Risk meeting, after care conferences, and as needed. An interview with the Registered Dietician (RD) on 1/29/25 at 11:15 A.M revealed the RD thought the information currently on the care plan was sufficient to address weight loss and noted they were following the interventions in the care plan. The RD did confirm that Resident 94 was now on a mechanical soft diet and that the care plan reflected a regular texture diet. The RD did confirm that the initiation date of the focus area and interventions were at admission or shortly after and that there were no revisions since that time. An interview with the Director of Nursing (DON) on 1/29/25 at 12:30 P.M revealed that the DON's expectation of the care plan is that the interdisciplinary team will add or revise it as needed. The DON confirmed that it is considered to be the facilities plan of care for each resident and confirmed that the weight loss should have been added under the core focus area.

Licensure Reference 175 NAC 12-006.09(G)(i) Based on record reviews and interview, the facility failed to develop and provide a discharge summary (a detailed document with individualized care instructions to ensure continuity of care and a safe return home for the resident) that included a recapitulation of stay; information regarding the resident's physical functioning and assistance level needs, continence, and skin condition; and a reconciliation of the resident's medications as required for 1 (Resident 102) of 1 sampled resident. The facility identified a census of 104. Findings are: A record review of an Admission Record indicated the facility discharge Resident 102 on 10/31/2024 at 2:00 PM. Resident 102 had diagnoses of a history of a right femur (thigh bone) fracture with surgical correction and high blood pressure. A record review of Resident 102's Discharge 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) with an Assessment Reference Date of 10/31/2024 indicated Resident 102 required supervision with bathing, setup assistance with eating, and was independent with oral hygiene, toileting, dressing, and personal hygiene. The MDS also indicated Resident 102 was occasionally incontinent of urine, had no skin conditions, and was on a high-risk medication of an anticoagulant (blood thinner.) A record review of Resident 102's Nursing Discharge Summary - V2 completed on 10/31/2024 by Licensed Practical Nurse (LPN) - D revealed the following: - Under the section Physical Functioning Status, the boxes regarding whether Resident 102 did or did not require assistance with Activities of Daily Living (ADLs) were not marked. - There was no information included under the section Skin/Foot Care. - There was no information included under the section Recapitulation Summary. - There was no information regarding Resident 102's continence needs. - The box for Reconciliation of all pre-discharge medication and post-discharge medications have been completed (both prescribed and over-the counter) box was not marked. An interview on 1/28/2025 at 12:40 PM with LPN-D confirmed the recapitulation of stay and skin condition sections were left blank, Resident 102's reconciliation of medications was not completed, and the level of assistance Resident 102 required with ADLs was not indicated. LPN-D was unaware these sections were required as part of the discharge summary. An interview on 1/29/2025 at 10:48 AM with the Director of Nursing (DON) confirmed the discharge summary should include a recapitulation of stay, reconciliation of the resident's medications, the level of assistance needed with ADLs, and a review of the resident's skin condition, noting if there are no skin concerns. An interview on 1/29/2025 at 9:50 AM with the Administrator revealed the facility does not have a policy regarding discharges but does a discharge checklist the facilities utilize to ensure all steps of discharge are completed. A record review of an undated facility-used checklist, Nursing Planned Discharge to Home revealed steps to complete both User-Defined Assessments (UDAs) in the Electronic Health Records (EHR) titled Discharge Instruction for Home Care and Nursing Discharge Summary with a special note to ensure to include medications, treatments, skin condition, and injection status on both, then save, sign, and lock and exit.

Licensure Reference 175 NAC 12- 002.10D Based on record reviews, observations, and interviews, the facility failed to administer medications to Resident 3 and Resident 99 according to their physician's order and administer the proper dosage of medication to Resident 96. The facility also failed to ensure a medication error rate of less than 5 percent (%) for 3 (Residents 3, 96, and 99) of 5 sampled residents. There were 32 opportunities observed with 3 errors observed, a total medication error rate of 9.38%. The facility identified a census of 104. Findings are: A record review of a policy provided by the facility Oral Drug Administration with a date of 5/20/2024 indicated the personnel administering the medication should verify the medication is being administered at the proper time, prescribed dose, and by the correct route to reduce the risk of medication errors. A. A record review of a Drug Safety Update for Rivaroxaban (Xarelto) from the Medicines and Healthcare Products Regulatory Agency with a date of 7/17/2019 indicated that rivaroxaban (a blood thinner) in the 15 milligram (mg) or 20 mg dose should be given with food as studies have shown a lack of efficacy for thromboembolic (blood clot) events when given on an empty stomach. A record review of an Admission Record indicated the facility admitted Resident 99 to the facility on [DATE] with diagnoses of dementia, a cardiac arrythmia (an abnormal heart rhythm, characterized by an irregular, too fast, or too slow heartbeat), a history of blood clots, and long term (current) use of anticoagulants (blood thinners.) A record review of Resident 99's Order Summary Report with an active orders date of 1/29/2025 revealed an order for rivaroxaban 20 mg with direction to give one tablet by mouth one time a day and administer with food for a history of blood clots. This medication had a start date of 12/21/2024. An observation on 1/29/2025 at 7:40 AM revealed Licensed Practical Nurse (LPN) - E administer Resident 99's rivaroxaban at this time. Resident 99 had been seated at the dining room table without food. Breakfast had not begun being served at this time. An interview on 1/29/2025 at 7:50 AM with LPN-E confirmed Resident 99's rivaroxaban was not administered with food as breakfast is not served until after 8:00 AM. B. A record review of Potassium Supplement (Oral route, parental route) article by Mayo Clinic with a last revised date of 12/31/2024 indicated potassium supplements should be given immediately after a meal or with food to lessen the possible stomach upset. A record review of an Admission Record indicated the facility admitted Resident 3 to the facility on [DATE] with diagnoses of Dementia and Gastro-Esophageal Reflux Disease (GERD, a chronic condition where stomach contents flow back up into the esophagus, causing irritation and discomfort.) A record review of Resident 3's Care Plan revealed a focus area for potential alteration in gastrointestinal status related to GERD with a last revised date of 7/13/2021. An intervention included to give medications as ordered. A record review of Resident 3's Order Summary Report with an active order date of 1/29/2025 revealed an order for Potassium Chloride 20 milliequivalents with directions to give one tablet by mouth one time a day with or after food to avoid gastrointestinal irritation. This medication had a start date of 9/3/2024. An observation on 1/29/2025 at 7:46 AM revealed LPN-E administer Resident 3's Potassium Chloride at this time. Resident 3 had been seated at the dining room table without food. Breakfast had not begun being served at this time. An interview on 1/29/2025 at 7:50 AM with LPN-E confirmed Resident 3's potassium chloride was not administered with food as breakfast is not served until after 8:00 AM. C. A record review of a Drug Fact - MiraLAX by the manufacture, [NAME], with a date of 11/1/2021 revealed directions for MiraLAX (a laxative for constipation) to fill to the top of the white section in the cap which is marked to indicate the correct dosage of 17 grams (g.) A record review of an Admission Record indicated the facility admitted Resident 96 on 10/16/2024 with diagnoses of a non-traumatic subarachnoid hemorrhage (brain bleed) and constipation. A record review of Resident 96's Order Summary Report with an active order date of 1/29/2025 revealed an order for MiraLAX 17 g with direction to give by mouth one time a day for constipation. This medication had a start date of 10/22/2024. An observation on 1/29/2025 at 8:09 AM revealed Registered Nurse (RN) - F had taken Resident 3's MiraLAX and poured the powder into a medication cup to the 30 cubic centimeters (cc) line instead of measuring into the lid of the MiraLAX bottle. At 8:16 AM, RN-F mixed the measured powder into Resident 3's drink and administered it to Resident 3. An interview on 1/29/2025 at 10:30 AM with RN-F revealed RN-F was not aware of how 30 cc would convert to 17 g and that MiraLAX should be measured in the lid to provide 17 grams.

Licensure Reference Number 175 NAC 12.006.12E8 Based on interview and record review, the facility failed to ensure 1 (Resident 76) of 5 sampled resident's Fentanyl Duragesic patch (a topical pain medication patch) destruction was witnessed by 2 credentialied individuals. The facility census was 98. Findings are: A record review of the facility's VSL ([NAME] Senior Living) Medication Destruction/Disposal Policy and Procedure dated 02/2020 revealed removed topical patches should have been disposed in the medication disposal system and 2 staff members needed to observe the disposal of a used Fentanyl patch. Ideally 2 nurses would observe the disposal of a removed Fentanyl patch. If 2 nurses were not available at least 1 staff member must be a nurse and the second may be a MA. Each person would initial witnessing the disposal on the Medication Administration Record (MAR). A record review of Resident 76's Admission Record dated 02/27/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 76's Order Summary Report dated 02/27/2024 revealed the resident was on a Fentanyl Transdermal Patch (pain patch applied to the skin) for pain that was to be changed every 3 days. The Order Summary Report dated 02/27/2027 also revealed there were orders to remove the patch from the resident in the presence of a witness, and a second signature was required for the witnessing of the removal and disposal of the Fentanyl patch every 3 days. A record review of Resident 76's Medication Administration Record (MAR) dated December 2023 revealed the Fentanyl Transdermal Patch was changed on the following dates but the staff member that changed the patch was the staff member that also signed they witnessed the patch being changed: - 12/06/2023 - 12/09/2023 - 12/12/2023 - 12/18/2023 - 12/21/2023 - 12/24/202 - 12/27/2023 - 12/30/2023 A record review of Resident 76's Medication Administration Record (MAR) dated January 2024 revealed the Fentanyl Transdermal Patch was changed on the following dates but the staff member that changed the patch was the staff member that also signed they witnessed the patch being changed: - 01/02/2024 - 01/11/2024 -01/17/2024 - 01/20/2024 - 01/23/2024 - 01/29/2023 A record review of Resident 76's Medication Administration Record (MAR) dated February 2024 revealed the Fentanyl Transdermal Patch was changed on the following dates but the staff member that changed the patch was the staff member that also signed they witnessed the patch being changed: - 02/04/2024 - 02/07/2024 - 02/10/2024 - 02/16/2024 - 02/22/2024 In an interview on 02/28/2024 at 3:35 PM, Licensed Practical Nurse (LPN)-B confirmed there should be a nurse that removed and disposed of a Fentanyl Transdermal patch and there should have been a different nurse there to witness the removal of the patch and the flushing of the patch in the toilet. LPN-B confirmed each of the 2 different nurses need to mark the removal and destruction of the patch on the MAR. In an interview on 02/28/2024 at 10:21 AM, The Assistant Director of Nursing (ADON) confirmed it was the facility's policy to have a witness observe and document the removal and disposal of the Fentanyl patch. The ADON confirmed that the MAR's revealed the same person that documented they remove and disposed of the Fentanyl patch was the same staff member that witnessed the removal and disposal of the Fentanyl Transdermal patch removal. The ADON confirmed it should have been the nurse that removed and disposed of the patch and another nurse or MA to witness the removal and destruction, but it was not.

Licensure Reference Number 175 NAC 12.006.17B Licensure Reference Number 175 NAC 12.006.17D Based on observation, interview, and record review, the facility failed to ensure that 1 (Resident 151) of 2 sampled resident's indwelling urinary catheter (a tube inserted in the bladder to drain urine) bag was kept off the floor and failed to ensure a clean barrier was used during tracheostomy (trach)(a breathing tube placed in the neck) care for 1 (Resident 58) of 1 sampled resident to prevent the potential for cross contamination, and failed to ensure handwashing was completed for at least 20 seconds during trach care for 1 (Resident 58) of 1 sampled resident. The facility census was 98. Findings are: A. A record review of the facility's Indwelling Urinary Catheter (Foley) Care and Management policy dated 12/11/2023 revealed the staff should not place the urinary catheter drainage bag on the floor to reduce the risk of contamination and subsequent Community Acquired Urinary Tract Infection (CAUTI). A record review of Resident 151s Admission Record dated 02/28/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 151's Medical Diagnosis dated 02/28/2024 revealed the resident had diagnoses of Chronic (long term) Kidney Disease, Stage 2 (Mild), Acute Pulmonary Edema (fluid in the lungs), Acute Systolic (Congestive) Heart Failure, and Hyperlipidemia (too many fats in the blood). A record review of Resident 151's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 02/07/2024 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 15 which indicated the resident was cognitively aware. The resident was dependent on staff or needed substantial assistance for most activities of daily living except oral hygiene which the resident needed partial/moderate assistance with. The MDS revealed Resident 76 had an indwelling catheter. A record review of Resident 151's Care Plan with an admitted [DATE] revealed the resident had a Focus area of indwelling catheter related to Urinary Retention and had associated interventions. An observation on 02/26/2024 at 1:29 PM revealed Resident 151's urinary catheter drainage bag was laying on the floor with the drain tube touching the carpet. An observation on 02/27/2024 at 9:04 AM revealed Resident 151's urinary catheter drainage bag was laying directly on the carpeted floor. An observation on 08/28/2024 at 8:20 AM revealed Resident 151's urinary catheter drainage bag was located on the floor next to the resident's recliner. An observation on 08/28/2024 at 8:27 AM with Registered Nurse (RN)-C revealed Resident 151's urinary catheter drainage bag was on the floor by the recliner. In an interview on 02/28/2024 at 8:27 AM, RN-C confirmed the that the urinary catheter drainage bag was laying on the carpeted floor. RN-C confirmed that was common practice for the staff to leave Resident 151's urinary catheter drainage bag on the floor because there was not really a place to hang it. In an interview on 02/28/2024 at 3:06 PM, the Director of Nursing (DON) confirmed the urinary catheter bag should not be placed on the floor. It should be kept off the floor to prevent the potential for an infection. 46245 B. A record review of Resident 58's Admission Record revealed the resident had been admitted to the facility on [DATE]. The section Diagnosis Information revealed Resident 58 had diagnoses of paralysis of vocal cords and larynx, unspecified, and tracheostomy (trach) status. A record review of Resident 58's MDS dated [DATE], Section 0-Special Treatments, Procedures, and Programs revealed the resident receives suctioning and tracheostomy care. A record review of Resident 58's Clinical Physician Orders revealed an orders for: - Weekly cleaning: trach is to be removed fully and cleaned with 1:1 peroxide and sterile water using tools in the trach cleaning trays to remove all mucus build up inside of the trach tube. Then, rinse trach with sterile water then replace using trach guide (which is then immediately removed after placement) and secure with trach collar every day shift every Thursday with a start date of 2/22/2024. - Suctioning: Do not insert suction catheter past 11 centimeters (cm) as marked on the catheter to avoid injury or damage to the airway. Then, suction at minimum first thing in the morning, at lunch time, at dinner time, and right before bed to avoid build up. If there is build up that prevents full insertions of catheter, get the catheter wet to loosen mucus build up in trach tube and to suction it out four times a day with a start date of 2/8/2024. - Trach Collar: Trach is secured by a trach collar which is to be fitted snug around the neck to avoid movement of the device when talking or coughing. The Trach is to be covered by a trach mask with a revision date of 2/8/24. - Split sponge: to be changed twice daily in the morning and at bedtime. The area around the trach and under the sponge to be cleaned and dried at this time prior to placing clean sponge two times a day with a start date of 2/8/2024. An observation on 2/27/2024 at 3:35 PM in Resident 58's room revealed the resident sitting in a chair with their feet elevated on a four-wheeled walker. Resident 58 had a mask for humidification covering their trach. An observation of tracheostomy care on 2/28/2024 at 9:01 AM revealed RN-E had donned gloves, removed Resident 58's trach and cleaned it in a peroxide and sterile water solution and a brush. RN-E was cleaning out mucous from the trach and the mucous fell on the left bare side of the resident's overbed table. Mucous and the solution were splattering while RN-E was cleaning the trach. RN-E had not sanitized the overbed table where the trach supplies were. RN-E had completed cleaning Resident 58's trach and reinserted it into the trach site. RN-E had suctioned Resident 58's trach. RN-E had doffed their soiled gloves and washed their hands with soap and water for 16 seconds. RN-E placed a split sponge gauze around Resident 58's trach site, placed the Velcro strap on the trach to secure it, and placed a mask and humidity over Resident 58's trach. RN-E washed their hands with soap and water for 16 seconds. RN-E wiped Resident 58's over-bed table with a dry paper towel and did not sanitize it before placing the resident's breakfast plate and drinks on the table and positioning the over-bed table in front of the resident. An interview on 2/28/2024 at 11:15 AM with the Director of Nursing (DON) revealed they expected the staff to sanitize and set up a clean filed before placing trach or wound care supplied on an overbed table/work area and after the treatment/procedure had been completed. The DON revealed they expect the staff to wash their hands with soap and water for a minimum of 20 seconds. An interview on 2/28/24 at 11:29 AM with RN-E confirmed they had not sanitized the residents over the bed table before placing the trach supplies on it and phlegm from the trach and the peroxide-sterile waster solution dripped onto the bare part of the resident's table. RN-E confirmed they had not sanitized Resident 58's overbed table after completing trach care had wiped the table with a dry paper towel and then placed the resident's breakfast (plate and drinks) on the overbed table. RN-E further confirmed they had washed their hands for less than 20 seconds. A record review of the facility's 5.6 Hand Hygiene with a revised date of 9/12/2017 revealed The LC ([NAME] Court) team will exercise proper hand hygiene technique to prevent the transmission of infectious agents. The Agency has adopted the CDC Hand Hygiene guidelines. LC has a continuing goal to improve compliance with the hand hygiene guidelines. The section, Procedure revealed Number 1) Hand hygiene is to occur after removing and disposing of gloves and other protective equipment; before handling invasive device for insertion; after contact with blood, body fluids, mucous membranes, non-intact skin, and wound dressings; and after contact with inanimate objects or medical equipment close to patient. 2) Procedure for hand hygiene with soap and water: Wet hands first, then apply soap. Using friction, rub hands together, cleaning under nails and between fingers thoroughly. Wash up to your wrists as well. Do this for 20 seconds. Rinse thoroughly without touching the inside of the sink or faucet as these are considered soiled. Leave the water running. Dry hands well with disposable towel. When finished, use a clean paper towel to turn off faucet. A record review of the facility's Respiratory System- Tracheostomy: Routine and Emegency Care with a copyright date of 2017, revealed the section titled Procedure. Number 1. Perform hand hygiene. Identify the patient according to agency policy. Explain procedure. Adhere to standard precautions. Assemble equipment. 5. Prepare equipment: a. Place a plastic trash bag near work site. b. Create a clean field for equipment by opening trach tray. 18. Clean reusable equipment. Wash hands.

LICENSURE REFERENCE NUMBER 175 NAC ,d+[DATE].05(9) Based on observation, interview, and record review; the facility failed to protect the facility residents from abuse by failing to provide supervision to prevent a resident with a history of abusing other residents, Resident 87, from abusing the facility residents. This affected 4 residents who were abused by Resident 87; (Resident 93, 154, 81, and 58) and had the potential to affect 9 residents who resided on the secure unit with Resident 87; (Residents 34, 80, 70, 95, 17, 98, 26, 9, and 54). This affected 13 of 17 residents reviewed. The facility identified a census of 100 at the time of survey. Findings are: A. -Review of Resident 17's Admission Record dated [DATE] revealed an admitted [DATE]. -Review of Resident 95's Admission Record dated [DATE] revealed an admitted [DATE]. -Review of Resident 98's Admission Record dated [DATE] revealed an admitted [DATE]. -Review of Resident 9's Admission Record dated [DATE] revealed an admitted [DATE]. -Review of Resident 26's Admission Record dated [DATE] revealed an admitted [DATE]. -Review of Resident 34's Admission Record dated [DATE] revealed an admitted [DATE]. -Review of Resident 54's Admission Record dated [DATE] revealed an admitted [DATE]. -Review of Resident 70's Admission Record dated [DATE] revealed an admitted [DATE]. -Review of Resident 80's Admission Record dated [DATE] revealed an admitted [DATE]. -Review of Resident 81's Admission Record dated [DATE] revealed an admitted [DATE]. B. Review of Resident 93's Admission Record dated [DATE] revealed an admitted [DATE]. Review of Resident 93's Progress Notes dated [DATE] revealed documentation Resident 93 was observed being grabbed by both arms by Resident 87. It was documented Resident 93 had new skin impairments: 0.5 cm (centimeter) x 0.5 cm abrasion to the right side of jaw, chin and on the right side on resident's neck and a 3 cm x 0.1 cm skin tear to back side of left hand. Review of the facility Investigation Report Physical Abuse dated [DATE] revealed Resident 93 was observed walking backwards out of Resident 93's room with their elbow bent and their hands up over their head, with Resident 87 holding both of Resident 93's wrists, directing Resident 93 backwards into the hallway. Resident 93 was noted to have an abrasion to the right side of neck and face, and a skin tear to the top of their left hand. C. Review of Resident 154's Admission Record revealed an admitted [DATE]. Resident 154 died in the facility on [DATE]. Review of Resident 154's Progress Notes revealed the following documentation: On [DATE] at 11:31 AM it was documented Resident 87 hit Resident 154 on their left eye and Resident 154 fell to the ground. At 1:12 PM the primary care provider was faxed with the following: Resident 154 was on the receiving end of a resident-to-resident altercation this morning and contact was made to Resident 154's left side of face. Has abrasion to left cheek, bruising to left eye, and hematoma to left eye lid. After the contact, resident had a witnessed fall to the floor. Has been refusing to open eyes for neuro assessments. On [DATE] at 1:15 PM it was documented a family member was here to visit Resident 154 and requested Resident 154 be sent to the ED (Emergency Department) for evaluation of their eye. At 1:34 PM it was documented Resident 154 had refused all neurological assessments (an assessment used to determine if there were any signs of brain damage). At 2:00 PM it was documented Resident 154 was taken to the emergency room at the local hospital. At 4:07 PM it was documented Resident 154 had a ruptured globe and was being transferred to a higher level of care at another hospital (globe rupture occurs when the integrity of the outer membranes of the eye is disrupted by blunt or penetrating trauma. Any full-thickness injury to the cornea, sclera, or both is considered an open globe injury and is approached in the same manner in the acute setting. Globe rupture is an ophthalmologic emergency and requires definitive management by an ophthalmologist. Although the globe's position within the orbit protects it from injury in many situations, damage to the posterior segment of the eye is associated with a very high frequency of permanent visual loss. Prompt recognition and ophthalmologic intervention are essential to maximizing functional outcome- Open globe injury (often referred to simply as an open globe) is the term for an eyeball injury where trauma has caused a full-thickness cut or defect in the wall of your eye. (This term comes from the fact that medical professionals often call the eyeball the globe.) Open globe injuries generally happen because of severe blunt or penetrating trauma to your eye. Various forms of open globe injury exist: Globe rupture (from blunt trauma). In all of these cases, a section of the eye wall is no longer intact, potentially allowing eye contents to extrude outside of the eye. The eye wall has two sections: the sclera and the cornea. The sclera is the white part of your eye. The cornea is the clear front portion. You have an open globe injury when a full-thickness cut goes through either the cornea or the sclera or through both of them). On [DATE] at 4:41 AM it was documented the nurse from the surgical hospital called to obtain more information on the incident. It was documented Resident 154 was in surgery. On [DATE] at 8:00 PM it was documented Resident 154 returned to the facility via stretcher from the hospital. On [DATE] at 11:37 PM it was documented from the hospital doctor notes that Resident 154 had an acute hemorrhage (bleeding) to the left optic globe (left eyeball) and overlying soft tissue injury was suspected and there was a rupture of the left globe with left periorbital (involves the area from the skin of the eyelid to the bony area that encloses the eye) hematoma (a localized swelling that is filled with blood caused by a break in the wall of a blood vessel). On [DATE] at 8:58 PM an Out of Character Response was documented: We continue to have a difficult time redirecting resident. Resident is not drinking well or eating well. Has increased confusion. This shift resident has refused all medication, when put in (gender) mouth (gender) spits it out, if medication is crushed resident will spit it out. Waiting on liquid Ativan from pharmacy for resident. Resident continues to need to be straight catheterization (a tube inserted into the bladder to drain urine) every 6 hours for no urine output. Urine is dark amber in color when obtained. On [DATE] at 11:52 AM it was documented Resident 154 had declined with all areas with ADLs (activities of daily living-walking, eating, dressing,bathing) needs more assistance, and had weight loss. On [DATE] at 10:32 PM it was documented Resident 154 was transferred to the hospital and returned to the facility at 9:27 AM on [DATE] related to altered mental status and complications with the Foley catheter (an tube placed and left in the bladder to drain urine). On [DATE] at 11:47 AM it was documented Resident 154 was unresponsive. On [DATE] at 12:47 PM it was documented the family elected to have hospice services (end of life services) provided. On [DATE] at 9:39 PM it was documented Resident 154 had no oral intake, Resident 154 would not open their eyes, and Resident 154 had less than 25 ml (milliliters) of bloody urine output. On [DATE] at 3:30 PM, it was documented Resident 154 had no signs of life and died in the facility. D. Observation of the secure unit in the facility on [DATE] at 12:50 PM revealed 6 residents were sitting in the dining room. Resident 87 was standing by Resident 81 who was seated at a table in the dining room. Resident 87 was telling Resident 81 to shut up several times as Resident 87 was poking Resident 81's right deltoid with Resident 87's right index finger. Resident 87 then walked back to their table and sat down. There were no staff in the dining room and no staff observed in the hall or the other areas of the unit. The dining room was immediately inside the locked entrance and the residential area. The entire hall was observed and there were no staff present. Observation of the dining room at 12:52 PM revealed Resident 81 continued to repeat you're a nice lady to the resident who was sitting across the table from them. Resident 87 got up from their dining room chair which was across from the table Resident 81 was sitting at, and walked over to Resident 81 and put their hand on Resident81's shoulder and pushed Resident 81's shoulder back and forth and told them to shut up. Resident 87 then called Resident 81 a stupid bitch to their face and said various profanities as Resident 87 walked back to their table and sat down. Observation of the hall outside Resident 54's door and across the hall revealed an unidentified visitor was sitting in a chair in the hall and reported the nurse and the aide were in taking Resident 54 to the bathroom. Observation of Resident 54's door revealed it was closed. Observation of the dining room at 12:55 PM revealed Resident 87 had gotten up from their chair again and had a paperback book in their hand and had walked over to Resident 81's table and in front of Resident 81, proceeded to slam the book on the table and tell Resident 81 to shut up in a loud and abrupt manner. Resident 81 continued to say you're a nice lady to their table mate. LPN-K (Licensed Practical Nurse) then opened the door and came out of Resident 54's room. When LPN-K was notified they needed to come to the dining room right away, LPN-K said, hold on, they needed to grab the tray cart which was parked outside Resident 54's door which was across the hall and 5 doors down from the dining room. When LPN-K was notified they were needed in the dining room immediately, LPN-K walked down the hall toward the dining room. As LPN-K walked to the dining room down the hall, Resident 87 was slamming the book down on the table in front of Resident 81 telling them to shut up several times. Resident 87 was agitated and was yelling shut up loudly. LPN-K stopped Resident 87 just as Resident 87 raised the book in the direction of Resident 81's face. LPN-K redirected Resident 87 back to their chair. Interview with LPN-K at 12:55 PM revealed there were not any staff to monitor the dining room, as it was just LPN-K and the aide MA-L (Medication Aide) on the unit and they had both been in Resident 54's room providing cares. LPN-K called the SSD (Social Services Director) and told them they needed to come back to the unit and LPN-K then called another staff person and told them they needed help back on the unit. Resident 87 was observed sitting in their chair at the dining room table as the SSD (Social Services Director), the FA (Facility Administrator), the DON (Director of Nursing), and LPN-N entered the unit then LPN-N sat down next to Resident 81 while Resident 81 finished eating their lunch. Review of the facility Investigation Reports of Physical Abuse revealed the following resident-to-resident altercations involving Resident 87: On [DATE], Resident 87 had a hold of Resident 93's arms and was pushing Resident 93 out of Resident 93's room. Resident 93 received injuries including abrasions to their right neck and face and a skin tear to their left hand. On [DATE], Resident 87 was observed twisting Resident 58's forearms. On [DATE], Resident 87 had closed Resident 58's door in their face as Resident 58 was standing in their own room. When Resident 58 attempted to leave their own room, Resident 87 grabbed Resident 58 by the arm. On [DATE], Resident 87 punched Resident 154 in the face. Resident 154 was transferred to the ED and was found to have a ruptured globe. Resident 154 was then transferred to another hospital for surgery. Resident 154 returned to the facility on [DATE]. Resident 154 was admitted to hospice care on [DATE] and died in the facility on [DATE]. Review of Resident 87's SCSA (Significant Change in Status) MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 13 which indicated Resident 87 was cognitively intact. Resident 87 was independent with transfer, walking in the room and corridor, and locomotion on the unit. Review of Resident 87's Quarterly MDS dated [DATE] revealed a BIMS score of 13. Physical and verbal behavioral symptoms directed toward others, rejection of care, and wandering occurred 1 to 3 days. Resident 87 was independent with transfers, walking in room and corridor, and locomotion on the unit. Review of Resident 87's Diagnoses included Alzheimer's Disease with late onset, dementia with agitation, and wandering. Review of Resident 87's Progress Noted dated [DATE] to [DATE] revealed the following documentation of altercations with other residents and staff: -[DATE] 10:16 PM Resident 87 walked out of their room and tried to go into another resident's room. Resident 87 did get a little agitated when the nurse tried to redirect the resident, but the resident did go to the bathroom. After the resident was done going to the bathroom the resident did come out of their room and did start having words with another resident. -[DATE] 12:50 PM Resident 87 was involved in a resident to resident with a (gender) resident. Resident 87 was picking up a Kleenex and the other resident hit the back of their hand with the back of their hand. The nurse was holding their hand and Resident 87 pointed a finger and called the other resident a b----. Redirected Resident 87 to a chair in the DR (dining room). -[DATE] 3:45 PM NA (Nursing Assistant) observed Resident 87 grab both arms of Resident 93. Resident 87 was pushing Resident 93 out into the hallway from Resident 93's room. -[DATE] 2:11 PM The nurse was notified that Resident 87 and Resident 58 were in the hallway and Resident 58 was yelling. Resident 87 had their hands on Resident 58's forearms and was twisting Resident 58's forearms. -[DATE] 12:08 AM Resident 58 was coming out of their room after going to the bathroom. Resident 87 was standing outside Resident 58's door attempting to shut the door as Resident 58 came out. Resident 58 said something to Resident 87, but the staff was unable to hear what was said. Resident 58 attempted to hit Resident 87 but missed them. Resident 58 started walking away from Resident 87 and Resident 87 started to say things to Resident 58. Resident 58 was walking away from Resident 87. Resident 87 grabbed a hold of Resident 58's right upper arm. -[DATE] 5:08 PM Resident 81 was talking to Resident 87. Resident 81 was repetitive. Resident 87 was heard saying why don't you shut your mouth, and Resident 87 did raise their hand. The nurse saw Resident 87 raise their hand and told Resident 87 not to hit Resident 81. -[DATE] 6:09 PM Resident 87 continued to sit at the table with Resident 81. Resident 81 has repetitive speech and Resident 87 tells 81 why don't you just shut up. Resident 87 was advised to not sit at same table as Resident 81 at which Resident 87 got upset and walked down hallway stating, I won't be here long anyway. -[DATE] 6:25 AM Resident 87 stated several times I'm going to kick a window out and leave and go home. Resident 87 did state open the door and let me go. Resident 87 paced the hallway throughout the shift trying to open the exit doors and push the keypad. -[DATE] 9:27 PM Resident 87 kept going into Resident 76's room and closed the door. Staff continued to redirect Resident 87 all of the time. -[DATE] 11:14 PM 10:00 PM Resident 87 opened the door to Resident 76's room. Resident 87 had been in there. Redirected Resident 87 that Resident 87 needed to leave door open. -[DATE] 9:34 PM Resident 87 getting agitated and angry toward another resident due to not understanding their words and continues repeating the same words. Resident 87 was also agitated towards staff too. -[DATE] 2:30 PM Resident 87 threatened two of the (gender) residents on the hall; Resident 87 threatened to knock them on their a** and was telling both (gender) residents to shut up. [DATE] 5:17 PM Resident 87 threatening to hit staff members for correcting behaviors towards two (gender) residents on the hall. Resident 87 stated to staff and both (gender) residents to just shut your mouths and threatened to knock {us} on your asses for correcting behavior. [DATE] 9:19 PM Resident 87 was threatening staff and one (gender) resident on the hall. Resident 87 threatened a staff member and another resident and said that they were going to knock them on their a** and that they were tired of all this sh*t. -[DATE] 8:27 PM There have been a total of four of these incidents: The nurse found Resident 87 in another resident's room with the door closed. The nurse suggested to keep the door open to ensure safety of both of the residents. Resident 87 got upset with the nurse and yelled Do whatever you want, but I will do whatever I want. You can't tell me what to do. The nurse encouraged the other resident out of the room since Resident 87 was adamant about staying in the room. This happened on four separate occasions (finding them in the same room, door closed, encouraged out, they got upset, and I escorted the other resident out of the room). After redirection, both residents were sitting in Resident 87's room; one is sitting in the recliner and the other was sitting on the bed. -[DATE] 3:30 PM Resident 87 was in another resident's room with the door closed. NA redirected resident to leave the door open per the safety of both the residents. Resident 87 got upset with staff, said do whatever the fuck you want and stormed off from the room. -[DATE] 6:54 PM Resident 87 attempted to enter the room of another (gender) resident while the (gender) resident was attempting to change. NA attempted redirection with resident, NA had said Resident 87, we can't go in there when (gender) is changing. Resident 87 had gotten upset with NA and said, You're a bitch and an asshole, you don't know anything and walked away mumbling under their breath. -[DATE] 9:20 PM Resident 87 became aggressive to NA on the floor. The NA had asked the resident if they had had a bowel movement-Resident 87 said it's none of your goddamn business. NA tried to explain the importance of knowing last known bowel movement, to which they responded, it's none of your fucking business, I don't care what the doctor says. Then resident stood up, cornered NA into the nurses' station corner, NA attempted to put a barrier between the resident and themselves and Resident 87 shoved that barrier towards the NA. Resident 87 cursed at the NA and NA de-escalated the situation by asking the resident to step away. They then walked back to their room. Resident 87 has become frequently more aggressive towards staff and other residents. -[DATE] 10:00 PM Resident 87 refused bath tonight and skin assessment. Resident 87 has been pacing up and down the hall. Resident refused all cares. Resident would cuss at aides when attempting cares for the resident. [DATE] 2:35 AM Resident 87 was wandering and going in and out of rooms. The nurse redirected resident. Resident got upset and said that these 2 are just assholes. Resident 87 then went into room [ROOM NUMBER] and took a water cup. They emptied the water into a trash can and then when walking by the nurse in the hall, threw the cup at the nurse. -[DATE] 8:22 PM Resident 87 was wandering the halls and required redirection. -[DATE] 8:33 PM Resident 87 was wandering the halls and was independent in ambulation. -[DATE] 9:44 PM Resident 87 has yelled at both the CNAs and the nurses during the shift. stated you don't know shit and you got something to fucking say to me--these were stated when nurse and aides attempted redirection after resident was wandering into another resident's room and upsetting them. -[DATE] 3:07 AM Resident 87 was up wandering the halls. Ambulates independently. -[DATE] 2:35 PM Resident 87 was sitting across the table from Resident 81. Resident 81 kept saying You are doing a good job. Resident 87 said, Shut up, shut up, shut up. -[DATE] 11:23 AM at 8:00 AM MA (Medication Aide) was entering nurses' station and heard Resident 87 state If you don't watch it, I will punch you to Resident 154. MA told Resident 87 to stop. Resident 87 contacted Resident 154 on the left side of Resident 154's face with their hand and Resident 154 fell to the ground. Resident 87 sat down in a chair near Resident 154. -[DATE] 6:13 PM Resident 87 wandering in halls at the time. Has expressed anger by yelling at other residents. Independent in their ambulation, requires redirection when wandering the halls. -[DATE] 2:13 AM Resident 87 is independent in ambulation. Requires redirection when with other residents. -[DATE] 10:00 PM Resident 87 has been wandering throughout shift. Resident 87 ambulates independently. Resident 87 refused cares from staff. -[DATE] 8:37 PM Resident 87 was found yelling at another resident If you don't stop repeating yourself, you're not going to get another chance to speak. -[DATE] 8:38 PM Resident 87 wandering the halls at the time. -[DATE] 7:02 PM Resident 87 refused a bath for the shift. Resident 87 was asked 3 times to take a bath and resident refused all three times. They became agitated with the NAs when they asked them if they would be willing to take a bath. Resident 87 refused for the nurse to check their skin, unable to do a skin check. Resident 87 became agitated when the nurse asked a second time if they could look at their skin. Unable to complete skin check. -[DATE] 9:27 PM Resident 87 was agitated and keep saying that they will hurt one of the other residents. -[DATE] 8:46 PM Resident 87 upset with two other residents on the same hall. They yelled at the first Resident to shut up and yelled at the second Resident to leave me the hell alone. Resident 87 wanders hallways independently, refuses to give back hoarded items in clothes (including forks, spoons, butterknives, napkins, masks, and Kleenex). Gets upset when asking if they need help or if we can have the items back. Gets upset when we ask to help them in getting them a snack instead of letting them roam through snack cabinet--tells the nurse to mind your business. -[DATE] 6:20 PM Resident 87 started to pace the floor as Resident 87 was trying to find the resident that was yelling. Resident 87 was pacing the dining room with clenched fists and said, Who the heck is yelling. Resident 87 was reassured that everyone is fine and that a resident was receiving a bath as Resident 87 tried to open the door to the spa room. -[DATE] 8:38 PM Resident 87 walked up to a resident in dining room and said, Shut up, I don't want to hear you anymore, shut up. -[DATE] 4:04 PM Resident 87 seemed agitated, they would pick up the cd on the table and kind of toss it across the table then they would glare at the other residents sitting at the table. -[DATE] 4:09 PM Resident 95 was sitting at table with Resident 87 reading paper out loud. Resident 87 stood up and told Resident 95 to knock it off and started to walk around the table toward Resident 95 and aide redirected Resident 87. Resident 95 walked to their room. -[DATE] 7:10 PM Resident 87 sat with another resident at the dining room table. Resident 87 told the other resident to shut the hell up when the other resident was attempting to converse with Resident 87. The nurse told Resident 87 to walk away if they did not want to converse with the other resident, to which Resident 87 told the nurse No, I don't have to listen to you. To which the nurse responded, If you're getting upset, it's best to remove yourself from the situation. to which Resident 87 replied you can kiss my ass and stormed off to their room. -[DATE] 3:57 PM Resident 87 has been aggressive toward staff whenever a bath and skin check has been mentioned. Swinging at staff, slamming closet doors shut. -[DATE] 4:10 PM Resident 87 was noted to be in hallway wandering; Resident 95 was also wandering in the hallway at the same time. Staff heard arguing between Residents 95 and 87. -[DATE] 12:40 PM Reported to the nurse that Resident 87 went over to Resident 81 and poked Resident 81 with their finger on their shoulder and told Resident 81 to shut up then put their open hand on Resident 81's shoulder and moved it back and forth and told Resident 81 to shut up. Then they sat back down and got back up with a magazine and slapped it on the table and called Resident 81 a Bit--. Observation of the secure unit in the facility on [DATE] at 4:22 PM revealed 2 staff were present on the unit. Interview with NA-J (Nursing Assistant) at that time revealed NA-J and MA-I (Medication Aide) were working on the unit. They said LPN-M was the nurse for the unit. NA-J said they did not usually work on that unit and they were a float (a staff person who works where needed in the facility and was not assigned to a designated unit). Observation of Resident 87 on [DATE] at 4:24 PM revealed Resident 87 was laying on their bed in their room. There were no staff supervising Resident 87 and no nurse was observed on the unit. Interview with MA-I at that time, who was observed standing in the hall outside the dining room area, revealed LPN-M was the nurse assigned to the unit and they had left the unit and were not present on the unit. MA-I verified they and NA-J were the only 2 staff on the unit at that time. NA-J was observed standing in the dining room and MA-I was standing in the hall on the unit with Resident 95. Resident 87 was not visible to either NA-J or MA-I. Resident 87's room was 4 doors down from the dining room toward the other end of the hall. At 4:26 PM, interview with MA-I revealed there were 3 residents residing on the unit who required the assistance of 2 staff: Resident 26, Resident 80, and Resident 54 as they were transferred with a lift and required 2 staff assist, which would leave no staff available to monitor Resident 87 when there were 2 staff on the unit assisting a resident who required the assistance of 2 staff. Observation of the secure unit on [DATE] at 4:25 PM revealed 10 residents were residing on the unit: Residents 87, 34, 80, 70, 95, 17, 98, 26, 9, and 54 which left 9 residents at risk for being abused by Resident 87 as Resident 87 had a history of abuse toward the other residents and was not being monitored. On [DATE] at 5:41 PM the DON (Director of Nursing) provided the Nursing Assignment sheets that had been requested to verify documentation of the number of staff that were assigned to the unit. Interview with the DON at that time revealed some of the assignment sheets missing as they were unable to locate them. Record review of the Nursing Assignment sheets for [DATE] to [DATE] revealed documentation 1 nurse and 1 aide were scheduled to work on the 6 AM to 2 PM shift on the unit; 1 nurse and 1 aide were scheduled to work on the 2 PM to 10 PM shift with 2 units sharing 1 nurse; and 1 aide was scheduled to work on the unit on the 10 PM to 6 AM shift which did not leave a staff person available to monitor Resident 87 if a resident requiring assistance of 2 staff required assistance on the 6 AM to 2 PM shift, or if any of the residents required assistance on the 2 PM to 10 PM shift or 10 PM to 6 AM shift as there was only 1 staff person scheduled on the unit at all times during those shifts. Interview with the FA (Facility Administrator) on [DATE] at 5:36 PM revealed Resident 87 was going to be placed on 1 on 1 (direct observation) monitoring until Resident 87 could have a behavioral health evaluation. The FA revealed they would probably have telehealth with the consultant psychiatrist as Resident 87 was already under their care. The FA revealed the facility staff would continue the one on ones until they can call the psychiatrist tomorrow and set up the appointment and will follow their recommendations from there. The FA revealed they will report when that appointment was and they will report what the psychiatrist recommendations are. The FA revealed the one to one direct observation was implemented at 5:36 PM, so the immediate jeopardy was abated and the citation was lowered to an H as resident harm had occurred. Interview with the DON on [DATE] at 5:36 PM revealed they would evaluate every 4 hours on how the one on ones were going for Resident 87. Interview with the FA on [DATE] at 11:04 AM revealed Resident 87's appointment with the psychiatrist via telehealth was scheduled for [DATE] and they would continue the one on one monitoring. Review of the facility policy Abuse and Neglect Prevention Standard dated ,d+[DATE] revealed the following: The facility team members will identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property was more likely to occur. All residents will be protected during an investigation. 41938 E. Record review of the Admission Record dated [DATE] for Resident 58 revealed that Resident 58 admitted into the facility on [DATE]. Diagnoses included Alzheimer's Disease, anxiety disorder, and depressive disorder. Record review of the progress note dated [DATE] at 12:50 PM revealed that an unidentified resident of the opposite sex was picking up a Kleenex and Resident 58 hit the back of the unidentified resident's hand. The unidentified resident pointed a finger at Resident 58 and called Resident 58 an offensive name. Record review of the progress note dated [DATE] at 9:15 PM revealed that staff heard Resident 58 screaming at an unidentified resident of the opposite sex. Resident 58 and the unidentified resident were wandering the hall. Staff intervened and separated the unidentified resident away from Resident 58. No injuries were found. Record review of the progress note dated [DATE] at 4:24 PM revealed that the nurse was notified that Resident 87 (a resident of the opposite sex from Resident 58) and Resident 58 were in the hallway with Resident 58 yelling at Resident 87. Resident 87 had their hands on Resident 58's forearms and was twisting Resident 58's forearms. The residents were separated. A skin assessment of Resident 58 revealed that Resident 58 had 5 new bruises. A 1-centimeter (cm) X 1cm bruise on the outside of the left forearm. A 1 cm x 1 cm bruise on the inside of the left forearm. A 0.5 cm x 0.5 cm bruise on the inside of the left forearm. A 2 cm x 2 cm bruise on the left wrist. A 1 cm x 1 cm bruise on the back of the left hand. Record review of the progress note dated [DATE] at 6:10 PM revealed that Resident 58 was coming out of their room. Resident 87 was standing outside of Resident 58's room door attempting to shut the door as Resident 58 came out. Resident 58 attempted to hit Resident 87 but missed. Resident 58 started walking away from Resident 87. Resident 87 started to say things to Resident 58. Resident 87 grabbed a hold of Resident 58's right upper arm. The staff was able to separate the residents. The nurse assessed Resident 58 and identified 2 small red areas that looked like fingernail marks on the inside of Resident 58's right bicep (the muscle of the upper arm). F. Interview with the FA (Facility Administrator) on [DATE] at 5:36 PM revealed Resident 87 was placed on 1 on 1 (direct observation) monitoring until Resident 87 could have a behavioral health evaluation. The FA revealed they would have telehealth with the consultant psychiatrist as Resident 87 was already under their care. The FA revealed the facility staff would continue the one on ones until they can call the psychiatrist and set up the appointment and will follow their recommendations from there. The FA revealed they will rep [TRUNCATED]

Licensure Reference Number 175NAC 12-006.04D2a Based on record review and interview, the facility failed to ensure that the Dietary Supervisor (Dietary Manager) was certified as a dietary manager to protect residents from the potential for foodborne illness. This affected all facility residents that received meals from the facility kitchen. The facility census was 100. Findings are: Record review of the Nebraska Food Code dated 7/21/16 section 2-102.11 revealed that based on the risks inherent to food operation the person in charge shall demonstrate knowledge of foodborne disease prevention. The person in charge shall demonstrate this knowledge by being a certified food protection manager (certified dietary manager/supervisor) who has shown proficiency of required information through passing a test that is part of an accredited program. Record review of the undated All Facility Staff List revealed that Dietary Manger (DM) was designated with the job title of Dietary Supervisor. Record review of the undated Personnel Review form (a listing of facility supervisory staff and any applicable license/certification numbers) completed by the facility revealed that the column for documenting the License number/Certificate number was blank for DM. Interview on 1/24/23 at 8:36 AM with the facility Director of Nursing (DON) confirmed that the Dietary Manager (DM) was not certified. Record review of the email sent by the Facility Administrator (FA) on 1/30/23 at 11:09 AM revealed that the DM would be testing for the Certified Dietary Manager (CDM) certification next month.