Every finding on record at Omaha Nursing and Rehabilitation Center

Licensure Reference Number 175 NAC 12-006.09(I)(i)(1). Based on observation, interview and record review, the facility failed to ensure fall interventions were implemented for 1(Resident 2) of 4 residents sampled. The facility census was 57. The findings are: Record review of the facility policy titled Incidents and Accidents dated 12-2023 revealed it is the policy of the facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. The purpose of incident reporting can include:-assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. -meeting regulatory requirements for analysis and reporting of incidents and accidents. Licensed staff will utilize Risk Management to report incidents/accidents and assist with completion of any investigative information to identify root causes. Record review of Resident 2's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored as a 2. According to the MDS Manual a score of 0-7 indicates severe cognitive impairment. -required total assistance with bed mobility, toileting, dressing, personal hygiene, transfers and bathing. Record review of the facility incident log printed on 03-31-2026 revealed Resident 2 had fallen on 11-09-2025 and 03-15-2026.Record review of Resident 2's Comprehensive Care Plan (CCP) printed on 03-31-2026 revealed Resident 2 was at risk for falls related to incontinence, weakness, osteoarthritis to bilateral hips, and history of falls at home. The goal was Resident 2 would not sustain serious injury through the review date. Interventions listed to achieve the goal were as follows:-03-01-2024 Keep call light in reach, ensure resident is wearing proper footwear when ambulating or in the wheelchair, therapy evaluation and treatment per physician orders, and keep needed items in reach. -06-10-2025 Bolster mattress-06-19-2025 Stop sign on bathroom door-08-10-2025 Fall mat at bedside.-9-24-2025 Staff will attempt to engage resident in activities in commons area between meals if not lying down. -11-09-2025 Dycem (a non-slip material used to stabilize objects) to the wheelchair cushion. -03-15-2026 Resident purse to be secured to the wheelchair-03-24-2026 Resident is allowed to use a seat belt in the wheelchair. Resident is able to unbuckle seatbelt independently. An observation conducted on 04-01-2026 at 5:50 AM revealed Resident 2 was in bed and the absence of Dycem on or underneath the wheelchair cushion. An observation conducted on 04-01-2026 at 11:15 AM revealed Resident 2 was in the therapy gym working with therapy and Resident 2's wheelchair did not have Dycem in place on or underneath the wheelchair cushion. An interview conducted on 04-01-2026 at 1:40 PM with the Assistant Director of Nursing (ADON) A confirmed there was no Dycem in place to Resident 2's wheelchair cushion and ADON A had placed a new Dycem in the wheelchair.

Licensure Reference Number 175 NAC 1-005.06(D)Based on observation, interview, and record review; the facility failed to perform hand hygiene between glove changes during the provision of wound care for 1 (Resident 2) of 3 sampled residents. The facility staff identified a census of 50.The findings are:Record review of a facility policy entitled Hand Hygiene revised 10/2022 revealed facility staff were to perform an alcohol-based hand rub containing at least 62 percent (%) alcohol; or alternatively, soap and water before handling clean or soiled dressings, gauze pads, etc.; before moving from a contaminated body site to a clean body site during resident care; after handling used dressings and contaminated equipment; and after removing gloves.Observation on 10/7/2025 from 9:54 AM through 10:05 AM of Licensed Practical Nurse (LPN)-A performing wound care treatments for Resident 2 revealed LPN-A washed hands with soap and water for 32 seconds and donned (applied) a gown and gloves. LPN-A washed the resident's right and left posterior thighs. LPN-A doffed (removed) gloves, and without performing hand hygiene donned a new pair of gloves. LPN-A washed Resident 2's right posterior heel and doffed gloves. Without performing hand hygiene, LPN-A donned new gloves and performed the wound treatment to Resident 2's right posterior heel. LPN-A doffed gloves, and without performing hygiene donned new gloves. LPN-A proceeded with the left and right posterior thigh treatment as ordered, and doffed gloves. Without performing hand hygiene, LPN-A donned new gloves and re-applied the treatment to Resident 2's right posterior heel as ordered. LPN-A doffed gloves, performed hand hygiene, and exited the room.An interview on 10/7/2025 at 10:07 AM with LPN-A confirmed hand hygiene had not been performed between glove changes and should have been.

Licensure Reference Number 175 NAC 12-006.09(H)Based on observation, interview, and record review; the facility failed to implement pain management interventions during the provision of wound care for 1 (Resident 1) of 2 sampled residents. The facility staff identified a census of 50.The findings are:Record review of a facility policy entitled Pain Recognition and Management revised 04/2025 revealed: -2. To the extent possible, staff will: -a. Recognize when a resident is experiencing pain and identify circumstances when pain can be anticipated; -b. Evaluate existing pain and the causes; and -c. Manages or prevents pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. -4. Management: -b. Medication(s) received, refused and response to medication will be documented on the Electronic Medication Administration Record (e-MAR). -c. If the pain management program is not effective, the licensed nurse will contact the resident's physician.Record review of Resident 1's Clinical Census printed on 10/2/2025 showed the facility admitted the resident on 01/24/2025.Record review of Resident 1's Medical Diagnosis printed on 10/2/2025 showed Resident 1 had diagnoses of depression, stage four pressure ulcer of the sacral region, osteoarthritis, and pain in the right knee.Record review of Resident 1's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 07/18/2025 revealed the resident had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 11/15. According to the MDS manual, a score of 11 indicated Resident 1 had moderate cognitive impairment. The MDS identified Resident 1 entered the facility with one stage-four pressure ulcer present on admission. According to the MDS Manual, a stage four press ulcer is a full thickness loss with exposed bone, tendon, or muscle. Further review of the MDS identified the following about Resident 1's Pain during the assessment reference period: -The resident almost constantly had pain or hurting over the last 5 days; -The pain occasionally made it hard for Resident 1 to sleep at night; -The pain frequently limited Resident 1's day-to-day activities; -Resident 1 rated pain at 7 on a scale of 0-10, with 10 being the worst pain. -Resident 1 received opioid pain medication; received scheduled and as-needed (PRN) pain medications, and received non-medication intervention for pain.Record review of Resident 1's Order Summary Report printed 10/02/2025 revealed orders for acetaminophen (non-opioid pain reliever) 1000 milligrams (mg) three times daily and oxycodone (an opioid pain reliever) 5 mg every four hours PRN pain.Record review of Resident 1's October 2025 Medication Administration Record (MAR) printed 10/7/2025 revealed Resident 1 received scheduled acetaminophen on 10/7/2025 at 6:00 AM with a pain rating of 5 out of 10 and administration of PRN oxycodone on 10/7/2025 at 5:17 AM with a pain rating of 5 out of 10.Observation on 10/7/2025 from 10:20 AM to 10:53 AM of Physician Assistant (PA)-B and the Assistant Director of Nursing (ADON) performing a negative pressure wound therapy (NWPT or wound vac, an active wound care treatment that uses controlled sub-atmospheric {negative} pressure to assist and accelerate wound healing. The therapy may be gauze based, foam based, or peel and stick, and includes an evacuation tube and a computerized pump that applies the negative pressure) dressing change revealed a softball sized stage four pressure ulcer approximately three centimeters (cm) deep to Resident 1's sacrum. The wound bed was beefy red and tissues surrounding the wound were intact. There was no noted odor. PA-B performed a wound assessment including measurements while ADON assisted Resident 1 to remain on the left side. PA-B cleansed the wound utilizing wound cleanser and a gauze square. PA-B informed Resident 1 that the cleanser was cold. Upon PA-B cleansing the wound, Resident 1 yelled out Ow! PA-B continued the wound treatment as ordered and placed Amchoplast (a skin substitute used in wound treatment designed to support wound healing and protection of the wound) in the base of the wound and applied drape around the wound. PA-B cut black foam to the size of the wound and placed the black foam in the wound bed. Resident 1 yelled out Ow! was facial grimacing and began to cry while both of Resident 1's shoulders were moving up and down. The ADON began rubbing Resident 1's back and utilized conversation to distract the resident. PA-B continued with the wound treatment and applied the top layer of drape while the ADON held the black foam in place. Resident 1 began crying again and yelled out that hurts! and was whimpering. PA-B and the ADON continued with the wound treatment, and Resident 1 continued crying and facial grimacing and yelling out Ouch! Oww! That Hurts! The wound dressing was completed, and the wound dressing was attached to the wound vac. The ADON powered on the wound vac device and when suction was applied, Resident 1 again yelled out Ow! That hurts! PA-B and the ADON provided verbal encouragement to Resident 1 at that time. Before leaving the room, the ADON asked Resident 1 if they felt better. Resident 1 responded A little bit.Throughout the treatment, neither PA-B nor the ADON stopped the treatment to inquire with the resident if the wound treatment should go on or if the resident's pain needed to be addressed.Interview on 10/7/25 at 10:57 AM with the ADON confirmed that the procedure can be painful and further confirmed that Resident 1 was crying out and yelling out ouch, oww, and that hurts. The ADON reported the resident received an as needed Oxycodone at 5:17 AM and scheduled acetaminophen at 6:00 AM. ADON confirmed a dose of oxycodone should have been administered prior to the treatment but was not.Interview on 10/7/2025 at 11:11 AM with Resident 1 and Licensed Practical Nurse (LPN)-A present, Resident 1 reported pain during the treatment was rated 10 out of 10. Resident 1 stated that's why I was crying. When asked if they would have liked staff to stop the treatment, Resident 1 stated they didn't give me a choice, they just kept going.During a follow-up interview on 10/7/2025 at 2:00 PM, the ADON stated Yes, we could have stopped and offered Resident 1 pain medication, but I feel like the response would have been the same.

Licensure Reference Number 175 NAC 12-006.09(I) Licensure Reference Number 175 NAC 12-006.09(I)(i)(1)Based on observation, interview, and record review, the facility failed to transfer a resident according to the plan of care resulting in a significant injury for 1 (Resident 32) of 1 resident sampled for transfers; and the facility failed to implement call interventions identified on the plan of care for 1 (Resident 68) of 3 residents sampled for falls. The facility staff identified a census of 64.The findings are:A. Record review of Resident 68’s Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 06-23-2025 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored at a 9. According to the MDS Manual a score of 8-12 indicates a person has moderate cognitive impairment. -required supervision and hands on assistance with transfers, toileting, hygiene and dressing. -had repeated falls. Record review of Resident 68’s Comprehensive Care Plan (CCP) dated 03-10-2025 revealed Resident 68 had an actual fall with no injury due to poor balance, poor communication/ comprehension and unsteady gait. Interventions listed on the care plan were: -03-10-2025 offer to assist resident to the bathroom at 2 AM. -03-14-2025 top blankets clipped to fitted sheet on the bed to prevent them from getting wrapped around the resident’s feet. -03-24-2025 offer to assist the resident to the bathroom at 5 AM. -04-10-2025 staff to ensure the resident has nonskid socks on while in bed. -06-15-2025 nursing staff will not leave resident sitting on the side of the bed unsupervised following an acute change of condition. -06-16-2025 resident is not to be left unattended in the therapy gym. -06-18-2025 Monthly lab work to assess creatinine. An observation on 07-29-2025 at 11:00 AM of Resident 68 lying in bed and the top covers are not pinned to the bottom sheet. An observation on 07-30-2025 at 5:10 AM of Resident 68 sitting on the side of the bed and top covers are not pinned to the bottom sheet. An observation on 07-30-2025 at 1:15 PM of Resident 68 with Nursing Assistant (NA) I confirmed the top covers were not pinned to the bottom sheet. An interview with NA I on 07-30-2025 at 1:20 PM revealed NA I was not aware the top covers needed to be pinned to the bottom sheet. An interview with Licensed Practical Nurse (LPN) D on 07-31-2025 at 9:35 AM confirmed Resident 68’s top covers were not pinned to the bottom sheet and should have been. Record review of the facility policy dated 12-2023 revealed it is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. On admission a fall risk evaluation will be completed to determine the resident risk for sustaining a fall. Resident with high risk factors identified on the fall risk evaluation will have an individualized care plan developed with interventions to prevent falls by addressing the risk factors and the particular elements of the evaluation that put the resident at risk. B. Record review of a facility policy entitled “Activities of Daily Living” revised 7/2015 revealed: A resident’s abilities in ADL’s do not diminish unless circumstance on the individuals' clinical condition demonstrate that diminution was unavoidable. This includes the resident’s ability to: bathe, dress, groom, transfer, ambulate, toilet, eat, and use speech, language, or other functional communication systems. Transfer as defined by the facility’s policy is how a resident moves between surfaces – to/from: bed, chair, wheelchair, standing position. Procedures: 1. The facility interdisciplinary team (IDT, in conjunction with the resident, resident’s family, surrogate, or representative, as appropriate) will develop quantifiable objectives for the highest level of functioning the resident may be expected to attain, based on the comprehensive assessment. The plan of care will be developed in the electronic health record (EHR). 3. Plans of care will include a focus (area of impairment to include what the impairment is related to), measurable and objective goals, and interventions unique to the resident’s needs and strengths. 4. The interventions will be provided by staff in accordance with professional standards of quality and clinical practices. 6. Nursing assistants will provide assistance with ADLs based on the resident’s individualized plan of care. These interventions will be on the Kardex, which ias accessed in Point of Care (POC). Any changes noted in the resident’s performance or abilities will be reported to the licensed nurse. 7. The licensed nurse will evaluate the resident for changes in their ADL status and coordinate necessary services in conjunction with the IDT. 10. If a resident chooses to decline an intervention in the plan of care, the licensed nurse and social services will be notified. The IDT will review the plan of care with the resident in an effort to find alternative means to address the need. Record review of Resident 32’s “Clinical Census” printed 7/27/2025 identified the facility admitted the resident on 4/21/2025. Record review of Resident 32’s “Medical Diagnoses” printed 7/27/2025included cirrhosis of the liver (widespread disruption of normal liver structure by fibrosis and the formation of regenerative nodules that is caused by any of various chronic progressive conditions affecting the liver [such as long-term alcohol abuse or hepatitis]), muscle weakness, generalized edema, and type 2 diabetes mellitus (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production). Record review of Resident 32’s admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident’s functional capabilities and helps nursing home staff identify health problems) dated 5/11/2025 revealed Resident 32 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15. According to the MDS manual, a score of 15 indicated the resident was cognitively intact. Further review of the MDS revealed Resident 32 was dependent upon staff for assistance to transfer from bed to wheelchair. Record review of Resident 32’s Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) revealed as of 5/19/2025, the resident was to be transferred with two staff members using a slide board to get out of bed and wheelchair, or use Hoyer lift with two staff. Record review of Resident 32’s “Progress Notes” dated 7/6/2025 revealed: -Resident was being transferred from bed to wheelchair with two assist, bumped left lower leg on leg of wheelchair where pedals attach resulting in a laceration measuring approximately 4.5 by (x) 6 x 3. Large amount of bleeding, pressure dressing applied after PRN Oxycodone given as per order, 911 notified, here at 7:05 PM to transport resident to hospital. DON notified, note left to update APRN. Resident awake and alert leaving with paramedics per stretcher. assessment of wound. VSS, alert and oriented. -Resident return from ER via ambulance at approximately 9:30 PM with new order of bacitracin 500 unit/gram ointment to be applied 2 times a day. Patient to F/U (follow up) with PCP in 10-14 days for wound re-eval and suture removal. An interview on 7/28/25 at 8:44 AM with Resident 32 revealed the resident sustained a laceration to the left lower leg during a transfer which required transport to the hospital for 11 stitches to be placed. An interview on 7/30/25 at 10:21 with Licensed Practical Nurse (LPN-D) revealed at the time of the incident, Resident 32 was assisted by one staff member. An interview on 7/30/2025 at 10:33 AM with Certified Medication Aide (CMA-E) revealed the only parties involved in the resident transfer were CMA-E and the resident. CMA-E reported after assisting Resident 32 with personal cares in bed, CMA-E turned around to get a blanket to place in the bottom of the wheelchair and when [gender] turned back around, Resident 32 was sitting at the edge of the bed. CMA-E reported that Resident 32 stated that the resident transfers independently without a slide board and instructed CMA-E how to arrange the chair. CMA-E placed the chair as the resident instructed and removed the arm rest from the wheelchair. Resident 32 proceeded to transfer, and CMA-E placed (gender) hand on the small of Resident 32’s back to provide support and guidance. CMA-E revealed that a gait belt was not used because Resident 32 stated that [gender] transferred independently. CMA-E stated that blood was noticed to the left lower leg immediately after Resident 32 was seated in the wheelchair. CMA-E stated it appeared Resident 32 had hit the left lower leg on the wheelchair pedal bracket which are permanently affixed to the wheelchair. A follow up interview on 7/30/2025 at 11:13 AM with CMA-E revealed a resident’s transfer status is determined by the plan of care. CMA-E further revealed other Nursing Assistants had informed [gender] that Resident 32 transferred independently. A follow up interview on 7/30/2025 at 11:22 AM with Resident 32 revealed the only staff member present during the transfer was CMA-E. A follow up interview on 7/30/2025 at 11:53 AM with LPN-D revealed Resident 32’s transfer status was two-person assist at the time of the laceration and further confirmed Resident 32 was transferred with only one staff member.

Licensure Reference Number 175 NAC 12-006.10(D). Based on interview and record review the facility failed to ensure resident's were free of significant medication errors for 1 (Resident 47) of 5 residents sampled. The facility census was 64. The findings are: Record review of Resident 47's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 07-12-2025 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].- had a subarachnoid hemorrhage (bleeding that occurs in the space between the brain and the surrounding membrane).-Brief Interview of Mental Status was scored at a 12. According to the MDS Manual a score of 8-12 indicates moderate cognitive impairment.-required total assistance with toileting-required moderate assistance with bed mobility, toilet transfers and lower body dressing.-required supervision with upper body dressing, and hygiene- was taking high risk medications including antipsychotics, antianxiety, antidepressants, anticoagulants, diuretics, and opioids. Record review of Resident 47's Medication Administration Record (MAR) for July 2025 revealed an order dated 04-08-2025 for Carvedilol 12.5 mg by mouth 2 times a day for high blood pressure and to hold the medication if systolic blood pressure (SBP: the top number of a blood pressure reading) is less than 110 or pulse less than 50. The MAR also revealed on 07-14-2025 at 8am Resident 47's systolic blood pressure was 99 and the carvedilol was administered. Record review of Resident 47's progress note dated 07-16-2025 revealed Resident 47 was at a doctor's appointment and (gender) blood pressure was low and was being sent to the emergency room (ER).Record review of Resident 47's progress note dated 07-17-2025 revealed Resident 47 had returned from the hospital after requiring overnight observation for a hypotensive (low blood pressure) episode at the doctor's office.Record review of Resident 47's MAR for July 2025 revealed an order dated 07-17-2025 revealed an order for Carvedilol 6.25mg by mouth 2 times a day for high blood pressure and to hold the medication if SBP 120 or less. The MAR also revealed the following: -07-17-2025 at 8 PM the SBP was 118 and Carvedilol was administered.-07-18-2025 at 8 the SBP was 117 and Carvedilol was administered.-07-19-2025 at 8 PM the SBP was 104 and Carvedilol was administered.-07-21-2025 at 8 AM the SBP was 120 and the Carvedilol was administered.-07-25-2025 at 8 AM the SBP was 106 and the Carvedilol was administered.-07-25-2025 at 8PM the SBP was 99 and the Carvedilol was administered.-07-27-2025 at 8 AM the SBP was 101 and the Carvedilol was administered. An interview conducted with Licensed Practical Nurse (LPN) D on 07-29-2025 at 10:30 AM confirmed the Carvedilol was given outside of the blood pressure parameters for Resident 47 and was a significant medication error considering the recent hospitalization for hypotension.Record review of the facility policy titled Medication Errors and Adverse Reactions dated 12-2019 revealed nursing service must immediately implement and follow the physician's orders.

Licensure Reference Number NAC 175 12-006.19(A)Based on observations and interviews, the facility failed to ensure an intact door seal was present on a refrigerator in the kitchen, resulting in the potential for inconsistent food temperatures. This had the ability to affect 62 of 64 residents who ate food produced by the kitchen.Findings are:An observation on 7/25/2025 revealed the middle refrigerator door in the kitchen had a broken seal and did not close completely.An observation on 7/30/2025 at 6:15AM with Dietary Aide C of the kitchen refrigerator confirmed the temperature reading on the portable temperature gauge behind the broken seal read 32 degrees.An observation on 7/30/2025 at 6:45AM with the Dietary Manager revealed the temperature reading on the portable temperature gauge behind the broken seal on the refrigerator door revealed the temperature was 41 degrees.An interview on 7/30/2025 at 6:15AM with Dietary Aide C confirmed the temperature gauge behind the broken refrigerator seal read 32 degrees.An interview on 7/30/2025 at 6:45AM with the DM confirmed the refrigerator temperature was not consistent behind the broken refrigerator temperature and could affect the safety of the food in the refrigerator.

Licensure Reference Number 175 NAC 12-006.18B Based on observation, interview and record review, the facility staff failed to use Personal Protective Equipment (PPE (gowns, gloves, masks and face shields)), during cares for 2 (Resident 10 and Resident 16) of 2 sampled residents, which were both identified to require Enhanced Barrier Precautions (EBP (A form of infection control to minimize transmission of infectious disease). Findings are: A.An observation on 07/29/2025 at 10:25 AM revealed a sign on Resident 10's door that indicated the resident was in EBP and the required PPE that should be worn by staff. An observation on 07/29/2025 at 10:25 AM revealed Certified Nursing Assistant-A (CNA) and CNA- B entered Resident 10's room and donned (put gloves on) gloves without performing any hand hygiene. During this observation, CNA-B turned the resident and preformed standard perineal care. CNA-B doffed (removed gloves) gloves, and applied Alcohol Based Hand Rub (ABHR) before donning a new pair of gloves to complete the Perineal care. CNA-B then doffed the gloves and donned a new pair of gloves without hand hygiene and placed a clean incontinent product on resident 10. CNA-B then repositioned Resident 10's head, covered the resident up and lowered the bed without changing gloves or completing hand hygiene. CNA-B doffed gloves into the trash can, tied the trash bag and used ABHR before exiting the room with the trash bag. CNA-A and CNA-B both performed cares without a gown on, and they both verbalized awareness of Resident 10's EBP status. An observation on 07/29/2025 at 10:45 am revealed Resident 10's room had a 3-drawer stand next to the resident's armoire that had all the PPE in it.An interview on 07/29/2025 at 10:34 AM with CNA-A and CNA-B confirmed the CNAs should have had a gown on when performing cares for Resident 10. An observation on 07/30/2025 at 4:59 AM revealed CNA-C in Resident 10's room preforming incontinent care without a gown and only 1 assist. An interview with CNA-C on 07/30/2025 at 5:02 AM revealed CNA-C, admitted Resident 10 was to have EBP precautions with PPE worn with cares. CNA-C admitted no gown was worn during cares for Resident 10. B. An observation on 07/30/2025 at 5:04 AM revealed a sign on Resident 16's door indicating the resident was on EBP precautions. An observation on 07/30/2025 at 5:04 AM revealed Licensed Practical Nurse (LPN)-F entered Resident 16's room and marked the piston syringe without hand hygiene (HH), donned gloves, then continued the G-Tube feeding without a gown. An observation on 07/30/2025 at 6:00 AM revealed the Director of Nursing (DON) entered Resident 16's room and verified the PPE for the resident was under the sink area. An interview on 07/30/2025 at 6:00 AM with the DON revealed there was gowns, and gloves in Resident 16's PPE cart. An interview on 07/30/2025 at 6:00 AM with LPN-F revealed the LPN did not wear a gown or preform HH during the G-tube cares for Resident 16. The facility provided an Infection Control Policy dated 10/2022. The policy is to implement infection control measures to prevent the spread of communicable disease and conditions. The policy identified Enhanced Barrier Protections (EBP): expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident to resident. PPE: The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply.

Licensure Reference Number 175 NAC 12-006.17Based on record review and interview, the facility failed to maintain an accurate medical record for 1 (Resident 32) of 1 sampled resident. The facility staff identified a census of 64.The findings are:Record review of Resident 32's Clinical Census printed 7/27/2025 identified the facility admitted the resident on 4/21/2025.Record review of Resident 32's Medical Diagnoses printed 7/27/2025included cirrhosis of the liver (widespread disruption of normal liver structure by fibrosis and the formation of regenerative nodules that is caused by any of various chronic progressive conditions affecting the liver [such as long-term alcohol abuse or hepatitis]), muscle weakness, generalized edema, and type 2 diabetes mellitus (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production).Record review of Resident 32's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 5/11/2025 revealed Resident 32 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15. According to the MDS manual, a score of 15 indicated the resident was cognitively intact. Further review of the MDS revealed Resident 32 was dependent upon staff for assistance to transfer from bed to wheelchair.Record review of Resident 32's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) revealed as of 5/19/2025, the resident was to be transferred with two staff members using a slide board to get out of bed and wheelchair, or use Hoyer lift with two staff.Record review of Resident 32's Progress Notes dated 7/6/2025 written by Registered Nurse (RN-G) revealed: -Resident was being transferred from bed to wheelchair with two assist, bumped left lower leg on leg of wheelchair where pedals attach resulting in a laceration measuring approximately 4.5 by (x) 6 x 3. Large amount of bleeding, pressure dressing applied after PRN Oxycodone given as per order, 911 notified, here at 7:05 PM to transport resident to hospital. DON notified, note left to update APRN. Resident awake and alert leaving with paramedics per stretcher. assessment of wound. VSS, alert and oriented.An interview on 7/28/25 at 8:44 AM with Resident 32 revealed the resident sustained a laceration to the left lower leg during a transfer which required transport to the hospital for 11 stitches to be placed.An interview on 7/30/25 at 10:21 with Licensed Practical Nurse (LPN-D) who was assigned responsibility for Resident 32 on 7/6/2025, revealed at the time of the incident Resident 32 was assisted by one staff member.An interview on 7/30/2025 at 10:33 AM with Certified Medication Aide (CMA-E) revealed the only parties involved in the resident transfer were CMA-E and the resident.A follow up interview on 7/30/2025 at 11:22 AM with Resident 32 revealed the only staff member present during the transfer was CMA-E.An interview on 7/30/2025 at 12:13 PM with the Director of Nursing (DON), with the Administrator (ADM) present revealed RN-G was a weekend supervisor and RN-G assisted LPN-D with documentation of the resident's laceration.A follow up interview on 7/30/2025 at 12:24 PM with LPN-D confirmed that the progress note dated 7/6/2025 inaccurately stated that Resident 32 was assisted with two staff members.

Licensure Reference Number 175 NAC 12-005 (G) The facility failed to ensure residents were free of unnecessary medications for 1 (Resident 47) of 5 residents sampled. The facility census was 64. The findings are:Record review of Resident 47's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 07-12-2025 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].- had a subarachnoid hemorrhage (bleeding that occurs in the space between the brain and the surrounding membrane).-Brief Interview of Mental Status was scored at a 12. According to the MDS Manual a score of 8-12 indicates moderate cognitive impairment.-required total assistance with toileting-required moderate assistance with bed mobility, toilet transfers and lower body dressing.-required supervision with upper body dressing, and hygiene- was taking high risk medications including antipsychotics, antianxiety, antidepressants, anticoagulants, diuretics, and opioids. Record review of Resident 47's Core LTC Pharmacy admission Medication Regimen Review (AMRR) dated 07-08-2025 revealed routine blood pressure and pulse monitoring was recommended due to hypertension medication Carvedilol. Record review of Resident 47's MAR for July 2025 revealed an order dated 07-17-2025 revealed an order for Carvedilol 6.25mg by mouth 2 times a day for high blood pressure and to hold the medication if Systolic Blood Pressure (SBP: the top number of a blood pressure reading) was 120 or less. The MAR also revealed the following: -07-17-2025 at 8 PM the SBP was 118 and Carvedilol was administered.-07-18-2025 at 8 the SBP was 117 and Carvedilol was administered.-07-19-2025 at 8 PM the SBP was 104 and Carvedilol was administered.-07-21-2025 at 8 AM the SBP was 120 and the Carvedilol was administered.-07-25-2025 at 8 AM the SBP was 106 and the Carvedilol was administered.-07-25-2025 at 8PM the SBP was 99 and the Carvedilol was administered.-07-27-2025 at 8 AM the SBP was 101 and the Carvedilol was administered. An interview with the Director of Nursing (DON) on 07-28-2025 at 3:45 PM confirmed that Carvedilol was administered when the SBP was too low and should not have been. Furthermore, the DON confirmed the AMRR was not acted upon by the facility. Record review of the facility policy Medication Regimen Review (MRR) dated 08-2017 revealed the following:-it is the policy of this facility that the drug regimen of each resident, which includes a review of the resident's medical chart; will be reviewed at least once a month by a licensed pharmacist. Irregularities will be documented on a separate written report and list the residents name, the relevant drug, and the irregularity the pharmacist identified. These reports will be sent to the facility to be acted upon.-admission orders for residents of the facility will undergo an admission Medication Regimen Review by a Licensed Pharmacist as part of the admission process.-the MRR includes identification of irregularities, medication-related errors, adverse consequences and use of unnecessary drugs.-An unnecessary drug is defined as medication ordered:-in excessive dosage (including duplicate drug therapy)-for excessive duration-without adequate monitoring-without adequate indications for its use-in the presence of adverse consequences which indicate the dose should be reduced or discontinued.

Licensure Reference Number 175 NAC 12-006.09 The facility failed to notify the practitioner of irregularities identified in the admission medication regimen review for 1 (Resident 47) of 1 resident's sampled. The facility census was 64. The findings are:Record review of Resident 47's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 07-12-2025 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].- had a subarachnoid hemorrhage (bleeding that occurs in the space between the brain and the surrounding membrane).-Brief Interview of Mental Status was scored at a 12. According to the MDS Manual a score of 8-12 indicates moderate cognitive impairment.-required total assistance with toileting-required moderate assistance with bed mobility, toilet transfers and lower body dressing.-required supervision with upper body dressing, and hygiene- was taking high risk medications including antipsychotics, antianxiety, antidepressants, anticoagulants, diuretics, and opioids. Record review of Resident 47's Medication Administration Record (MAR) revealed the following orders:-antipsychotic medication (medications that alter brain chemistry to help reduce psychotic symptoms like hallucinations)Seroquel 12.5mg at 5 AM, Seroquel 50mg at 1 PM, and Seroquel 100mg at bedtime dated 07-07-2025 and haloperidol 1mg twice a day dated 07-07-2025.-antidepressant medication (medications used to treat depression)sertraline 50mg daily dated 07-08-2025, and trazadone 100 mg at bedtime dated 07-08-2025 and an order for trazadone dated 07-08-2025 100mg as needed for insomnia without a stop date.-antianxiety medications (medications that calm the nervous system)buspirone HCL 5mg twice a day dated 07-08-2025 and clonazepam 0.5mg twice a day dated 07-08-2025. Record review of Resident 47's Core LTC Pharmacy admission Medication Regimen Review (AMRR) dated 07-08-2025 revealed the Licensed Pharmacist noted the following:-the resident was receiving psychotropic medications, please ensure there is a proper diagnosis to support use along with behavior and side effect monitoring for clonazepam, buspirone HCL, haloperidol, trazadone, sertraline and Seroquel.-recommend Antipsychotic Monitoring Form or monitoring for tardive dyskinesia (a drug induced movement disorder characterized by involuntary, repetitive and sometimes sudden movements of the face, limbs and trunk.-resident is on an as needed psychotropic medication, trazadone if physician does not want to discontinue the medication in 14 days please provide the rationale and duration of continued use.-duplicate therapy to treat specific disease states, please review antidepressants trazadone and sertraline and antipsychotics Seroquel and haloperidol-resident is currently on a medication for insomnia, consider a 3-day sleep study and complete a sleep assessment. Record review of Resident 47's Electronic Health Record (EHR) revealed no indication the AMRR recommendations were acted upon. An interview with the Director of Nursing on 07-30-2025 at 2:41 PM confirmed the AMRR was not acted upon by the facility staff. Record review of the facility policy Medication Regimen Review (MRR) dated 08-2017 revealed the following:-it is the policy of this facility that the drug regimen of each resident, which includes a review of the resident's medical chart; will be reviewed at least once a month by a licensed pharmacist. Irregularities will be documented on a separate written report and list the resident's name, the relevant drug, and the irregularity the pharmacist identified. These reports will be sent to the facility to be acted upon.-admission orders for residents of the facility will undergo an admission Medication Regimen Review by a the Licensed Pharmacist as part of the admission process.-the MRR includes identification of irregularities, medication-related errors, adverse consequences and use of unnecessary drugs.-An unnecessary drug is defined as medication ordered:-in excessive dosage (including duplicate drug therapy)-for excessive duration-without adequate monitoring-without adequate indications for its use-in the presence of adverse consequences which indicate the dose should be reduced or discontinued.

Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g)Based on observation, interview, and record review, the facility failed to obtain and implement physician's orders for the use of a continuous positive airway pressure (CPAP) non-invasive ventilator for 1 (Resident 65) of 1 sampled resident. The facility staff identified a census of 64.The findings are:Record review of Resident 65's admission Record printed 7/29/2025 revealed the facility admitted the resident on 5/29/2025. Further review of the admission record identified Resident 65 had diagnoses which included atrial fibrillation (a-fib, very rapid uncoordinated contractions of the atria of the heart resulting in a lack of synchronism between heartbeat and pulse beat), anxiety an abnormal and overwhelming sense of apprehension and fear often marked by physical signs, by doubt concerning the reality and nature of the threat, and by self-doubt about one's capacity to cope with it), heart failure, chronic obstructive pulmonary disease (COPD, pulmonary disease that is characterized by chronic typically irreversible airway obstruction resulting in a slowed rate of exhalation), and tobacco use.Record review of Resident 65's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 6/2/2025 identified the resident had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 13. According to the MDS manual, a score of 13 indicated the resident was cognitively intact. Further review of the MDS revealed non-invasive ventilator was not selected on the assessment.Record review of Resident 65's Progress Notes dated 5/29/2025 revealed a statement that the resident wears a BiPAP at night on each of the following dates: 6/6/2025, 6/10/2025, 6/11/2025, 6/17/2025, 6/21/2025, 6/22/2025, 6/23/2025, and 7/1/2025.Record review of Resident 65's electronic health record (EHR) including physician's orders, medication administration records (MAR), treatment administration records (TAR), comprehensive care plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment), and scanned documents lacked any entry regarding Resident 65's use of a BiPAP device.An observation on 7/28/2025 at 7:44 AM revealed a BiPAP machine, mask, and tubing sitting at Resident 65's bedside. The BiPAP mask was observed laying directly on the bedside table with no barrier. The mask seal was shiny and oily, and debris was noted inside the facemask.An observation on 7/29/2025 at 11:18 AM revealed a BiPAP machine, mask, and tubing sitting on the bedside table. The mask had no barrier or bag to store it in. The mask seal was shiny and oily, and debris was noted inside the facemask.An interview on 7/29/2025 at 11:34 AM with Licensed Practical Nurse (LPN-D) revealed that the BiPAP mask should be in a bag when not in use and if the resident is able to remove the mask independently, the facility staff would have a bag for the resident to place the mask in once it was removed. LPN-D confirmed that there was no bag for the BiPAP mask available in the room. LPN-D confirmed that the mask and seal appeared dirty. LPN-D further confirmed that there were no orders for either the use of the BiPAP machine, or the cleaning of the BiPAP equipment.An interview on 7/29/2025 at 2:40 PM with the Director of Nursing (DON) confirmed the DONs expectation is that there were orders for the use and cleaning of the BiPAP machine.

Licensure Reference Number 175 NAC 12-006.09(H)(iv)(1). Based on observation, interview and record review, the facility failed to perform catheter care in a manner to prevent cross contamination for Resident 9; and the facility failed to assess an indwelling catheter for continued use for Resident 7. The facility census was 64. The findings are: A.Record review of Resident 9's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 06-16-2025 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored at 12. According to the MDS Manual a score of 8-12 indicates a person has moderate cognitive impairment. -required total assistance with hygiene, dressing, toileting, bathing, bed mobility and transfers. -had a urinary catheter. Record review of the Resident 9's Order Summary Report (OSR) printed on 07-30-2025 revealed an order dated 06-12-2025 for indwelling catheter care every shift. Observation on 07-30-2025 at 9:40 AM of Nursing Assistant (NA) J providing catheter care to Resident 9 revealed NA J used a disposable wipe and wiped around the catheter insertion site, then discarded the wipe in the trash. NA J obtained another disposable wipe and starting at the insertion site of the catheter, wiped down the tubing (down from the resident) and back (towards the resident) without folding or changing the wipe. Licensed Practical Nurse (LPN) D was present during the observation. An interview conducted with LPN D on 07-30-2025 at 10:00 AM confirmed NA J used a back-and-forth motion while providing catheter care and should not have. Record review of the facility policy titled Indwelling Catheter Care dated 06-22-2023 revealed it is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and as needed for soiling. The purpose of the policy is to promote hygiene, comfort, and decrease the risk of infection for a resident with an indwelling catheter. Under the section Procedure using a disposable wipe, clean the catheter in a downward motion beginning at the insertion point and at least 4 inches down (from the resident toward the collection bag). Use a fresh disposable wipe for one cleansing motion. B. Record review of Resident 7's Census List printed 7/27/2025 revealed the facility admitted the resident on 1/24/2025. Record review of Resident 7's Medical Diagnoses printed 7/27/2025 identified the resident had diagnoses which included nontraumatic chronic subdural hemorrhage (a collection of blood that forms between the brain and its outer covering), traumatic brain injury and osteoarthritis. Record review of Resident 7's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 4/19/2025 identified the resident had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 12. According to the MDS manual, a score of 12 indicated the resident had moderate cognitive impairment. The MDS further identified Resident 7 had an indwelling urinary catheter (flexible tubing inserted into the bladder used to drain urine). Record review of Resident 7's Order Summary Report and Treatment Administration Record (TAR) printed 7/30/2025 revealed an order dated 4/16/2025 that read Indwelling Catheter #16 French (Fr, size of catheter), 10 milliliter (mL) balloon to closed drainage system. The diagnosis to support the use of the catheter was left blank. Record review of Resident 7's Office Visit Form dated 5/8/2025 revealed Resident 7 was seen on 75/8/2025 by urology with orders to continue the indwelling urinary catheter, change catheter every four weeks, okay for PRN (as needed) changes if indicated with 30-50 mL sterile water flushes, and to return to urology PRN. The form lacked a diagnosis for the continued use of the catheter. An interview on 7/31/2025 at 7:48 AM with the Director of Nursing (DON) revealed the facility does not perform an assessment for continued use of indwelling urinary catheters. A follow up interview on 7/31/2025 at 8:30 AM with the DON revealed the facility does not have a policy regarding the assessment for continued use of indwelling urinary catheters.

Licensure Reference Number 12-006.09(H)(v)Based on observation, interview, and record review, the facility failed to implement interventions to prevent a potential decrease in range of motion for 1 (Resident 7) of 1 sampled resident. The facility staff identified a census of 64.The findings are:Record review of a facility policy entitled Adaptive Equipment dated revised 10/2023 revealed:It is the policy of this facility to evaluate and provide adaptive equipment for residents who have been identified for at risk for contractures, skin breakdown, etc.Procedures: 1. On admission the resident will be assessed for needs for adaptive devices. 2. Residents needing adaptive equipment will be screened by therapy or nursing and equipment will be supplied for respective resident. 3. Residents will be assessed quarterly for continued needs of the adaptive equipment.Record review of Resident 7's Census List printed 7/27/2025 revealed the facility admitted the resident on 1/24/2025.Record review of Resident 7's Medical Diagnoses printed 7/27/2025 identified the resident had diagnoses which included nontraumatic chronic subdural hemorrhage (a collection of blood that forms between the brain and its outer covering), traumatic brain injury and osteoarthritis.Record review of Resident 7's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 4/19/2025 identified the resident had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 12. According to the MDS manual, a score of 12 indicated the resident had moderate cognitive impairment. The MDS further identified Resident 7 had a limitation in range of motion (ROM) to one upper extremity.Record review of Resident 7's Order Summary Report and Treatment Administration Record (TAR) printed 7/30/2025 revealed an order dated 5/19/2025 to apply left arm brace at night and remove in the morning every day to prevent contractures with documentation throughout the month of July that showed the splint was applied as ordered.Record review of Resident 7's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) revealed an intervention dated 5/20/2025 that read please put on left arm brace at night, remove in morning when [gender] gets up.Record review of Resident 7's Occupational Therapy Outpatient Therapy Daily Treatment Note (OT Note) dated 5/19/2025 revealed the resident was fitted with a resting hand splint and Resident 7 was able to wear the splint all day without complaints of pain or discomfort. Further review of the OT Note revealed the therapist created an ADL communication form for CNAs and discussed the wearing schedule with the resident and the resident's family member. Parties verbalized understanding of the need to wear at night and off during the day to prevent contractures and maintain range of motion.Record review of Resident 7's Occupational Therapy Outpatient Discharge Summary dated 7/1/2025 revealed training was provided to the resident and primary caregivers in positioning/pressure relieving techniques, positioning maneuvers, functional maintenance program, compensatory strategies and splinting/orthotic schedule specifically, to decrease pain, contracture and increase ROM in left upper extremity (LUE) in order to preserve current level of function and prevent decline from current level of skill performance with 100% carryover demonstrated.Record review of Resident 7's Progress Notes dated 6/1/2025 through 7/30/2025 showed no notes regarding the brace, including whether it was refused or removed.An observation on 7/28/2025 at 2:18 PM revealed Resident 7 with contractures to the fourth and fifth digits on the left hand. The fourth and fifth digits were tucked close to the palm while the remaining digits remained freely moveable.An observation on 7/30/2025 at 5:14 AM revealed Resident 7 lying in bed without a splint applied to the left arm. The splint was observed lying on a table near the door and out of the resident's reach.An observation on 7/31/2025 at 6:04 AM revealed Resident 7 lying in bed without a splint applied to the left arm. The splint was observed lying on the table near the door and out of the resident's reach.During an interview on 7/28/2025 at 2:18 PM, Resident 7 reported that a splint was to be applied to the left arm. Resident 7 further reported that a brace has never been applied to her arm.An interview on 7/31/2025 at 6:07 AM with Nursing Assistant (NA-H) confirmed the brace was not in place. NA-H reported this being the first date a brace had been observed in the room.

Licensure Reference Number 175 NAC 12-006.09(E)Licensure Reference Number 175 NAC 12-006.09(F)(iii)Based on observation, interview, and record review, the facility failed to develop a respiratory care plan including the use of a bilevel positive airway pressure (BiPAP, a technique that is used for relieving breathing problems (such as those associated with sleep apnea or congestive heart failure) by pumping a flow of air through the nose to prevent the narrowing or collapse of air passages or to help the lungs expand) non-invasive ventilator for 1 (Resident 65) of 1 sampled resident. The facility staff identified a census of 64.The findings are:Record review of a facility policy entitled Care Planning dated reviewed 5/2021 revealed: -It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The care plan will be revised as needed, and interventions will be implemented. 3. The care plan will be revised as needed for resident changes in condition, and interventions will be implemented as appropriate.Record review of Resident 65's admission Record printed 7/29/2025 revealed the facility admitted the resident on 5/29/2025. Further review of the admission record identified Resident 65 had diagnoses which included atrial fibrillation (a-fib, very rapid uncoordinated contractions of the atria of the heart resulting in a lack of synchronism between heartbeat and pulse beat), anxiety an abnormal and overwhelming sense of apprehension and fear often marked by physical signs, by doubt concerning the reality and nature of the threat, and by self-doubt about one's capacity to cope with it), heart failure, chronic obstructive pulmonary disease (COPD, pulmonary disease that is characterized by chronic typically irreversible airway obstruction resulting in a slowed rate of exhalation), and tobacco use.Record review of Resident 65's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 6/2/2025 identified the resident had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 13. According to the MDS manual, a score of 13 indicated the resident was cognitively intact. Further review of the MDS revealed non-invasive ventilator was not selected on the assessment.Record review of Resident 65's Progress Notes dated 5/29/2025 revealed a statement that the resident wears a BiPAP at night on each of the following dates: 6/6/2025, 6/10/2025, 6/11/2025, 6/17/2025, 6/21/2025, 6/22/2025, 6/23/2025, and 7/1/2025.Record review of Resident 65's electronic health record (EHR) including physician's orders, medication administration records (MAR), treatment administration records (TAR), comprehensive care plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment), and scanned documents lacked any entry regarding Resident 65's use of a BiPAP device.An observation on 7/28/2025 at 7:44 AM revealed a BiPAP machine, mask, and device tube sitting at Resident 65's bedside.An observation on 7/29/2025 at 11:18 AM revealed a BiPAP machine, mask, and device tube sitting on the bedside table.An interview on 7/29/2025 at 11:34 AM with Licensed Practical Nurse (LPN-D) confirmed the use of the BiPAP. LPN-D further confirmed the CCP did not identify the use of the BiPAP listed and should have.

Licensure Reference Number 175 NAC 12-006.09 (c)(ii)Based on interview and record review, the facility failed to perform a significant change assessment for 1 (Resident 44) of 21 sampled residents. The facility staff identified a census of 64.Record review of the Centers for Medicare and (&) Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's (RAI) Manual dated October 2023 revealed: -A significant change is a major decline or improvement in a resident's status that: -1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; -2. Impacts more than one area of the resident's health status; and -3. Requires interdisciplinary review and/or revision of the care plan. -When a resident's status changes and it is not clear whether the resident meets the significant change in status assessment guidelines, the nursing home may take up to 14 days to determine whether the criteria are met.Record review of Resident 44's admission Record printed 7/29/2025 identified the facility admitted the resident on 2/5/2025 and included the following diagnoses: unspecified severe protein-calorie malnutrition; dehydration; hypokalemia; and dysphagia. Further review of the admission record revealed a new diagnosis of malignant neoplasm (cancerous tumor) of the esophagus dated 7/15/2025.Record review of Resident 44's Census List printed 7/29/2025 revealed the facility transferred the resident to the hospital on 7/8/2025. Further review of the Census List revealed the resident re-entered the facility on 7/15/2025.Record review of Resident 44's Order Summary Report printed 7/29/2025 revealed orders that the resident was to have nothing by mouth (NPO) and enteral tube feeding four times a day for Gastrostomy tube (g-tube).Record review of Resident 44's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 5/8/2025 identified Resident 44 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 10. According to the MDS manual, a score of 10 indicated the resident had moderate cognitive impairment.Record review of Resident 44's MDS records revealed an incomplete quarterly and 5-day assessment dated [DATE]. 7/29/2025 marked day 15 post significant change in status.An interview on 7/29/2025 at 1:40 PM with the MDS Coordinator (MDSC) confirmed Resident 44's MDS dated [DATE] should have been completed as a significant change in status assessment.An interview on 7/30/2025 at 6:32 AM with the Director of Nursing revealed the facility does not have a policy on MDS completion. Instead, the facility staff were to follow the RAI manual.

Licensure Reference Number 175 NAC 12-006.02(H)Based on record review and interview, the facility failed to investigate a resident transfer which resulted in significant injury for 1 (Resident 32) of 1 resident sampled. The facility staff identified a census of 64.The findings are:Record review of a facility policy entitled Abuse: Prevention of and Prohibition Against dated revised 10/2022 revealed:The facility will provide oversight and monitoring to ensure that its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be from [sic] abuse, neglect, misappropriation of resident property, and exploitation.This policy applies to all facility staff including, but not limited to, employees, consultants, contractors, volunteers, students, and other caregivers who provide care and services to residents on behalf of the facility.Definitions:Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.E. Identification:1. Facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor or the facility administrator immediately. The facility will assist staff in identifying abuse, neglect, and exploitation of residents, and misappropriation of resident property. This includes identifying the different types of abuse-mental/verbal, sexual, physical, and the deprivation by an individual of goods or services.2. Because some cases of abuse are not directly observed, understanding resident outcomes of abuse can assist in identifying whether abuse is occurring or has occurred. Possible indicators of abuse include, but are not limited to: -Bruises, skin tears and injuries of unknown source; -Extensive injuries; -Injuries in an unusual location; -Occurrences, patterns, and trends that may constitute abuse; -Episodes of resident to resident altercation, willful or accidental, with or without injury; -Sudden or unexplained changes in behaviors or activities (e.g., fear of a person or place, feelings of guilt or shame, etc.).F. Investigation1. All identified events are reported to the Administrator immediately.2. After receiving the allegation, and during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm.3. A licensed nurse will immediately examine the resident upon receiving reports of alleged physical or sexual abuse. The findings of the examination shall be recorded in the resident's medical record.4. All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee.5. The investigation will include the following: -An interview with the person(s) reporting the incident; -An interview with the resident(s); -Interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate; -A review of the resident's medical record; -An interview of with staff members (on all shifts) who may have information regarding the alleged incident; -An interview with staff members (on all shifts) having contact with the accused employee; and -A review of all circumstances surrounding the incident.6. To the extent there is evidence that could be used in a criminal investigation, staff will immediately notify the Administrator or his/her designee. Staff are not to tamper with or destroy any such evidence at any time.7. At the conclusion of the investigation, the facility will attempt to determine if abuse, neglect, misappropriation of resident property, or exploitation occurred.8. The investigation, and the results of the investigation, will be documented.9. All phases of the investigation will be kept confidential in accordance with the Facility's policies governing the confidentiality of medical records and privilege of quality assurance/quality improvement programs. 6. At the conclusion of the investigation, the facility will take action, as necessary, in light of the information gathered, which may include but is not limited to: -If the allegation is substantiated, analyzing the occurrence to determine why abuse, neglect, misappropriation of resident property, or exploitation occurred, and determining what changes are needed to prevent further occurrences; -Defining how care provision will be changed and/or improved to protect residents receiving services, if appropriate; -Training staff on changes made and demonstration of staff competency after training is implemented; -Identifying staff responsible for the implementation of corrective action; -The expected date for implementation; and -Identifying staff responsible for monitoring the implementation of the plan.Record review of Resident 32's Clinical Census printed 7/27/2025 identified the facility admitted the resident on 4/21/2025.Record review of Resident 32's Medical Diagnoses printed 7/27/2025included cirrhosis of the liver (widespread disruption of normal liver structure by fibrosis and the formation of regenerative nodules that is caused by any of various chronic progressive conditions affecting the liver [such as long-term alcohol abuse or hepatitis]), muscle weakness, generalized edema, and type 2 diabetes mellitus (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production).Record review of Resident 32's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 5/11/2025 revealed Resident 32 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15. According to the MDS manual, a score of 15 indicated the resident was cognitively intact. Further review of the MDS revealed Resident 32 was dependent upon staff for assistance to transfer from bed to wheelchair.Record review of Resident 32's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) revealed as of 5/19/2025, the resident was to be transferred with two staff members using a slide board to get out of bed and wheelchair, or use Hoyer lift with two staff.Record review of Resident 32's Progress Notes dated 7/6/2025 revealed: -Resident was being transferred from bed to wheelchair with two assist, bumped left lower leg on leg of wheelchair where pedals attach resulting in a laceration measuring approximately 4.5 by (x) 6 x 3. Large amount of bleeding, pressure dressing applied after PRN Oxycodone given as per order, 911 notified, here at 7:05 PM to transport resident to hospital. DON notified, note left to update APRN. Resident awake and alert leaving with paramedics per stretcher. assessment of wound. VSS, alert and oriented. -Resident return from ER via ambulance at approximately 9:30 PM with new order of bacitracin 500 unit/gram ointment to be applied 2 times a day. Patient to F/U (follow up) with PCP in 10-14 days for wound re-eval and suture removal.Record review of a Skin Alteration document dated 7/6/2025 revealed: -Incident Description: Resident was being transferred from bed to wheelchair with two assist, bumped left lower leg on leg of wheelchair where pedals attach resulting in a laceration measuring approximately 4.5 x 6 x 3. Large amount of bleeding, pressure dressing applied after assessment of wound. VSS, alert and oriented. -Immediate action taken: PRN (as needed) Oxycodone given as per order, 911 notified, here at 7:05 PM to transport resident for sutures. DON notified, note left to update APRN. -Agencies/People Notified: Dr. [NAME] 7/6/2025.Record review of Resident 32's Medication and Treatment Administration Records dated July 2025 revealed the following orders dated 7/6/2025: bacitracin (antibiotic ointment) to be applied to Resident 32's left lower leg laceration twice daily; change of condition monitoring related to laceration to left lower extremity with sutures; and follow up with primary care provider for wound re-evaluation and suture removal in 10-14 days.An interview on 7/28/25 at 8:44 AM with Resident 32 revealed the resident sustained a laceration to the left lower leg during a transfer which required transport to the hospital for 11 stitches to be placed.An interview on 7/30/25 at 10:21 with Licensed Practical Nurse (LPN-D) revealed at the time of the incident, Resident 32 was assisted by one staff member.An interview on 7/30/2025 at 10:33 AM with Certified Medication Aide (CMA-E) revealed the only parties involved in the resident transfer were CMA-E and the resident. CMA-E reported after assisting Resident 32 with personal cares in bed, CMA-E turned around to get a blanket to place in the bottom of the wheelchair and when [gender] turned back around, Resident 32 was sitting at the edge of the bed. CMA-E reported that Resident 32 stated that the resident transfers independently without a slide board and instructed CMA-E how to arrange the chair. CMA-E placed the chair as the resident instructed and removed the arm rest from the wheelchair. Resident 32 proceeded to transfer, and CMA-E placed her hand on the small of Resident 32's back to provide support and guidance. CMA-E revealed that a gait belt was not used because Resident 32 stated that [gender] transferred independently. CMA-E stated that blood was noticed to the left lower leg immediately after Resident 32 was seated in the wheelchair. CMA-E stated it appeared Resident 32 had hit the left lower leg on the wheelchair pedal bracket which are permanently affixed to the wheelchair.A follow up interview on 7/30/2025 at 11:13 AM with CMA-E revealed a resident's transfer status is determined by the plan of care. CMA-E further revealed other Nursing Assistants had informed [gender] that Resident 32 transferred independently.A follow up interview on 7/30/2025 at 11:22 AM with Resident 32 revealed the only staff member present during the transfer was CMA-E. Resident 32 further revealed that Resident 32 did not tell CMA-E that they transferred independently, and at the time of the injury CMA-E said, that's my fault and I'm so sorry. Resident 32 said CMA-E did not mean for the resident to get hurt.A follow up interview on 7/30/2025 at 11:53 AM with LPN-D confirmed Resident 32's transfer status as listed on the care plan was two-person assist at the time of the laceration and Resident 32 was transferred with only one staff member.An interview on 7/30/2025 at 12:13 PM with the Director of Nursing (DON) with the Administrator (ADM) present revealed the DON would complete an investigation when needed. The DON reported according to the documentation within the medical record, Resident 32's care plan was being followed. The DON confirmed that the investigation into Resident 32's laceration was incomplete.

Licensure Reference Number 175 NAC 12-006.02(H)The facility failed to report a transfer which resulted in significant injury to the State Agency for 1 (Resident 32) of 1 resident sampled. The facility staff identified a census of 64.The findings are:Record review of a facility policy entitled Abuse: Prevention of and Prohibition Against dated revised 10/2022 revealed:The facility will provide oversight and monitoring to ensure that its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be from [sic] abuse, neglect, misappropriation of resident property, and exploitation.This policy applies to all facility staff including, but not limited to, employees, consultants, contractors, volunteers, students, and other caregivers who provide care and services to residents on behalf of the facility.Definition:Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.2. Because some cases of abuse are not directly observed, understanding resident outcomes of abuse can assist in identifying whether abuse is occurring or has occurred. Possible indicators of abuse include, but are not limited to: -Bruises, skin tears and injuries of unknown source; -Extensive injuries; -Injuries in an unusual location; H. Reporting/Response1. All allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator.2. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations.Record review of Resident 32's Clinical Census printed 7/27/2025 identified the facility admitted the resident on 4/21/2025.Record review of Resident 32's Medical Diagnoses printed 7/27/2025 revealed the following: cirrhosis of the liver (widespread disruption of normal liver structure by fibrosis and the formation of regenerative nodules that is caused by any of various chronic progressive conditions affecting the liver [such as long-term alcohol abuse or hepatitis]), muscle weakness, generalized edema, and type 2 diabetes mellitus (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production).Record review of Resident 32's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 5/11/2025 revealed Resident 32 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15. According to the MDS manual, a score of 15 indicated the resident was cognitively intact. Further review of the MDS revealed Resident 32 was dependent upon staff for assistance to transfer from bed to wheelchair.Record review of Resident 32's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) revealed as of 5/19/2025, the resident was to be transferred with two staff members using a slide board to get out of bed and wheelchair, or use Hoyer lift with two staff.Record review of Resident 32's Progress Notes dated 7/6/2025 revealed: -Resident was being transferred from bed to wheelchair with two assist, bumped left lower leg on leg of wheelchair where pedals attach resulting in a laceration measuring approximately 4.5 by (x) 6 x 3. Large amount of bleeding, pressure dressing applied after PRN Oxycodone given as per order, 911 notified, here at 7:05 PM to transport resident to hospital. DON notified, note left to update APRN. Resident awake and alert leaving with paramedics per stretcher. assessment of wound. VSS, alert and oriented. -Resident return from ER via ambulance at approximately 9:30 PM with new order of bacitracin 500 unit/gram ointment to be applied 2 times a day. Patient to F/U (follow up) with PCP in 10-14 days for wound re-eval and suture removal.Record review of a Skin Alteration document dated 7/6/2025 revealed: -Incident Description: Resident was being transferred from bed to wheelchair with two assist, bumped left lower leg on leg of wheelchair where pedals attach resulting in a laceration measuring approximately 4.5 x 6 x 3. Large amount of bleeding, pressure dressing applied after assessment of wound. VSS, alert and oriented. -Immediate action taken: PRN (as needed) Oxycodone given as per order, 911 notified, here at 7:05 PM to transport resident for sutures. DON notified, note left to update APRN. -Agencies/People Notified: MD 7/6/2025.Record review of Resident 32's Medication and Treatment Administration Records dated July 2025 revealed the following orders dated 7/6/2025: bacitracin (antibiotic ointment) to be applied to Resident 32's left lower leg laceration twice daily; change of condition monitoring related to laceration to left lower extremity with sutures; and follow up with primary care provider for wound re-evaluation and suture removal in 10-14 days.An interview on 7/28/25 at 8:44 AM with Resident 32 revealed the resident sustained a laceration to the left lower leg during a transfer which required transport to the hospital for 11 stitches to be placed.An interview on 7/30/25 at 10:21 with Licensed Practical Nurse (LPN-D) revealed at the time of the incident, Resident 32 was assisted by one staff member.An interview on 7/30/2025 at 10:33 AM with Certified Medication Aide (CMA-E) revealed the only parties involved in the resident transfer were CMA-E and the resident. CMA-E reported after assisting Resident 32 with personal cares in bed, CMA-E turned around to get a blanket to place in the bottom of the wheelchair and when [gender] turned back around, Resident 32 was sitting at the edge of the bed. CMA-E reported that Resident 32 stated that the resident transfers independently without a slide board and instructed CMA-E how to arrange the chair. CMA-E placed the chair as the resident instructed and removed the arm rest from the wheelchair. Resident 32 proceeded to transfer, and CMA-E placed her hand on the small of Resident 32's back to provide support and guidance. CMA-E revealed that a gait belt was not used because Resident 32 stated that [gender] transferred independently. CMA-E stated that blood was noticed to the left lower leg immediately after Resident 32 was seated in the wheelchair. CMA-E stated it appeared Resident 32 had hit the left lower leg on the wheelchair pedal bracket which are permanently affixed to the wheelchair.A follow up interview on 7/30/2025 at 11:13 AM with CMA-E revealed a resident's transfer status is determined by the plan of care. CMA-E further revealed other Nursing Assistants had informed [gender] that Resident 32 transferred independently.A follow up interview on 7/30/2025 at 11:22 AM with Resident 32 revealed the only staff member present during the transfer was CMA-E. Resident 32 further revealed that Resident 32 did not tell CMA-E that they transferred independently, and at the time of the injury CMA-E said, that's my fault and I'm so sorry. Resident 32 said CMA-E did not mean for the resident to get hurt.A follow up interview on 7/30/2025 at 11:53 AM with LPN-D confirmed Resident 32's transfer status as listed on the care plan was two-person assist at the time of the laceration and Resident 32 was transferred with only one staff member.An interview on 7/30/2025 at 12:13 PM with the Director of Nursing (DON) with the Administrator (ADM) present confirmed Resident 32's transfer status was listed on the care plan as two-assist at the time of the incident. The DON further confirmed that the laceration which required 911 services, and 11 stitches should have been reported and was not.

Licensure Reference Number 175 NAC 12-006.05 (G) The facility failed to ensure residents were free from chemical restraints for 1 (Resident 47) of 5 sampled residents. The facility census was 64. The findings are:Record review of Resident 47's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 07-12-2025 revealed the following about the resident:-admitted to the facility on [DATE].- had a subarachnoid hemorrhage (bleeding that occurs in the space between the brain and the surrounding membrane).-Brief Interview of Mental Status was scored at a 12. According to the MDS Manual a score of 8-12 indicates moderate cognitive impairment.-required total assistance with toileting-required moderate assistance with bed mobility, toilet transfers and lower body dressing.-required supervision with upper body dressing, and hygiene-was taking high risk medications including antipsychotics, antianxiety, antidepressants, anticoagulants, diuretics, and opioids. Record review of Resident 47's Medication Administration Record (MAR) revealed the following orders:-antipsychotic medication (medications that alter brain chemistry to help reduce psychotic symptoms like hallucinations)Seroquel 12.5mg at 5 AM, Seroquel 50mg at 1 PM, and Seroquel 100mg at bedtime dated 07-07-2025 and haloperidol 1mg twice a day dated 07-07-2025.-antidepressant medication (medications used to treat depression)sertraline 50mg daily dated 07-08-2025, and trazadone 100 mg at bedtime for insomnia dated 07-08-2025 and an order for trazadone dated 07-08-2025 100mg as needed for insomnia without a stop date.-antianxiety medications (medications that calm the nervous system)buspirone HCL 5mg twice a day dated 07-08-2025 and clonazepam 0.5mg twice a day dated 07-08-2025.Furthermore, the MAR revealed no indication for use of sertraline, and no stop date or rationale to continue trazadone as needed beyond 14 days. Record review of Resident 47's Electronic Health Record revealed no rationale for the use of more than 1 antipsychotic medication and not rationale for the use of more than on antianxiety medication. Record review of Resident 47's Core LTC Pharmacy admission Medication Regimen Review (AMRR) dated 07-08-2025 revealed the Licensed Pharmacist noted the following:-the resident was receiving psychotropic medications, please ensure there is a proper diagnosis to support use along with behavior and side effect monitoring for clonazepam, buspirone HCL, haloperidol, trazadone, sertraline and Seroquel.-recommend Antipsychotic Monitoring Form or monitoring for tardive dyskinesia (a drug induced movement disorder characterized by involuntary, repetitive and sometimes sudden movements of the face, limbs and trunk.-resident is on an as needed psychotropic medication, trazadone if physician does not want to discontinue the medication in 14 days, please provide the rationale and duration of continued use.-duplicate therapy to treat specific disease states, please review antidepressants trazadone and sertraline and antipsychotics Seroquel and haloperidol-resident is currently on a medication for insomnia, consider a 3-day sleep study and complete a sleep assessment. An interview with the Director of Nursing on 076-30-2025 at 2:41 PM confirmed the AMRR was not acted upon by the facility staff. Record review of the facility policy titled Psychoactive Medication dated 11-2021 revealed the following:-it is the policy of this facility to maintain every resident's right to be free from use of psychoactive medication.-a physician's order is necessary for the use of psychoactive medication.-psychoactive medications are to be administered only when required to treat the resident's medical symptoms.-no psychoactive medications will be utilized without a diagnosed specific condition.-as needed psychotropic medications will have an initial 14-day duration. If the medication is to be extended the medical provider must explain the benefits versus risks, and reorder with another defined duration of use.

Nebraska Licensure Reference 175 NAC 12-006.12Based on interview and record review, the facility failed to ensure medications were available for 1 (Resident 5) of 4 residents sampled. The facility staff identified a census of 65.The findings are: Record review of Resident 5's admission Record revealed the facility admitted the resident on 08/27/19 and identified Resident 5 had diagnoses which included pneumonia, chronic inflammatory demyelinating polyneuritis (an autoimmune disorder that attacks the nerve cell coverings), carpal tunnel of unspecified upper limb, neuropathy (nerve pain), chronic pain, and osteoarthritis.Record review of Resident 5's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 05/01/25 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14. According to the MDS manual, a BIMS score of 14 indicated that the resident had intact cognition. Further review of the MDS revealed the facility assessed the following about Resident 5:-received scheduled and PRN (as needed) pain medications.-experienced pain that affected sleep and day-to-day activities almost constantly.-experienced pain that affected therapy activities frequently.Record review of Resident 5's Medication Administration Record (MAR) for March 2025 revealed an order to administer one half tablet of buprenorphine 2 milligram (mg) three times per day for pain. Further review of the March 2025 MAR revealed buprenorphine was not administered on the following dates:-two doses on 03/09/25-two doses on 03/10/25-three doses on 03/14/25-three doses on 03/15/25-three doses on 03/16/25.Record review of Resident 5's MAR for May 2025 revealed the following:-fish oil 1,000 mg give 2 capsules twice daily not administered once on 5/16/25 and once on 05/17/25.-polyethylene glycol (Miralax, a laxative) 17 grams (g) four times daily not administered three doses on 05/17/25.-lubiprostone (medication to treat chronic constipation) 24 micrograms (mcg) twice daily not administered once on 05/17/25.Record review of Resident 5's MAR for June 2025 revealed the following:-fish oil not administered once on 06/05/25 and once on 06/23/25.Record review of Resident 5's MAR for July 2025 revealed the following:-Bactrim DS tablet 800-160 mg give one half tablet by mouth at bed time not administered on 07/03/25, 07/04/25, and 07/05/25.-Metamucil powder give 1 packet by mouth one time a day for constipation not administered on 07/01/25.-Buprenorphine tablet sublingual 2 mg give 1 tablet three times a day not administered for a total of 11 consecutive administrations from 07/03/25 through 07/07/25.An interview on 07/09/25 at 1:09 PM with the Unit Manager (UM-B) confirmed Resident 5 did not receive 11 consecutive scheduled doses of buprenorphine from 07/03/25 through 07/07/25. UM-B reported that more education needed to be completed with licensed nurses regarding reordering medications.An interview on 07/09/25 at 3:55 PM with the DON confirmed Resident 5 did not receive all scheduled medications on 05/16/25, 05/17/25, 06/05/25, 06/23/25, and 07/01/25.An interview on 07/10/25 at 9:45 AM with the DON further confirmed Resident 5 did not receive buprenorphine on 03/09/25, 03/10/25, 03/14/25, 03/15/25, and 03/16/25 due to waiting delivery from pharmacy. The DON revealed the facility does not have a policy regarding unavailable medications.

Nebraska Licensure Reference Number 175 NAC 12-006.09(H)Based on interview and record review, the facility failed to manage pain for 1 (Resident 5) of 4 sampled residents. The facility staff identified a census of 65.The findings are:Record review of Resident 5's admission Record revealed the facility admitted the resident on 08/27/19 and identified Resident 5 had diagnoses which included pneumonia, chronic inflammatory demyelinating polyneuritis (an autoimmune disorder that attacks the nerve cell coverings), carpal tunnel of unspecified upper limb, neuropathy (nerve pain), chronic pain, and osteoarthritis.Record review of Resident 5's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 05/01/25 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14. According to the MDS manual, a BIMS score of 14 indicated that the resident had intact cognition. Further review of the MDS revealed the facility assessed the following about Resident 5:-received scheduled and PRN (as needed) pain medications.-experienced pain that affected sleep and day-to-day activities almost constantly.-experienced pain that affected therapy activities frequently.-received opioid pain medication.Record review of Resident 5's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) identified the following interventions for pain all dated 11/12/21:-able to: call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increases or alleviates pain;-administer analgesia medication as per orders. Give half an hour before treatments or care dated; and-anticipate need for pain relief and respond immediately to any complaint of pain. Non-pharmacological interventions 1. Distraction. 2. Spiritual.Record review of Resident 5's Pain Management Review (PMR) dated 06/27/25 identified Resident 5's pain medication regimen included Cymbalta (an antidepressant medication), a Lidoderm patch, and buprenorphine (an opioid pain medication) scheduled; and acetaminophen as needed (PRN). Further review of the PMR revealed Resident 5's pain is worst in the early morning and late evening and an acceptable pain rating level of 4 on a scale of 0-10. Record review of Resident 5's Medication Administration Record (MAR) dated July 2025 revealed buprenorphine was ordered to be administered three times per day and was not administered on the following dates:-07/03/25 at 8:00 PM with no recorded pain level;-07/04/25 at 8:00 AM with a pain rating of 5, at 2:00 PM with a pain rating of 7, and at 8:00 PM with no recorded pain level;-07/05/25 at 8:00 AM with a pain rating of 9, at 2:00 PM with a pain rating of 9, and at 8:00 PM with no recorded pain level;-07/06/25 at 8:00 AM with a pain rating of 8, at 2:00 PM with a pain rating of 8, and at 8:00 PM with a pain rating of 8; and-07/07/25 at 8:00 AM with a pain rating of 8.Further review of Resident 5's Electronic Health Record including MAR and progress notes showed no evidence of any interventions for pain management offered until 07/07/25 at 2:25 PM in the absence of scheduled buprenorphine.Record review of Resident 5's Progress Notes (PN) revealed buprenorphine was awaiting pharmacy delivery or unavailable to be administered on 07/03/25, 07/04/25, 07/05/25, 07/06/25, and 07/07/25.Record review of Resident 5's PN revealed on 07/03/25 an Advanced Practice Registered Nurse (APRN) was notified on 07/03/25 to request a one-time order for buprenorphine as the resident's supply from pharmacy was in transit. The APRN's response was pending. There was no indication the facility followed up until 07/07/25.An interview on 07/09/25 at 1:09 PM with Unit Manager (UM-B) confirmed the APRN was notified on 07/03/25 that Resident 5's buprenorphine would run out. A one-time order was requested but no response was received from APRN. UM-B further confirmed Resident 5 did not receive scheduled buprenorphine for 11 consecutive doses from 07/03/25 through 07/07/25. UM-B confirmed that a pain rating of 8-9 is considered a severe pain rating. UM-B confirmed that there was no documentation the resident was offered any interventions for pain until 07/07/25. UM-B identified the nurses assigned to care for Resident 5 from 07/03/25 through 07/06/25 should have offered the resident an intervention for pain. UM-B reported that further education needed to be completed with licensed nurses regarding reordering medications enough in advance, so the medications arrive at the facility before running out, and what to do when pain medications are not available.An interview on 07/10/25 at 8:32 AM with Resident 5 revealed the resident was utilizing a tablet computer to track when the buprenorphine was unavailable. Resident 5 identified buprenorphine was unavailable from 07/03/25 through 07/07/25. Resident 5 identified he did receive buprenorphine at 8:00 pm on 07/07/25. Resident 5 stated rated pain at 15 on a scale of 0-10 in the period when the buprenorphine was unavailable. Resident 5 further stated on the second day of the medication being unavailable, [gender] had trouble concentrating and it gets so bad I shake and cannot function.

Licensure Reference Number 175 NAC 12-006.09(J)(i)(1) Based on observation, record review, and interview; the facility staff failed to evaluate and implement interventions to prevent significant weight loss for 1 (Resident 2) of 3 sampled residents. The facility staff identified a census of 63. Findings are: Record review of Resident 2's Order Summary Report (OSR) printed on 10-30-2024 revealed Resident 2 admitted to the facility on [DATE] with a diagnoses of: Hyperlipidemia (fat particles in the blood system) Hypokalemia (low potassium level) Muscle weakness, Dysphagia (difficulty swallowing), Disorder of Plasma-protein Metabolism, Unspecified Protein Calorie Malnutrition. According to the OSR printed on 10-30-2024 Resident 2's diet was a general regular diet. Record review of Resident 2's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 9-25-2024 revealed Resident 2 was assessed with a Brief Interview of mental Status (BIMs, a score from the BIMS assessment that indicates a person's cognitive function) of a 12. According to the MDS [NAME] a score of 8 to 12 indicates a person has moderately impaired cognition. Required set up for meals and Resident 2's weight was 179.0 pound. Record review of Resident 2's Comprehensive Care Plan (CCP) dated 2-08-2024 revealed Resident 2 had the potential for nutritional problems related to diet restriction. The goal identified for Resident 2 was Resident 2 would eat 50-75% of most meals . The interventions identified on Resident 2's CCP were to provide the diet as ordered, Register Dietician (RD) was to evaluate and make diet change recommendation as needed. An undated portion of Resident 2's CCP dated 6-28-2024 revealed Resident 2 was a Lacto-ovo-vegetarin (some one who does not eat meat or seafood, but eats dairy and eggs). Record review of Resident 2's weight in their Electronic Medical Record ( EMR) revealed the following: -8-12-2024, 183.6 pounds (lbs). -9-25-2024, 178.8 lbs,a loss of 4.8 lbs or a loss of 2.61%. -10-09-2024, 163.2 lbs, a loss of 15.6 lbs or a loss of 8.72% within 30 days. -According to Resident 2's weight record in Resident 2's EMR revealed from 8-12-2024 to 10-09-2024 Resident 2 lost 20.4 lbs or a loss of 11.11% with in 90 day. Record review of Resident 2's Nutrition -Quarterly Evaluation sheet dated as completed on 9-27-2024 revealed the facility RD identified Resident 2 diet was regular , the consistency was regular had religious/ethnical/cultural food habits, weight was 178.8 as of 9-25-2024 and had a usual weight of 170-180 lbs. Record review of Resident 2's Progress Note (PN) dated 10-10-2024 revealed the facility RD requested a re-weigh of Resident 2. Review review of Resident 2's EMR that included RD notes, practitioner order, Resident 2's CCP and Resident 2's PN from 8-12-2024 through 10-30-2024 revealed there was no follow up to the the re-weight the facility RD request and further revealed there was no assessment of Resident 2's significant weight loss within 30 days or 90 time frames. In addition there was no information related to how the facility staff were to meet Resident 2's nutritional needs based upon Resident 2's vegetarian diet or what Resident 2's food preference were. Record review of Resident 2's dietary information sheet dated 10-30-2024 for breakfast revealed the following: -Diet and texture was regular. -Diet other was identified as Vegetarian. -Hot cereal, toast, 2 juice, no biscuit gravy. Likes fish. According to Resident 2 dietary information sheet dated 10-30-2024 Resident 2 was to receive the following for the lunch meal: -Beef stroganoff over noodles was marked off the list. -Resident 2 was to receive a 4 ounce (oz) portion of crumb topped Cauliflower, a portion of blue berry Cobbler and a 8 oz beverage. Observation on 10-30-2024 at 12:14 Revealed Resident 2 was in the dinning room and was served a large mix of salad greens for lunch, there was no protein or salad dressing served with the mixture of salad greens, a small 4 ounce drink and a portion of a apple filling type of desert with a portion of whip cream on top. Observation on 10-30-2024 at 1:15 PM revealed Resident 2 remained in the dinning room and had taken a few bites of the salad mixture, had drank all of the drink and a bite of desert. On 10-30-2024 at 1:15 PM an interview was conducted with Resident 2. During the interview Resident 2 reported not wanting just salad and nothing else. On 10-30-2024 at 12:23 PM an interview was conducted with the Dietary Supervisor (DS). During the interview the DS reported not being aware of what to give Resident 2 due to the vegetarian diet. The DS further reported not being aware of Resident 2's significant weight loss. On 10-30-2024 at 1:01 PM an interview was conducted with the facility RD via phone. During the interview the RD reported there was a list of food items Resident 2 could have and reported not being aware of what the plan was to meet the resident needs. On 10-30-2024 at 3:14 PM the DS reported there was no evaluation of Resident 2's food preferences . On 10-31-2024 at 12:58 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON reported the facility RD had made the request for a re-weigh on 10-10-2024 and this had not been completed. The DON reported the expectation was the re-weigh should have been obtained within the week. The DON confirmed during the interview Resident 2 had significant weight loss as of 10-09-2024 and Resident 2's significant weight loss had not been evaluated and no new interventions had been implemented for Resident 2.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on observations, record review, and interviews; the facility administration staff failed to ensure effective management of facility resources to maintain the highest practical wellbeing of residents and the facility environment as evidenced by failure to implement an effective plan of action to maintain correction for previously cited areas of deficient practice and failure to ensure the facility identified and developed plans of action to identify multiple issues of deficient practice. The facility staff identified a census was 62. Findings are: Review of the facility during the current survey revealed the following deficiencies: -F550. The facility failed to ensure resident dignity was maintained for 2 of 3 residents. -F583. The facility failed to ensure full privacy in 11 of 20 dual occupancy rooms. -F584. The facility failed to ensure that rooms appeared homelike in 5 of 17 rooms. -F609. The facility failed to report an elopement for 1 resident in the required time frame. -F623. The facility failed to ensure the resident and/or the resident's representative were notified in writing of the reason for transfer to the hospital. -F638. The facility failed to ensure residents Minimum Data set (a federally mandated assessment tool used for care planning) were completed within 14 days od the Assessment reference date. -F644. The facility failed to ensure a new PASSAR (Pre-admission Screening and Resident Review) were completed after a diagnosis of mental illness was identified. -F684. The facility failed to ensure Geri Sleeves were in place as ordered for 2 residents. -F676. The facility failed to ensure an air loss mattress was set to relieve pressure and failed to ensure residents were turned and repositioned for pressure relief. -F689. The facility failed to implement interventions to prevent elopement and failed to implement interventions to prevent elopement into the kitchen. -F692. The facility failed to ensure interventions were in place to prevent weight loss and failed to implement interventions to prevent potential dehydration for a sampled resident. -F760. The facility failed to ensure 2 residents were free of significant medication errors. -F801. The facility failed to have a qualified Dietary Manager. -F865. The facility failed to have a effective Quality Assurance and Process Improvement (QAPI) program. -F880. The facility staff failed to donn personal protective equipment (PPE) and preform hand hygiene and gloves changes in a manner to prevent potential cross contamination during personal cares and treatments. On 5-03-2023 at 11:05 AM an interview was conducted with the facility Administrator. During the interview the Administrators reported the elopement (see F689), infection control (see F880) medication errors (see F760) and skin breakdown (see 684 and F686) were not identified as a issue in the facility to work on.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and interview; the facility staff failed to implement interventions to prevent elopement for 2 (Resident 31 and 50) of 2 sampled residents. The facility staff identified a census of 62. The findings are: A Record review of the Policy and Procedure for Elopement with a revision date of 2/2022 revealed residents identified to be at risk for elopement will have an individualized care plan and interventions implemented. Residents whose assessment identified wandering behavior shall also be considered at risk for elopement. If the resident is identified at risk for elopement, the following steps will be taken and or verified that completed by the individual completing the assessment: -An alarm bracelet may be placed on the resident to audibly alert staff of attempts to exit. -The residents care plan shall address behavior using resident specific goals and approaches as assessed by the Interdisciplinary Team (IDT). -Residents with an elopement incident from the facility either on or off the grounds shall be considered at higher risk for further attempts at elopement. These residents will have the following precautionary measures implemented to prevent repeat incidents of elopement: -Resident will wear an alarm bracelet to alert staff if trying to leave the facility. -The bracelet will be checked daily to assure that it is functional, and checks will be logged. Record review of the progress notes for Resident 31 revealed the following: On 3/28/2023 at 9:40 PM, Resident 31 called 911 wanting to leave the facility. The police arrived and spoke to Resident 31 and redirected resident in the facility. On 3/29/2023 at 5:18 AM, Resident 31 was exit seeking and pulled the fire alarm. On 4/5/2023 at 8:39 PM Resident 31 was noted wandering most of the shift. Review of the facility investigation report dated 4/3/23 revealed a door alarm sounded at 8:18 AM. According to the report Staff initiated response and went to the front exit door, nurse followed procedure and paged overhead. Resident easily redirected and escorted back into building by staff. Change of condition elopement assessment completed by DNS (Director of Nursing Service). Review of Resident 31's Elopement Evaluation dated 3/29/23 revealed Resident 31 was a high risk for elopement. Record review of Resident 31's Care Plan revealed the following: -Elopement risk/wanderer related to impaired safety awareness with an actual elopement on 3/29/23. -The Date of Resident 31's elopement risk/wanderer was initiated on 03/30/2023. -Will not leave facility unattended through the review date. Date Initiated: 04/03/2023. -Safety will be maintained through the review date. Date Initiated: 04/03/2023. - Will demonstrate happiness with daily routine through the review date. Date Initiated: 04/03/2023. -Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Date Initiated: 03/30/2023 -Wander guard ( a device to alert staff if resident exits the building) placed on Resident 31. Date Initiated: 03/30/2023 An observation on 4/30/23 at 6:30 AM revealed a white device located on the door frame of Resident 31's room which was in the off position and the door to the room was in an open position. Resident 31 did not have a wander guard device on. An observation on 4/30/23 at 9:00 AM revealed the white device located on the door frame of Resident 31's room remained in the off position. Resident 31 was lying in the resident's bed and did not have a wander guard device on. An observation on 4/30/23 at 11:37 AM revealed the white device in the doorway of Resident 31's room remained in the off position, the door to the resident;s room was open and Resident 31 did not have a wander guard on. An observation on 4/30/23 at 12:33 PM revealed the white device located on the door frame of Resident 31's room remained in the off position and Resident 31 did not have a wander guard on. An observation on 4/30/23 at 1:06 PM revealed the white device located on the door frame of Resident 31's room remained in the off position and Resident 31 did not have a wander guard on. An observation on 4/30/23 at 2:04 PM revealed the white device located on the door frame of Resident 31's room remained in the off position and Resident 31 did not have a wander guard on. An interview with Nursing Assistant (NA)-G on 4/30/23 at 1:17 PM revealed Resident 31 has a wander guard on their leg and sometimes the resident takes the wander guard off. NA-G was not sure if Resident 31 has a wander guard on right now. An interview conducted on 4/30/23 with NA-E at 1:21 PM revealed Resident 31 did not have a wander guard and NA-E was unaware of what the white device was on the door of Resident 31's room. NA-E confirmed at this time there was no wander guard on Resident 31's legs or arms. An interview conducted with NA-D on 4/30/23 at 2:10 PM revealed that Resident 31 wanders at night. NA-D revealed Resident 31 was to have a wander guard on and that Resident 31 takes off the wander guard easily and frequently. NA-D stated that there is an additional intervention in place which includes a door alarm (the white device on the doorframe of Resident 31's room) which if Resident 31 opens the door it makes a loud alarm. NA-D verified at this time the door alarm was off and was unsure why the door alarm was off. An interview conducted with Registered Nurse (RN)-H on 4/30/23 at 2:21 PM revealed Resident 31 wanders and the staff round often (check on) on Resident 31. RN-H revealed that Resident 31 had a witnessed elopement and that Resident 31 knows the exact seconds 12 seconds that the front door takes to lock after a visitor leaves the front door. RN-H revealed that Resident 31 does not utilize a wander guard at the facility. It had previously been care planned that Resident 31 was to utilize a wander guard but Resident 31 refused it. RN-H revealed Resident 31 does have a door alarm on the door which functions and makes a loud noise when the door is open, however the alarm is not being used as Resident 31's roommate prefers the door open. B. A review of the progress notes for Resident 31 revealed on 3/6/2023 at 2:56 AM Resident 31 was found lying on their left side next to the wheelchair facing toward the doorway between the middle kitchen isle and stove. Resident 31 had a laceration located on back of their head. 911 was called for immediate attention. Resident 31 stated (gender) was looking for something to eat and another resident (Resident 50) came through the kitchen doors wondering what Resident 31 was doing in the kitchen. Resident 50 proceeded to pick Resident 31 up from the wheelchair and then push Resident 31 down to the floor resulting in injury. Record review of the facility report dated 3/6/23 revealed at approximately 12:15 AM, while doing rounds NA-D heard someone yelling in the kitchen and went to investigate and noted Resident 50 standing at the kitchen door telling Resident 31 to stay on the ground. Resident 31's wheelchair was on its side, just inside the kitchen door. Resident 31 was lying on the floor in front of the prep tables. Resident 31 stated (gender) was hungry and went into the kitchen to find something to eat and that Resident 50 came into the kitchen and pushed Resident 31 down. Preventative measures put into place revealed new doorknobs with self-locking mechanisms were placed on kitchen doors to prevent residents from going into the kitchen unattended. All staff educated that residents are not allowed in the kitchen area, and kitchen doors shall remain locked when dietary staff are not present. Observation at 6:00 AM on 4/30/23 upon entering the facility revealed there were 2 kitchen doors that enter the kitchen. One door had a mechanism and the other door was open. Observational revealed there were no dietary staff present at this time in the kitchen. C. Record review of the progress notes for Resident 50 revealed on 3/27/2023 at 2:54 am a Late Entry note revealed the Facility Administrator exited the building and noted Resident 50 outside in the parking lot stepping off the driveway. Resident 50 was easily redirected and escorted back into the facility. An elopement assessment was completed and determined the resident to be low risk. The Medical Doctor (MD) and family notified. Interventions were to implement every 15 minute checks x 72 hours. A record review of Resident 50's Elopement Risk assessment dated [DATE] revealed Resident 50 was a low risk for elopement. The Elopement Risk Assessment revealed an answer to the question Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside facility) and the staff answered the question as not applicable because the resident has no history or current behaviors of wandering. Record review of the Facility Report dated 3/28/23 revealed the door alarm sounded at 9:20 AM and staff initiated response and went to the exit doors. The Administrator exited the building and noted Resident 50 outside in the parking lot stepping off the driveway. Resident 50 was easily redirected and escorted back into the building without difficulty. The interventions put into place were as follows: -verbal and written education to staff. -Plan of Care updated to include resident's change of condition. -RN evaluation completed. -Change of Condition Elopement Assessment completed. -The Director of Nursing reviewed all resident elopement assessments and plan of care interventions. -Communication placed at First and Second Floor Nurses Station. Review of Resident 50's current Care Plan revealed no focus area for elopement risk. Interview with Resident 50 on 4/30/23 at 1:00 PM revealed Resident 50 wanted to leave and wanted to get a car. An interview was conducted with NA-O on 4/30/23 at 2:19 PM which revealed Resident 50 does wander frequently and the intervention in place was visual checks. NA-O revealed Resident 50 does have a wander guard. An interview on 4/30/23 with RN-H revealed Resident 50 does wander. RN-H was unaware if Resident 50 has a wander guard on. RN-H stated the facility staff redirect Resident 50 when wandering. An interview on 4/30/23 at 2:48 PM with the Administrator revealed the facility staff were surprised that Resident 50 was at low risk per the elopement risk assessment dated [DATE] and the facility did not put additional interventions in place. Based on information provided on 4/30/23 to remove the immediacy of the situation the facility staff provided the following information to protect the residents: -Resident 50 will be reassessed for elopement risk, Wander guard will be placed on the resident and monitoring implemented on the electronic health record. The resident's care plan will be updated with the intervention on 4/30/23. -Resident 31 will be reassessed for elopement risk, Wander guard will be placed on resident and monitoring implemented on the electronic health record. The resident's care plan will be updated with interventions on 4/30/23. To protect other potential residents: -The DNS (Director of Nursing Services) will audit all resident's elopement risk, interventions and care plan to ensure monitoring and interventions are in place. This will be completed by end of day 4/30/23. -The kitchen door will have an automatic lock installed by 4/30/23. -The DNS or designee will educate staff on 4/30. Education will include the need to implement immediate monitoring and interventions for residents identified high risk for elopement. Education will also include expectation that kitchen doors are to be locked at all times when staff are not present and the expectation of new lock/code system on the dietary door. Monitoring: -The DNS or designee will audit new admissions and high risk residents daily X 5, then 3X/week for 12 weeks to ensure monitoring and interventions are in place for those residents at risk. -The ED (Executive Director) or designee will verify that the doors to the kitchen are locked when staff are not present every shift X 3 days. -The Maintenance Director will audit functioning of automatic locks daily X 7 days, then 3X/week for 12 weeks.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and staff interviews; the facility Quality Assessment Performance Improvement Plan (QAPIP) failed to identify ongoing issues relevant to F550, F580, F609, F657, F676, F689, F712, F730, F755, F758, F761, F812, F835 and F867 and implement plans of action to identify and correct the deficient practice. The QAPI failed to ensure repeated deficiencies at F692 and F697 were corrected and the correction maintained. This deficient practice had the potential to affect all residents who reside in the facility. The facility staff identified a census of 92. Findings are: Record review of a undated facility Quality Assurance and Performance Improvement (QAPI) program revealed the following information: -Goal: -1. Implement a QAPI program that involves all staff and focuses on benchmarks to ensure quality of care and quality of life. -3. Continued improvement of management of risk including but not limited to preventative interventions to reduce adverse outcomes. On 5-02-2023 at 2:00 PM an interview with Nursing Assistant (NA) K was conducted. During the interview NA K reported not knowing what the QAPI committee was working on. On 5-02-2023 at 2:12 PM an interview was conducted with NA L. During the interview NA L reported not being sure what the QAPI committee was working on or who the members were. On 5-02-2023 at 2:15 PM an interview was conducted with Dietary Assistant (DA) M. During the interview DA M reported not knowing what QAPI was. On 5-03-2023 at 6:40 AM an interview with NA N was completed. During the interview NA N reported not knowing what the QAPI committee was working on or who the members were. On 5-3-2023 at 6:52 AM an interview was complete with Registered Nurse (RN) C. During the interview RN C reported not knowing what QAPI was or who was on the committee. On 5-3-2023 at 11:05 AM an interview was completed with the facility Administrator. During the interview the facility Administrator reported elopement was not identified as a QAPI issue that needed to be worked on, infection control was not identified as an issue, and medication errors were not identified as an issue the QAPI committee needed to work on.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8a Based on observation, record review and interview; the facility failed to ensure interventions were in place to prevent a significant weight loss and ensure hydration for 1 (Resident 16) of 4 sampled residents. The facility staff identified a census of 62. The findings are: On 04/30/23 at 10:30 AM interview was conducted with Resident 16's family member which revealed Resident 16 had lost weight and the family member didn't think the facility ever gave Resident 16 breakfast. Continued interview in Resident 16's room revealed there was not a water pitcher available for Resident 16. During the interview Resident 16's family member reported the facility never has a pitcher of water for Resident 16. The facility may bring the resident a glass of water at times. Record review of Resident 16's documented weights in the electronic medical records revealed the following; -4/21/2023 at 12:55 PM, 152.1 Lbs in the wheelchair -4/19/2023 at 1:57 PM, 152.5 Lbs in the wheelchair -4/10/2023 at 9:04 PM, 152.7 Lbs -3/13/2023 at 9:41 PM, 152.6 Lbs -2/16/2023 at 9:02 PM, 152.6 Lbs in the wheelchair -1/18/2023 at 2:06 PM, 152.5 Lbs in the wheelchair -1/16/2023 at 4:14 PM, 159.2 Lbs Hospital weight -1/16/2023 at 3:29 PM, 185.4 Lbs Hospital weight 2/17/2023 1:23 PM Incorrect entry -1/16/2023 at 12:31 AM, 159.2 Lbs Hospital weight -1/4/2023 at 1:34 PM, 159.2 Lbs Hospital weight 1/6/2023 1:29 PM Incorrect entry -12/5/2022 at 2:43 PM, 189.8 Lbs in the wheelchair -12/4/2022 at 12:03 PM, 188.5 Lbs in the wheelchair The weight of 189.8 Lbs. on 12/5/22 and the weight on 4/21/23 of 152.1 Lbs. is a difference of 37.7 lbs in 4 months or -19.58% weight loss. Record review of the MDS (Minimum Data Set; a federally mandated comprehensive assessment tool used for care planning) dated 2/17/23 revealed a weight of 153 and no identified weight loss was coded. The MDS further revealed Resident 16 required limited assistance with eating. Record review of Resident 16's Care Plan for Activities of Daily Living Self Care Performance Deficit dated 11/28/22 revealed the following interventions with dates of when the intervention was initiated: -11/18/22: Needs 1 to1 assistance for all meals. Requires upright position when eating in bed. Date Initiated: 11/28/2022 -11/21/22: Please have Resident 16 up in chair in dining room for all meals. Resident 16 needs assist to dine. Date Initiated: 11/28/2022 -Staff to assist Resident 16 up by 7:00 AM per (gender) request. Date Initiated: 12/14/2022 Observation on 5/01/23 at 8:46 AM revealed Resident 16 was lying in bed. No breakfast tray was in the room and Resident 16 did not have a water pitcher with water. Observation on 5/01/23 at 9:13 AM revealed Resident 16 continued to be in bed with no breakfast tray. Observation on 5/1/23 at 10:55 AM revealed Resident 16 was lying in bed in Resident 16's room and there was no water pitcher or food within the room. Observation on 5/01/23 at 11:05 AM revealed Resident 16 lying in bed. Resident 16 did not have a breakfast tray in the room and no water pitcher avalable. Observation on 5/1/23 at 12:43 PM revealed Resident 16 was in the dining room knocking on the table and requested coffee and food. Resident 16's family member assisted Resident 16 in setting up food. Resident 16 was able to eat without difficulty. Interview on 5/1/23 at 11:30 AM with Registered Nurse (RN)-H confirmed that Resident 16 had not had a breakfast tray delivered as Resident 16 was asleep. RN-H stated that Resident 16 does not usually eat breakfast. RN-H was unaware of Resident 16's request to be up by 7:00 AM and that the resident wanted to eat all meals in the dining room due to needing assistance with meals. Observation on 5/2/23 at 9:30 AM revealed Resident 16 was lying in bed and there was no water pitcher or breakfast tray in room. Observation on 5/2/23 at 10:30 AM revealed Resident 16 was lying in bed and there was no water pitcher in the room, however Resident 16's breakfast tray was sitting in the room untouched. Observation on 5/02/23 at 11:54 AM revealed Resident 16 was lying in bed and Resident 16's family member removed the breakfast tray from the room with Resident 16's meal untouched. Interview with RN-C on 5/2/23 at 11:54 AM confirmed the breakfast tray for Resident 16 had not been touched as Resident 16 was asleep in the bed. Observation on 5/02/23 at 12:00 PM revealed Resident 16 was in bed and reported being hungry. Observation on 5/2/23 at 12:45 PM revealed Resident 16 was in the dining room with the resident's family member and Resident 16 was eating lunch. Resident 16 ate 100% of their lunch meal and reported it was good. Interview on 5/2/23 at 2:30 PM with the DNS (Director of Nursing Service) confirmed the care plan of Resident 16 addressed that Resident 16 requested to be up by 7:00 AM and to be in the dining room for all meals due to need for assistance. DNS stated that Resident 16 really hasn't been getting up for breakfast since the resident went onto hospice. The DNS further confirmed Resident 16's significant weight loss of 37.7 lbs.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on record review and interview; the facility staff failed to ensure 2 (Resident 44 and 171) of 10 sampled residents were free of significant medication errors. The facility staff identified a census of 62. Findings are: A. Record review of an Order Summary Report (OSR) sheet printed on 5-03-2023 of active orders for Resident 171 revealed Resident 171 was admitted to the facility on [DATE] with the diagnoses that included Diabetes, Major Depressive Disorder and Dementia. Further review of Resident 171's OSR printed on 5-03-2023 revealed Resident 171's practitioner ordered medications that included Lispro insulin 4 units to be given before meals and further ordered if Resident 171's blood sugar (BS) levels were between 7 and 120 the Lispro insulin was to be held. Record review of Resident 171's Medication Administration record (MAR) for 6-2021 revealed the following information: - June,2021 at 7:30 AM: -6-19-2021, BS was 89 and insulin was administered. -6-20-2021, BS was 91 and insulin was administered. -6-22-2021, BS was 100 and insulin was administered. -6-27-2021, BS was 27 and insulin was administered. -6-27-2021, BS was 61 and insulin was administered. -June 2021 at 11:30 AM: - 6-19-2021, BS was 104 and insulin was administered. -6-23-2021, BS was 93 and insulin was administered. -6-24-2021, BS was 74 and insulin was administered. -June 2021 at 4:30 PM: -6-24-2021, BS was 105 and insulin was administered. -6-26-2021, BS was 47 and insulin was administered. -July 2021 at 7:30 AM: -7-04-2021, BS was 118 and insulin was administered. -7-06-2021, BS was 102 and insulin was administered. -7-07-2021, BS was 113 and insulin was administered. -July 2021 at 11:30 AM: -7-02-2021, BS was 82 and insulin was administered. -7-03-2021, BS was 86 and insulin was administered. -July 2021 at 4:30 PM: -7-05-2021, BS was 100 and insulin was administered. -7-16-2021, BS was 100 and insulin was administered. -August 2021 at 7:30 AM: -8-07-2021, BS was 101 and insulin was administered. Review of Resident 171's Progress Note (PN) dated 8-07-2021 at 12:47 PM revealed Resident 171 was laying in bed diaphoretic (excessive sweating), with cold and clammy skin. Further review of Resident 171's PN dated 8-07-2021 revealed Resident 171 was lethargic, eye rolled back and had a blood sugar of 33. According to Resident 171's PN dated 8-07-2021 orange juices and Glucerna was given with a resident blood sugar level of 37. The facility staff called 911 as Resident 171 was not getting better. On 5-03-2023 at 7:58 AM an interview was conducted with the Director of Nursing (DON). During the interview review of Resident 171's MAR's for June, July and August of 2021 were reviewed. The DON confirmed insulin was given when it should not have been. The DON further confirmed Resident 171 was sent to the hospital on 8-07-2021 due to low blood sugar levels. The DON confirmed insulin was given at 7:30 AM on 8-07-2021 at 7:30 AM when it should have not been given. The DON confirmed the error was a significant medication error. On 5-03-2023 at 8:20 AM an interview was conducted with Registered Nurse (RN) C. During the interview review of Resident 171's MAR for 8-07-2021 was completed. During the interview RN C confirmed insulin should not have been given on 8-07-2021 at 7:30 AM and that Resident 171 was sent to the hospital related to low BS level. B. Record review of Resident 44's OSR printed on 5-02-2023 revealed Resident 44's practitioner ordered medications that included Humalog insulin . According to the Humalog insulin order nursing staff were to hold the insulin if Resident 44's blood sugar level was below 120. Record review of Resident 44's MAR for April 2023 revealed the following information for the administration of the Humalog insulin: -8:00 AM: -4-02-2023, BS was 119 and insulin was administered. -4-05-2023, BS 111 and insulin was administered. -4-09-2023, BS was 111 and insulin was administered. -11:30 AM: -4-09-2023, BS was 113 and insulin was given. -4-12-2023, BS was 102 and insulin was administered. On 5-02-2023 at 1:30 PM an interview was conducted with the DON. During the interview review of Resident 44's MAR for April 2023 were reviewed. The DON confirmed during the interview Humalog insulin was administered to Resident 44 with blood sugar levels were below 120. According to Mount [NAME]. org a normal BS level is between 70 and 100. According to www.CDC.gov symptoms of low BS levels include shaking, sweating and confusion.

LICENSURE REFERENCE NUMBER 175 NAC 12.006.09D2a Based on observation, record review and interview; the facility staff failed to ensure an air loss mattress was set to relieve pressure and failed to reposition for pressure relief for 1(Resident 16) of 3 sampled resident resulting in additional pressure ulcers. The facility staff identified a census of 62. The findings are: Review of Resident 16's electronic medical record revealed that Resident 16 was hospitalized on [DATE] and returned to the facility on [DATE] with the following identified wound areas: - Coccyx unstageable (full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed) pressure ulcer. - Left and right gluteal folds stage 1 pressure ulcer (a red nonblanchable area with no open areas). -Right 3rd toe trauma, right 4th toe trauma, right 4th toe base trauma, right 5th toe trauma, right 3rd/4th toe, right 4th/5th toe. -Right exterior foot #1 SDTI (Suspected Deep Tissue Injury; a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying tissue from pressure and/or shear), -Right exterior foot #2 SDTI. -Right great toe trauma -Right hip SDTI. -Right medial foot SDTI. -Left inner ankle scab. -Right Forearm bruise. -Moisture Associated Skin Damage (MASD) to the scrotum. Further review of the electronic medical record revealed a new SDTI to the left hip that was identified on 4/27/23. Review of Resident 16's Care Plan dated 4/27/23 revealed the following intervention to prevent skin breakdown: - Encourage to turn and reposition, provide assistance as necessary with a date initiated of 11/28/22. -Low air loss mattress, Prevalon boots on Bilateral Lower Extremities when in bed. Observation on 5/1/23 at 6:30 AM revealed Resident 16 lying in bed on (gender) left side. Observation on 5/1/23 at 8:00 AM revealed Resident 16 lying in bed on (gender) left side. Resident 16 was lying on a low air loss mattress that was set on static mode (a setting that does not deflate any of the chambers in the mattress. The real value of a loss air loss mattress is the rotating deflation of the chambers that support the user, giving relief to otherwise constant pressure between the resident and the mattress). Observation on 5/1/23 at 9:00 AM revealed Resident 16 lying in bed on (gender) left side. Resident 16 was lying on a low air loss mattress that was set on static mode. Observation on 5/1/23 at 11:00 AM revealed Resident 16 lying in bed on (gender) left side. Observation on 5/2/23 at 6:30 AM revealed Resident 16 lying in bed on (gender) right side. Resident 16 was lying on a low air loss mattress that was set on static mode. Observation on 5/2/23 at 8:00 AM revealed Resident 16 lying in bed on (gender) right side. Observation on 5/2/23 at 9:00 AM revealed Resident 16 lying in bed on (gender) right side. Resident 16 was lying on a low air loss mattress that was set on static mode. Observation on 5/2/23 at 11:00 AM revealed Resident 16 lying in bed on (gender) right side. Observation on 5/2/23 at 11:54 AM revealed Resident 16 lying in bed on (gender) right side. Observation of wound care on 5/2/23 between 12:44 PM-1:27 PM with the ADON (Assistant Director Of Nursing) revealed during the observation ADON reported the SDTI on the left hip was a new wound being treated with Skin Prep (a wipe that forms a barrier on the skin). During the observation the ADON confirmed the settings on the low air loss mattress was set on Static mode. An interview with the ADON on 5/2/23 at 12:58 PM regarding the air mattress setting of static revealed that when cares are being provided the bed is placed on static so it is not alternating during cares. Interview with Nursing Assistant (NA)-B on 5/2/23 at 1:27 PM revealed nursing assistants do not touch the setting on the low air loss mattress. Interview with the ADON on 5/2/23 at 1:30 PM confirmed that mattress was set on static most of the time and would have to check on who can adjust settings on the air mattress. Observation on 5/2/23 at 2:52PM revealed the mattress remained on Static mode. Interview on 5/2/23 at 2:57 PM with the DNS (Director of Nursing Service) confirmed mattress should be on alternating and not static due to static mode not providing pressure relief.

Licensure reference: 175 NAC ,d+[DATE].09C2 Based on record review and interview, the facility failed to arrange necessary services related to wound care and medications to ensure a safe discharge plan for 1 [Resident 1] of 4 sampled residents. The facility had a total census of 49 residents. Findings are: A review of Resident 1's Progress Notes dated [DATE] revealed a representative from the homeless shelter had reported that the rescue squad had to be called to pick up Resident 1 when Resident 1 was dropped off by the nursing home to the homeless shelter. According tothe [DATE] Progress Note, the homeless shelter representative reported Resident 1 did know where Resident 1 was or how Resident 1 got to the homeless shelter. Resident 1 was incontinent of bladder. A review of Resident 1's Progress Notes revealed the following notes regarding discharge planning: -[DATE] 3:55 PM: Resident 1 readmitted to the facility today. -[DATE] 8:20 AM: Social Worker met with Resident 1 regarding potential apartments that would take Section 8. Resident 1 told Social Worker that resident would not call apartment. Social Worker discussed losing Section 8 voucher and possible discharge to shelter. -[DATE] 8:03 PM: Social Worker discussed with Resident 1 completing applications and calling Section 8 properties. Resident 1 had not followed up. Social Worker explained Resident 1 needed to be thinking about where Resident 1 was going to stay if Resident 1 did not have an apartment. -[DATE] 3:02 PM: Social Worker gave information for Resident 1 to call regarding apartment openings. -[DATE] 3:54 PM: Social Worker met with Resident 1 to discuss last covered day on [DATE]. Resident 1 unsure where to discharge to. Discussed shelter. -[DATE] 10:32 AM: Social Worker discussed shelter placement and making arrangements for transportation with Resident 1. -[DATE] 4:56 PM: Social Worker spoke with doctor's office about discharge on [DATE]. Resident 1 does not have a place to go. Resident 1 given Section 8 resources with minimal follow up by Resident 1. Resident 1 agreed to discharge to shelter. -[DATE] 12:20 PM: Resident 1 given list of local shelters. Resident 1 unsure of what time the resident will discharge tomorrow. -[DATE] 8:33 AM SW [Social Worker] spoke to resident via phone due to resident stating that [Resident 1 gender] wasn't aware that today was DC [discharge]. SW explained that this SW gave [Resident 1 gender] a list of shelters on [DATE]. SW also reminded [Resident 1 gender] of conversation with nursing, therapy and SW with (the resident's) DR [doctor] office on [DATE]. SW explained to resident that [Resident 1 gender need to have $6000.00 up front. Resident reported that [Resident 1 gender] did not have $6000.00. SW to follow up with resident regarding DC plans. -[DATE] 8:14 AM: Social Worker spoke with Resident 1's physician regarding discharge plans. Social Worker explained that Resident 1 could see a nurse and get medications at clinic that was on the same campus as the homeless shelter. Social Worker explained that shelter could assist residents with getting their own apartment. Resident 1's physician was ok with this. -[DATE] 11:55 AM: Social Worker met with Resident 1 about discharge planning today. Resident 1 was given physician's phone number due to Resident 1 wanting to talk with physician about discharge. Social Worker discussed shelter options again with Resident 1 and payment to the facility. Resident 1 stated that the resident does not have any money. -[DATE] 12:36 PM: Social Worker notified one shelter of admission. That shelter was full. Social Worker then contacted another shelter. That shelter had an opening. -[DATE] 12:48 PM: Social Worker assisted Resident 1 in calling physician. Nurse reminded Resident 1 that Resident 1 had declined Section 8 and insurance is declining the resident's eligibility. -[DATE] 1:58 PM: Resident 1 was discharged to a homeless shelter with all of Resident 1's belongings and personal items transported by the facility. Resident 1 had discharge orders for treatments to bilateral extremities with Resident 1. A review of Resident 1's BIMS [Brief Interview for Mental Status], a tool used to evaluated cognitive status, dated [DATE] identified Resident 1's BIMS score as 9 which placed Resident 1 in the moderately impaired category. A review of Resident 1's plan of care revealed a focus area dated [DATE] of wishes to return/be discharged to a shelter. Goals dated [DATE] included: -Will be able to verbalize/communicate required assistance post-discharge and the services required to meet needs before discharge -Will demonstrate correct administration of medications/treatments -Will verbalize/communicate and understanding of the discharge plan and describe the desired outcome by the review date. A review of Resident 1's plan of care revealed the following interventions for discharge planning: -Encourage to discuss feelings and concerns with impending discharge. Monitor for and address episodes of anxiety, fear, distress. -Establish a pre-discharge plan with the resident, family/caregivers and evaluate progress and revise plan -Evaluate and discuss with resident/family/caregivers the prognosis for independent or assisted living. Identify, discuss and address limitations, risks, benefits and needs for maximum independence. -Evaluate motivation to return to the community. -Invite resident and requested family to care plan quarterly & PRN [as needed] -Prepare and give resident, family member, care giver contact numbers for all community referrals. A review of Resident 1's Discharge Summary and Post-Discharge Plan of Care revealed medication and dressing changes to be completed by clinic on the homeless shelter's campus. The Post-Discharge Plan of care identified Resident 1 had burn treatments to right front lower leg, right rear lower leg, left front lower leg and left rear lower leg. A review of an order summary report attached to Resident 1's Discharge Summary and Post-Discharge Plan of Care revealed the following medication and treatment orders: -Left leg burn. Wash left leg burn daily with soap and water. Remove therabond [a wound dressing] gently from the wound bed. If dressing adheres to the wound, moisten, soak with removal. Place on a clean surface, Rinse therabond with tap water, ring out, to use for 14 days. Place therabond in wound bed, wrap with kling, and ace wrap. Every day shift for wound care. -Right leg burn. Wash right leg burn daily with soap and water. Remove therabond gently from the wound bed. If dressing adheres to the wound, moisten, soak with removal. Place on a clean surface, Rinse therabond with tap water, ring out, to use for 14 days. Place therabond in wound bed, wrap with kling, and ace wrap. Every day shift for wound care. -[MEDICATION(S)] aerosol solution [a bronchodilator] 108 ACG/ACT; 1 puff inhale orally every 6 hours as needed for wheezing -[MEDICATION(S)] power [a medication for loose stools] 4 gm/dose; give 1 packet by mouth two times a day -[MEDICATION(S)] sulfate [iron] table 325 mg; give 1 tablet by mouth one time a day -[MEDICATION(S)] capsule [a medication for benign prostatic hyperplasia] .4 mg; give 1 capsule by mouth one time a day -[MEDICATION(S)] tablet [a nutritional supplement] 1 mg; give 1 tablet by mouth one time a day -[MEDICATION(S)] tablet [an antihistamine] 10 mg; give 1 tablet by mouth every 6 hours as needed -[MEDICATION(S)] [CONDITION(S)] solution [a medication used to treat the complications of liver disease] 19 gm/15 ml; give 30 ml by mouth every 8 hours -[MEDICATION(S)] tablet [a diuretic] 20 mg; give 1 tablet by mouth one time a day -Multivitamin give 1 tablet by mouth one time a day; -[MEDICATION(S)] [a medication used to treat high blood pressure] capsule delayed release 40 mg one time a day -[MEDICATION(S)] capsule [a medication used to treat gastroesophgeal reflux disease] delayed release 40mg; one tablet two times a day -[MEDICATION(S)] tablet [a medication for pain] ,d+[DATE]; give 1 tablet by mouth every 6 hours -[MEDICATION(S)] extended release [a supplement] 20 meq; give 1 tablet by mouth two times a day -[MEDICATION(S)] [a medication to treat irritable bowel syndrome] 550 mg; give 1 tablet by mouth tow times day -[MEDICATION(S)] tablet [a medication to treat gas] 80 mg; give 1 tablet by mouth as needed for gas 4 times per day -[MEDICATION(S)] HCL tablet [a supplement] 100 mg; give 1 tablet by mouth one time a day -[MEDICATION(S)] tablet [a medication to treat gout] 80 mg; give 1 tablet by mouth as needed daily In an interview on [DATE] at 2:45 PM, Licensed Practical Nurse A reported taking care of Resident 1 on day of discharge. Licensed Practical Nurse A reported printing discharge summary, order summary and face sheet that where sent with Resident 1 when Resident 1 discharged . Order summary was not signed by a physician. Licensed Practical Nurse A reported that no medications were sent with Resident 1 and Licensed Practical Nurse A did not send any medication orders to a pharmacy. Licensed Practical Nurse A reported Licensed Practical Nurse did not make contact with the homeless shelter or the clinic on the campus of the homeless shelter or fax any orders to the homeless shelter. In interviews on [DATE] at 12:55 PM and 3:06 PM, Social Worker B reported contacting the homeless shelter on the day of discharge and speaking with someone who answered the phone. Social Worker B believed that individual may have been a volunteer. The individual who answered the phone reported the shelter had an opening. Social Worker B reported that the shelter manager was not available when Social Worker B called and Social Worker B did not have any contact with the shelter manager. Social Worker B confirmed Social Worker B did not make contact with any one at the clinic on the homeless shelter campus or provide any medication or treatment orders to the clinic. According to Social Worker B, Resident 1 was provided with a list of orders and it was up to Resident 1 to give the orders to the clinic. Social Worker B reported that Social Worker B assisted Resident 1 with calling a Section 8 apartment but Resident 1 did not follow up with completing the application. Social Worker B was uncertain when Resident 1's Section 8 voucher had expired. A review of the facility policy dated ,d+[DATE] with subject title Resident Discharge revealed the following: A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care shall indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care, return of person belongings, and any post-discharge medical and non-medical services. Abatement statement The facility provided the following corrective action plan dated [DATE] to address immediate concerns related to discharge planning: 1. The DNS or designee will provide education to nurses and social services designee on coordination to include the following: -Assisting resident to set up wound care services and providing instructions prior to discharge. -Providing prescription to pharmacy of resident choice or sending medications and instructions with resident -Social Service Designee will use discharge coordination checklist to verify planning for wound care services and prescription medications has been arranged prior to discharge. Discharge coordination checklist will include verifying cognitive status of resident and made sure services are included if resident is cognitively impaired. -Facility will ensure discharge location has services in place to provide care for the ongoing needs of the resident. 2. The Executive Director will provide education to Social Service Designee on [DATE] regarding the need to offer residents assistance with applying for financial assistance. 3. The Executive Director will audit staff roster on [DATE] to verify all nurses and Social Service Designee received education immediately on discharge coordination needs listed above. 4. Facility interdisciplinary team to include: Executive Director, Director Nursing Services, Minimum Data Set nurse and Social Service Designee will meet on [DATE] to review next pending discharge for [DATE] to verify discharge components are arranged. 5. On [DATE] the Director Nursing Services or designee will verify that wound care and prescription services were provided prior to resident leaving the facility and for consecutive discharges x 2 months. 6. The Executive Director or designee will discuss pending discharges and review previous days discharges summary during morning stand up 3 x week x 12 weeks to verify wound care services and prescription medications have been coordinated with community provider and pharmacy. 7. The above audits will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is determined. Based on the facility abatement plan, the immediacy was removed. The deficient practice was not totally corrected but severity was lowered to an F level.

Licensure Reference Number: 175 NAC 12-006.09D7a Based on record review and interviews, the facility failed to implement interventions to prevent falls with an injury for 1 resident (Resident 4) of 4 residents reviewed and to prevent a fall without injury for 1 resident (Resident 1) of 4 residents reviewed. The facility census was 40. Findings are: A. Review of Resident 4's EMR (electronic Medical Record) revealed an admitted [DATE]. Review of Resident 4's diagnosis list in the EMR revealed Resident 4 was admitted with the following diagnosis: -Pain in left knee -[CONDITION(S)] -[CONDITION(S)] (inability to use lower extremities) -Muscle weakness -Lack of coordination Review of Resident 4's Admission Fall Risk Evaluation dated 12/12/2020 revealed Licensed Practical Nurse (LPN)-D evaluated Resident 4 to be at Medium Risk for falls. Review of Resident 4's MDS (MDS: Minimum Data Set: a federally mandated tool used in assessing residents and development of a plan of care) dated 12/18/2020 revealed Resident 4 required extensive assistance of 2 staff for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, or standing position). Review of the facility fall incident log revealed Resident 4 experienced a fall on 1/22/2020. Review of the medical record revealed Resident 4 was being assisted by Nursing Assistant (NA)- E and Resident 4 was lowered to the floor. Review of the Facility Investigation dated 12/29/2020 revealed Resident 4 continued to complain of Left knee pain and was sent to the emergency room per ambulance and an x ray diagnosed a Distal Femur Fracture (The upper leg bone near the knee was broken) Interview with the administrator revealed NA-E was the only NA in the room assisting Resident 4 and Resident 4's MDS assessment required 2 assist. B. Review of Resident 1's EMR revealed Resident 1 had the following diagnosis: -Below the knee amputation -Dementia -history of falls Review of the facility fall incident log revealed Resident 1 experienced falls on 1/12/2021 Review of Resident 1's care plan revealed on 1/12/2021 an intervention for a fall was to place dycem (a plastic material to prevent slipping) in the recliner. Review of the facility fall log revealed Resident 1 fell on [DATE] and the interventions was to educate the staff about the dycem. Interview with NA B revealed the staff have access to a Kardex that has the needs of the resident. Review of Resident 1's care plan revealed Resident 1 experienced 14 falls in 60 days.

Licensure Reference No. 1[AGE] NAC ,[DATE].02 Based on Record Review and Interview the Administration failed to utilize resources to ensure facility staff had the correct information regarding CPR status for 4 of 53 Residents, resident 3,30,32,38. The facility staff identified a census of 53. Findings are : D. [DATE] 09:46 AM Record Review of Resident 38 Admission record sheet printed [DATE] , in the section identified as Advance Directive revealed a DNR ( Do Not Resuscitate) or commonly known as a no code. Record review of resident 38 CSP( Code Status Policy) dated [DATE] revealed Resident 38 representative indicated Resident 38 was a Full Code. Further review of Resident 38 CSP sheet revealed Resident 38 Practioner signed the CSP sheet that identified Resident 38 as a Full Code on [DATE]. [DATE] 4:30PM Interview with LPN C ,revealed that to check the code status of facility residents, she would look at electronic records, or she would look in the Code Status Book. If the resident was going to the hospital she would send a copy of the Admission record from either the electronic records or from the Code Status Book. DB [DATE] 1:00PM Record review of all Residents Advance Directives , electronic records, and Facesheets confirmed that 4 of 53 Residents, resident 3,30,32,38, had a discrepancy regarding thier CPR status. A. Record review of undated Code Status Policy (CSP) sheet revealed the following information: -Full Code: -We will initiate basic life support (oxygen therapy, establishing an airway, providing manual respirations and chest compression). In the event of [MEDICAL CONDITION] or [MEDICAL CONDITION] 911 will be notified immediately for transport to the nearest hospital. -No Code: If the death of a resident is inevitable we do not call 911 for transport to the nearest hospital. We do perform all acts that will give comfort such as oxygen if needed, pain management control, suctioning etc. We keep the physician and family updated on any condition change. The resident will remain in the facility with their normal care givers. In the event either family, resident pr physician change their minds about the code status, CPR will be preformed and then be transported to the nearest hospital. B. Record review of Resident 3's Code Status Policy (CSP) sheet with a dated of [DATE] revealed Resident 3's Representative had marked the section on the CSP to indicate Resident 3 was a full Code. Record review of a second CSP dated [DATE] for Resident 3 revealed Resident 3's Representative indicted Resident 3 was a Full Code. Further review of Resident 3's second CPS revealed Resident 3's practitioner signed the CSP that identified Resident 3 as a Full Code on [DATE]. Record review of Resident 3's Admission Record sheet printed on [DATE] in the section identified as Advanced Directive revealed A DNR (Do Not Resuscitate , or commonly known as a no code). On [DATE] at 2:20 PM an interview was conducted with Licensed Practical Nurse (LPN) A. During the interview LPN A reported if a resident codes or goes to the hospital, there is a binder with a code sheet and face sheet (also known as a Admission record sheet). On [DATE] at 2:23 PM an interview was conducted with LPN C. During the interview LPN C reported there is a binder with a code sheet and face sheet and we can use both. On [DATE] at 4:25 PM an interview was conducted with LPN B. During the interview LPN B reported if some one goes to the hospital or codes we use the code sheet and also can use what is in the computer. On [DATE] at 4:39 PM an interview was conducted with Resource Nurse (RN) A. During the interview, review of Resident 3's CSP dated [DATE] and Admission Record sheet were reviewed. During the interview, RN A confirmed Resident 3 CSP and Admission record sheet printed on [DATE] did not match and should have. C. Record review of Resident 32's CSP revealed on [DATE] Resident 32's Representative signed that Resident 32 was a No Code. Further review of Resident 32's CSP signed by Resident 32's Representative on [DATE] revealed Resident 32's practitioner signed the CSP on [DATE]. Record review of Resident 32's Admission Record sheet printed on [DATE] revealed in the section identified as Advance Directive identified Resident 32 as a Full Code. On [DATE] at 4:39 PM an interview was conducted with Resource Nurse (RN) A. During the interview, review of Resident 32's CSP dated [DATE] and Admission Record sheet were reviewed. During the interview, RN A confirmed Resident 3 CSP and Admission record sheet printed on [DATE] did not match and should have. Record review of Resident 30's admission record reveals her advanced directive is listed as Do Not Resuscitate. Record review of the code status policy which is kept in the Code Status/Face Sheet book reveals that the code status for Resident 30 is listed as Full Code. Record review of the physician orders [REDACTED]. An interview with RN- J and LPN-B on [DATE] at 2:30 PM revealed that it depends on where they are when a code is called. If they are way down the hall then they would look at the Electronic medical record on the computer which may, or may not be, correct. F. Based on the information provided on [DATE] to remove the immediacy of the situation, the facility staff provided the following information. Immediate action; 1. For the 5 residents identified, the code status has been verified and updated in the electronic health record ( Advanced Directive, 2.Physcians orders, Face sheet) and in the Code Status Binder. 3. The director of nursing, or the designee will stay in facility and ensure records are correct, with a 100% audit of all residents code status. 4. All nursing staff will be educated on identifying code status preference and where that information is located before leaving this shift. All scheduled staff will be educated before being able to work, until all of nursing staff has been educated. 5. ED or designee will stay to ensure that the aforementioned bullets are completed. Monitoring: 1. Clinical Resources will audit above commitments daily until above audits and education are completed. 2. director of Nursing or designee will audit all new admissions to verify clear identification of code status with 24 hours of admission. 3. Above audits will be documented and brought to QAPI for further review and discussion, X3 months or until substantial compliance is determined.Licensure Refernce Number 1[AGE] NAC ,[DATE].02 [DATE] 11:13 AM Interview with Clinical Resource Nurse (CRN) , D and Administrator in Training E, confirmed, the CRN D and the current Administrator had knowledge of the Sister Facility being sited for not having consistent and clear information for facility residents on CPR status. CRN, D confirmed that an Audit was done at this facility to identify CPR status. CRN D confirmed certain staff members were identified to follow thru with this task and they did not. CRN D confirmed that binders were put in place to include Advance directives, and Face sheets for each resident. CRN D confirmed that new system was not audited to make sure the system was working. Cross Reference F Tag 678.

LICENSURE REFERENCE NUMBER 1[AGE] NAC ,[DATE].09 Based on record review and interviews; the facility staff failed to ensure desired code status was identified consistently and correctly for 4 (Resident 3, 32, 30 and 38) of 53 sampled residents. The facility staff identified a census of 53. Findings are: A. Record review of undated Code Status Policy (CSP) sheet revealed the following information: -Full Code: -We will initiate basic life support (oxygen therapy, establishing an airway, providing manual respirations and chest compression). In the event of [MEDICAL CONDITION] or [MEDICAL CONDITION] 911 will be notified immediately for transport to the nearest hospital. -No Code: If the death of a resident is inevitable we do not call 911 for transport to the nearest hospital. We do perform all acts that will give comfort such as oxygen if needed, pain management control, suctioning etc. We keep the physician and family updated on any condition change. The resident will remain in the facility with their normal care givers. In the event either family, resident pr physician change their minds about the code status, CPR will be preformed and then be transported to the nearest hospital. B. Record review of Resident 3's Code Status Policy (CSP) sheet with a dated of [DATE] revealed Resident 3's Representative had marked the section on the CSP to indicate Resident 3 was a full Code. Record review of a second CSP dated [DATE] for Resident 3 revealed Resident 3's Representative indicated Resident 3 was a Full Code. Further review of Resident 3's second CPS revealed Resident 3's practitioner signed the CSP that identified Resident 3 as a Full Code on [DATE]. Record review of Resident 3's Admission Record sheet printed on [DATE] in the section identified as Advanced Directive revealed A DNR (Do Not Resuscitate , or commonly known as a no code). On [DATE] at 2:20 PM an interview was conducted with Licensed Practical Nurse (LPN) A. During the interview LPN A reported if a resident codes or goes to the hospital, there is a binder with a code sheet and face sheet (also known as a Admission record sheet). On [DATE] at 2:23 PM an interview was conducted with LPN C. During the interview LPN C reported there is a binder with a code sheet and face sheet and we can use both. On [DATE] at 4:25 PM an interview was conducted with LPN B. During the interview LPN B reported if some one goes to the hospital or codes we use the code sheet and also can use what is in the computer. On [DATE] at 4:39 PM an interview was conducted with Resource Nurse (RN) A. During the interview, review of Resident 3's CSP dated [DATE] and Admission Record sheet were reviewed. During the interview, RN A confirmed Resident 3 CSP and Admission record sheet printed on [DATE] did not match and should have. C. Record review of Resident 32's CSP revealed on [DATE] Resident 32's Representative signed that Resident 32 was a No Code. Further review of Resident 32's CSP signed by Resident 32's Representative on [DATE] revealed Resident 32's practitioner signed the CSP on [DATE]. Record review of Resident 32's Admission Record sheet printed on [DATE] revealed in the section identified as Advance Directive identified Resident 32 as a Full Code. On [DATE] at 4:39 PM an interview was conducted with RN A. During the interview, review of Resident 32's CSP dated [DATE] and Admission Record sheet were reviewed. During the interview, RN A confirmed Resident 32's CSP and Admission record sheet printed on [DATE] did not match and should have. D. [DATE] 09:46 AM Record Review of Resident 38's Admission Record sheet printed [DATE] , in the section identified as Advance Directive revealed a DNR ( Do Not Resuscitate) or commonly known as a no code. Record review of Resident 38's CSP( Code Status Policy) dated [DATE] revealed Resident 38's representative indicated Resident 38 was a Full Code. Further review of Resident 38's CSP sheet revealed Resident 38's Practitioner signed the CSP sheet that identified Resident 38 as a Full Code on [DATE]. [DATE] 4:30 PM an interview with LPN C revealed to check the code status of facility residents, (gender) would look at electronic records, or would look in the Code Status Book. If the resident was going to the hospital (gender) would send a copy of the Admission record from either the electronic records or from the Code Status Book. E. Record review of Resident 30's admission record reveals the advanced directive is listed as Do Not Resuscitate. Record review of the code status policy which is kept in the Code Status/Face Sheet book revealed the code status for Resident 30 was listed as Full Code. Record review of the physician orders [REDACTED]. An interview with Registered Nurse (RN)- J on [DATE] at 2:30 PM stated that when determining code status for a resident it depends on where they are when a code is called. An interview with LPN-B on [DATE] at 2:30 PM revealed that if they are way down the hall then I would look at the Electronic medical record on the computer which may, or may not be, correct. F. Based on the information provided on [DATE] to remove the immediacy of the situation, the facility staff provided the following information. Immediate action; 1. For the 5 residents identified, the code status has been verified and updated in the electronic health record (Advanced Directive, Physicians orders, Face sheet) and in the Code Status Binder. 3. The Director of Nursing, or the designee will stay in facility and ensure records are correct, with a 100% audit of all residents code status. 4. All nursing staff will be educated on identifying code status preference and where that information is located before leaving this shift. All scheduled staff will be educated before being able to work until all of nursing staff has been educated. 5. Executive Director (ED) or designee will stay to ensure that the aforementioned bullets are completed. Monitoring: 1. Clinical Resources will audit above commitments daily until above audits and education are completed. 2. Director of Nursing or designee will audit all new admissions to verify clear identification of code status with 24 hours of admission. 3. Above audits will be documented and brought to Quality Assurance Performance Improvement (QAPI) for further review and discussion,for 3 months or until substantial compliance is determined.

State Licensure tag 175 NAC ,[DATE].10. Based on interview, observation and record review; the facility failed to administer medications for Residents 1 and 2 using the 5 Rights of medications administration. This affected 2 of 2 sampled residents. The facility identified a census of 63 at the time of the survey. Findings are: The 5 Rights of medication administration are The Right Medication The Right Dose The Right Time The Right Route The Right Patient The five rights, as stated, focus on the performance of individuals and do not reflect the fact that drug safety is a culmination of efforts of professionals from several disciplines, the responsibility for accurate drug administration lies with multiple individuals and reliable systems. Some of the factors contributing to a medical team's failure to accurately verify the five rights, despite their best efforts, include: Poor Lighting [NAME] An interview with the DON (Director of Nurses) at [DATE] at 10:48 AM revealed; that the staff had done a sweep of the property and found a bottle of Smirnoff Vodka 375ml. This was found in the front of Entrance of the building in a trash can. In the interview with the DON confirmed; that the medication administration for Resident 1 and Resident 2 was done outside the building. The DON reported that they did not know how well lit the area was at the time of medication administration. The DON confirmed that both Resident 1 and Resident 2's medication were delivered at the same time, outside. An interview on [DATE] at 10:48AM with RN (Registered Nurse) at UNMC (University of Nebraska Medical Center) revealed; Resident 1 was positive for opioid and alcohol. Resident 1's BAC (Blood Alcohol Concentration) was 239. The specific opioid and [MEDICATION NAME]. Record review of Resident 1's MAR (Medication Administration Record) revealed; No record of [MEDICATION NAME]. Record review of Resident 1's Quarterly MDS (Material Data Set- a comprehensive federally mandated process for clinical assessment to determine the functional and health care needs of residents) dated [DATE] revealed; Section C BIMS (Brief Interview for Mental Status-is a calculator that checks the residents cognitive impairment and whether further intervention is required for dementia diagnosis.) Score of 13, a score of 13 shows intact cognition. Section D Total Severity Score was 03 with Section [NAME] Little interest or pleasure in doing things ,[DATE] days section G trouble concentrating on things such as reading the newspaper or watching television ,[DATE] days. Section [NAME] Behaviors: indicates no behaviors. Section G Functional Status: indicates toilet use one assist, set up. Requires supervision for bed mobility, walking in corridor, locomotion off the unit, eating and toilet use. Section G 0300 Balance during transitions and walking-was steady at all times. Section I Diagnosis: [REDACTED]. Section J Health conditions- No pain, has had a fall with no injury, Section K: Nutrition: 5'1 and weight was 156 Section M: medications: [REDACTED]. Record review of Resident 1's Lab reports from UNMC dated [DATE] revealed; the toxicity screen for Resident 1 showed that the positive results for: Opiates and [MEDICATION NAME]. Record review of Initial Visit Critical Care Medicine dated [DATE] at 1:18Am revealed Resident 1 had a history of [REDACTED]. Resides at Nursing Home and was found unresponsive and purple. CPR was performed for 3 minutes. There was a pulse when paramedics arrived and was given [MEDICATION NAME] without effect. Resident 1 reported nonsmoking and had quit 8 months ago. Resident 1 reported no drug use. Physical exam revealed: Alert, appears stated age, cooperative, no distress and sedated and on a ventilator. Record review of UNMC Assessment and Plan dated [DATE] revealed; the principle problem was [MEDICAL CONDITION], elevated lactic acid level, acute [MEDICAL CONDITIONS], altered mental status, Insulin dependent diabetes mellitus. Record review of Attending Neurology dated [DATE] revealed; Resident 1 had a history of [REDACTED]. Resident 1 required resuscitation and CPR. Resident 1 was found to have an alcohol level over 200. Resident 1 continued to be intubated, alert and cooperative. Resident 1's parent was concerned about further [MEDICAL CONDITION]. Record review of Resident 1's Medication Admin Audit Report dated [DATE] the medications were documented at 23:53PM (11:53PM) [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) Tablet 500mg BID, [MEDICATION NAME] (benzodiazepines used to treat anxiety disorders) Tablet 0.5mg at HS, [MEDICATION NAME] (used to treat certain mental/mood conditions (such as [MEDICAL CONDITIONS] disorder, episodes [MEDICAL CONDITION] depression)Tablet 25mg at HS, [MEDICATION NAME] (a natural hormone associated with sleep onset) Tablet 3 mg 1 tablet at HS for sleep, Jolessa (a combination hormone medication used to prevent pregnancy) Tablet 0.15mg-0.03mg 1 tablet at HS, and [MEDICATION NAME] (medicine that helps lower LDL cholesterol) Tablet mg at HS. (RESIDENT WAS ALREADY OUT TO THE HOSPITAL AT THE TIME THE MEDICATIONS WERE GIVEN) [MEDICATION NAME] (a man-made rapid acting insulin for adults with diabetes) Flex Pen Sliding scale documented at 00:14AM (12:14AM) [MEDICATION NAME] Flex Pen Inject 5 units SUBQ. B. An interview with Resident 2, on [DATE] at 4:30PM revealed, that (gender) felt like the facility was blaming them for Resident 1's incident. Resident 2 reported if they would have known Resident 1 was drinking they would have got the nurse. Resident 1 had laid on Resident 2's bed, head on the pillow. Resident 2 reported Resident 1 started to snore. Resident 1 had told Resident 2 they did not snore so Resident 2 thought it was cute. Resident 2 reported that about 2 minutes later Resident 2 observed that Resident 1 was no longer snoring and assisted Resident 1 onto back. Resident 2 reported Opened Resident 1's eye lid was dilated, Lips turned blue did a sternal rub. Resident 1 did not respond, so Resident 2 went to the nurse told the nurse that it was a code, Resident 2 reported the nurse started chest compressions and within a minute they got Resident 1 back. Resident 2, who was visibly upset and reported that Resident 1 spoke about drinking all the time. Resident 2 encouraged Resident 1 not to drink and reported that the parents would not have put Resident 1 here if it was not necessary. Resident 2 reported had started smoking since the stress- 5 people have died at the facility since admission and had starting smoking related to that. Resident 2 reported that (gender) told the nurses Resident 2 thought (gender) did not get their own medications. There were not enough medications in the cup. Resident 2 reported the nurse questioned whether or not the residents were given each resident the right medications. Resident 2 requested for the nurse to check the medication administration sheets and the nurse refused telling Resident 2 that the right medications had been given. Resident 2 reported that in the cup of medications were only 3 small round pills, and there should have been more pills. Resident 2 reported that Resident 1 had already swallowed the medications. Resident 2 felt if brought to the attention of the nurses the medications were mixed that Resident 1 could have been given [MEDICATION NAME] to reverse the effects. Resident 2 reported that (gender) approached the nurse about the mix up of medication and the nurse would not check to see if the medication was given. Resident 2 reported that (gender) had some medical training. Resident 2 reported that Resident 1 called 8:13 and next time at 9pm and they followed Resident 1 outside and had a smoke. No words were slurred. Reported that the medication were given was 20 minutes with the time lapse Resident 2. Resident 2 reported that for some the Administrator wanted someone to observe Resident 2 is outside, sign out write the time. It is something they do if they sign out supposed to sign out and Resident 1 never does. Resident 2 pointed out the area both residents were sitting in and reported that area was not well lit and Nurse A delivered both residents medications at the same time. C Record Review of Administrator notes interview with Nurse A: Nurse A indicated that Resident 1 and Resident 2 were seen to be exiting the facility shortly before 8PM on [DATE]. Nurse A reported that Resident 2 told the nurse that (gender) would get medication is a little while. Resident 1 and 2 were noted to be in the garden area. Nurse A reported when it was time for medication administration, Nurse A prepared Resident 1 and 2 medications and took them outside and delivered the medications to each of them. Nurse A reported picking up cups that were outside with Resident 1 and 2. Nurse A reported that there was an energy drink present and described it as looking like red bull. Nurse A reported smelling something strange and in hindsight thinks this could have been alcohol, but at the time assumed it was water. Nurse A reported it was roughly 10 pm when Resident 1 and 2 came inside and stopped at the nurse's desk on the way to Resident 2's room. Nurse A reported after 10pm nurse arrived, Resident 2 came out of their room and reported Resident 1 was not breathing. Nurse A rushed to the room, confirmed no pulse/respirations and called for nurses from other floor to come down. Nurse B came in and placed the board under Resident 1 and began compressions. Nurse C called 911 and entered the room and began compressions to Resident 1. Nurse A reported prepared oxygen and suction machine for use if needed. Shortly after compression and respirations Nurse B and C were able to restore a pulse and breathing. Shortly after EMT arrived and took over. An interview with Nurse B on [DATE] revealed; Nurse B reported that they were finishing documentation and giving report to the night shift nurse when heard the page for stat response to 1st floor. Nurse B reported they used the stairs and rushed to 1st floor and was directed to go to Resident 2's room where she encountered Nurse A preparing to respond to code. Nurse B reported that Resident 1 had no pulse of respirations. Nurse B placed that code board under Resident 1 and coordinated with Nurse C to support rescue breathing while Nurse B did compressions. Nurse B reported that Resident 1's respirations and pulse were restored.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation record review and interview; the facility staff failed to evaluate nutritional requirements for pressure ulcer healing, failed to evaluate casual factors for the development of a pressure ulcer and failed to evaluate the condition of a pressure ulcer for 1(Resident 3) of 3 sampled residents. The facility staff identified a census of 63. Findings are: A. Record review of a Physicians Order Sheet and Progress Notes (POSPN) form revealed the facility staff had requested the practitioner evaluate a blister that was forming on Resident 3's left heel. According to the POSPN dated 2-09-2018, the practitioner ordered Prevalon (type of pressure reliving intervention) boots when in bed, a treatment to the left heel blister and for the facility to have the Wound Physician see Resident 3. Record review of a Mobile Wound Solutions (MWS) assessment dated [DATE] for Resident 3 revealed the practitioner had assessed Resident 3 with a stage 2 (Stage 2 Pressure Ulcer: Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister) pressure ulcer to the left heel that measured 4.50 centimeters (cm) by 3.70 cm with depth being 0.10 cm. Record review of Resident 3's MWS assessment dated [DATE] revealed the practitioner assessed Resident 3 with a stage 2 pressure ulcer to the left heel that measured 6.20 cm by 6.0 cm and 0.10 depth. The left heel pressure ulcer remained at a stage 2 pressure ulcer level. Record review of Resident 3's MWS assessment dated [DATE] revealed Resident 3 was assessed with [REDACTED]. Observation on 4-23-2018 at 9:58 AM revealed Registered Nurse (RN) A obtained the required treatment supplies for Resident 3's left heel. Observation of the pressure ulcer revealed it was approximately 6.2 cm oblong, with black tissue in the center. No drainage was noted. Record review of Resident 3's medical record revealed there was no evidence the facility staff had evaluated Resident 3's nutritional requirements for wound healing for the pressure ulcer to the left heel. On 4-23-2018 at 2:57 PM an interview was conducted with the Director of Nursing (DON). During the interview, the DON confirmed a nutritional evaluation had not been completed for pressure ulcer healing and reported a nutritional evaluation for pressure ulcer healing should have been completed. B. Record review of a Skin Ulcer Non-Pressure Weekly sheet dated 3-22-2018 revealed the facility staff had evaluated Resident 3 with a pin point open area to the right buttocks. Review of Resident 3's record revealed there was no evidence the facility had monitored the wound to the right buttock. Record review of Resident 3's progress notes dated 4-16-2018 and 4-22-2018 revealed Resident 3 had a pressure ulcer to the right buttocks. Further review of Resident 3's medical record revealed there was no evidence the facility had evaluated the condition of the right buttocks that included the size, the depth, and if there was drainage from the pressure ulcer or, how Resident 3 developed the pressure ulcer. Observation on 4-23-2018 at 2:15 PM of the pressure ulcer to the right buttocks with the DON and RN A revealed the DON removed a dressing to Resident 3's right buttocks revealing a quarter sized area with whitish tissue in the center of the pressure ulcer. On 4-23-2018 at 2:25 PM an interview was conducted with the DON. The DON confirmed the area to Resident 3's buttocks was pressure and was unstageable. Record review of the facility Policy and Procedure for the Care and treatment of [REDACTED]. -Policy: -A resident having a pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. -Procedures: -Assessment of the ulcer: -Type, Stage, Characteristics, Progress towards healing or potential complications, Infection and treatment. -3. Treatment: -Nutrition and Hydration management.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09d2b Based on observations record review and interview; the facility staff failed to evaluate the presence of pressure ulcers on admission, failed to monitor and implement a treatment for [REDACTED]. The facility staff identified a census of 60. Findings are: Record review of a Resident Information sheet printed on 12-07-2015 revealed Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident 4's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 11-30-2015 revealed the facility staff assessed the following about the resident: -Resident 4's cognition was severely impaired. -Required extensive assistance with bed mobility, transfers, dressing and toilet use. -Required total assistance with personal hygiene. - Used a feeding tube. Record review of a LN (Licensed Nurse) Admission Assessment Comprehensive (AAC) sheet dated 11-17-2015 revealed Resident 4 had had an open area to the right ankle bone that measured 1 centimeter (cm) by 1 cm, left heal had eschar (dead tissue) 0.2 cm by 0.2 cm's and area on right inner buttock that measured 5.5 cm by 2.9 cm. Record review of Resident 4's undated Comprehensive Care Plan (CCP) revealed the open area was identified as a stage 3 (Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) to the (right) buttocks, and an unstageable pressure ulcer to the right ankle and left heel. Record review of Resident 4's LN-Skin Pressure Ulcer Weekly (LN-SPUW) sheets dated 12-03-2015 revealed the facility staff assessed the right buttocks as a stage 3 pressure ulcer (PU) that measured 2 cm by 2.2 cm with a depth of 0.1 cm. The Right outer ankle was assessed as unstageable that measured 0.8 cm by 0.9 cm and had slough/eschar (dead tissue) and the left heel measured 0.5 cm by 0.5 cm and was unstageable. Record review of a Fax sheet dated 11-23-2015 revealed the facility Registered Dietician (RD) recommended [MEDICATION NAME] 1 scoop mixed with 2 to 4 ounce's of water via peg tube ( tube placed through the abdominal area into the stomach for feeding, water and medications) for additional protein to aid in wound healing. Record review of Resident 4's record revealed there had not been a response to the fax as of the start of survey on 12-3-2015. An interview on 12-03-2015 was conducted with the facility Assistant Director of Nursing (ADON). During the interview, review of the fax sheet dated 11-23-2015 of the RD recommendation was completed with the ADON. The ADON confirmed the recommendation had not been followed up on and should have been. Observations on 12-07-2015 at 5:30 PM with Licensed Practical Nurse (LPN) A and Nursing Assistant (NA) B revealed Resident 4 was positioned onto the left side. LPN A reported Resident 4 had a pressure ulcer on the right buttock. Observation of the right buttock pressure ulcer revealed the size measured approximately 2 cm round. The wound bed had blackish tissue and the bed of the wound was not visible. LPN A reported the PU was unstageable. Further observations revealed Resident 4 had a pressure ulcer to the coccyx that measured approximately 0.6 cm by 0.2 cm and had black looking tissue and the wound bed was not visible. The resident also had a pressure ulcer to the sacrum that measured approximately 0.6 cm's. The LPN reported Resident 4 was admitted with the pressure ulcers. On 12-07-2015 at 7:25 AM a follow up interview was conducted with LPN A. During the interview, LPN A reported Resident 4's PU were worse. On 12-07-2015 at 11:14 AM an interview was conducted with the ADON. During the interview the ADON confirmed the PU to the coccyx and sacrum were not identified on the admission assessment, no treatment had been implemented and there was no monitoring of the areas. The ADON confirmed Resident 4's PU had worsened.