Every finding on record at Mid-Nebraska Lutheran Home

Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to report, to investigate and then to submit the results of the investigation to the required state agency, an allegation of potential neglect for 1 (Resident 3) of 3 sampled residents. The facility census was 35.Findings are: A. Review of the facility Abuse and Neglect Policy and Procedure with a reviewed date of 8/19/24 revealed the facility would not condone any forms of resident abuse or neglect. To prevent abuse, all personnel were to report any signs and symptoms of abuse/neglect to their supervisor or the Director of Nursing (DON) immediately. The following procedure was identified related to notification: -stop the abuse.-contact the Charge Nurse and notify of the abuse.-the Charge Nurse was then responsible for reporting to the DON, the Social Service Director (SSD) and the Administrator immediately.-the DON, Administrator and/or the SSD were to follow through with the investigation and reporting process as well as follow up with the staff who made the report. -allegations were to be reported to the Adult Protective Services (APS). All suspected violations and all substantiated incidents of abuse were to be immediately reported to the appropriate agencies and other entities or individuals as may be required by law. The following procedure interpretation and implementation were identified:1. Should a suspected violation or substantiated incident of mistreatment, neglect, injury of unknown origin, or abuse be reported, the facility Administrator, or his/her designee, would follow the steps described then promptly notify the following persons or agencies of such an incident: -the State licensing/certification agency responsible for surveying/licensing the facility.-the local state Ombudsman.-the resident's representative.-APS.-the resident's Primary Care Physician (PCP). -the Medical Director.2. Notices to agencies were to be made as soon as possible with the maximum notification within 24 hours of the occurrence of such an incident. If actual harm has occurred, the police and APS must be notified within 2 hours of the event. Notices were to include:-the name of the resident.-the room number of the resident.-the type of abuse that was committed with details of the incident.-the date and time the alleged incident occurred.-where the incident occurred.-effect of the incident on the resident or their reaction to the incident.-the name of all persons involved in the alleged incident.-the immediate action taken by the facility. The Administrator, or his/her designee were to provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within 5 working days of the incident. B. Review of Resident 3's Minimum Data Set (MDS-a federally mandated assessment tool used for care planning) dated 3/27/26 revealed diagnoses of non-traumatic brain dysfunction, Alzheimer's disease with late onset, high blood pressure, end stage renal disease, Non-Alzheimer's dementia, anxiety, and psychotic disorder. The facility assessed the following regarding the resident:-impaired cognition.-behaviors which included rejection of cares.-required partial to moderate assistance with toileting and dressing.-one fall without injury since the previous assessment. Review of the residents' current Care Plan with a revision date of 4/29/26 revealed the resident was admitted to the Memory Care Unit (dedicated area with structured routines, specialized staff and a secure environment for residents who require continuous supervision) on 9/29/25 due to wandering, verbal behaviors directed at others and rejection of cares. Review of Resident 3's Nursing Progress Notes dated 5/9/26 at 11:45 PM revealed a Police Officer was at the facility on a complaint of neglect. The police had received a report that the resident was locked in their room. Review of Facility Investigations of potential abuse/neglect and misappropriation from 11/17/25 to 5/13/25 revealed no evidence the allegation of neglect was reported to the State Agency or that an investigation had been completed of the allegation. During an interview on 5/13/26 at 2:00 PM, the Administrator confirmed the following:-a Police Officer came to the facility on 5/3/26 at 11:45 PM to investigate an allegation of neglect regarding Resident 3.-the police did not substantiate the allegation.-the facility failed to investigate and to report the allegation and then failed to submit the results of the investigation to the State Agency as requiresd

License Reference Number: 175 NAC 12-006.18(A)Based on record review and interviews; the facility failed to offer and/or provide the influenza vaccine to Resident 14 and to ensure Residents 11 and 22 were offered and/or provided the pneumococcal vaccine and the residents were educated about the risks and benefits associated with the vaccines. The sample size was 5 and the facility census was 30. Findings are:A. Review of the undated facility policy Pneumococcal Vaccine revealed the receipt of vaccinations was essential for the prevention of pneumonia/pneumococcal infections. The following procedures were identified:-residents were to be screened prior to or upon admission to determine vaccine eligibility and then offered the vaccine series within 30 days of admission.-before offering the vaccine each resident and/or their representative were to receive education regarding the benefits and potential side effects of the immunizations. Information related to education or refusal of the vaccine was to be documented in the resident's medical record.-the vaccine was to be administered to residents per the facility's physician-approved vaccination protocol.-if refused, appropriate information was to be documented in the resident's medical record indicating the date of refusal.-for each resident who received the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination were to be documented in the resident's medical record.B. Review of Resident 11's electronic medical record revealed the resident was admitted on [DATE]. Review of a Prevnar 20 Consent Form and Administration Record dated 4/28/25 (2 months later) revealed the resident's representative had documented acceptance of the vaccine for the resident. Further review revealed no evidence the resident had received the pneumococcal vaccine. C. Review of Resident 22's electronic medical record revealed the resident was admitted [DATE]. There was no evidence the facility had screened Resident 22 to determine the resident's vaccination status, education was provided regarding the risks and benefits associated with the pneumococcal vaccine, or the resident was offered and/or received the vaccine. D. Review of the undated Influenza Vaccine policy revealed all residents were to be offered the vaccine unless medically contraindicated on an annual basis. The facility was to provide pertinent information about the significant risks and benefits of the vaccine to the residents and their representative. The following procedure was identified:-between 10/1 and 3/31 each year, the influenza vaccine was to be offered unless medically contraindicated or the resident had already been immunized.-prior to the vaccination, the resident and/or their representative would be provided information and education regarding the benefits and potential side effects.-provision of the education was to be documented in the resident's medical record. -for those who received the vaccination, staff were to document the date of vaccination, lot number, expiration date, the person administering, and the site of the vaccination in the resident's medical record.-a resident/representative refusal was to be documented on the informed consent for the influenza vaccine. E. Review of Resident 14's electronic medical record revealed the resident was admitted [DATE]. These was no evidence the resident was provided education regarding risks and benefits of the influenza vaccine, or the resident was offered and/or received the vaccine. F. During an interview on 9/23/25 at 8:49 AM, the Infection Preventionist confirmed the following:-Resident 11 was admitted [DATE] but was not provided education regarding the Prevnar 20 vaccine until 4/28/25. The resident's representative signed a consent on 4/28/25 however, the facility failed to provide the pneumococcal vaccine. -Resident 22 was admitted [DATE] but there was no evidence the resident was provided education regarding the risks and benefits of the pneumococcal vaccine or that the vaccine was offered and/or provided to the resident.-Resident 14 was admitted [DATE] and there was no evidence the resident was provided information regarding the risks and the benefits of the influenza vaccine or was offered and/or provided the vaccine.

Number of residents sampled: 5Number of residents cited:4 Licensure Reference Number 175 NAC 12-006.12Based on record review and interview; the facility failed to have signed informed consent in advance for the use of psychotropic medications (medications which alter consciousness, mood and thoughts) for Residents 1, 2, 11, and 21. The sample size was 5 and the facility census was 30. Findings are:A. Review of the facility policy Psychotropic Medication Use dated 7/2022 revealed the following: -residents wound not receive medications that were not clinically indicated to treat a specific condition, -psychotic medications were subject to prescribing, monitoring, and review requirements that were specific to psychotropic medications, -residents would not be given these medications unless the medication was determined to be necessary to treat a specific condition that was diagnosed and documented in the medical record, and - residents and/or representatives were educated on the risks related to not taking the medications as well as appropriate alternatives. B. Review of Resident 11's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) dated 8/22/25 revealed the resident was admitted [DATE]; had severe cognitive impairment; had behaviors of hallucinations, delusions, verbal behaviors, and wandering; received assistance with dressing and supervision with toileting and hygiene; had diagnoses of Non-Traumatic Brain Dysfunction, Dementia, Parkinson's Disease, Anxiety, and Depression; and received anti-anxiety, anti-psychotic, and anti-depressant medications. Review of Resident 11's Care Plan with a revision date of 9/6/25 revealed the resident received psychotropic medications for behavior management; behaviors included delusion, grabbing, wandering, rejection of care, physical aggression, agitation, and anxiety; and the resident required supervision and/or cueing assistance with hygiene and toileting. Review of Resident 11's Medication Administration Records (MAR's) revealed the following orders: -an increase of Fluoxetine (an anti-depressant medication) started 4/13/25, -an order of for Lorazepam (an anti-anxiety medication) started 5/13/25 -an increase in Seroquel (an anti-psychotic medication) started 6/13/25, and -an order for Depakote (a psychotropic medication) started 6/17/25. Review of the facility forms Psychoactive Medication Informed Consent regarding Resident 11 revealed the consents were signed on 7/3/25 for the following medications: -Fluoxetine 82 days after the start of the medication, -Lorazepam 52 days after the start of the medication, -Seroquel 21 days after the start of the medication, and -Depakote 17 days after the start of the medication. Interview on 9/22/25 at 2:15 PM with the MDS Coordinator confirmed there was no evidence the consents for psychotropic medications for Resident 11 were obtained prior to the administration of the psychotropic medications. C. Review of Resident 21's MDS dated [DATE] revealed the resident was admitted [DATE]; had severe cognitive impairment; had physical behaviors, verbal behaviors, and rejected care; required assistance with toileting, dressing, transfers, and hygiene; had diagnoses of Dementia, Anxiety, and Depression; and received anti-psychotic, anti-anxiety, and anti-depressant medications. Review of Resident 21's Care Plan last revised 8/4/25 revealed the resident received psychotropic medications for behavior management; behaviors included hitting, kicking, wandering, physical aggression, resistance to cares, delusions, agitation, and anxiety; and the resident was dependent on staff for transfers, toileting, dressing, and hygiene. Review of Resident 21's MAR revealed the following: -an order for Venlafaxine (an anti-depressant) started 12/30/24, -an order for Buspar (an anti-anxiety medication) started 3/5/25, and -an order for Seroquel started 4/12/25. Review of the facility forms Psychoactive Medication Informed Consent regarding Resident 21 revealed the following: -Venlafaxine signed 2/6/25 which was 39 days after the start of the medication, -Buspar signed 5/21/25 which was 78 days after the start of the medication, and -Seroquel signed 5/21/25 which was 40 days after the start of the medication. Interview on 9/22/25 at 2:15 PM with the MDS Coordinator confirmed there was no evidence the consents for psychotropic medications for Resident 21 were obtained prior to the administration of the psychotropic medications. D. Review of Resident 1's MDS dated [DATE] revealed the resident was admitted on [DATE]; had severe cognitive impairment; received assistance with dressing, bathing, toileting and standing up and ambulating; had diagnosis of Stroke, Cancer and Depression; and received an antidepressant medication. Review of Resident 1's Care Plan with a revision date of 7/23/25 revealed the resident received psychotropic medication for depression; resident can be demanding and made negative statements; resident ambulates with 1 assist and walker, 1 assist with dressing upper and lower extremities, bathing and toileting cares. Review of Resident 1's Medication Administration Record (MAR) revealed the following order: -an increase in Sertraline (an anti-depressant medication) started 4/13/25. Review of the facility forms Psychoactive Medication Informed Consent regarding Resident 1 revealed the consent was signed by the Resident Representative on 5/27/25, 44 days after the start of the medication. Interview on 9/22/25 at 8:30 AM with the MDS Coordinator confirmed the consent for psychotropic medication for the increase in Sertraline on 4/13/25 was obtained after the medication was started. E. Review of Resident 2's MDS dated [DATE] revealed the resident was admitted on [DATE]; thinking and memory were normal; resident had physical and verbal behaviors; received assistance with bathing and supervision with toileting hygiene; had diagnosis of Anxiety, Depression and Bipolar Disorder; received an antianxiety and antidepressant medication. Review of Resident 2's Care Plan with a revision date of 8/26/25 revealed the resident received psychotropic medications related to bipolar disorder, mild cognitive impairment, depression and non-compliance with other medical treatment and regimen; behaviors included negativity, repetitive health concerns, repetitive statements, anger, delusions, demanding, yelling, hitting, kicking, grabbing, wandering, abusive language, threatening behavior, rejected cares, throwing items, crying, refusing medications; and the resident received 1 assist with bathing and was supervised with toileting cares. Review of Resident 2's MAR revealed the following: -a decrease in Buspirone (an anti-anxiety medication) started 5/22/25. -a decrease to Trazadone (an anti-depressant medication) started 8/7/25. -an increased to Sertraline (an anti-depressant) started 6/11/27. Review of the facility forms Psychoactive Medication Informed Consent regarding Resident 2 revealed the following: -Buspirone signed 8/26/25 which was 96 days after the start of the medication, -Trazadone signed 8/26/25 which was 19 days after the start of the medication, -Sertraline did not have a Psychoactive Medication Informed Consent signed. An interview on 9/23/25 at 9:20 AM with the MDS Coordinator confirmed the consent for psychotropic medication for the change in dosage for Buspirone and Trazadone was obtained after the medication was started and there was not a consent for psychotropic medication form signed for Sertraline.

Licensure Reference Number 175 NAC 12-006.02(H)Based on observation, record review and interview; the facility failed to complete an investigation and report the results of the investigation to the State Agency for an injury of unknown origin for 1 (Resident 8) of 2 sampled residents. The facility census was 30.Findings are:A. Review of the facility policy Reporting Abuse to State Agencies and other Entities/Individuals dated 12/1/2017 revealed all suspected violations and all substantiated incidents of mistreatment, neglect, injuries of an unknown source or abuse were to be reported to the Administrator or their designee. In addition, the following agencies or persons were to be notified of the incident:-the State licensing/certification agency.-the ombudsman.-the resident's representative.-Adult Protective Services (APS). -the resident's physician. Notices to the agencies were to be made as soon as possible with the maximum notification within 24 hours and if actual harm, APS was to be notified within 2 hours. The Administrator or designee were to then complete an investigation and then send the results of the investigation to the appropriate agencies within 5 working days. B. Review of Resident 8's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 6/27/25 revealed the resident was admitted on [DATE]; had severe cognitive impairment; was dependent on staff for toileting cares, bathing cares, upper and lower extremity dressing, repositioning in bed, moving from bed to chair and from chair to bed and all wheel chair mobility; had physical behaviors and other behavioral symptoms not directed at others (hitting or scratching self); had diagnosis of Non-Alzheimer Dementia (a progressive decline in cognition ability that is not caused by Alzheimer's Disease) and Psychotic Disorder. Review of a Nursing Progress Note dated 9/16/25 at 4:01 PM revealed the physician was notified of yellow bruising to the top of the right foot that measured 15 centimeters (cm) by 13 cm with minimal swelling and purple and yellow bruising to the bottom of the right foot that measured 9 cm by 7 cm with minimal swelling noted. Review of the investigation completed by the facility on 9/17/25 revealed the staff determined the resident's foot had potentially bumped into the mechanical lift during a transfer. Further review revealed no staff were interviewed regarding the use of the mechanical lift for the resident or an evaluation was not completed to ensure the staff were transferring the resident safely. An observation on 9/18/25 at 10:35 AM revealed that the resident had yellow bruising to the top of the right foot and the bottom of the foot had yellow/purple bruising with minimal swelling to foot. Resident had no response when asked if the right foot hurt. An interview on 9/22/25 at 1:00 PM with the Director of Nursing and Administrator confirmed that the bruising and swelling to Resident 8's right foot was an injury of unknown origin and that staff failed to complete a thorough investigation to determine the cause of the resident's bruising and swelling to the right foot and no investigation was sent to the Agency.

Licensure Reference Number 175 NAC 12-006.02(H)Based on observation, record review and interview; the facility failed to report an injury of unknown origin for 1 (Resident 8) of 2 sampled residents. The facility census was 30.Findings are:A. Review of the facility policy Reporting Abuse to State Agencies and other Entities/Individuals dated 12/1/2017 revealed all suspected violations and all substantiated incidents of mistreatment, neglect, injuries of an unknown source or abuse were to be reported to the Administrator or their designee. In addition, the following agencies or persons were to be notified of the incident:-the State licensing/certification agency.-the ombudsman.-the resident's representative.-Adult Protective Services (APS). -the resident's physician. Notices to the agencies were to be made as soon as possible with the maximum notification within 24 hours and if actual harm, APS was to be notified within 2 hours. The Administrator or designee were to then complete an investigation and then send the results of the investigation to the appropriate agencies within 5 working days. B. Review of Resident 8's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 6/27/25 revealed the resident was admitted on [DATE]; had severe cognitive impairment; was dependent on staff for toileting cares, bathing cares, upper and lower extremity dressing, repositioning in bed, moving from bed to chair and from chair to bed and all wheel chair mobility; had physical behaviors and other behavioral symptoms not directed at others (hitting or scratching self); had diagnosis of Non-Alzheimer Dementia (a progressive decline in cognition ability that is not caused by Alzheimer's Disease) and Psychotic Disorder. Review of a Nursing Progress Note dated 9/16/25 at 4:01PM revealed the physician was notified of yellow bruising to the top of the right foot that measured 15 centimeters (cm) by 13 cm with minimal swelling and purple and yellow bruising to the bottom of the right foot that measured 9 cm by 7 cm with minimal swelling noted. An observation on 9/18/25 at 10:35 AM revealed that the resident had yellow bruising to the top of the right foot and the bottom of the foot had yellow/purple bruising with minimal swelling to foot. Resident had no response when asked if the right foot hurt. An interview on 9/22/25 at 1:00 PM with the Director of Nursing confirmed the following:-The staff did not witness the incident which had caused the injury to Resident 8's right foot.-The facility should have reported the significant bruising and swelling to the resident's right foot as an injury of unknown to the State Agency, and -the facility failed to report the injury.

Licensure Reference Number 175 NAC 12-006.09Based on observation, record review and interview; the facility failed to identify a change of condition for 1 (Resident 1) of 1 sampled resident. The facility census was 30. Findings are: A. Review of the facility policy Change in a Resident's Condition or Status with a revision date of 8/11 revealed it was the policy of the facility to promptly notify the resident, their physician, and their responsible party of changes in the resident's medical/mental condition and/or status. A significant change of condition was identified as a decline or an improvement in the resident's status that:-would not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions.-impacts more than one area of the resident's health status.-requires interdisciplinary review and/or revision to the care plan. The policy further revealed the resident's physician was to be notified when there had been:-an incident/accident involving the resident.-a discovery of an injury of unknown source.-a significant change in the resident's physical/emotional/mental condition.-a need to alter the resident's medical treatment significantly. -a need to transfer the resident to a hospital or treatment center. Except in medical emergencies, notifications were to be made within 24 hours of a change occurring in the resident's status. In addition, the Charge Nurse was to document in the resident's medical record information related to the change on the resident's condition or status. B. Review of Resident 1's Care Plan revised 7/23/25 revealed the resident had a history of pneumonia and coughing with fluids (when drank liquids). Observation on 9/18/25 revealed the following:-At 9:25 AM the resident was sitting in recliner with feet elevated. Licensed Practical Nurse (LPN)-E administered oral medications to Resident 1. Resident began coughing forcefully and complaining of increased shortness of breath. LPN-E had resident take swallows of water to get the medications swallowed. -At 11:05 AM staff assisted resident to the bathroom, resident ambulated with walker and with 1 staff member without difficulty. Resident continued to cough.-At 12:10 PM the resident was sitting in the dining room eating noon meal, took bites of food and sips of water without difficulty.-At 1:15 PM the resident sat in the dining room at an activity, refused to drink water when offered, reported being afraid of coughing or choking on the water. Resident stated not liking thick liquids and would refuse to drink if that's what the staff would do. -At 2:45 PM the resident was sitting in recliner in resident's room, cough noted. Review of Nurses Notes on 9/23/25 at 7:30 AM revealed the following:-No documentation of Resident's 1 coughing on 9/18/25 had been documented in the chart.-On 9/20/25 at 12:34 AM the resident had a productive cough with thick white phlegm. Temperature was 98.8, oxygen saturation was 94%. Lung sounds had wheezes in the lower right lung field.-On 9/20/25 at 3:49 AM resident continued to have productive cough, coughing up yellow/green phlegm. -On 9/20/25 at 11:20 AM resident was weak and leaning when sat on the edge of the bed. Temperature was 98.0, respirations were 20, blood pressure was 98/58 and oxygen level was 92%. Lung sounds were diminished with an occasional productive cough. A nurse called the clinic for the resident to be seen. The Director of Nursing was notified. Son was notified that the resident was going to the clinic. The nurse was notified that the resident was being admitted to [NAME] County Hospital with a diagnosis of pneumonia. An interview on 9/22/25 at 10:30AM with the Director of Nursing confirmed that there was no documentation completed on 9/18/25 that resident had a cough after taking morning medications. There were no vital signs, respiratory assessment or oxygen levels charted on 9/18/25 or 9/19/25. The nurses should have been completing vital signs, lung sounds and oxygen levels on 9/18/25 and 9/19/25. The physician was not notified of the residents cough and should have been.

Licensure Reference Number 175 NAC 12-006.05Based on record review and interview; the facility failed to ensure Resident 21 had a resident specific rationale as to why a Gradual Dose Reduction (GDR) was not attempted for psychotropic medications (medications which alter consciousness, mood and thoughts). The sample size was 5 and the facility census was 30. Findings are:Review of the facility policy Psychotropic Medication Use dated 7/2022 revealed the following: -residents would not receive medications that were not clinically indicated to treat a specific condition,-psychotic medications were subject to prescribing, monitoring, and review requirements that were specific to psychotropic medications,-residents would not be given these medications unless the medication was determined to be necessary to treat a specific condition that was diagnosed and documented in the medical record, and-residents on psychotropic medications would receive GDR's (gradual dose reduction) unless contraindicated in an effort to discontinue these medications, -if psychotropic medications were identified as possibly causing or contributing to adverse effects, the prescriber would determine whether the medication should be continued and would document the rationale, and- residents and/or representatives were educated on the risks related to not taking the medications as well as appropriate alternatives. Review of Resident 21's Minimum Data Set (MDS- a federally mandated assessment tool used in care planning) dated 7/18/25 revealed the resident was admitted [DATE]; had severe cognitive impairment; had physical behaviors, verbal behaviors, and rejected care; required assistance with toileting, dressing, transfers, and hygiene; had diagnoses of Dementia, Anxiety, and Depression; and received anti-psychotic, anti-anxiety, and anti-depressant medications. Review of Resident 21's Care Plan last revised 8/4/25 revealed the resident received psychotropic medications for behavior management; behaviors included hitting, kicking, wandering, physical aggression, resistance to cares, delusions, agitation, and anxiety; and the resident was dependent on staff for transfers, toileting, dressing, and hygiene. Review of the facility form Order Summary Report for Resident 21 revealed the resident had active orders for Venlafaxine (an antidepressant medication and Divalproex ER (a psychotropic medication). Review of the facility form facsimile (fax) to the prescriber regarding Resident 21 revealed on 2/5/25 a GDR for Divalproex ER was sent and was contraindicated for a dose reduction. There was no documentation for a resident specific rationale. Review of the facility form fax to the prescriber for Resident 21 dated 5/21/25 revealed a GDR for Venlafaxine was contraindicated for a dose reduction. There was no documentation for a resident specific rationale. An interview on 9/23/25 at 2:15 PM with the MDS Coordinator confirmed there was no resident evidence of a specific rationale documented for the contraindication of a dose reduction for the Venlafaxine and the Divalproex ER.

Licensure Reference Number 175 NAC 12-006.18Based on observation, record review and interview; the facility failed to wash hands and change gloves at appropriate intervals during the preparation of medication for administration for Resident 9. The facility census was 30.Findings are:A. Review of the facility's undated Medication Administration policy revealed the following regarding medication handling and administration procedure:-staff were to wash hands prior to beginning medication administration.-oral medications in pill/gel/capsule form in bottles were to be put in medication cups or plastic cups prior to administration and not placed in a gloved hand. B. Review of Resident 9's Medication Review Report dated 8/8/25 revealed the following medications:-Mega (gender) Sport Multivitamin 1 tablet by mouth daily in the morning and -L-Methylfolate Oral Capsule (nutritional supplement for folate deficiency) 15 milligrams by mouth in the morning. C. An observation on 9/18/25 at 8:10 AM revealed the following:-Licensed Practical Nurse (LPN)-E walked up to the medication cart, did not wash hands or use hand sanitizer and put on a pair of disposable gloves. -LPN-E touched the mouse to the computer, pulled the medication cart drawer open with gloved hands, picked up the multivitamin pill bottle and poured a pill out of the bottle into gloved hand, picked up a medication cup and placed the pill into the cup. -LPN-E touched the mouse to the computer and documented the pill was ready to administer. -The bottle of multivitamin was put back into the medication cart and the drawer to the medication was closed using the gloved hand. -LPN-E touched the mouse to the computer with gloved hand, opened the drawer to the medication cart, picked up the bottle of L-Methylfolate and poured a pill out of the bottle into gloved hand, picked up the medication cup and placed the pill into the cup. C. An interview on 9/22/25 at 3:05 PM with the Director of Nursing confirmed that staff were to wash hands before administering medications and medications should not be placed in gloved hands, and the pills should be poured directly into a medication cup.

License Reference Number: 175 NAC 12-006.18(A)Based on record review and interviews; the facility failed to provide evidence 2 (Residents 11 and 22) of 5 sampled residents were offered the COVID-19 vaccine and/or were educated about the risks and benefits associated with the vaccine. The facility census was 30. Findings are:A. Review of the facility policy Coronavirus (COVID-19) Vaccination of Residents dated 2/21 revealed the policy was based on the Center for Disease Control (CDC) recommendations for infection prevention and control practices for COVID-19. The following procedures were identified: -residents were to be screened at admission to determine vaccine status and eligibility to receive the COVID-19 vaccine.-before offering the vaccine each resident and/or their representative were to receive education regarding the benefits and potential side effects of the immunizations. Information related to education or refusal of the vaccine was to be documented in the resident's medical record. -the vaccine could be offered and administered if the benefits of the vaccine outweighed the risks, the resident or the resident's representative provided consent and the resident's physician approved. -individual resident information was to be documented in the resident's electronic medical health record. B. Review of Resident 11's electronic medical record revealed the resident was admitted on [DATE]. Review of a COVID-19 Consent Form and Administration Record dated 4/28/25 (2 months later) revealed the resident's representative had documented acceptance of the vaccine for the resident. Further review revealed no evidence the resident had received the COVID-19 vaccine. C. Review of Resident 22's electronic medical record revealed the resident was admitted [DATE]. There was no evidence the facility had screened Resident 22 to determine the resident's vaccination status, education was provided regarding the risks and benefits associated with the COVID-19 vaccine, or the resident was offered and/or received the vaccine. D. During an interview on 9/23/25 at 8:49 AM, the Infection Preventionist confirmed the following:-Resident 11 was admitted [DATE] but was not provided education regarding the COVID-19 vaccine until 4/28/25. The resident's representative signed a consent on 4/28/25 however, the facility failed to provide the COVID-19 vaccine. -Resident 22 was admitted [DATE] but there was no evidence the resident was provided education regarding the risks and benefits of the COVID-19 vaccine or that the vaccine was offered and/or provided to the resident.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on record review and interviews; the facility failed to notify Resident 1's Primary Care Practitioner of changes in the resident's condition related to behaviors, increased confusion, and back pain. The sample size was 5 and the facility census was 30. Findings are: A record review of the undated facility policy Change in a Resident's Condition or Status revealed the following; -the facility promptly notified the resident, the attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status, -the nurse would notify the resident's attending physician or on-call physician when there had been, accident/incidents involving the resident, injuries or unknown source, adverse reactions to medications, a significant change in the resident's condition, a need to significantly alter the resident's medical treatment, refusal of medication or treatments 2 or more consecutive times, or a need to transfer or discharge the resident, -prior to notifying the physician the facility nurse would make detailed observations and gather relevant and pertinent information for the provider, -except in emergencies notifications would be made within 24 hours of a condition change, and -a nurse would record in the resident's medical record information relative to the change in the resident's condition. A record review of Resident 1's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 3/21/25, revealed the resident was admitted with diagnoses of cancer, anemia, dementia, seizure disorder, anxiety, depression, and psychotic disorder. The following was assessed for Resident 1: -moderate cognitive impairment. -behaviors which included rejection of cares and verbal behaviors directed toward others. -required staff assistance with transfers, bed mobility, dressing, toileting, and personal hygiene. -frequently incontinent of urine. -one fall without injury since previous assessment. A record review of Resident 1's Nursing Progress Notes revealed the following: -4/7/25 at 5:17 AM the resident had a fall at 4:30 AM outside of the resident's bathroom. The resident had been incontinent of urine and had a 2 centimeter (cm) superficial cut to the back of the resident's head. The resident was complaining of back pain which the resident had rated at an 8 out of 10. -4/7/25 at 7:06 PM the resident continued to complain of back pain with little relief from the as needed Tramadol (medication used to treat pain). -4/7/25 at 5:10 PM the resident was having lower back pain and had a headache. The resident received Ultram (medication used to treat pain) 50 milligrams (mg). -4/7/25 at 6:53 PM the resident's pain was a 7 out of 10 and the Ultram given at 5:10 PM was ineffective. The resident was also complaining of neck pain. -4/10/25 at 11:42 AM the resident was complaining of back pain and was unable to turn in bed without yelling in pain. -4/11/25 at 9:05 AM (4 days after the resident's fall) the resident was found slumped in the recliner. The resident was lethargic and unable to follow simple commands. The resident's pupils were fixed and did not respond to light. -4/11/25 at 9:07 AM the resident had a dark purple bruise on the back of the resident's head. -4/11/25 at 9:34 AM the resident was transferred by ambulance to the Emergency Room. -4/11/25 at 1:01 PM the resident was transferred to a hospital in Omaha due to a brain bleed. During an interview on 4/24/25 at 2:00 PM, the Director of Nursing (DON) confirmed the resident had a history of falls with the resident's last fall happening on 4/7/25 at 4:30 AM. The resident also had a history of moderate back pain.After the resident's fall on 4/7/25, the resident had increasing pain to the resident's back. A record review of Resident 1's medical records revealed no evidence that the facility staff had notified the resident's PCP of the resident's complaints of increased back pain until 4/11/25 (4 days after the resident's fall) when the resident was hospitalized .

Licensure Reference Number 175 NAC 12-006.09D Based on record review and interviews; the facility failed to monitor and to assess Resident 1 for a change of condition after a fall with injury. The sample size was 4 and the facility census was 30. Findings are: A record review of the undated facility policy Change in a Resident's Condition or Status revealed the following; -the facility promptly notified the resident, the attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status, -the nurse would notify the resident's attending physician or on-call physician when there had been, accident/incidents involving the resident, injuries or unknown source, adverse reactions to medications, a significant change in the resident's condition, a need to significantly alter the resident's medical treatment, refusal of medication or treatments 2 or more consecutive times, or a need to transfer or discharge the resident, -prior to notifying the physician the facility nurse would make detailed observations and gather relevant and pertinent information for the provider, -except in emergencies notifications would be made within 24 hours of a condition change, and -a nurse would record in the resident's medical record information relative to the change in the resident's condition. A record review of Resident 1's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) dated 3/21/25, revealed the resident was admitted with diagnoses of cancer, anemia, dementia, seizure disorder, anxiety, depression and psychotic disorder. The following was assessed for Resident 1: -moderate cognitive impairment. -behaviors which included rejection of cares and verbal behaviors directed toward others. -required staff assistance with transfers, bed mobility, dressing, toileting and personal hygiene. -frequently incontinent of urine. -one fall without injury since previous assessment. A record review of Resident 1's Nursing Progress Notes revealed the following: -3/18/25 at 10:52 AM the resident was alert and oriented to self with periods of confusion. Resident 1 had increased weakness and required 2 staff to assist with transfers. -3/19/25 at 1:51 PM the resident was alert and oriented with periods of confusion. -3/27/25 at 2:15 PM the resident was found lying on their right side on the floor of the resident's room. The note indicated the resident had ongoing issues with back pain. -4/7/25 at 5:17 AM the resident had a fall at 4:30 AM outside of the resident's bathroom. The resident had been incontinent of urine, had a 2 centimeter (cm) superficial cut to the back of the resident's head. The resident was complaining of back pain which the resident had rated at an 8 out of 10. -4/7/25 at 7:06 PM the resident continued to complain of back pain with little relief from their as needed Tramadol (medication used to treat pain). -4/7/25 at 5:10 PM the resident was having lower back pain and had a headache. The resident received Ultram (medication used to treat pain) 50 milligrams (mg). -4/7/25 at 6:53 PM the resident's pain was a 7 out of 10 and the Ultram given at 5:10 PM was ineffective. The resident was also complaining of neck pain. -4/10/25 at 12:03 AM the resident had increased behaviors, tried to walk in the corridor with a walker, and struck out at staff and tried to ram staff with the wheelchair when attempted to redirect. -4/10/25 at 5:51 PM the resident was showing signs of confusion with behavioral issues. In addition, the resident refused to allow staff to assist with care. -4/10/25 at 11:42 AM the resident was complaining of back pain and was unable to turn in bed without yelling in pain. -4/11/25 at 9:05 AM (4 days after the resident's fall) the resident was found slumped in their recliner. The resident was lethargic and unable to follow simple commands. The resident's pupils were fixed and did not respond to light. -4/11/25 at 9:07 AM the resident had a dark purple bruise on the back of the resident's head. -4/11/25 at 9:34 AM the resident was transferred by ambulance to the Emergency Room. -4/11/25 at 1:01 PM the resident was transferred to a hospital in Omaha due to a brain bleed. During an interview on 4/24/25 at 2:00 PM, the Director of Nursing (DON) confirmed the resident had falls on 3/16/25 at 5:08 AM, 3/27/25 at 2:15 PM and on 4/7/25 at 4:30 AM. The resident had been complaining of increased back pain, had increased confusion, and behaviors. In addition, the resident required 2 assists for transfers. Further interview revealed no assessments were completed and/or documented regarding the resident's back pain, increased confusion, or behaviors.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(I)(i). Based on record review and interview; the facility failed to identify causal factors and to revise and/or develop additional interventions for the prevention of ongoing falls for Resident 29 and falls with injury for Resident 135. The sample size was 5 and the facility census was 34. Findings are: A. Review of the facility Falls-Clinical Protocol with a revision date of 3/2018 revealed the facility was to review each resident's risk factors for falling and document in the resident's medical record. If the resident had a fall, staff were to identify possible causes within 24 hours of the fall. The facility would then identify pertinent interventions to try to prevent subsequent falls and then monitor and document the resident's response to the interventions. If the interventions were successful in fall prevention the approaches would be continued. Staff were to assess the need for changes on the approaches of the plan of care and develop additional approaches to prevent ongoing falls as needed. B. Review of Resident 135's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/19/24 revealed diagnoses of fractures, arthritis, osteoporosis, previous stroke, non-Alzheimer's dementia, anxiety, and depression. The MDS further indicated Resident 135 had: -moderately impaired cognition, -was dependent on staff for assist with eating/drinking, personal hygiene, dressing, bed mobility and transfers, -incontinence of bowel and bladder, and -experienced 2 or more falls with no injury, 2 or more falls with injury (except major) and 1 fall with major injury. Review of Resident 135's Progress Notes revealed the following: -1/29/24 at 8:10 AM the resident had a witnessed fall in the resident's room. Resident 135 had fallen backwards when transferred by a staff member and was then lowered to the floor. Staff placed the resident in the lobby area for increased supervision and therapy was to assess the resident. -1/31/24 at 1:38 PM received orders for Occupation Therapy (OT) and Physical Therapy (PT) services. -1/31/24 at 9:10 PM the resident was found on the floor in front of the recliner in the lobby area. A new intervention was developed for a drug review due to increased confusion in the evenings. The Primary Care Provider (PCP) changed the resident's antidepressant medication to be given in the morning instead of the evening to minimize side effects. -2/27/24 at 1:00 PM the resident was found on the floor next to a chair in the resident's room. An immediate intervention to check the resident every 30 minutes for 8 hours was identified. Further review revealed no ongoing interventions and/or causal factors were identified related to the resident's fall. -2/27/24 at 2:55 PM revealed the resident was to be discharged from PT and OT due to goals met and resident had reached a plateau. -2/29/24 at 7:45 AM the resident was found on the floor in the resident's room. No causal factors were identified regarding the fall. The resident's medications were reviewed but no changes were made. -3/12/24 at 10:45 AM the resident was found on the floor of the resident's room. The resident had been lying in bed and stated a desire to get into the chair. A new intervention was developed to place non-skid strips next to the resident's bed. -4/11/24 at 4:00 PM the resident was found on knees on the floor. No causal factors were identified, and staff failed to revise current interventions or to develop new interventions to prevent further falls. -4/18/24 at 12:44 PM the facility visited with the family about the resident's behaviors and requested to move the resident to the Memory Unit. The family felt this would increase the resident's confusion and declined having the resident moved. -4/19/24 at 11:07 AM the resident was heard calling for help and was found on the floor in the resident's room. The resident had attempted to remove slacks and urinary incontinence brief. The resident, despite ongoing confusing was educated to use the call light to seek staff assistance. No further interventions were identified. -5/20/24 at 7:45 PM the staff heard a noise in the resident's room and found the resident sitting on the floor. The resident had been talking on the phone to family prior to the fall and fell when trying to hang up the phone. The resident was encouraged to call for assist as needed. The resident was screened by PT and orders were received for therapy to treat on 5/23/24. -6/18/24 at 3:23 PM the resident was discharged from PT as on 6/14/24 the resident was admitted to Hospice. -6/24/24 at 8:15 PM the resident was found on the floor of the resident's room and was lying on right hip. Hospice was to bring a scoop mattress for the resident's bed. -7/14/24 at 9:00 PM the staff heard the resident screaming in their room and calling for help. The resident was found on the floor next to the bed and was assisted to the bathroom. No causal factors were identified, and the facility failed to revise current interventions or to develop new interventions to prevent further falls. The staff sent a note to the PCP regarding assessment for a possible fracture but did not receive a response. -7/15/24 at 9:20 AM the resident had been positioned in a wheelchair at a table in the lobby area. The wheelchair brakes had been locked. The resident attempted to move the wheelchair back away from the table and tipped over backwards in the chair. The resident was unable to bear weight with continued complaints of hip pain. At 10:30 AM the resident was transferred to the emergency room (ER) for assessment. -7/15/24 at 2:49 PM anti-tip bars were placed on the resident's wheelchair after returned from the ER with diagnosis of 2 pelvic fractures. -7/17/24 at 4:22 PM the resident was found on the floor beside the resident's bed. The resident's incontinence brief was partially removed and there was urine on the floor. Staff identified interventions to toilet the resident every 2 hours and to position the resident to the middle of the mattress. -7/18/24 at 2: 25 PM the resident was found on the floor next to the resident's bed. The resident had a scoop mattress and body pillow in the bed when staff had checked the resident 2 minutes prior to the fall. An intervention was identified for a fall mat to the floor next to the resident's bed. -7/19/24 at 10:00 PM the resident had passed away. An interview with Licensed Practical Nurse (LPN)-B on 9/12/24 at 9:57 AM confirmed the following: -2/27/24 at 1:00 PM after the resident's fall, the staff were to do 30-minute checks for 8 hours. No further interventions were developed to prevent further falls and no casual factors were identified. -2/29/24 at 7:45 AM the resident was found on the floor in the resident's room. No causal factors were indicated. Medications were reviewed but no changes were made to prevent further falls. -4/11/24 at 4:00 PM when the resident was found on their knees, no casual factors were identified, and no additional interventions were developed. -4/19/24 at 11:07 AM the resident was found on the floor of the resident's room with brief and slacks lowered. Education was provided to the resident regarding calling for assistance despite the resident's confusion and safety impairment. -6/14/24 the resident was admitted to Hospice. -7/14/24 at 9:00 PM the resident was found on the floor of the resident's room. The resident had been restless earlier in the shift and had been positioned at the Nurse's Station for constant monitoring. The resident had complained of right hip pain and a facsimile was sent to the PCP regarding assessment for fracture of the resident's right hip. The facility again asked the family about moving the resident to the Memory Unit, but the family refused. -7/15/24 at 9:20 AM the resident had another fall when the resident tipped the wheelchair over backwards. The resident continued to complain of hip pain and was unable to bear weight. At 10:30 AM the resident was sent to the ER for evaluation. The resident was found to have 2 fractures of the resident's right pelvis. Anti-tip bars were placed on the resident's wheelchair upon return from the hospital and staff were instructed not to lock the wheelchair brakes when the resident was at the table. -7/17/24 at 3:25 PM the resident had another fall out of bed. The staff were educated to position the resident in the middle of the bed and to toilet the resident every 2 hours. -7/18/24 at 2:25 PM staff had checked on the resident who had been lying in bed with the scoop mattress and a body pillow. Two minutes later the resident was found on the floor. A fall mat was placed on the floor next to the resident's bed. -7/19/24 at 10:00 PM the resident passed away. C. Review of Resident 29's MDS dated [DATE] revealed diagnoses of non-traumatic brain dysfunction, Alzheimer's disease, depression, anxiety, and dementia. The MDS further indicated Resident 29 had: -severely impaired cognition, -behaviors which included resistance with cares, wandering and verbal behaviors directed toward others, -was dependent on staff for assist with personal hygiene, dressing, bed mobility and transfers, -incontinence of bowel and bladder, and -experienced 2 or more falls with no injury. Review of Resident 29's Nursing Progress Notes revealed the following: -1/13/24 at 4:10 AM the resident was on the bathroom floor and was incontinent of urine. Staff felt the resident had been awakened on safety rounds. New interventions were identified to have staff do rounds more quietly and to toilet the resident at least 2 times throughout the night. -1/14/24 at 10:11 PM the resident was found on the floor in the corridor. No causal factors were identified, and staff indicated an intervention for therapy to re-screen the resident even though the resident was currently on therapy caseload. -1/15/24 at 8:00 PM the resident was found sitting on the floor of the resident's room. Family was concerned about a possible urinary tract infection (UTI) and new orders for a urinalysis. 1/18/24 a new antibiotic was ordered to treat the infection. -3/13/24 at 1:07 PM the resident was found on the floor next to the resident's bed. No causal factors were identified. The facility completed urinalysis which was negative, and therapy re-screened the resident but did not pick up for therapy. -5/14/24 at 11:28 PM the resident was observed seated on the floor in front of the recliner. Staff assisted the resident out to the commons area for closer supervision. Staff were to do frequent checks and encourage the resident to remain in the recliner in the commons area for supervision. In addition, a new order was received to increase the resident's Tylenol Arthritis to three times a day for pain control. -6/25/24 at 3:30 PM the resident was found sitting on the floor of the resident's room. The resident was assisted into the wheelchair and out to the common's area for closer supervision. Further review revealed no causal factors were determined and no additional interventions were identified. -6/26/24 at 2:22 AM the resident was found on the floor next to the resident's bed and in front of the wheelchair. The resident was incontinent of urine. A new intervention was developed for use of a pancake call light which was to be positioned on the right side of the bed. -6/30/24 at 3:10 PM the resident was lowered to the floor when became unsteady during assisted toileting transfer. Further review revealed no evidence current fall interventions were revised or new interventions developed. -8/6/24 at 2:29 PM the resident was found on the floor of the commons area next to the resident's wheelchair. The resident had attempted to stand and sat down on the floor. An intervention was put into place for one staff on the Memory Unit to always supervise the resident. -8/28/24 at 11:00 PM the staff entered the resident's room and witnessed the resident stand and then slide down to the floor. The resident was barefoot and had been incontinent of urine. An intervention was added to the resident's treatment sheet for the Charge Nurse to verify the resident was wearing gripper slippers when not wearing shoes. 9/8/24 at 5:47 AM the was found seated on the floor in the doorway of the resident's room. The resident was not wearing shoes or the gripper socks. Staff received written education regarding use of the gripper socks and the resident's bed was no longer to be placed in the lowered position but was to be placed at the height of the resident's wheelchair. During an interview pm 9/11/24 at 11:22 AM, LPN-B confirmed the following regarding fall prevention assessment and interventions for Resident 29: -1/14/24 fall at 10:11 PM there were no causal factors identified regarding the resident's fall. A screen went out to have therapy re-screen the resident despite already being on their case load. No further interventions were identified. -3/13/24 fall at 1:07 PM there were no causal factors identified. A urinalysis was completed and was negative. In addition, a therapy screen was completed but therapy did not pick the resident up for treatment. No new interventions were indicated to prevent further falls. -6/25/24 at 3:30 PM the resident was found on the floor of the resident' room. The resident was assisted into the wheelchair and then out to the common's area for increased supervision at the time of the fall. No causal factors and no further interventions were identified. -6/30/24 at 3:10 PM the resident fell when the staff were transferring the resident onto the toilet. There was no evidence current interventions were revised or additional interventions developed.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E1 Based on observation, record review and interview; the facility failed to provide safe storage of drugs and biological's as a medication cart was left unlocked and unattended, and medications were left unsecured in Resident 21's room. The sample size was 6 and the facility census was 34. Findings are: A. Review of the facility policy titled Medication Labeling and Storage with a revision date of 2/23 revealed the following: -the facility was to store all drugs and biological's in a safe, secure, and orderly manner; -the Charge Nurse was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner, and -compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biological's were to be locked when not in use, and trays or carts used to transport such items were not to be left unattended if open or otherwise potentially available to others. B. Observations in Resident 21's room revealed the following: -9/9/24 at 8:30 AM a clear medication cup was observed lying on its side atop a blanket on the floor next to the resident's recliner. One pill (Plavix 75 milligram (mg) 1 tablet) remained in the cup. Further observation revealed the presence of 7 additional medications in the folds of the blanket (Amlodipine (used to treat high blood pressure) 5 mg 1 tablet, Isorbide (medication used to treat chest pain) 30 mg 1 tablet, Loratadine (used to treat allergies) 10 mg 1 tablet, Pantoprazole (used to treat heart burn) 40 mg 1 tablet, Eliquis (blood thinner) 2.5 mg 1 tablet, Guaifenesin (used to treat cough) 600 mg 1 capsule and Metoprolol (used to treat high blood pressure) 25 mg 1 tablet). Resident 21 confirmed the staff would leave the resident's morning medications in the resident's room as the resident preferred to take the medication with the breakfast meal. -9/10/24 at 8:38 AM the resident was seated in a recliner in the resident's room. Next to the chair on a table was a clear medication cup which contained the same 8 medications as the previous day. C. During an observation on 9/11/24 at 8:31 AM, the Medication Cart which was positioned outside of the dining room in the 300 corridor was left unlocked and no staff were observed in the immediate area. At 8:34 AM, Medication Aide (MA)-H returned to the cart. MA-H confirmed the cart had been left unlocked and unattended while the MA was in the dining room. D. During interview on 9/11/24 at 3:09 PM, the Director of Nursing (DON) verified medications were to be stored inside the medication cart and the medication cart was to be always locked when unattended. In addition, Resident 21 had not been assessed and did not have an order for self-administration of medications.

Licensure Reference Number 175 NAC 12-006.09 Based on record review and interview, the facility failed to ensure Resident 4's antibiotic ointment use had an ordered duration to prevent potential adverse outcomes. The sample size was 5 and the facility census was 34. Findings are: A. Review of the facility undated policy Antibiotic Stewardship; revealed the following: -The facility's antibiotic stewardship program promoted the appropriate use of antibiotics and a system of monitoring to improve resident outcomes and reduce antibiotic resistance. -Antibiotic were prescribed for the correct indication, dose, and duration to appropriately treat the resident while attempting to reduce the development of resistant organisms or other adverse consequences or outcomes. Review of Resident 4's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident Care Plans) dated 6/21/24 revealed the resident took antibiotic medication. Further review revealed the resident received enteral (nutrition provided using the gut or tube feeding) nutrition. Review of Resident 4's Care Plan with a revision date of 7/17/23 revealed the resident had a feeding tube (tube inserted through the abdominal wall and into the stomach to provide nourishment) and staff were to change the dressing to the tube site daily, observe for signs and symptoms of infection and apply Bacitracin (antibiotic) ointment to the site twice daily every 3rd day. Review of Resident 4's Medication Administration Record (MAR) date August 2024 revealed the resident received Bacitracin Ointment starting 2/27/19 (5 and 1/2 years). During an interview on 9/11/24 at 10:41 AM the Director of Nursing confirmed the facility did not have an ordered stop date or duration of use orders for Resident 4's Bacitracin ointment. In addition, the ongoing use of an antibiotic without a defined duration or clinical rationale for continued use was not in accordance with the facility antibiotic stewardship policy.

Based on record review and interview: the facility failed to submit their Payroll Based Journal (PBJ) data for quarter 3 of 2024 as required. This had the potential to affect all residents residing within the facility. The facility identified a census of 34. Findings are: A record review of the PBJ report from Centers for Medicare and Medicaid services (CMS) revealed the facility had failed to submit data for the third quarter (April 1 to July 30) in 2024. The PBJ report is a collection of staffing information and is a requirement of all long-term facilities to promote accountability and consistency. During an interview on 9/10/24 at 3:09 PM, the Provisional Administrator, revealed the facility did not know how to submit the required information and confirmed no information had been submitted.

Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review and interview, the facility failed to notify the physician of a significant change for Resident's 8 and 29. The sample size was 18 and the facility census was 33. Findings are: A. Review of the facility policy Change in a Resident's Condition or Status with a revision date of 2/2021 revealed the following; -the facility promptly notified the resident, the attending physician, and the resident representative of changes in resident's condition/status. -the nurse notified the resident's attending physician or physician on call when there had been a change in the resident's physical/emotional/mental condition, or a need to alter the resident's medical treatment significantly, -the facility defined a significant change of condition as a major decline or improvement in the resident's status that would not normally resolve itself without intervention, impacted more than one area of the resident's health status, and required interdisciplinary review and/or revision to the care plan, and -except for in emergencies, notifications of change would be made within 24 hours of a change occurring, B. Review of Resident 8's Minimum Data Set (MDS-federally mandated comprehensive assessment used in the development of resident care plans) dated 7/21/23 revealed the following; -The resident received limited assistance with bed mobility, transfers, and toileting, -had a diagnosis of heart disease, high blood pressure, anxiety, depression, and -used oxygen. Review of Resident 8's Care Plan with a revision date of 8/15/23 revealed the following; -the resident returned to the facility following a hospitalization for sepsis from a broken tooth and pneumonia, -used oxygen as needed, and -needed limited assistance of 1 staff member for bed mobility, transfers, and hygiene. Review of Resident 8's Progress Notes revealed the following; -On 8/3/23 at 2:46 PM the resident complained of feeling tired and used a wheelchair to get to and from meals. -On 8/4/23 at 2:35 AM the resident had activity intolerance, tired quickly after minimum efforts, used a wheelchair to get to and from meals and used a Stand-up Lift -(mechanical lift on wheels used to aid the resident to a standing position and move the resident from a sitting to a standing position and then back to a sitting position) was activity intolerant, and tired easily. -On 8/4/23 at 7:03 PM the resident reported terrible when asked how they were, complained of a headache, right arm and shoulder pain, and used a wheelchair to and from meals. -On 8/5/23 at 3:28 AM the resident continued to be activity intolerant, used a wheelchair for meals, and required 2 staff to transfer. -On 8/5/23 at 4:04 PM the resident had been coughing up mucus, had rattling lung sounds, continued to feel weak, and staff had used the stand lift for transfers. The facility faxed the physician requesting nebulizer (inhaled breathing treatments often used to treat shortness of breath, chronic lung conditions, or acute lung/breathing conditions) and no evidence the physician responded to the request. -On 8/6/23 at 1:27 AM the resident had a body temperature of 99 degrees and had coarse lung sounds, and a productive cough with thick phlegm. -On 8/6/23 at 9:49 AM the resident had a body temperature of 100.3 degrees, oxygen saturations between 85-88% (90 -100 is normal), and unstable vital signs, a pain rating of 10 out of 10, and was sent to the emergency room (ER) by ambulance. (At the time of the transfer the physician had still not responded to the fax sent on the previous day). Review of a Fax Communication to Physician for Resident 8 dated 8/5/23 revealed no response other than a signature to a request for nebulizer treatment and an x-ray that was not noted (signed by a nurse acknowledging the physician directions) until 8/7/23 (1 day after the resident had been taken to the emergency room (ER) and admitted to the hospital). During an interview on 8/23/23 at 11:15 AM Registered Nurse (RN)-G confirmed the facility did not receive a signed physician response for Resident 8, in regard to the facilities request for a nebulizer treatment and/or an x-ray for Resident 8 on 8/5/23 until 2 days later on 8/7/23 at which time the resident had already been taken to the ER for evaluation. During an interview on 8/23/23 at 11:30 AM the Director of Nursing (DON) revealed the facility had no evidence the facility attempted to contact the physician for Resident 8 after not receiving a fax response to a request for nebulizer treatments and an x-ray on 8/5/23. Further interview confirmed the resident was taken to theER on [DATE] for unstable vital signs and continued condition decline. In addition, the DON confirmed the facility should have contacted the physician again on 8/5/23 when a response was not received regarding the request for treatment of the resident's change in condition. 45739 C. Review of Resident 29's MDS dated [DATE] revealed the following: -the resident was cognitively intact, - the resident was independent with transfers and dressing, needed supervision with eating, and limited assistance with toileting, - had diagnosis of cancer, heart failure, renal (kidney) disease, and pulmonary (lung) disease, -had shortness of breath with exertion and when lying flat, and -was on supplemental oxygen. Review of Resident 29's Care Plan with a last revision date of 8/19/23 revealed the following: -the resident was sent to the hospital on 8/12/23 and readmitted to the facility on [DATE] with a diagnosis of pneumonia, -the resident could be tested for Covid-19 as needed, and -the resident was to wear oxygen during the night and staff were to offer oxygen during the day. Review of Resident 29's Progress Notes dated 8/11/23 at 7:30 PM revealed the resident complained of not feeling good and stated that when the resident coughed, the residents whole body hurt. The resident's lung sounds were diminished (decreased air movement which makes lung sounds hard to hear) and had wheezes. The resident reported coughing up green phlegm. The resident's oxygen saturation was at 85% (normal is above 90) and oxygen was placed on the resident and a fax was sent to the provider. Review of the Resident 29's Progress Notes dated 8/12/23 at 10:44 AM revealed the resident stated the resident was not feeling good and didn't want to get out of bed. The resident reported every time the resident coughed, it hurt the residents back and abdomen. The resident asked the Registered Nurse to call (gender) son and that the resident wanted to be seen in the clinic that day. The RN assessed the resident and the resident continued to have diminished lung sounds and wheezing. Further review revealed at 11:40 AM the son updated the facility that the resident was admitted to the hospital with pneumonia. Interview with Resident 29 on 8/21/23 at 10:32 AM revealed the resident was recently in the hospital with pneumonia and was taking an antibiotic. Interview on 8/22/23 at 12:15 PM with RN-R revealed that if the nurse faxes the physician after clinic hours or on a weekend, they will follow up the next day or on Monday. Further interview at 2:30 PM revealed if the nurse faxes on the weekend, they were to follow up or refax on Monday, but they would monitor the resident's symptoms. If the condition persisted or worsened, they were to call the Provider. Interview on 8/22/23 at 2:44 PM interview with Licensed Practical Nurse (LPN-Q) revealed that if the resident's condition persisted the nurses were to send the resident to the ER if the provider or family wanted. Interview on 8/22/23 at 2:49 PM Interview with RN-R revealed the facility had no evidence the facility notified the provider regarding Resident 29's condition. Further interview confirmed no documentation that the fax was followed up on and that the resident requested to be seen by the provider the next day and was admitted to the hospital.

Licensure Reference Number 175 NAC 12-006.17 Based on interview and record review; the facility failed to ensure the designated Infection Preventionist (IP-staff who looks for patterns, observes and educates staff on infection control and compiles infection data) met the required qualifications for the position and was not the Director of Nursing (DON) . This had the potential to affect all residents. The total sample size was 18 and the census was 33. A. Review of the facility policy Infection Preventionist with a revision date of 9/22 revealed the following responsibilities were identified for the role: -coordinates the development and monitoring of infection prevention and control program; -reports information related to compliance with the infection prevention and control program to the Administrator and the Quality Assurance team; -collects, analyzes and provides infection antibiotic usage data and trends to nursing staff and health care practitioners; and -provides education and training on evidenced based infection prevention and control practices. The IP is employed on site and at least part time. Additional hours are scheduled as indicated by the needs identified in the facility assessment. The IP is scheduled with enough time to properly assess, develop, implement, monitor and manage the Infection Prevention Control Program, address training requirements and participate in required committees such as Quality Assurance. B. During the entrance conference on 8/21/23 at 7:42 AM, the DON confirmed working a minimum of 40 hours each week as the DON and was also the only designated facility IP. During an interview on 8/21/23 at 03:04 PM, the Administrator confirmed the facility did not have an IP who was employed at least part time and the DON was functioning as both the IP and the DON.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10A3 Based on record review and interview; the facility failed to ensure staff had the required certification when administering medications for 1 Medication Aide (MA-S). The total sample size was 18 and the facility census was 33. Findings are: Review of MA-S's Certification of Nebraska Licensure form indicated MA-S was not currently registered on the MA registry with a 40-hour MA license. Review of the facility Nursing Schedule from 3/1/23 through 5/31/23 revealed MA-S was scheduled as an MA and administered medication to residents on: -3/20, 3/21, 3/22, 3/25, 3/26, 3/28, 3/29 and 3/30; -4/4, 4/5, 4/6, 4/10, 4/11 and 4/12; and -5/10, 5/15, 5/16, 5/24 and 5/25. Interview with the Director of Nursing (DON) on 8/22/23 at 1:30 PM revealed MA-S was employed from a staffing agency with a contract from 3/1/23 to 6/5/23. The facility failed to check MA-S' license and was not aware MA-S did not have a 40-hour MA license. The DON confirmed MA-S administered medications throughout 3/23, 4/23 and 5/23 without the required license.

Licensure Reference Number 175 NAC 12-006.09A Based on record review and interview, the facility failed to ensure Resident 14's Pre-admission Screening and Resident Review (PASRR-screening used to determine if a person had or was suspected of having Mental Illness (MI), Intellectual Disability (ID) or a Related Condition (RC)) was completed accurately. The sample size was 6 and the facility census was 16. Findings are: Review of the facility policy Behavioral Assessment, Intervention and Monitoring with a revision date of 3/2019 revealed the following; -the facility provided residents with behavioral health services as needed to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. -behavioral symptoms were identified using facility approved behavioral screening tools and the comprehensive assessment, -residents who did not display symptoms of, or had not been diagnosed with, mental, psychiatric, psychosocial adjustment, substance abuse or post-traumatic stress disorder(s) would not develop behavioral disturbances that could not be attributed to specific clinical conditions that made them unavoidable, -behavioral health services were provided by qualified staff who had the competencies and skills necessary to provide appropriate services, -residents would have minimal complications associated with the management of altered or impaired behavior, and -the facility would comply with regulatory requirement related to the use of medications to manage behavioral changes, -as part of the initial assessment, the nursing staff and attending physician would identify individuals with a history of impaired cognition, altered behavior, substance use disorder, or mental disorder, -all residents would receive a Level 1 PASRR-screen prior to admission, -if the level 1 screen indicated that the individual met the criteria for MI, ID or RC the resident would be referred to the state PASRR representative for a Level 2 (comprehensive evaluation required as a result of a positive level 1 screen used to determine whether placement or continued stay in a Nursing Facility was appropriate) evaluation and determination process, and -the level 2 evaluation report would be used when conducting the resident assessment and developing the care plan. Review of Resident 14's Minimum Data Set (MDS-federally mandated comprehensive assessment used in the development of resident care plans) dated 8/1/22 revealed the following; -The resident was admitted on [DATE], -was not considered by the state PASRR to have MI, ID or RD, and -had diagnoses of depression, bipolar disorder (mood disorder characterized by depressive lows and manic highs), and schizophrenia (a range of problems affecting thinking, behavior, and emotions). Review of Resident 14's PASRR completed by the facility on 7/26/22 revealed the resident had no suspected Mental Illness or Related Disorder. Review of Resident 14's Diagnosis Report dated 7/26/22 revealed the following diagnoses; Adjustment Disorder with mixed anxiety and depression (the development of emotion and or behavior symptoms related to a stressor but out of proportion to the stressor) and Schizoaffective Disorder, bipolar type (a chronic mental health condition characterized by symptoms of schizophrenia, such as delusions and hallucinations and symptoms of mood disorders such as mania or depression). Review of Resident 14's Care Plan with a revision date of 8/5/23 revealed the resident had an Adjustment Disorder with mixed anxiety and depressed mood, Schizophrenia, Schizoaffective Disorder, and the resident took psychotropic (drugs that affect a person's mental state) medications. During an interview on 8/22/23 at 1:42 PM the Social Services Director confirmed Resident 14's PASRR was completed incorrectly and did not accurately reflect the resident's MI diagnoses. In addition, due to the incorrect level 1 PASRR screen a level 2 PASRR was not completed.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7(a) (b) Based on record review and interview; the facility failed to identify causal factors, to develop new interventions and/or revise current interventions to prevent ongoing falls for 2 (Residents 10 and 19) of 4 sampled residents. The facility census was 33. Findings are: A. Review of Resident 19's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/2/23 revealed the resident was admitted [DATE] with diagnoses of dementia, anxiety, depression, Chronic Obstructive Pulmonary Disease (COPD) and hip fracture. The following was assessed regarding the resident: -cognition was severely impaired; -behaviors which included delusions, verbal and physical behaviors directed at others, rejection of cares and wandering; -extensive staff assistance with transfers, bed mobility, dressing, toilet use and personal hygiene; -frequently incontinent of bowel and bladder; -not steady and only able to stabilize with staff assistance during transfers, when walking and when moving from a seated to standing position; and -functional limitation of range of motion to one side of lower extremities. Review of an Incident Report dated 12/21/22 at 1:41 PM revealed the resident was found on the floor of the resident's room. The resident's foot was caught between the recliner and a magazine rack. The resident reported standing at the window and looking out. When the resident turned around, the resident's foot got caught between the recliner and a magazine rack. A new intervention was developed to move the magazine rack to the other side of the recliner. Review of a Progress Note dated 1/9/23 at 5:41 AM revealed the resident fell outside and landed on bottom when out walking with family. No injury was noted. Further review of the resident's medical record revealed no evidence causal factors were assessed, a new intervention developed, or current fall interventions revised to prevent further falls. Review of an Incident Report dated 2/27/23 at 4:15 AM revealed the staff heard a noise and found the resident lying on the floor in the center of the resident's room. The resident indicated going to the bathroom, slipping and falling. The resident complained of left hip pain. The resident was sent to the emergency room for evaluation and then admitted to the hospital with a fractured hip. Review of a facility investigation dated 3/2/23 revealed causal factors for the resident's fall on 2/27/23 included drowsiness, a current urinary tract infection and incontinence. The resident was not wearing proper footwear and had self-transferred and ambulated to the bathroom without assistance. New interventions included reminding the resident to use the call light for assistance with toileting, treatment of infection, staff to apply gripper socks at night and the resident was started on Physical Therapy. B. Review of Resident 10's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of dementia, multiple sclerosis, seizure disorder, anxiety and depression. The following was assessed regarding resident 10: -cognition was severely impaired; -behaviors which included delusions, verbal and physical behaviors directed at others and other behavioral symptoms (hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes or verbal/vocal symptoms like screaming or making disruptive noises) and rejection of cares; -requires extensive staff assistance with transfers, bed mobility, dressing, toilet use and personal hygiene; -always incontinent of bowel and bladder; and -2 or more falls without injury and 1 fall with injury (except major) since the previous assessment. Review of an Incident Report dated 3/17/23 at 8:25 PM revealed the resident was found on the floor between the wheelchair and the resident's bed. The resident reported trying to get into the bed. An intervention was identified to position the resident in the commons area after meals while waiting for staff to assist into bed. Review of an Incident Report dated 4/19/23 at 7:15 PM revealed the resident was lowered to the floor by staff while using the sit-to-stand mechanical lift (device that allows transfer from a seated to a standing position. Designed to support only the upper body and requires the resident have some weight-bearing capability). Staff failed to secure the resident's lower extremities in the lift and resident could not maintain foot placement on the lift. An intervention was identified to educate the staff on proper use of the lift. Review of an Incident Note dated 5/2/23 at 5:30 PM revealed the resident had a witnessed fall. The staff had assisted the resident to a seated position on the side of the bed. The resident leaned over and then fell on to the floor. An intervention was identified for staff to use 2 assist to transfer the resident out of bed. Review of an Incident Report dated 6/30/23 at 11:15 AM revealed the resident was found on the floor between the resident's bed and the sit-to-stand lift. Further review of the report indicated a causal factor for the resident's fall related to incorrect use of the lift. An Agency staff had attempted to transfer the resident by themselves with the lift instead of using 2 staff. C. Interview with the Director of Nursing (DON) on 8/22/23 at 2:37 PM revealed the Charge Nurses were to complete an Incident Report for each resident fall. Staff were to determine causal factors for falls and then revise current interventions or develop new fall interventions. The DON confirmed the following: -staff failed to complete an Incident Report after Resident 19's fall on 1/9/23 at 5:41 AM. No causal factors were identified, and interventions were not revised or new interventions for fall prevention developed; and -Resident 10 had falls on 4/19/23 at 7:15 PM, 5/2/23 at 5:30 PM and on 6/30/23 at 11:15 AM due to staff failure to transfer the resident and/or to use the mechanical lift in accordance with facility policy. Interventions were identified for education to be provided to the staff however, there was no evidence the facility provided education to all staff regarding transfers and use of the lift for the resident.

Licensure reference: 175 NAC 12-006.04C3a(6) Based on record review and interview, the facility failed to notify physician and family of a change in condition for 1 (Resident 1) of 3 sampled residents. The facility had a total census of 30 residents. Findings are: Resident 1 was admitted to the facility on ,[DATE] with a [DIAGNOSES REDACTED]. A review of Progress Note for Resident 1 dated 8/7/19 revealed Resident 1's left 4th toe had moderate amount of thin, Malodorous, straw colored [MEDICAL CONDITION] drainage with no [DIAGNOSES REDACTED], warmth or swelling. Progress note stated Resident 1's physician was updated regarding odor. A review of physician's orders [REDACTED]. A physician's orders [REDACTED]. Order was also received for a follow up visit with podiatry if not already scheduled. Progress Note dated 8/9/19 at 11:03 AM revealed Resident 1's family was updated on regarding change in orders for antibiotic. Progress Note dated 8/9/19 at 2:48 PM revealed Resident 1 was sleepy with decreased appetite. Resident 1's color was noted to be ashen. Progress Note dated 8/9/19 at 3:09 PM revealed Bactrim DS was taken from E-Box and administered to Resident 1. Progress Note dated 8/10/19 at 1:57 PM revealed Resident 1 was drowsy and unable to hold self up. Resident 1 head falls forward and unable to hold on to handles. Resident 1 could not keep food in mouth during breakfast. Resident 1 wanted to eat but food would fall back out. Resident 1 refused lunch and stayed in bed. Resident 1 drowsy in afternoon and giving minimal responses. Resident 1 color is ashen and pale appears to have 1 plus [MEDICAL CONDITION] in hands. Progress Note dated 8/10/19 at 4:09 PM revealed Resident 1's oxygen level was fluctuating from 83-91% according to pulse oximetry with oxygen level greater than 90% for last 30 minutes. Resident 1 was noted to be drowsy and weak. Resident 1 vital Summary dated 8/10/19 at 4:07 PM identified 91% oxygen saturation on room air, pulse 98 beats per minute, blood pressure 98/58, and temperature 97.3 degrees F (Fahrenheit). Progress Note dated 8/10/19 at 8:30 PM stated Resident 1 blood pressure was unable to be attained, oxygen saturation level was unable to be obtained, pulse 60, respirations 18, and lung sounds clear to auscultation. Resident 1 was not responding to voice. Resident 1 had no intake today. Call was placed to rescue squad and Resident 1 was transferred to the hospital. Progress note dated 8/11/19 at 4 AM revealed Resident 1 was diagnosed with [REDACTED]. Progress note dated 8/13/19 stated Resident 1 passed away on 8/12/19. In an interview on 8/26/19 at 2:17 PM, Licensed Practical Nurse A reported that Resident 1 was lethargic throughout the day on 8/10/19. Licensed Practical Nurse A reported deep breathing exercises and coughing were used to get Resident 1's oxygen level up. Licensed Practical Nurse A reported Resident 1's doctor and family were not contacted by Licensed Practical Nurse A as Resident 1's vitals were stable and was expecting Resident 1's physician to be coming to Resident 1. In an interview on 8/26/19 at 3:10 PM, Registered Nurse B reported that Resident 1's oxygen level did come back up over 90% on room air. Registered Nurse B reported that Resident 1's doctor was not contacted as Registered Nurse B believed Resident 1's doctor was coming to the facility. In an interview on 8/26/19 at 4:15 PM, Licensed Practical Nurse C reported the nurse aides had reported to Licensed Practical Nurse C that Resident 1 did not look right. Licensed Practical Nurse C reported Resident 1 was not responding. Licensed Practical Nurse C reported the squad was called and Resident 1 was transported to the hospital. Resident 1's family was present at time of transfer. In an interviews at 8/26/19 at 4:42 PM, 8/27/19 at 11:11 AM and 12:18 PM, the Director of Nursing reported that the staff had continued to monitor Resident 1 vital signs and oxygen saturation levels. The Director of Nursing reported it was not uncommon for Resident 1 to have good and bad days and that the decrease in appetite was attributed to taking antibiotics. A review of facility policy revised (MONTH) (YEAR) titled Change in a Resident's Condition or Status revealed the following: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): -accident or incident involving the resident; -discovery of injuries of an unknown source; -adverse reaction to medication; -significant change in the resident's physical/emotional/mental condition; -need to alter the resident's medical treatment significantly; -refusal of treatment or medications two (2) or more consecutive times); -need to transfer the resident to a hospital/treatment center; -discharge without proper medical authority; and/or -specific instruction to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: -Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting): -Impacts more than one area of the resident's health status; -Requires interdisciplinary review and/or revision to the care plan; and -Ultimately is based on the judgment of the clinical staff and the guidelines outlined the Resident Assessment Instrument. 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: -The resident is involved in any accident or incident that results in an injury including injuries of an unknown source; -There is a significant change in the resident's physical, mental, or psychosocial status; -There is a need to change the resident's room assignment; -A decision has been made to discharge the resident from the facility; and/or -It is necessary to transfer the resident to a hospital/treatment center 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observations, record review and interview; the facility failed to assess causal factors and to develop/revise and implement interventions for the prevention of falls for Resident 26 who sustained falls with injury. The facility census was 36. Findings are: Review of Resident 26's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/18/16 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident required extensive assistance for bed mobility, transfers and ambulation. Review of Resident 26's current Care Plan (dated 8/14/15) revealed the resident was at risk for fall related injuries as evidenced by a history of falls. The Care Plan indicated Resident 26 had poor safety awareness and was resistive to staff assistance at times. Interventions included the following: -Anticipate and meet resident's needs. -Be sure call light is within reach and encourage to use call light as needed for assistance. -Ensure resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. -Keep bed in low position. -Therapies to screen/evaluate as needed. -Extensive assist of 1-2 with gait belt and walker to ambulate in hall. -9/5/15 sensor chair and bed alarms (electronic pressure sensitive pad designed for use in chairs or beds which will alarm if a resident tries to get up without assistance) both initiated. -9/17/15 TABS alarm (an alarm with a pull string that attaches magnetically to the alarm with a garment clip to the resident. When a resident attempts to rise out of the chair or bed the pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the care giver) when seated in the wheelchair. Review of a Fall Risk assessment dated [DATE] revealed Resident 26 was at high risk for falls. Review of Resident 26's Nursing Progress Notes revealed the following: -10/4/15 at 9:30 AM- Staff were assisting the resident with ambulation to the bathroom. The resident was using the walker, complained of feeling weak and was lowered to the floor. -10/6/15 at 4:43 PM- A risk review of the resident's fall on 10/4/15 indicated staff were to use 2 assist with the resident due to increased weakness. The resident had refused use of a gait belt and staff were instructed to use the gait belt routinely and to educate the resident regarding safety needs. -10/20/15 at 2:53 PM- Due to use of duplicate alarms in the wheelchair, staff discontinued the sensor chair alarm. Staff were to continue use of the TABS chair alarm and the sensor bed alarm. -10/28/15 at 8:56 AM, the resident had ambulated independently out of the Dining Room with a walker, lost balance and fell to the right side. Review of Resident 26's medical record revealed no documentation to indicate causal factors for Resident 26's fall on 10/28/15 were assessed and no new interventions for the prevention of on-going falls were developed. Review of Resident 26's Nursing Progress Notes revealed the following: -10/29/15 at 8:17 AM- The staff were to continue the use of the TABs chair alarm (already in use) due to fall on 10/28/15 and a screen was to be sent to therapy. -10/29/15 at 6:30 PM- The resident refused to participate in the therapy screen. Review of Resident 26's Care Plan revealed an intervention dated 11/18/15 to discontinue the resident's chair sensor alarm per the family's request. Review of Resident 26's Nursing Progress Notes revealed the following: -11/19/15 at 8:00 AM- The resident was observed seated upright on the floor of the room, leaning against the recliner. The resident indicated while picking out clothing in closet, the resident lost balance and fell . An intervention to reinitiate the sensor chair alarm was identified. -11/20/15 at 10:42 AM- The facility staff called the resident's family on 11/18/15 about discontinuing the sensor chair alarm. However, the alarm had not been removed by the staff prior to the resident's fall on 11/19/15, as indicated on the resident's Care Plan. The resident had removed the alarm independently. Staff were to continue use of alarm due to recent fall. The resident did indicate to staff the alarm would not prevent the resident from falling as the resident would remove the alarm, and get up out of the wheelchair whenever the resident wanted. Review of Resident 26's medical record revealed no evidence to indicate current fall prevention interventions were revised after the resident's fall on 11/19/15, or that new interventions were developed to prevent further falls. Review of Resident 26's Nursing Progress Notes revealed the following: -12/1/15 at 2:20 PM- The resident was observed disabling the TABs chair alarm on 2 different occasions. The resident was educated on the need to call staff for assistance. The resident denied the need for assistance and stated, That alarm won't keep me from falling. -12/1/15 at 4:29 PM- The resident remained angry regarding alarm use and stated, I can't stand being tied down, I'll fall whether it is on or not. The resident requested staff call family to get rid of that thing. -12/1/15 at 4:52 PM- A call was placed to the resident's family to discuss use of alarms. The family agreed to discontinue the TABs chair alarm but requested continued use of the bed sensor alarm. The resident was notified the TABs chair alarm was to be removed and was re-educated on the need to call staff for assistance with cares. The resident indicated no staff assistance was needed. Review of Resident 26's Care Plan revealed an intervention dated 12/1/15 which indicated the resident's TABs chair alarm was discontinued per the resident's demand and family agreement. Review of Resident 26's Nursing Progress Notes revealed the following: -12/7/15 at 2:50 PM- The resident was heard hollering for help. The resident was found on the floor next to the bed. The resident indicated while trying to assist spouse to lie down, the resident lost balance and fell . Review of the Resident 26's Care Plan revealed an intervention dated 12/7/15 which identified the resident's spouse was not to nap in the resident's room and the resident was educated not to provide care assistance to the spouse. Review of Resident 26's Nursing Progress Notes revealed the following: -12/12/15 at 9:03 AM- The resident was walking alone in the corridor after breakfast. Staff heard a noise and found the resident lying on the floor of the corridor. The resident voiced complaint of right sided pain and difficulty with breathing. -12/12/15 at 10:30 AM- The resident was admitted to the hospital due to [DIAGNOSES REDACTED]. Review of Resident 26's Care Plan revealed an intervention dated 12/12/15 for staff to provide the resident with ongoing education of the need to call for assistance with ambulation. Review of Resident 26's Nursing Progress Notes revealed the following: -12/21/15 at 5:30 PM- The resident returned from the hospital and agreed to have the TABs alarm placed on the wheelchair. -12/22/15 at 4:22 PM- The resident was assisted to the bathroom and then transferred back into the wheelchair with the TABs alarm in place. Staff left the resident's room and immediately heard the alarm activate as the resident attempted to disable the alarm. -12/22/15 at 4:41 PM- Staff reported the resident continued to remove the TABs alarm from wheelchair and a sensor alarm was placed in the seat of the wheelchair, in addition to the TABs alarm. -12/29/15 at 5:26 PM- A risk review of the resident's fall on 12/12/15 indicated the discharge summary from hospital identified the resident had a fall, with post fall fluid in chest. While in the hospital, the resident was in respiratory failure after placement of a chest tube (hollow, flexible tube placed in the chest to act as a drain) and required mechanical ventilation (method to mechanically assist or replace spontaneous breathing). The resident also had [DIAGNOSES REDACTED]. Review of Resident 26's Care Plan revealed an intervention dated 12/31/15 which indicated a sensor alarm was placed on the resident's room door. The Care Plan further identified the resident continued to attempt to self-transfer to the bathroom. Review of Resident 26's Nursing Progress Notes revealed the following: -1/5/16 at 8:08 AM- The resident's cognition was assessed as variable. The resident continued to attempt self-transfers and self-ambulation despite ongoing education of safety risks. -1/13/16 at 11:55 AM- A Brief Interview of Mental Status (BIMs-assessment tool used to determine a resident's cognitive status) was completed and the resident scored 9, indicating the resident's cognition was moderately impaired. -1/16/16 at 9:15 AM- The resident was observed on the floor of the bathroom and lying on the right side. Review of Resident 26's Care Plan revealed an intervention dated 1/16/16 to place a TABs alarm on the resident when the resident was in the bathroom. Review of Resident 26's Care Plan revealed an intervention dated 1/19/16 which indicated the TABs alarm was discontinued while resident in the bathroom. Staff were to provide direct supervision instead. If the resident refused to allow staff to directly observe, then staff were to remain outside the bathroom and to listen at the door for any activity. Review of Nursing Progress Notes dated 1/23/16 at 11:50 PM revealed the resident's alarm was sounding and the resident was found on the floor next to the bed. The resident was alert but confused and commented about being on the way to breakfast. Review of Resident 26's medical record revealed no documentation to indicate causal factors for Resident 26's fall on 1/23/16 were assessed and no new interventions for the prevention of on-going falls were developed. Review of Nursing Progress Note dated 1/25/16 at 9:50 PM revealed staff heard the resident's alarms and found the resident on the floor of the resident's room. Review of Resident 26's medical record revealed no documentation to indicate causal factors for Resident 26's fall on 1/25/16 were assessed and no new interventions for the prevention of on-going falls were developed. Review of Resident 26's Nursing Progress Notes dated 1/30/16 at 5:43 PM revealed the resident refused to remain in the Dining Room for the evening meal and displayed very poor safety awareness. The resident self-propelled out of the Dining Room and back to the resident's room. Staff heard the resident's alarms sounding and found the resident lying on the floor between the bed and the closet. The resident voiced complaints of pain to the right hip and was admitted to the hospital with [REDACTED]. Review of a Nursing Progress Note dated 2/4/16 at 3:19 PM revealed the resident returned from the hospital. Review of Resident 26's Care Plan revealed a new fall prevention intervention dated 2/4/16 for a scoop mattress (mattress with a raised, defined edge which helps to reduce the risk of falls out of bed) to the resident's bed and to place a mattress on the floor next to the resident's bed to help protect the resident from injury. Review of a Nursing Progress Note dated 2/8/16 at 4:08 PM revealed the resident refused to allow staff to place the sensor alarm in the seat of the wheelchair. The note indicated a TABs alarm was to be used when the resident was lying in bed or when seated in a wheelchair. The sensor alarm was to be used when the resident was lying in bed. Observations on 2/17/16 from 1:55 PM to 3:00 PM, revealed Resident 26 was lying in bed with eyes closed. No TABs alarm was observed on the resident's bed. Observation on 2/18/16 at 10:30 AM, revealed Resident 26 was lying in bed with eyes closed. No mattress was observed on the floor next to the resident's bed. During observations on 2/22/16 from 7:16 AM to 7:55 AM, Resident 26 was lying in bed with eyes closed. No TABs alarm was observed on the resident's bed. During an interview on 2/22/16 from 8:00 AM to 8:10 AM, Nursing Assistant (NA)-C confirmed Resident 26 was to have the following fall prevention interventions: -Bed in low position whenever resident in bed. -Scoop mattress to bed. -Sensor alarm to bed. -TABs alarm when in wheelchair and when in bed. -Sensor alarm to the door of the resident's room. Mattress on the floor next to resident's bed when resident in bed. NA-C further identified Resident 26 was frequently confused and the resident had significant impaired safety awareness. Interview with the Director of Nursing (DON) on 2/23/16 from 9:20 AM to 10:00 AM, revealed facility staff were to assess each resident fall and identify causal factors. New interventions were to be developed or current interventions were to be revised after each fall to prevent ongoing falls. Resident 26 remained at high risk for falls with injury and fall prevention interventions should be implemented as identified on the resident's individualized plan of care. The DON confirmed causal factors were not identified and interventions were not revised or new interventions developed after each of Resident 26's falls.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on observations, record review and interviews; the facility failed to implement nutritional interventions to address significant weight loss for Resident 26 and to provide supervision with eating for Resident 28 who was at risk for weight loss. Facility census was 36. Findings are: A. Review of Resident 26's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/18/16 revealed [DIAGNOSES REDACTED]. The MDS indicated the resident required supervision with eating, weight was 113 pounds, and the resident was on a mechanically altered (diet which includes foods which can be easily chewed and swallowed) therapeutic diet. Review of Resident 26's Care Plan dated 9/1/15 indicated the resident had inadequate oral intakes and a poor appetite. Dietary interventions included the following: -Resident to sit at an assisted table in order to receive help with meals. -Supplements as ordered for weight loss prevention and to meet the resident's nutritional needs. -Provide mechanical soft diet as ordered. Review of a Registered Dietician's (RD) Note dated 9/1/15 revealed documentation the resident had an order dated 8/26/15 for a Mighty Shake (frozen nutritional supplement with additional calories and protein) 4 ounces (oz.) BID (twice a day). The RD further indicated Resident 26 had accepted the supplement only once since it was initiated. The RD made a recommendation to discontinue the Mighty Shake and recommended Med Pass (nutritional shake with additional calories and protein) 120 cubic centimeters (cc) BID. Review of Resident 26's Medication Administration Record [REDACTED]. Review of a Dietary Progress Note dated 9/8/15 at 1:15 PM revealed the RD observed Resident 26 at the noon meal and due to continued poor intakes (0-25 percent) the RD recommended Breeze (fruit flavored drink with additional calories and protein) supplement 4 oz. daily. The RD indicated a facsimile (fax) was to be sent to the resident's physician to obtain an order for [REDACTED].>Review of a RD Note dated 9/15/15 revealed the 4 oz. of Breeze supplement was initiated on 9/15/15 (7 days after the RD recommendation). Review of Resident 26's Bath Sheet (form used to document bath dates and weights) revealed the resident's weight on 9/22/15 was 124 pounds. Further review revealed the resident's weight on 9/28/15 was 118 pounds. (4.8% weight loss in 6 days). Review of a RD Note dated 9/29/15 revealed the resident's intakes remained inadequate at meals. No further recommendations were made. Review of a Dietary Progress Note dated 10/14/15 at 12:46 PM revealed the resident continued to receive 120 cc of Med Pass BID and 4 oz. of Breeze once a day. However, the resident was no longer drinking the Breeze supplement. The RD made a recommendation to change the Breeze to a Mighty Shake 4 oz. every day. Review of a Dietary Progress Note dated 10/21/15 (7 days after recommendation by the RD) at 1:35 PM revealed the Breeze supplement was discontinued and Mighty Shake 4 oz. was initiated at breakfast. Review of Resident 26's Bath Sheet revealed the resident's weight on 10/23/15 was 116 pounds (a significant weight loss of 6.4% in 1 month). Review of a Fax Communication to Physician form dated 12/3/15 revealed the RD sent a recommendation to discontinue the Med Pass 120 cc due to the resident's refusal and to initiate Mighty Shakes 4 oz. TID (three times a day). Review of Resident 26's medical record revealed the nutritional intervention for Mighty Shakes 4 oz. TID was not implemented until 12/18/15 (15 days after the RD's recommendation). Review of Resident 26's Bath Sheet revealed the resident's weight on 12/29/15 was 113 pounds (a significant weight loss of 8.9% in 3 months). Review of an RD Note dated 1/6/16 revealed a recommendation to reduce the Mighty Shake supplement from TID to BID as the resident was refusing it. Review of a Dietary Progress Note dated 1/12/16 at 1:52 PM revealed a physician's orders [REDACTED]. Review of Resident 26's Bath Sheet on 1/29/16 revealed the resident's weight was 110 pounds (11.3% weight loss in 4 months). During interview on 2/22/16 from 11:00 AM to 11:20 AM, the Dietary Manager (DM) confirmed Resident 28 had a significant weight loss and weight loss interventions were not implemented when recommended by the RD to manage the resident's nutritional needs. B. Review of Resident 28's MDS dated [DATE] indicated the resident had [DIAGNOSES REDACTED]. Review of the current Care Plan revised on 2/16/16 revealed Resident 28 had nutritional problems, and the goal was to maintain the usual body weight (UBW) range within 5 pounds of 125 pounds. Interventions included the following: - Magic Cup (a nutritional supplement) BID, - sit at a cued table at meals to help encourage good oral intakes, - offer snacks from the snack cart 3 times daily, and - enjoys ice cream and snacks at activities. Review of a Full Nutrition Assessment by the RD dated 1/26/16 indicated Resident 28 was at moderate risk for nutritional problems, was receiving Magic Cup BID at noon and 6:00 PM, and had weights stable at 124 pounds over the last 6 months. Review of electronic documentation of weights indicated Resident 28 weighed 124 pounds on 2/2/16. The following observations were made of Resident 28 on 2/22/16: - 9:02 AM-A staff person delivered a breakfast tray to the room exited. - 9:02 AM until 10:03 AM-The resident was seated in a chair in room with eyes closed. The breakfast plate was in the resident's lap and contained a fried egg, bacon, toast and a bowl of hot cereal. The food tray was on the mattress at the foot of the bed and holding a glass of orange juice and a cup of coffee with cellophane coverings. No one was observed to enter the room to cue the resident or offer assistance. - 10:03 AM until 10:11 AM-The resident wakened enough to put a spoonful of cereal to mouth, then immediately placed the spoon back into the bowl without taking a bite. When asked how breakfast was the resident responded oh, it's alright. The hot cereal was observed to be congealed. The resident closed eyes and continued to sit in the chair without eating. No one was observed to enter the room to cue the resident or offer assistance. - 10:11 AM (1 hour and 9 minutes after the breakfast tray was delivered to Resident 28) until 10:12 AM-Nursing Assistant (NA)-C entered the room with a mug of fresh water and asked the resident if finished with breakfast. The resident responded no. NA-C responded that's good, you just keep on eating and exited the room without offering assistance. - 10:12 AM until 10:15 AM-The resident remained in the chair with eyes closed and breakfast meal positioned in lap. - 10:15 AM-NA-D entered the room, offered juice from the snack cart, poured the juice, handed it to the resident, and exited the room. No cueing or assistance was offered. The resident initially took sips of the juice, then closed eyes and sat without eating or drinking and with the juice glass in hand. - 10:15 AM until 11:11 AM-The resident remained seated in the chair with eyes closed and holding the juice glass in hand and the breakfast plate in lap. The cellophane covered liquids remained on the meal tray on the bed. No one was observed to enter the room to cue the resident or offer assistance. - 11:11 AM until 11:15 AM-Housekeeper-K entered the room and asked Are you done? You ate nothing. Do you want coffee?. The housekeeper placed the plate of food onto the meal tray on the bed, removed the cellophane from the cup of coffee, handed it to the resident and exited the room. The resident took sips from the cup of coffee, then sat with the cup in hand. - 11:15 AM-NA-H entered the room and stated You didn't eat much. Can I take the coffee? It's probably pretty cold. NA-H then took the cup from the resident and the meal tray from the bed and exited the room. During observations of the noon meal on 2/22/16 from 12:29 PM until 12:46 PM, and the breakfast meal on 2/23/16 from 8:18 AM until 8:23 AM, Resident 28 was observed seated at a dining room table located immediately outside the kitchen door. During interview on 2/23/16 at 8:23 AM, the DM identified the cued tables as 2 groupings of tables with 2 tables each, 1 located in the center of the dining room and the other in the far corner of the dining room directly opposite of the table where Resident 28 was seated. (Each of these table groupings had staff members seated at them to provide assistance and cueing to the residents seated at the tables.) The DM verified Resident 28 was not seated at a cued table in accordance with interventions on the Care Plan. Review of the Bath Sheet dated 2/22/16 revealed Resident 28 weighed 121.5 pounds (a 2.5 pounds weight loss since the last weight recorded on 2/2/16).