Every finding on record at Prestige Care Center of Plattsmouth

Nebraska Licensure reference: NAC 75: 12-006.11(E); NAC 75: 12-007.10(A) Based on observation, interview, and record review, the facility failed to ensure all foods were labeled, sealed, and dated after opening, ensure outdated foods were not available for use, and satellite refrigerators were kept clean, ensure staff performed hand hygiene and gloving to prevent cross contamination during meal prep and dining, and failed to handle resident dinnerware and utensils in a sanitary manner. The facility census was 87 residents.Findings are: Record review of the facility Food Safety Requirement policy revised 03/2026 revealed the following: -Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. -Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. -Preparation of food, including thawing, cooking, cooling, holding, and reheating. - Employee hygienic practices. -Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded; -Keeping foods covered or in tight containers -Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. -Staff shall wash hands according to facility procedures. -Staff shall not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas. A) Observation of Dry storage room near kitchen on 3/30/26 at 7:25 AM revealed the following: -2 bins of individually packaged salad dressings. There was no date on the bins and no date on any of the dressing packets. -Plastic bin on upper shelf of dry storage had many tea bags floating in container filled with water. Tea was in plastic bags. and was dated. -Dietary Manager (DM) pointed to ceiling and stated that there is a pipe up there that leaks sometimes It is an old building. -Water-filled container removed by cook for disposal. Observation of additional storage room near time clock on 3/30/26 at 7:32 AM revealed the following: -Freezer used for supplements revealed many were sticky, bottom shelf of freezer was dirty with a dry white substance. Observation of Dementia Care Unit on 3/30/26 at 1:15 PM revealed the following: The refrigerator contained: -3 buns/rolls with no date on bags -5 portion cups with white condiment with no date, -Opened a supplement with no date when opened -Tub of packaged dressings resting in container of clear liquid The upper cabinet next to refrigerator included: -Opened coffee dated but not bagged. -Partially used jar of hot cocoa with expiration date of 4/24 and no opened date -Box of cocoa packets with no expiration date found and no date opened -Shaker bottle of Cinnamon with expiration of 12/2/2021 -Tea box expiration of 2/24 and no date opened. -Upper cabinet's lowest shelf contained spills of white and black crystals as well and some red colored crystals. Observation of Activity Room refrigerator and freezer on 3/30/26 at 1:30 PM revealed the following: The refrigerator contained: -Opened container of lemon juice, not dated -Multiple opened coffee creamers (caramel macchiato, French vanilla and fudgy chocolate) none were dated -Strawberry syrup, opened, not dated -Jar of relish, opened, not dated -Jar of minced garlic, expired 04/2025, opened, not dated The freezer contained -3 bags of 48 ounce mixed fruit in sealed plastic bags (unopened). The first bag expired 10/27/24. Bags 2 and 3 expired 1/6/25. Food Cupboards contained -Decorative sprinkles x 7 open, no date -Salt, opened, not dated -Multiple seasoning containers, opened, not dated -Two containers of baking soda, opened, not dated -Sugar crystals, opened, not dated -Soap pads in food cupboard On 3/30/2026 at 12:55 PM an interview was conducted with the Activity Director (AD). During the interview the AD confirmed the items were outdated or not marked when opened. The AD further reported being unaware that AD was supposed to check for expiration dates. Interview with Dietary Manager (DM) on 03/30/2026 at 1:30 PM revealed that dietary/ kitchen staff are responsible for dating and monitoring food taken to dementia unit. Any other food items are the responsibility of the staff on the dementia unit. B. Record review of the facility Policy titled Hand Hygiene revised on 12/2025 revealed: 5. Hand hygiene technique when using soap and water: a. Wet hands with water. Avoid using hot water to prevent drying of skin.b. Apply to hands the amount of soap recommended by the manufacturer.c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers.d. Rinse hands with water.e. Dry thoroughly with a single-use towel.f. Use clean towel to turn off the faucet 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Record review of the facility Policy titled Food Safety Requirements revised on 03/2026 revealed the following: 7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. a. Staff shall wash hands according to facility procedures.b. Staff shall not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas. Observation on 04/01/2026 at 10:04 AM revealed the DM preparing the spinach bake: The DM noted to remove gloves after cutting raw bacon, then obtained a new box of bacon from the freezer. The DM applied new gloves without the benefit of hand hygiene. After cutting bacon, the DM removed the gloves and touched the clean dishes. At that time, the DM washed their hands for 22 seconds and then touched their own face and clothes. The DM chopped the onion with bare hands and washed their hands for 25 seconds. Observation on 04/01/2026 at 1:18 PM revealed Dietary Aide (DA) M emptied food from steam trays to the garbage can. DA M without hand hygiene began to serve fruit in bowls with bare hands touching the inside of bowls without the benefit of hand hygiene. A interview on 04/01/2026 at 11:26 with the DM confirmed that utilization of gloves and hand hygiene was not completed during the cooking process and should have been. A Interview on 04/01/2026 at 2:13 PM with the DM confirmed that DA M did not follow hand hygiene when serving and should have been. C. An observation on 04/01/2026 at 7:50 AM – 8:10 AM revealed DA B poured Resident 14 a glass of milk and sat down in front of the resident with DA-B's fingers touching the drinking surfaces (the area of a glass or cup where a resident would place their lips). DA-B then poured Resident 89 a cup of coffee and a glass of milk and placed them in front of the resident while touching the drinking surfaces and not completing hand hygiene between residents 14 and 89. DA-B went to the kitchen, returned, and poured Resident 20 drinks and placed them in front of the resident with DA-B's fingers on the drinking surfaces. DA-B then got Resident 43 a cup of coffee and Resident 48 a glass of tea and a glass of milk and sat them down in front of the residents while DA-B's fingers were holding the drinking surfaces. DA-B got Resident 71 a cup of coffee while touching the drinking area of the cup's lid. DA-B touched DA-B's surgical mask and then got Resident 73 two drinks in spill proof cups and covered the cups while touching the drinking surfaces of the lids. DA-B got Resident 49 two glasses of milk and a glass of apple juice and sat them down in front of the resident while touching the drinking surfaces. The observation did not reveal DA-B completed hand hygiene between the residents. In an interview on 04/02/2026 at 7:56 AM, the facility's Administrator confirmed the dietary staff should not have touched the drinking surfaces of the resident's glasses or cups when serving drinks and should have done hand hygiene between getting the residents drinks.

Licensure Reference Number 175 NAC 12.006.19(C)(i)Licensure Reference Number 175 NAC 12.006.18(B)Licensure Reference Number 175 NAC 12.006.18(D)Based on observation, interview, and record review, the facility failed to ensure staff handled clean clothing and linens, completed hand hygiene during 1 (Resident 2) of 4 sampled resident's wound care, failed to ensure a medication aide wore gloves when opening a medication capsule for 1 (Resident 69) of 4 sampled residents, failed to ensure 1 (Resident 34) of 1 sampled resident's Continuous Positive Airway Pressure device (CPAP)(a machine used to treat sleep apnea) mask and nebulizer (neb)(a machine used to deliver liquid medications to the lungs) kit were stored, failed to ensure staff performed hand hygiene between glove changes to prevent potential cross contamination (transfer of bacteria from one surface to another), and failed to follow Enhanced Barrier Precautions (EBP) during high contact cares for Resident 66. The facility census was 87. Findings are:A. A record review of the facility's Handling Clean Linen policy with a date reviewed/revised of 03/2026 revealed the staff should handle and transport clean linen in a safe and sanitary manner to prevent cross contamination. Staff should have carried clean linens away from their bodies. An observation on 03/31/2026 at 12:08 PM – 12:16 PM revealed Laundry Aide (LA)-C took hanging clothes off the clothing rack and delivered the resident's clothing to resident room [ROOM NUMBER] with the clothing dragging on the floor and against LA-C's clothing. LA-C then took hanging clothes off the clothing rack and delivered them to resident in room [ROOM NUMBER] and allowed the resident's clothing to touch LA-C's clothing. LA-C took a pair of pants off the clothing rack, removed the pants from the hanger, and held the pants against LA-C's body and clothing as they were delivered to resident room [ROOM NUMBER]. LA-C then took hanging resident clothing off the clothing rack and allowed the hanging resident clothing to come in contact with LA-C's clothing as it was delivered to resident rooms [ROOM NUMBERS]. LA-C took a hanging dress and other clothes and delivered to resident room [ROOM NUMBER] and allowed the clothing to contact LA-C's clothing and the dress to drag on the floor. LA-C then delivered hanging resident clothes to resident room [ROOM NUMBER] while allowing the resident clothing to contact LA-C's clothing. An observation on 04/01/2026 at 12:27 PM revealed Medication Aide (MA)-B carried a stack of towels from the supply closet to the bath house on MA-B's left arm and against MA-B's chest and clothing. An observation on 04/02/2026 at 7:55 AM revealed Nursing Assistant (NA)-E carried a stack of towels to the bath house on NA-E's left arm and against NA-E's chest and clothing. In an interview on 03/31/2026 at 12:16 PM, LA-C confirmed that LA-C should not have allowed the resident's clothing to contact LA-C's clothing or the floor during delivery to the resident's rooms. In an interview on 04/01/2026 at 12:27 PM, MA-B confirmed MA-B carried the stack of towels to the bath house against MA-B body and clothing and should not have. In an interview on 04/02/2026 at 7:55 AM, NA-E confirmed NA-E should not have carried the stack of towels against NA-E's body. In an interview on 03/31/2026 at 3:40 AM, the facility's Director of Nursing (DON) confirmed the staff should not have allowed clean resident laundry to come in contact with the staff's clothing or the floor. B. Policy review on 04/01/2026 at 12:01 PM titled Hand Hygiene revised 12/2025 revealed the following : 3. Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. 4. Hand hygiene technique when using an alcohol-based hand rub: a. Apply to palm of one hand the amount of product recommended by the manufacturer. b. Rub hands together, covering all surfaces of hands and fingers until hands feel dry. c. This should take about 20 seconds. 5. Hand hygiene technique when using soap and water a. Wet hands with water. Avoid using hot water to prevent drying of skin. b. Apply to hands the amount of soap recommended by the manufacturer. c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers.d. Rinse hands with water.e. Dry thoroughly with a single-use towel.f. Use clean towel to turn off the faucet.Additional considerations:a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. According to the facility hand hygiene table, either soap and water or alcohol-based hand rub should be performed in the following situations: After handling contaminated objects, before applying and after removing personal protective equipment (including gloves), and before and after handling clean or soiled dressings. Policy review on 04/01/2026 at 11:53 AM titled Clean Dressing Change revised on 03/2026 revealed the following: 5. Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application6. Establish area for soiled products to be placed (Chux or plastic bag).7. Wash hands and put on clean gloves.8. Place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sites.9. Loosen the tape and remove the existing dressing. If needed to minimize skin stripping or pain, moisten with prescribed cleansing solution or use adhesive remover to remove tape.10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle.11. Wash hands and put on clean gloves.12. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other the wound (i.e. clean outward from the center of the wound). Pat dry with gauze. Record review of Registered Nurse-I (RN-I)'s competency check list revealed RN-I had been educated on hand hygiene and wound care as of 06/26/25 and 06/30/25. Observation on 03/31/2026 from 12:19 PM to 12:55 PM revealed Registered Nurse- I (RN-I) performing wound care on Resident 2. Present in the room was also Medication Aide-L (MA-L). During observation the following occurred:-RN-I removed a gown out of container which touched the ground multiple times. -RN-I performed hand hygiene, applied gloves, and provided privacy with curtains -A barrier with paper towels was placed on the cluttered tv stand and RN-I applied a piece of tape to a basin to, later secure a dressing -RN-I was observed to drop a Q-Tip package on floor and then picked up the package to be used with clean supplies-RN-I removed gloves, washed hands for 17 seconds, placed a new paper towels on top of the toilet, and applied new gloves-RN-I removed gloves without the benefit of hand hygiene, continued to remove old dressing with bare hand, then new gloves were applied-RN-I touched the residents bed and then touched Resident 2's wound, then touched residents bed, touched a measuring tape directly to the wound bed-RN-I removed gloves, then touched multiple objects throughout the room-RN-I washed hands for 18 seconds, and than applied new gloves-RN applied betadine to a gauze, touched their own face with gloved hands, repetitively rubbed betadine soaked gauze throughout the wound bed, and placed the gauze directly to the wound bed, applied ABD (a thick absorbent dressing) layer on top and wrapped it with kerlix-RN-I was observed touch their own face, placed tape from basin on dressing with date and initials- RN-I was observed to use old previously used betadine gauze off of dirty disposable bed pad to paint on skin - RN-I removed gloves, washed hands for 17 seconds, applied new gloves, immediately removed the gloves, washed hands for 12 seconds, and without gloves touched dirty supplies and placed in container-RN-I without completing hand hygiene applied new gloves-RN-I was observed to empty a garbage can, then left the room with container of dirty supplies-RN-I while using dirty gloves, sat the used container of dirty supplies in hall, held onto the handrail in the hall and opened soiled utility room door-RN-I applied new glove to right hand to carry supplies, then placed the supply container on the medication cart. RN continued to use the dirty glove on right hand to clean bottom of container with hand sanitizer on paper towel.-RN-I removed the glove and without the benefit of hand hygiene continued to touch the medication cart. A interview on 03/31/2026 at 3:32 PM was conducted with RN-I. During the interview RN-I confirmed the concerns about cross contamination and hand hygiene. A interview on 04/01/2026 at 8:45 AM with RN-I confirmed handwashing should be completed for 20 seconds and that hand hygiene should be completed before and after glove changes. RN-I confirmed that glove changes should also be completed after the removal of a dirty dressing. A interview on 04/01/2026 at 9:45 AM was conducted with the Director of Nursing (DON). During the interview the DON reported the expectation of hand hygiene should be prior to and after any glove changes and that glove changes should be done when soiled or dirty. C. An observation on 3/30/2026 at 7:57AM of the medication administered by Medication Aide F (MA F) to Resident 69 revealed the following: MA F used hand sanitizer, opened the medication cart, and removed Resident 69's medication cards. MA F compared the medications to Resident 69's electronic health record and placed the medications into a medication cup. MA F removed a medication capsule from the cup, opened the capsule, and sprinkled the contents into another medication cup without using gloves. MA F crushed the other medications in a plastic pouch and added them to the medication cup. MA F added grape jelly to the crushed medications and mixed them together. MA F gathered gloves, medications and eye drops and approached Resident 69. MA F used a spoon to administer the crushed medications along with a glass of water. MA F donned gloves, without using hand sanitizer, and administered the eye drops by having Resident 69 tilt their head back as MA F pulled down on the lower eye lid and placed a drop in each eye. MA F returned to the cart, removed their gloves, and charted the administration without using hand sanitizer. The following medications were administered. Acetaminophen (a pain relief tablet used to treat mild to moderate pain) 500 milligrams (mg - a unit of measurement) tablets. Take 2 tablets by mouth three times daily. Artificial tear drops. (lubricating eye drops used to relieve dry, irritated eyes) Instill 1 drop in both eyes daily. Wait 5 minutes before administering different eye drops. Eliquis (a prescription blood thinner) 2.5mg tablet by mouth twice daily. Ferrous Sulfate (supplement to treat iron deficiency) (325mg tablet. Take 1 tablet by mouth every morning on Mondays and Thursdays. Furosemide (a medication that increased the output of urine) 40mg tablet. Take 1 tablet by mouth daily. Vitamin D3 (a supplement that helps to absorb calcium) tablet 2000Unit (U – unit of measurement). Take 1 tablet by mouth daily. Losartan Potassium (a medication used to treat high blood pressure) 50mg tablet. Take 1 tablet by mouth daily. Nitrofurantoin (an antibiotic used to treat urinary tract infections) 100mg Capsule. Take by mouth twice daily for 7 days. Do not crush/chew. Pantoprazole (a prescription medication used to reduce stomach acid production) 40mg tablet. Take 1 tablet by mouth daily. Do not crush. An interview on 3/30/2026 at 7:57AM with MA F confirmed they did not use hand sanitizer before donning or after doffing gloves and did not wear gloves when opening a medication capsule and should have done so. MA F confirmed these actions were a breach of infection control. An observation on 3/30/2026 at 9:10 AM of blood glucose monitoring by MA G for Resident 47 revealed the following. MA G gathered a box containing Resident 47's insulin, blood glucose monitor, alcohol wipes, test strip, and lancets. MA G donned gloves without using hand sanitizer, opened and alcohol wipe and wiped Resident 47's index finger with the wipe. MA used the lancet to pierce Resident 47's skin and when blood welled up, MA G used the blood glucose monitor with a test strip to test the blood for a blood sugar level of 184. MA G removed their gloves and donned clean gloves without using hand sanitizer. MA G used an alcohol wipe to clean an area on Resident 47's left abdomen and administered the ordered amount of insulin via injectable pen. MA G removed their gloves, discarded their trash, and returned to the medication cart with Resident 47's supply box. MA G used hand sanitizer and documented the blood glucose test results and the insulin amount administered. An interview on 3/30/2026 at 9:10 AM with MA G confirmed they had not used hand sanitizer when donning and doffing gloves and they should have done so. MA G confirmed this action was a breach of infection control. D. Record review of facility policy entitled Nebulizer Therapy dated revised 03/2026 revealed once the nebulizer was cleaned and completely dried, the nebulizer cup and mouthpiece would be stored in a zip lock bag. Observations on 03/30/2026 at 8:27 AM and 1:22 PM revealed Resident 34's CPAP mask with the mask side resting on the handle of the oxygen (O2) concentrator with no barrier and the nebulizer kit resting with the mask up and on the bedside table with no barrier. Observation on 04/01/2026 at 9:21 AM with the Infection Preventionist (IP) revealed the CPAP mask with the mask side resting on the handle of the O2 concentrator with no barrier and the nebulizer kit with the mask up and on the bedside table with no barrier. An interview on 04/01/2026 at 9:21 AM with the IP confirmed the CPAP mask was stored face down on the on the O2 concentrator handle with no barrier and further confirmed the nebulizer kit was stored face up on the beside table without a barrier. The IP confirmed the storage of the CPAP mask and nebulizer kit promoted the potential for cross contamination. The IP reported the CPAP mask and nebulizer kit should have been stored in a resident drawer or plastic bag when not in use. E. Record review of facility policy entitled Enhanced Barrier Precautions revised 02/2025 revealed: -Enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted down and gloves use during high contact resident care activities. -2b. An order for enhanced barrier precautions will be obtained for residents with any of the following: -i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident I snot known to be infected or colonized with a multi-drug resistant organism (MDRO). -4. High-contact resident care activities include: -f. Changing briefs or assisting with toileting. -h. Wound care: any skin opening requiring a dressing. Record review of Resident 66's admission Record (AR) revealed the facility admitted the resident on 01/31/2025. Record review of Resident 66's Order Summary Report revealed an order for enhanced barrier precautions due to a chronic wound dated 01/28/2026. Record review of Resident 66'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 Resident 66 required enhanced barrier precautions dated 01/29/2026. Observation on 03/31/2026 from 9:37 AM to 10:02 AM with of wound and perineal care provided to Resident 66 by Registered Nurse (RN)-I and Medication Aide (MA)-O revealed RN-I washed hands with soap and water for 22 seconds and MA-O washed hands with soap and water for 18 seconds. Both RN-I and MA-O donned gloves, while neither RN-I nor MA-O wore a gown. RN-I removed the old dressing, discarded gloves and performed hand hygiene. RN-I donned (applied) new gloves and applied the wound treatment, doffed (removed) gloves and without the benefit of hand hygiene donned new gloves. RN-I asked, Do I need to wash my hands again? and proceeded to complete the wound treatment. RN-I doffed gloves, and without the benefit of hand hygiene donned new gloves to assist MA-O to perform perineal care. MA-O, with clean gloves, removed Resident 66's brief and disposable bed pad and discarded. MA-O doffed gloves and without the benefit of hand hygiene, donned new gloves. MA-O cleaned Resident 66's back side. MA-O doffed gloves and without the benefit of hand hygiene donned new gloves. MA-O applied a new brief and cleaned Resident 66's front side. MA-O doffed gloves and without the benefit of hand hygiene donned new gloves, cleansed Resident 66's front side again and doffed gloves. Without the benefit of hand hygiene, MA-O applied new gloves, and with the assistance of RN-I repositioned Resident 66 and placed pillows for support and comfort. Interview on 03/31/2026 at 1:56 PM with MA-O confirmed EBP including gown and gloves should have been used when assisting RN-I with wound care and while performing perineal cares. MA-O further confirmed hand hygiene should have been performed between gloves changes and was not completed. Interview on 03/31/2026 at 2:02 PM with RN-I confirmed hand hygiene as not performed between glove changes and should have been. RN-I further confirmed Resident 66 was in enhanced barrier precautions and a gown was not worn as part of EBP and should have been.

Licensure Reference Number 175 NAC 12.007.04(D)Licensure Reference Number 175 NAC 12.006.19(A)Licensure Reference Number 175 NAC 1.009.02Based on observation, interview, and record review, the facility failed to ensure the exhaust ventilation system was working in all resident's restrooms. This affected all residents that resided in the facility. The facility census was 87. Findings are:A record review of the facility's Safe and Homelike Environment policy with a date reviewed/revised of 03/2026 revealed the resident rooms would have adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two. Observation on the following dates and times revealed the following resident restroom exhaust ventilations systems (vents) were not working and pulling air from the restrooms: - 03/30/2026 at 9:01 AM in room [ROOM NUMBER] - 03/30/2026 at 1:47 PM in room [ROOM NUMBER] - 03/30/2026 at 9:51 AM in rooms [ROOM NUMBERS] - 03/30/2026 at 10:23 AM in room [ROOM NUMBER] - Strong urine odor - 03/30/2026 at 1:19 PM in room [ROOM NUMBER] - 03/30/2026 at 9:15 AM in room [ROOM NUMBER] - 03/30/2026 at 1:20 PM in Room SN00007 - 03/30/2026 at 10:27 AM in room [ROOM NUMBER] - 03/30/2026 at 10:34 AM in room [ROOM NUMBER] - 03/30/2026 at 8:50 AM in room [ROOM NUMBER] - 03/30/2026 at 12:47 PM in Room SN00006 - 03/30/2026 at 9:05 AM in room [ROOM NUMBER] - 03/30/2026 at 11:59 AM in Room SN00002 - 03/30/2026 at 12:22 PM in Room SN00007 - 03/30/2026 at 8:50 AM in room [ROOM NUMBER] - 03/30/2026 at 9:34 AM in room [ROOM NUMBER] - 03/30/2026 at 10:25 AM in room [ROOM NUMBER] - Strong urine smell - 03/30/2026 at 11:52 AM in Rooms 408 - Strong feces odor - 03/30/2026 at 10:26 AM in room [ROOM NUMBER] An observation on 04/02/2026 at 8:04 AM - 8:46 AM with the facility's Administrator and Building Maintenance Aide (BMA)-A revealed the BMA-A checked all resident restroom exhaust ventilations (vents) systems in the facility and the vents were not working or pulling air from the restroom. There were no windows in any of the restrooms. In an interview on 04/02/2026 at 8:46 AM, BMA-A confirmed that none of the facility's exhaust vents in the resident restrooms were working and they should have been.

Nebraska Licensure reference: 175 NAC 12-006.09(I)Nebraska Licensure reference: 175 NAC 1-009.04(D)(i)(1&2)Based on observation, interview, and record review, the facility failed to maintain safe hot water temperatures to prevent accidents in occupied resident rooms 301, 302, 303, 306, 308, 503, 506, and 512. The facility census was 87 residents.The findings are: Review of facility's Safe Water Temperature policy, implemented 4/19 and revised 5/25 indicated that the maximum water temp for sinks is 120 degrees. A. Record review of admission Record for Resident 30 revealed admission date of 2/7/23 with diagnoses that included severe vascular dementia with mood disturbance. Resident 30's Annual Minimum Data Set (MDS, a standardized assessment tool completed by long-term care facilities to evaluate resident health status and care needs) was completed in February of 2026. The Brief Interview for Mental Status (BIMS) score obtained on the MDS was 0. A BIMS score of 0 indicated severe cognitive impairment. Further review of MDS revealed that Resident 30 was independent with mobility. During initial tour of Resident 30's room on 03/30/2026 at 9:23 AM, examination of bathroom (bathroom for rooms [ROOM NUMBERS] are shared) revealed the water temperature of the bathroom sink was tested at this time and found to be 140 degrees Fahrenheit. Observation on 3/30/36 at 10:01 AM revealed Facility Maintenance Supervisor (MS) obtaining a water temperature of 162 degrees for shared bathroom sink of rooms [ROOM NUMBERS] using MS' infrared thermometer. MS verbalized that this is the same sink that was 160 degrees last week when checked. The facility administrator (ADM) was present during the testing of the sink's water temperature and asked what MS did about the high reading received at this sink last week. The MS replied turned hot water heater down but did not go back to check temperature again afterward to determine if sink's temperature remained unsafe. On 4/1/26 at 08:35 AM an interview with NA-N revealed that Resident 30 independently goes into the bathroom (where sink is located) to change their incontinent brief. Review of facility's Safe Water Temperature policy, implemented 4/19 and revised 5/25 indicated that the maximum water temp for sinks is 120 degrees. B. Record review for Resident 28 shows an admission date of 6/10/1986 with diagnoses that include non-active primary progressive multiple sclerosis, major depressive disorder, Alzheimer's disease and senile degeneration of the brain. Resident 28's Quarterly MDS was completed in January of 2026. The Brief Interview for Mental Status (BIMS) score obtained on the MDS was 2. A BIMS score of 2 indicated severe cognitive impairment. Further review of the MDS showed that Resident 28 is independent with manual wheel chair mobility and supervision was required for eating. During initial tour of Resident 28's room on 03/30/2026 at 09:23 AM, examination of bathroom (bathroom for rooms [ROOM NUMBERS] are shared) revealed that the water temperature of the bathroom sink was tested and found to be 140 degrees Fahrenheit. Observation on 3/30/36 at 10:01 AM revealed Facility Maintenance Supervisor (MS) obtaining a water temperature of 162 degrees for shared bathroom sink of rooms [ROOM NUMBERS] using MS' infrared thermometer. MS verbalized that this is the same sink that was 160 degrees last week when checked. The facility administrator (ADM) was present during the testing of the sink's water temperature and asked what MS did about the high reading received at this sink last week. The MS replied turned hot water heater down but did not go back to check temperature again afterward to determine if sink's temperature remained unsafe. Direct observation of Resident 28 on 3/30/2026 at 10:15 AM revealed Resident 28 independently entering bathroom in her room. Resident 28 was able to open the bathroom door, push the door toward the closet and open the doorway wide enough to enter using her wheelchair, propelling with feet. Resident 28 then sat in bathroom facing sink. C. Tour of the room [ROOM NUMBER] occupied by Resident 2 on 03/30/2026 at 8:50 AM identified the sink hot water temperature of 127.2 degrees F (Fahrenheit). Resident 2 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15, which identified the resident as cognitively intact. Tour of the room [ROOM NUMBER] occupied by Resident 8 on 03/30/2026 at 8:50 AM identified a hot water temperature of 143.2 degrees F. Resident 8 had a BIMS score of 5, which identified resident with severe cognitive impairment. Tour of the room [ROOM NUMBER] occupied by Resident 71 on 03/30/2026 at 8:50 AM identified a hot water temperature of 143.2 degrees F. Resident 71 had a BIMS score of 15, which identified resident was cognitively intact. Interview on 03/30/2026 at 9:54 AM with Nurse Aide J (NA-J) confirmed that the water temperature is not checked during showers. NA-J stated that they used the back of their hand, then the resident checked with the back of their hand. The temperatures are checked once weekly, and the temperature dial was adjusted as needed. Interview on 03/30/2026 at 8:55 AM with Resident 2 revealed that they could wheel themselves to the sink in the bathroom independently. Interview and facility tour on 03/30/2026 at 10:01 AM with the Maintenance Supervisor and the Administrator to confirm water temperatures using an infrared thermometer revealed the temperatures in rooms: 301 and 303 at 144 degrees F302 at 125 degrees FThe Administrator confirmed that during the temperature checks, the facility did not have a temperature control valve for hot water. The Maintenance Supervisor reported and confirmed that during the temperature checks the previous week that there was a room that had a temperature of 160s and nothing was done to correct it. Interview on 03/30/2026 at 10:07 AM with Resident 71 revealed that they were ambulatory and could walk into the bathroom independently. Resident 71 reported that the water temperature in the room was ok, but the showers got very warm. They stated that staff do not measure the water temperature and allowed them to independently turn the dial to their own preference. Interview on 03/30/2026 at 11:02 AM with Nurse Aide-K (NA-K) reported that to check the temperature of the water, they used their wrist, then checked with the resident. NA-K confirmed that they had not previously ran into issues with hot water but would have reported it. Interview on 03/31/2026 at 12:05 PM with Resident 8 revealed that they could self-propel to the bathroom and independently wash their hands. It was reported that they preferred cold water but sparingly used hot water. It was stated that they never had a history of issues with water being too hot. D. A record review of the facility's undated 64 MAX, 62 MAX+ and 62 MAX IR (Infrared) Thermometers Technical Data and 62 MAX/62 MAX + Infrared Thermometer User Manual dated 11/99 did not reveal those models of thermometers were approved for hot water testing. An observation on 03/30/2026 at 10:26 AM revealed that Resident 9 (room [ROOM NUMBER]) and 89's (room [ROOM NUMBER]) restroom sink's hot water temperature was 124.9 degrees Fahrenheit (F). An observation on 03/30/2026 at 10:27 AM revealed that Residents 15 (room [ROOM NUMBER]) and 44's (room [ROOM NUMBER]) restroom sink's hot water temperature was 122.4 degrees F. An observation on 03/30/2026 at 9:04 AM revealed that Resident 58's (room [ROOM NUMBER]) restroom sink's hot water temperature was 122.4 degrees F. An observation on 03/30/2026 at 10:12 AM – 10:16 AM with the facility's Maintenance Supervisor (MS) revealed that the restroom sink's hot water temperature in Residents 9 and 89's room registered 132.8 degrees F with MS's infrared thermometer. Residents 15 and 44's restroom sink's hot water temperature was 128 degrees F with MS's thermometer. Resident 58's restroom sink's hot water reading was 127.6 degrees F with MS's infrared thermometer. In an interview on 03/30/2026 at 10:56 AM, MS confirmed the facility's infrared thermometer was approved for testing hot water temperatures. MS confirmed on 3/23/2026, resident room [ROOM NUMBER]'s water temperature was 162 degrees F, MS adjusted the hot water heater down, but the staff did not re-check the room's hot water temperature. He confirmed that hot water temperatures in resident rooms should have been between 100 degrees F and 110 degrees F. In an interview on 03/30/2026 at 12:54 PM. The facility's Administrator confirmed that the facility's infrared thermometer was not appropriate for water temperature testing. In an interview on 03/31/2026 at 3:36 PM, the Director of Nursing (DON) confirmed that resident rooms hot water temperatures should not have been over 120 degrees F and the bath house's hot water temperatures should not have been over 110 degrees F.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11D Based on observation and interview, the facility staff failed to ensure food was provided in a manner that was maintained at a temperature that was appealing to residents. This had the potential to affect 72 residents. Findings are:Observation on 04/01/2026 at 1:55 PM revealed the final room trays were being plated to serve to the facility residents by the Dietary Manager (DM). The lunch meal consisted of pork, mashed potatoes, brown gravy, spinach bake, and green beans. During the observation a test tray was requested to be prepared and provided with room trays for residents who ate in their rooms. On 04/01/2026 at 2:09 PM the DM accompanied the room trays including the test tray out of the kitchen. Once the final resident room tray was delivered, the test tray was delivered to the recreation room at 2:13 PM. The DM and using the facility thermometer obtained the temperature of the food with the following results:-The pork temperature did not register. The pork had good flavor but was cold.-The mashed potatoes and gravy temperature did not register. The mashed potatoes and gravy had good flavor but was cold.-The green bean temperature did not register. The green beans were cold. A interview with the DM on 04/01/2026 at 2:13 PM confirmed that the pork, mashed potatoes and gravy, and green beans were cold.

Based on observation, interview, and record review, the facility failed to ensure all residents in semi-private rooms had their own private designated closet space. The facility census was 87. Findings are:A record review of the facility's Resident Rooms policy with a date reviewed/revised of 03/2026 revealed that each resident bedroom would have individual private closet space with cloths racks and shelves assessable to the resident. A record review of the facility's Safe and Homelike Environment policy with a date reviewed/revised of 03/2026 revealed the facility will provide sufficient individual closet space in each resident room. A record review of the facility's Daily Census dated 04/01/2026 revealed 11 rooms occupied on 200 hall, 18 occupied on 500 hall, 15 occupied in unit, 5 occupied beds in 100 hall, 18 on 200 hall, 19 on 400 hall for a total of 87 total resident. There was 26 rooms that were semi-private and 52 residents had shared closets. An observation on 03/30/2026 at 9:15 AM revealed resident room [ROOM NUMBER] had 2 residents that resided in the room and there was only 1 closet with 1 door. The hanging clothes appeared to be separated by a small square on the bar, but the upper shelf and the floor space were not separated or private. An observation on 03/30/2026 at 9:51 AM revealed resident room [ROOM NUMBER] had 2 residents that resided in the room and there was only 1 closet with 1 door. The hanging clothes appeared to be separated by a small square on the bar, but the upper shelf and the floor space were not separated or private. An observation on 03/30/2026 at 11:52 AM revealed resident room [ROOM NUMBER] had 2 residents that resided in the room and there was only 1 closet with 1 door. The hanging clothes appeared to be separated by a small square on the bar, but the upper shelf and the floor space were not separated or private. An observation on 04/02/2026 at 8:04 AM - 8:46 AM with the facility's Administrator and Building Maintenance Aide (BMA)-A revealed that all the resident's rooms were checked and all the semi-private rooms only had 1 closet. The only thing that separated the closet was a small white square tag on the bar, or a small wood block that the closet bar went through. The upper shelf and the floor areas were not separated and were not private. In an interview on 04/02/2026 at 8:46 AM, the facility's Administrator confirmed the only separation or privacy in the closet in the resident's rooms was the small white tag or wood block on the hanging clothes bar. In an interview on 04/02/2026 at 8:04 AM, BMA-A confirmed the only thing that separated the closet was a small white square tag on the bar, or a small wood block that the closet bar went through. The upper shelf and the floor areas were not separated and were not private.

Licensure Reference Number 175 NAC 12-006.10(D)Based on observation, interview and record review, the facility failed to ensure that the medication error rate was less than 5%. The facility had a census of 87.Findings are:A.A record review of Resident 69's order summary revealed the following medication orders: Acetaminophen (a pain relief tablet used to treat mild to moderate pain) 500 milligrams (mg - a unit of measurement) tablets. Take 2 tablets by mouth three times daily.Artificial tear drops (lubricating eye drops used to relieve dry, irritated eyes) instill 1 drop in both eyes daily. Wait 5 minutes before administering different eye drops.Eliquis (a prescription blood thinner) 2.5 mg tablet by mouth twice daily.Ferrous Sulfate (supplement to treat iron deficiency) (325mg tablet. Take 1 tablet by mouth every morning on Mondays and Thursdays).Furosemide (a medication that increased the output of urine) 40 mg tablet. Take 1 tablet by mouth daily.Vitamin D3 (a supplement that helps to absorb calcium) tablet 2000 Units (U - a unit of measurement). Take 1 tablet by mouth daily.Losartan Potassium (a medication used to treat high blood pressure) 50 mg tablet. Take 1 tablet by mouth daily.Nitrofurantoin (an antibiotic used to treat urinary tract infections) 100 mg capsule. Take by mouth twice daily for 7 days. Do not crush/chew.Pantoprazole (a prescription medication used to reduce stomach acid production) 40 mg tablet. Take 1 tablet by mouth daily. Do not crush. An observation on 3/30/2026 at 7:45 AM of medication administration by Medication Aide (MA) F to Resident 69 revealed MA F crushed the Pantoprazole medication along with Eliquis, Ferrous Sulfate, Vitamin D3, Losartan Potassium Furosemide and Acetaminophen, mixed the medications with grape jelly and administered the medications by mouth to Resident 69. An interview on 3/30/2026 at 8:09 AM with MA F confirmed they had crushed the Pantoprazole before administering it to Resident 69 and it should not have been crushed. B. A record review of Resident 47's order summary revealed the following orders: Accu-Chek (a check of blood glucose levels) before meals and at bedtime. Notify MD (medical doctor) if BS (blood sugar) <60 or >450.Insulin Novolog Injectable 100/ml. Inject 12 units subcutaneously twice daily with breakfast and lunch. An observation on 3/30/2026 at 9:10 AM of MA G revealed they had checked Resident 47's blood glucose level at 9:10 AM for a measurement of 184 and administered 12 units of insulin Novolog immediately after the blood glucose check. An interview on 3/30/2026 at 9:10 AM with MA G confirmed the blood glucose monitoring was ordered for before meals and confirmed the insulin Novolog administration was scheduled for 7:00 AM. MA G confirmed they had performed the blood glucose check after Resident 47 had eaten breakfast. MA G confirmed the physician's order stated the insulin should be given with meals. MA G confirmed they had administered the insulin at 9:10 AM when Resident 47 had returned to their room from the dining room.

Licensure Reference Number 175 NAC 12-006.10(D)Based on observation, interview and record review, the facility failed to ensure that 1 resident (Resident 47) of 4 residents surveyed was free of a significant medication error. The facility had a census of 87.Findings are:A record review of Resident 47's order summary revealed the following orders: Accu-Chek (a check of blood glucose levels) before meals and at bedtime. Notify MD (medical doctor) if BS (blood sugar) <60 or >450.Insulin Novolog Injectable 100/ml. Inject 12 units subcutaneously twice daily with breakfast and lunch. An observation on 3/30/2026 at 9:10 AM of MA G revealed they had checked Resident 47's blood glucose level at 9:10 AM for a measurement of 184 and administered 12 units of insulin Novolog immediately after the blood glucose check. An interview on 3/30/2026 at 9:10 AM with MA G confirmed the blood glucose monitoring was ordered for before meals and confirmed the insulin Novolog administration was scheduled for 7:00 AM. MA G confirmed they had performed the blood glucose check after Resident 47 had eaten breakfast. MA G confirmed the physician's order stated the insulin should be given with meals. MA G confirmed they had administered the insulin at 9:10 AM when Resident 47 had returned to their room from the dining room.

Licensure Reference Number 175 NAC 12-006.09(D) Based on observation, record review, and interviews, the facility failed to ensure that the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning), was accurately coded related to incontinence and an indwelling catheter for 1 (Resident 8) of 3 sampled residents. The facility census was 87. Findings are:Record review of Resident 8's MDS section H: Bladder and Bowel, dated 02/12/2026, revealed that the resident was always incontinent with urine and did not have an indwelling catheter. Record review of Resident 8's Care Plan identified use of a suprapubic catheter dated 1/18/2021. Observation on 04/01/2026 at 07:39 AM, Resident 8 in bed with catheter bag noted to be hanging on side of bed. An interview on 04/02/2026 at 9:58 AM the Minimum Data Set Coordinator (MDS Coordinator) confirmed that bowel and bladder section of the MDS was coded incorrectly. They revealed that floor nurses complete nursing MDS assessments and the only MDS assessment completed personally by the MDS Coordinator is the Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment). The MDS assessments are signed off by the Director of Nursing (DON). An interview on 04/02/2026 at 10:15 AM with the Director of Nursing (DON) revealed that it was the expectation of nursing to complete MDS nursing assessments and the MDS Coordinator completed only the BIMs. The DON signs the MDS and audits a certain amount per month. The DON confirmed that MDS dated [DATE] was incorrect on resident 8.

Licensure Reference Number 175 NAC 12-006.09Based on observation, interview, and record review the facility failed to ensure that providers orders were followed for wound care for Resident 5. The facility had a census of 87.Findings are:A record review of Resident 5's Clinical Resident Profile revealed Resident was admitted on [DATE].A record review of Resident 5's Minimum Data Set (MDS - a federally mandated, standardized clinical assessment used in Medicare/Medicaid certified nursing homes to evaluate resident functional, medical, psychosocial and cognitive status) dated 12/17/2025 revealed Resident 5 had a Brief Interview for Mental Status (BIMS - a standardized 15-point screening tool used to assess a patient's cognitive function) of 3 indicating Resident 5 is severely cognitively impaired.A record review of Resident 5's medical record revealed the following diagnoses: Hemiplegia (severe paralysis) and Hemiparesis (partial weakness) following cerebral Infarction (stroke) affecting the left side, Infection following left hip surgery, vascular dementia (a declining in thinking skills caused by conditions that block or reduce blood flow to the brain) with other behavioral disturbance (persistent patterns of disruptive, aggressive, or defiant actions that interfere with daily functioning.A record review of Resident 5's physician orders revealed the following wound care orders:-Left anterior (near the front) ankle cleanse with saline, swab with betadine, repeat twice daily (BID) and as needed (PRN) for soiling. Prescriber Written Active date of 03/17/2026.-Left anterior ankle cleanse with saline, swab with betadine, repeat BID and PRN for soiling. Prescriber written active date 03/17/2026.-Left posterior (near the back) ankle cleanse with saline, swab with betadine, repeat BID and PRN for soiling. Prescriber written active date 03/30/2026.-Left posterior ankle cleanse with saline, swab with betadine, repeat BID and PRN for soiling. Prescriber written active 03/30/2026.-Left buttock: cleanse with saline, apply Calmoseptine to wound, cover with silicone superabsorbent dressing, change daily and PRN for soiling. Prescriber written active dated 03/30/2026.-Left buttock: cleanse with saline, apply Calmoseptine to wound, cover with silicone superabsorbent dressing, change daily and PRN for soiling. Prescriber written active 03/30/2026.-Left buttock: cleanse with saline, apply triad to peri wound, silver alginate to wound bed, cover with silicone super absorbent, change daily and PRN for soiling. Phone active date 03/31/2026.-Left lateral (farther from midline of body) 5th toe cleanse with saline, swab with betadine, repeat BID and PRN for soiling. Prescriber written active 03/30/2026.-Left lateral foot cleanse with saline, swab with betadine, repeat BID and PRN for soiling. Prescriber written active 03/30/2026.-Left lateral foot proximal (closer to midline of the body) cleanse with saline, swab with betadine, repeat BID and PRN for soiling. Prescriber written active 03/30/2026.-Left lateral heel cleanse with saline, swab with betadine, repeat BID and PRN for soiling. Prescriber written active 03/30/2026.-Left lateral heel cleanse with saline, swab with betadine, repeat BID and PRN for soiling. Prescriber written active 03/30/2026.-Left lateral hip: start: cleanse with saline, swab with betadine, repeat daily and PRN for soiling at bedtime. Prescriber written active 03/31/2026.-Right lateral hip: cleanse with saline, apply silver alginate to wound bed, cover with silicone superabsorbent dressing, change daily and PRN for soiling. Prescriber Written active 03/30/2026.-Right lateral hip: cleanse with saline, apply silver alginate to wound bed, cover with silicone superabsorbent dressing, change daily and PRN for soiling. Prescriber written active 03/31/2026.An observation of wound care on 3/31/26 at 2:00PM provided by Licensed Practical Nurse H (LPN) for Resident 5. LPN H entered Resident 5's room after knocking. LPN H donned a gown and washed their hands. LPN H placed paper towels on the bedside table as a barrier and placed the wound supplies on the table. These consisted of silver alginate dressing, a bordered foam dressing, a cup with 4 x 4 gauze dressings, a bottle of saline and 3 packs of betadine swabs along with a box of gloves. LPN H used hand sanitizer and donned (put on) gloves. LPN H removed the dressing from Resident 5's right lateral hip surgical wound and discarded it in the trash along with their gloves. LPN H used hand sanitizer, donned gloves, and poured the saline into the cup to soak the gauze 4 x 4's. LPN H used the gauze to clean the wound, discarding each piece of gauze after 1 swipe down the wound. LPN H removed their gloves when the gauze was gone, used hand sanitizer and donned clean gloves. LPN H opened the silver alginate dressing and the bordered foam dressing packet. LPN H placed the alginate dressing directly on the wound. LPN H discarded their gloves, used hand sanitizer, and donned new gloves. LPN H placed the foam dressing on the wound over the alginate dressing. LPN H removed the boot from Resident 5's left foot and removed their sock. LPN H removed gloves, used hand sanitizer, and donned clean gloves. LPN H opened the betadine packets, picked up Resident 5's left foot with their left hand, extracted a betadine swab and used it to paint the scabbed area under the residents lateral toes. LPN H discarded the swab, removed a new swab, and painted the lateral side of Resident 5's foot over small, scabbed areas. LPN H removed a new swab and painted the scabbed area on the dorsal (back) side of the left foot/lower shin. LPN H held the residents foot until the betadine dried and then replaced the residents sock and boot and replaced the bed covers. LPN H discarded the trash, dirty gloves and gown, used hand sanitizer, and exited the room.An interview on 3/31/26 at 3:10PM with LPN H confirmed they did not apply saline to Resident 5's foot wounds before applying betadine as per the order. LPN H confirmed Resident 5 had multiple orders for the same wounds. LPN H confirmed they had missed the newest order for the buttock wound which was dated 3/31/26 and therefore did not dress the buttock wound. LPN H confirmed Resident 5's wound care was not completed as ordered by the physician.

Licensure reference: 175 NAC 12-006.09(H)(ii)Based upon record review and interview, the facility failed to ensure that 1 (resident 3) of 1 sampled resident received proper treatment and assistive device to maintain vision. The facility census was 87 residents at the time of survey. The findings are: Record review of facility's Use of Outside Resources policy, reviewed/revised 03/2026 stated that the facility would assume responsibility for the timeliness of services provided, that arrangements would include the communication structure, and that the facility would maintain documentation and reports of recommendations of the services provided. Record review of a signed but undated Facility Services Agreement between the facility and the vendor shows that under item 2.6, the facility shall continue to assume responsibility for obtaining services that meet professional standards and principals and b) the timeliness of the services. Review of Resident 3's admission Record revealed that Resident 3 was admitted on [DATE] with diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Resident 3's Minimum Data Set (MDS, a standardized assessment tool completed by long-term care facilities to evaluate resident health status and care needs) was completed in February of 2026. The MDS included a Brief Interview of Mental Status (BIMS) Summary Score of 15. A BIMS score of 13-15 indicated normal thinking and memory (no or very little impairment).Interview with Resident 3 on 3/30/26 at 11:42AM revealed that an eye exam was completed after admission and a prescription for glasses was written but corrective lenses were never received. Resident 3 was utilizing non-prescription reading glasses but reported that vision remains blurry even with use of this device.Record review of Resident 3's Eye Care Chart Note dated 8/19/25 revealed that Resident 3 had an eye exam and a prescription for corrective lenses was included.During interview with Social Services Director (SSD) on 3/31/26 at 3:20PM, SSD detailed that the facility utilized an outside vendor for vision services. SSD reported that facility only followed up if a resident or family expressed concerns. During follow up interview with SSD 4/1/26 at 8:40AM, SSD shared that the outside vendor scans visit notes into the resident chart at the facility so facility does not receive any notice or reminders to follow up. Interview via phone on 4/2/26 at 8:43AM with facility vision vendor contact revealed that the notes for Resident 3's eye exam and prescription were sent via email to SSD and uploaded directly to the chart on 8/20/25. During follow up interview with SSD on 4/2/26 at 9:15AM, SSD confirmed that the facility should follow up with the recommendations from vendor.

Licensure Reference Number 175 NAC 12-006.09(H)Based on record review and interview, the facility failed to monitor and record blood pressures for the continued use of blood pressure support medications for 1 (Resident 66) of 5 sampled residents. The facility staff identified a census of 87.Findings are:Record review of facility policy titled Unnecessary Drugs-Without Adequate Indication for Use dated revised 01/2026 revealed: - 2. The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents and/or representatives, other professionals, and the interdisciplinary team. Each resident's drug regimen will be reviewed on an ongoing basis, taking into consideration the following elements: -a. Dose (including duplicate therapy) -b. Duration of use -c. Indications and clinical need for medication -d. Adequate monitoring for efficacy and adverse consequences -e. Preventing, identifying and responding to adverse consequences. -3. Documentation will be provided in the resident's medical record to show adequate indications for the medication's use and the diagnosed condition for which it was prescribed.Record review of Resident 66's admission Record (AR) showed the facility admitted the resident on 1/31/2025. Further review of the AR revealed Resident 66 had conditions that included aneurysm (bulge or ballooning caused by a weak spot) of the heart and hypertension (high blood pressure).Record review of Resident 66's Order Summary Report revealed an order for midodrine (a medication used to increase blood pressure) tab 5 milligrams (mg) one tablet by mouth before meals with a notation to hold the medication for a systolic blood pressure greater than 140 for hypotension (low blood pressure) dated 03/20/2026.Record review of Resident 66's March 2026 Medication Administration Record (MAR) revealed the midodrine order was entered to be administered at 8:00 AM, 12:00 PM, and 4 PM. Further review of the MAR revealed there was no location within the MAR to record Resident 66's blood pressure at the time of administration.Record review of Resident 66's Weights and Vitals Summary (WVS) revealed there was no blood pressure recorded for the following dates and times of administration: -03/21/2026 at 12:00 PM -03/22/2026 at 8:00 AM -03/23/2026 at 12:00 PM -03/24/2026 at 12:00 PM -03/25/2026 at 12:00 PM and 4:00 PM -03/26/2026 at 12:00 PM and 4:00 PM -03/27/2026 at 8:00 AM and 12:00 PM -03/28/2026 at 8:00 AM and 12:00 PM -03/29/2026 at 8:00 AM, 12:00 PM, and 4:00 PM -03/30/2026 at 8:00 AM, 12:00 PM, and 4:00 PM -03/31/2026 at 8:00 AM, 12:00 PM, and 4:00 PM.Interview on 04/02/2026 at 7:38 AM with the Director of Nursing (DON) confirmed the absence of recorded blood pressures for the preceding dates and times listed. The DON further confirmed Resident 66's blood pressure should have been monitored and recorded according to the physician's orders.

Based on interview and record review, the facility failed to ensure that the daily posted nurse staffing sheets included the facility name and staffing number and actual hours worked for each shift. The facility census was 87. Findings are:A record review of the facility's Nurse Staffing Posting Information policy with a date reviewed/revised of 03/2026 revealed that the Nurse Staffing Sheet would include the facility's name. The Nurse Staffing Sheet would contain the total number and the actual hours worked by Registered Nurses, Licensed Nurses, and Nursing Assistants directly responsible for resident care each shift. A record review of the facility's PPD (Per Patient Day) Calculator v.1.0 posted nursing staff sheets dated 02/28/2026 - 03/29/2026 did not reveal the facility's name or each shifts staffing numbers or hours worked. A record review of the facility's PPD (Per Patient Day) Calculator v.1.0 posted nursing staff sheet dated 04/02/2026 with the facility's Administrator revealed did not reveal the facility's name. A record review of the facility's PPD (Per Patient Day) Calculator v.1.0 posted nursing staff sheets dated 02/28/2026 - 03/29/2026 with the facility's Staffing Coordinator (SC) did not reveal the facility's name or each shifts staffing numbers or hours. In an interview on 04/02/2026 at 7:56 AM, The Administrator confirmed the facility's PPD (Per Patient Day) Calculator v.1.0 posted nursing staff sheet dated 04/02/2026 did not reveal the facility's name and should have. In an interview on 04/02/2026 at 10:40 AM the SC confirmed the facility's PPD (Per Patient Day) Calculator v.1.0 posted nursing staff sheets dated 02/28/2026 - 03/29/2026 did not reveal the facility's name or each shifts staffing numbers or hours and should have.

Licensure Reference Number NAC 175 12-006.11(E) Nebraska Food Code 2017 4-202.16 Based on observation, interview, and record review; the facility failed to maintain the reach in refrigerator and a utility cart in a sanitary manner and failed to ensure food containers were not placed directly on the floor in the facility kitchen. This had the potential to affect 81 of 82 residents that ate food from the facility kitchen. The facility failed to ensure food items were sealed and dated on the memory care unit which had the potential to affect 16 of 16 residents that reside on the memory care unit. The facility identified a census of 82. Findings are: Observation on 02/03/25 at 7:45 AM revealed a reach-in refrigerator with white and red liquid splashes on the walls and a black utility cart with breadcrumbs and food debris on the second and third shelves. Observation on 02/04/25 at 9:10 AM revealed [NAME] B was preparing the lunch meal. [NAME] B retrieved a large container of sugar from the shelf and placed the container directly on the floor with no barrier beneath. [NAME] B measured the required amount, placed the lid on the container and returned the container to the shelf. [NAME] B retrieved a large container of flour and placed the container directly on the floor with no barrier beneath. [NAME] B measured the required amount, placed the lid on the container and returned the container to the shelf. Observation on 02/04/25 at 9:33 AM with the Certified Dietary Manager (CDM) revealed two open, unsealed bags of cereal in the Memory Care Unit. Interview on 02/04/25 at 9:33 AM with the CDM confirmed the bags of cereal should be sealed in a container and dated. Interview on 02/04/25 at 09:37 AM with the CDM confirmed the presence of breadcrumbs and food debris on the shelves of the utility cart and the liquid splashes inside the refrigerator. The CDM revealed that there was a cleaning schedule for the kitchen, but it had not been filled out. The CDM confirmed that the utility cart should be cleaned daily, and the refrigerator should be cleaned of any spills at the time of occurrence. Interview on 02/05/25 at 12:01 PM with the CDM revealed that 81 of 82 residents receive food prepared by the facility and 16 of 16 residents receive food in the Memory Care Unit. A review of the facility policy entitled Sanitation Inspection dated 01/2025 revealed the following: 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. 2. The department shall establish a sanitation program for food services based on applicable state and federal requirements. 3. The sanitation program will provide for inspections to be conducted of the food service areas. 4. Sanitation inspections will be conducted in the following manner: a. Daily: food service staff shall inspect refrigerators/coolers, freezers, storage area temperatures, and dishwasher temperatures daily. b. Weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations. A record review of Nebraska Food Code dated 2017 revealed the following: 4-202.16 Nonfood-Contact Surfaces shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance.

Licensure Reference Number 175 NAC 12-006.19 Based on observation, and interview the facility failed to ensure that a doorbell was functional at the north entrance of the facility, this had the potential to affect 32 residents identified as independent with mobility from a facility census of 82. The facility failed to ensure wallpaper,walls, light covers,and fixtures were maintained in clean condition and good repair, in 9 (302, 303, 306, 405, 408, NW4, NW7, NW8, and NW9) of 43 occupied resident rooms. The facility failed to maintain a utility sink in good repair in the memory care unit. This had the potential to affect 15 of 16 residents that reside on the unit. The facility to ensure an exterior stair hand railing was secured to the bottom step at the entrance to the south side of the facility. This had the potential to affect 12 residents identified as self-mobile without assistive devices. The facility census was 82. The findings are: A. An interview conducted with Social Service Director (SSD) on 02-05-2025 at 11:52 AM revealed that residents that are outside can enter the south entrance to the facility by the push button automatic door and the main entrance and the service entrance both have doorbells for the residents to ring if they need help back in the facility. An observation conducted on 02-05-2025 at 1:06 PM of the front door revealed when the doorbell was pushed that no one answered the door. The temperature outside was 26 degrees Fahrenheit. An interview conducted on 02-05-2025 at 1:12 PM with the Receptionist (Rec) E confirmed that the doorbell at the main entrance did not sound when pushed. An interview conducted with the Administrator in Training (AIT) on 02-05-2025 at 1:23 PM confirmed the doorbell chime was not plugged in at the main entrance as it should have been, therefore the doorbell did not sound. 45614 B. An observation on 02/16/2025 at 1:09PM with the Maintenance Director (MD) during a facility tour revealed the following: -room [ROOM NUMBER] had a hole in the wall at the floorboard level of the bathroom. -room [ROOM NUMBER] the base of the toiled was stained, there was a hole at the base of the bathroom door, the caulking around the bathroom sink was visibly cracked and there was a strong urine odor. -room [ROOM NUMBER] had unpainted repairs to the wall around the window. -room [ROOM NUMBER] had a stained toilet base with a strong urine odor, scratches to the wall behind the bed nearest the door and the caulking around the heating unit was cracked. -room [ROOM NUMBER] was missing a light cover over bed nearest the window, the base of the toilet was stained, and 2 lights were out in the bathroom. -In the memory care unit, the wallpaper border above the rooms NW4, NW7, NW8 and NW9 was torn and missing in places. -The utility sink in the memory care unit had a sharp uneven hole to the right rear of the sink unit and the back board of the sink was cracked and separating from the counter. -The handrail to the exterior steps beside the south entrance was rusted and not secured to the right side of the bottom step. An interview with the Maintenance Director at 1:09 PM confirmed the above issues and further confirmed there were no active work orders for any of the issues mentioned.

Licensure Reference Number 175 NAC 12-006.18(B) Based on observation, record review and interview; the facility failed to follow Enhanced Barrier Precautions (EBP, use of gown and gloves during high-contact resident care activities) and failed to ensure supplies for wound care were not in contact with soiled items for 1 (Resident 49) of 5 sampled residents. The facility identified a census of 82. Findings are: A review of the facility policy entitled Enhanced Barrier Precautions dated 12/2023 revealed the following: -Policy Explanation and Compliance Guidelines: 1c. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. 2. Initiation of Enhanced Barrier Precautions b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds and/or indwelling medical devices. Record review of Resident 49's Quarterly Minimum Data Set (Minimum Data Set - a comprehensive standardized assessment of resident's functional capabilities and health needs) dated 11/01/24 revealed the resident had unclear speech and was rarely/never understood and rarely/never understands. The BIMS (Brief Interview for Mental Status, an assessment to aide in identifying cognitive impairment) assessment was not completed due to the resident was rarely/never understood. The staff assessment indicated the resident had a short-term and long-term memory problem and had no memory recall. The resident was identified as dependent on staff for all cares except the resident required substantial/maximum assistance with transfers. The MDS identified that Resident 49 had an open lesion (e.g. cancer lesion), had a pressure reducing device for the bed and chair, and application of non-surgical dressings other than to feet. A record review of Resident 49's Physician Orders revealed the following orders: - 1/18/2025 Clean left shoulder open area with soap and water, pat dry, and apply border gauze daily. Observation on 02/04/25 at 11:09 AM revealed that EBP signage was located on the door of Resident 49s room and that a gown and glove use were required during high-contact cares. The resident's name label on the outside of the door was marked with an orange EBP label which indicated Resident 49 was on EBP. Observation on 02/04/25 at 11:10 AM revealed Registered Nurse (RN) A knocked on the door, entered the room with no gown in place, and placed a stack of wash cloths on top of the covers at the foot of the bed with no barrier beneath. RN A explained to the resident that they were going to perform a wound treatment. RN A washed hands for 24 seconds, donned gloves and prepared a pink basin of soapy water. RN A placed the basin directly on the floor near the head of the bed with no barrier between the basin and the floor. RN A proceeded to perform wound care to the left shoulder. RN A doffed gloves, performed hand hygiene for 19 seconds, donned new gloves and applied a pre-dated and initialed dressing. RN A doffed gloves and performed hand hygiene for 22 seconds. Throughout the observation of wound care, RN A did not have a gown on as required by EBP. Interview on 02/04/25 at 11:30 AM with RN A confirmed that treatment supplies, including the basin of water and the washcloths were placed on soiled surfaces with no barrier beneath them. RN A confirmed that the basin of water should not have been placed directly on the floor and washcloths should not have been placed directly on the bed linens. RN A confirmed that no gown was donned prior to performing wound care treatment for Resident 49. Interview on 02/04/25 at 12:00 PM with Director of Nursing (DON) confirmed wound supplies should be placed on an overbed table with a barrier or place a barrier on the floor if supplies needed to be placed there. The DON confirmed that there should be a barrier for wound treatment supplies if placed directly on the bed. The DON confirmed that Resident 49 was on EBP and that a gown should have been worn during the wound treatment.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(3) Based on observation, interview and record review the facility failed to ensure wound treatment orders were provided according to the practitioner's orders for 1 (Resident 331) of 4 residents sampled. The facility census was 82. The findings are: Record review of Resident 331's care plan revealed the following about the resident: -had wounds to the right lower leg -required 1-2 staff members for transfers -had a diagnosis of heart disease and seizures Record review of Resident 331's orders revealed an order for betadine (an antiseptic that is used in a medical setting to help promote healing of skin wounds) paint the second digit of the left foot and the bottom of the right foot daily. An observation of wound care on 02-04-2025 at 10:22 AM with Registered Nurse (RN) C revealed the RN painted the left foot second toe with betadine and did not paint the area to the bottom of the right foot. An interview conducted with RN C on 02-05-2025 at 2:05 PM revealed the area to the bottom of the right foot should have been painted with betadine along with the left foot second toe. An interview conducted with the Wound Nurse (WN) D on 02-06-2025 at 9:35 AM confirmed the order was to apply betadine to the left foot second toe and to the area on the bottom of the right foot. Record review of the facility policy Wound Treatment Management dated 01/2023 revealed a policy statement to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.

Licensure Reference Number 175 NAC 12-006.09(I)(i)(1) Based on observation, interview and record review the facility failed to implement interventions to prevent falls for 1 (Resident 54) of 4 residents sampled. The facility census was 82. The findings are: Record review of Resident 54's Minimum Data Set (MDS; a federally mandated assessment tool used for care planning) dated 12-30-2024 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as a 0. According to the MDS Manual a score of 0-7 indicates severe cognitive impairment. -required extensive assistance with toileting and showering -required moderate assistance with dressing, transfers, and bed mobility Record review of Resident 54's Comprehensive Care Plan revealed Resident 54 was at risk for falls and the interventions dated 01-06-2025 to prevent falls for Resident 54 was Dycem (a non-slip product that grips on both sides to prevent sliding) to the wheelchair seat. An observation on 02-05-2025 at 7:36 AM revealed no Dycem in Resident 54's wheelchair. An observation on 02-05-2025 at 9:30 AM revealed no Dycem in Resident 54's wheelchair. An interview with Nursing Assistant (NA) I on 02-05-2025 at 9:40 AM revealed fall interventions for Resident 54 were for gripper socks, non-skid strips next to the bed and to wear shoes when transferring. NA I reported Resident 54 doesn't need anything applied to the wheelchair because Resident 54 does well in the wheelchair. An observation on 02-06-2025 at 12:22 PM of Resident 54's wheelchair with the Director of Nursing (DON) revealed no Dycem on the seat of the wheelchair. An interview conducted with the DON immediately following the observation confirming the intervention of Dycem in the wheelchair was not implemented according to the care plan. Record review of the facility policy Fall Prevention revealed the following: -Policy statement: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. -provide additional interventions as directed by the resident's assessment including but not limited to assistive devices, increased frequency of rounds, low bed, alternative call system access and therapy referrals. -each resident's risk factors and environmental hazards will be evaluated when developing the comprehensive plan of care. Interventions will be monitored for effectiveness, and the plan of care will be revised as needed.

Licensure Reference Number 175 NAC 12-006.09(J) Based on record review and interview the facility failed to provide nutritional supplements for 1 (Resident 54) of 2 residents sampled. The facility census was 82. The findings are: Record review of Resident 54's Minimum Data Set (MDS; a federally mandated assessment tool used for care planning) dated 12-30-2024 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as a 0. According to the MDS Manual a score of 0-7 indicates severe cognitive impairment. -required extensive assistance with toileting and showering -required moderate assistance with dressing, transfers, and bed mobility. Record review of Resident 54's physician orders dated 2-05-2025 revealed an order for Med Pass 2.0 give 4 ounces 4 times a day for weight loss. Record review of Resident 54's progress notes revealed Resident 54 did not receive med pass 2.0 on 02-05-2025 at 8:00 PM due to the supplement was unavailable. An interview conducted with the Certified Dietary Manager (CDM) on 02-06-2025 at 9:15 AM revealed the facility had Med Pass 2.0 on hand. An observation conducted on 02-06-2025 at 9:20 AM revealed a carton of Med Pass 2.0 in the refrigerator at the nurse's station for Resident 54. An interview with Registered Nurse (RN) H on 02-06-2025 at 12 PM with the Director of Nursing (DON) present revealed Resident 54 did not receive Med Pass 2.0 at 10:00 AM today because RN H did not know what it was. An interview conducted with DON on 02-06-2025 at 9:43 AM confirmed the progress note from 02-05-2025 at 8:00 PM indicated that Med Pass 2.0 was not given because it was unavailable. A follow up interview conducted on 02-06-2025 at 12:30 PM with the DON confirmed the nutritional supplement was not administered as ordered. Record review of the facility policy Weight Monitoring dated 01/2025 revealed the following: -Policy statement- based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. -the facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes developing and consistently implementing pertinent nutritional approaches.

Licensure Reference Number 175 NAC 12-006.10(D) Based on observation, interview and record review the facility failed to ensure a medication error rate of 5% or less as evidenced by 2 errors out of 28 opportunities for error resulting in a medication error rate of 7.14%. This affected 1 (Resident 328) of 3 residents sampled. The facility census was 82. The Findings are: An observation on 02-05-2025 at 9:50 AM of Medication Aid (MA) J administering medications for Resident 328 revealed MA J administered the following: -levothyroxine 75 micrograms (mcg) administered 1 tablet -Tylenol 500 milligrams (mg) tablet administered 2 tablets -lansoprazole 3mg per 1 milliliter (ml) administered 10 ml. An interview was conducted with MA J during the observation on 02-05-2025 at 9:50 AM revealed Resident 328 had already ate breakfast. Record Review of Resident 328's physician orders dated 1-25-2025 revealed the following: -levothyroxine 75 micrograms (mcg) tablet give 1 tablet on an empty stomach. Give 30 minutes prior to the meal. -Tylenol 500 milligrams (mg) tablets give 2 tablets three times a day. -lansoprazole 3mg per 1 milliliter (ml) give 10 ml by mouth with breakfast. An interview with MA J on 02-06-2025 at 6:48 AM confirmed levothyroxine should have bee given 30 minutes prior to breakfast and lansoprazole should have been given with breakfast. Record review of the facility policy Medication Administration dated 01-2025 revealed the following: -Policy statement: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. - compare medication with the medication administration record to verify the resident's name, medication name, form, dose, route, and time. -administer medication as ordered in accordance with manufacturer's specifications.

Licensure Reference Number: 175 NAC 12-006.07 Based on observations, record reviews and interviews; the facility failed to maintain a quality assurance performance improvement plan to address current and past non-compliance with federal and state regulations. The facility census was 88. Findings are: Review of the facility policy titled Quality assurance Performance Improvement (QAPI) Plan dated January 1,2020 revealed the plan is to establish and maintain an organized facility-wide program that is data-driven and utilizes a proactive approach to improving quality of care and services throughout the facility. Interview on 01/24/23 at 11:50 AM with the DON revealed the committee is working on several Performance Improvement Plans (PIP)s to include: -Skin -Falls -Behavior management -Environmental issues -Staffing Observations, record reviews and interview were completed on randomly sampled residents during the annual survey completed on 1/24/2023 and deficient practices were Identified. Findings from the survey include repeated deficient practice from the survey completed on 9/14/2021 in the following areas: -695 Respiratory care and cleanliness -689 Accidents -802 Dietary staffing -812 Kitchen cleanliness Additional deficient practice was identified during the current survey to include: -580 Notification of change -584 Safe/clean/Homelike environment -609 Reporting and investigating of abuse -676 Activities of daily living Maintain abilities -679 Activities meet resident needs -686 Treatment and prevention of pressure ulcers -690 Bowel and bladder incontinence -725 Sufficient Nursing staff -801 Qualified dietary manager -804 Nutritive value food preparation -880 Infection Control -923 Ventilation system Interview with the Regional Director of Operations (RDO) on 1/24/2023 at 4:00 PM at survey status meeting revealed the facility has difficulty with educating and initiating PIPs related to staff turnover and use of contracted staff.

Licensure Reference Number: 175 NAC 12-006.09D2a and 175 NAC 12-006D2b Based on observations, record review and interviews; the facility failed to provide care and treatment to prevent pressure ulcers and promote healing of pressure ulcers for 2 residents, Resident 24 and 75. The facility census was 88. Findings are: A. Review of Resident 75's admission assessment dated [DATE] revealed Resident 75 was admitted on [DATE]. Review of Resident 75's Skin assessment on admission revealed Resident 75 had no skin issues on admission. Review of Resident 75's Summary of Skilled Services 8/3/2022 in the progress notes of the Electronic Medical Record (EMR) revealed Resident 75 has paralysis on their right side from a stroke and utilizes a brace to their right foot. Review of Resident 75's Care plan with revisions dating back to admission revealed no entry regarding resident wearing a brace in the resident's shoe. No entry regarding monitoring of brace for potential pressure points. Review of Resident 75's Nursing progress note dated 9/25/2022 revealed Resident 75 has soft boggy area to right heel. Resident 75's healthcare provider was notified, and treatment orders were received with an order to float heels (place pillows so heel does not rest on the bed). Skin assessment dated [DATE] documented by Wound Nurse S revealed a pressure ulcer originally noted on 9/25/2022. Patient has a history of CVA and wears a custom Brace to right foot. Physical therapy and Occupational therapy (PT/OT) to evaluate and treat for ill-fitting brace. Review of Physical Therapy (PT) documentation since admission revealed PT notes do not mention a brace to right lower extremity. Review of Resident 75's nursing progress note dated 10/3/2022 revealed the staff received an order for heel lift boots while in bed. Review of Physician orders dated 10/3/2022 revealed an order for the heel lift boot to be on at all times. Observation on 01/23/2023 at 9:00 AM revealed Resident 75 was lying in bed with no boot on the right lower extremity. Heel was observed to be resting on the bed and not floated with pillows. Observed boot to be in recliner chair across the room. Interview on 1/23/2023 at 9:00 AM with Resident 75 revealed Resident 75 has been without the boot all night. Interview on 1/23/2023 at 3:35 PM revealed Resident 75 expressed frustration regarding the wound on the right heel and revealed Resident 75 wants this healed and over with. Interview on 01/24/23 at 11:23 AM with the Director of Nursing (DON) revealed Resident 75 should have boots on if there is an order. 47733 B. Record review of facility policy Pressure Injury Prevention Guidelines 12/2022 identified the following interventions. - Prevention devices will be utilized in accordance with manufacture recommendations. - Use positioning devices or folded linens to keep body surfaces from rubbing against one another. - Routine repositioning schedule: every two hours, using both side lying and back positions. Reposition when in bed, and out of bed. - Apply heel suspension devices according to the manufacturer's instructions, for prevention stage 1, or 2: use pillows or heel suspension devices, if using heel protectors, will still need to utilize pillows for floatation. - For stages 3, 4, unstageable, or deep tissue injury: Place foot and leg into a heel suspension boot that elevates the heel from the surface of the bed, completely offloading the pressure injury. Record review of Resident 24's diagnoses are as follows: Alzheimer's Disease with late onset, Muscle Weakness, Difficulty in walking, other lack of coordination, unspecified abnormalities of gait and mobility. Record review of Resident 24's Minimum Date Set (MDS, a federally mandated assessment tool used for care planning) dated 1/3/2023 revealed that the facility staff assessed the following: Section M included pressure ulcer for Resident 24. Section G of the MDS assessed functional status and Resident 24 was total dependance with bed mobility, transfers, and repositioning. Record review of Resident 24's BIMS (Brief Interview of Mental status, a tool used to assess a resident's cognitive ability) revealed a score of zero and zero indicates Severe cognitive impairment. Record review of the Care plan dated 5/17/2021 revealed Resident 24 should be repositioned every 2-3 hours and as needed, no pressure relieving devices for feet noted on the care plan. The care plan also indicated the resident should always have a washcloth in left hand for pressure relief from contracture to hand. (A contracture is defined as: a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Record review of Resident 24's Braden Assessment Score (a tool used to assess a resident's risk for developing a pressure ulcer. Scoring risk is as follows; Moderate risk 13-14, High risk 10-12, Very high risk 9 or below) revealed on 12/29/22 a score of 9, which indicated the resident was at high risk for developing a pressure ulcer. Record review of Resident 24's Weekly Skin Review dated 12/3/2022 revealed the resident had developed an unstageable (Full thickness tissue loss in which actual depth of the ulcer is completely obscured) pressure ulcer to left heel. Measurement of the wound was 1.73 centimeters (cm) in length by 2.07 cm in width and 0.10cm depth. Record review of Resident 24's Physician Orders dated 12/4/2022 revealed a new order for Prevalon Boots (devices used to prevent pressure ulcers to the heels) or elevation of heels, to wear at all times. On 1/23/23 at 9:00 AM an interview with Registered nurse (RN) L confirmed that the Prevalon boots are to be worn at all times. An observation on 1/17/23 at 10:15 AM revealed Resident 24 was in the assigned room sitting in the wheelchair with legs and arms crossed. No washcloth in either hand and the resident had a Prevalon boot on the left foot, none on the right foot. An observation on 1/17/23 at 11 AM revealed Resident 24 remained up in the wheelchair, in the same position with left preavlon boot on. An observation on 1/17/23 at 1:05 PM revealed Resident 24 in the dining room in wheelchair with left prevalon boot on and remained in the same position as prior observation. An observation on 1/17/23 at 1:45 PM revealed Resident 24 was in the resident's room, in wheelchair with prevalon boot on left foot, no washcloth in left hand, and remained in the same position until 3 PM. An observation on 1/23/23 at 7:10 AM revealed the pump on the pressure relieving mattress was flashing a red light. Observed the light to be flashing power failure and low pressure. The resident was in the bed and the mattress appeared flat. An observation on 1/23/23 at 7:40 AM revealed nurse aides positioning Resident 24 following a transfer to the wheelchair. No prevalon boots were placed on Resident 24's feet and no washcloth to left hand. An observation on 1/23/23 at 8:51 AM revealed Resident 24 was in the resident's room with no prevalon boots in place on resident's feet. An observation on 1/23/22 at 10:49 AM revealed Resident 24 in assigned room and air mattress was not inflated and resident was laying in the bed. An observation on 1/24/23 at 9:05 AM revealed Resident 24 was sitting in wheelchair in room without prevalon boots on, or a washcloth in the left hand. An observation on 1/24/23 at 10:30 AM of Resident 24's left heel with the Infection Preventionist (IP) (a nurse that tracks and records infections) revealed the left heel has newly epithelized (the thin tissue forming the outer layer of a body's surface) heel wound. The IP nurse had obtained a 2nd prevalon boot for the resident. An interview on 1/24/23 at 10:30 AM with the IP nurse confirmed the resident did not have any Prevalon boots on and the washcloth to the left hand was not in place. On 1/24/23 at 8:12 AM an Interview with the MDS nurse confirmed that the Prevalon boot order was received on 12/4/22. The pressure ulcer was discovered on 12/3/22. The order is for prevalon boots to bilateral feet. The MDS Nurse also confirmed no previous pressure relieving interventions were on the care plan for the feet. On 1/24/23 at 10:20 AM an Interview with the IP nurse confirmed that no interventions were in place to the resident's Left heel prior to the pressure ulcer being identified 12/3/22.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.04C3a(6) Based on record review and interview, the facility staff failed to assess and monitor 2 of 6 residents reviewed (Residents 1 and 4) with a change of condition to prevent hospitalization . The facility Census was 66. Findings are: Review of Resident 1's Electronic Medical Record (EMR) revealed progress notes dated 8/17/2019 at 09:52 as a Nursing Late Entry(indicates when a note is written at a time other than when the incident occurred) created by RN-A on 8/18/2019 4:01 PM for events on 8/17/2019. Review of Progress note for 8/17/2019 revealed at 9:52 Resident 1 was not talking and was staring in one direction. An assessment was completed and RN -A and revealed grips were weak and vital signs are stable with no documentation of what the vital sign readings were. RN-A discussed Resident 1's condition with co-workers and considered it might be caused by a recent medication change, however did not call Resident 1's physician to report Resident 1's condition and documented the staff will continue to monitor Resident 1. Review of Resident 1's MAR indicated [REDACTED]. Review of Resident 1's EMR revealed no documentation of further monitoring of Resident 1's condition or repeated vital signs. Review of Resident 1's progress note dated 8/17/2019 at 7:02 PM revealed Resident 1 was transported to the hospital by emergency ambulance and left the facility at 6:50 PM. Review of Progress note dated 8/17/2019 at 7:02 PM revealed Resident 1 was unresponsive to verbal commands, staring and unable to move eyes when asked. Resident did not respond when spoken to by family member. Progress notes dated 8/17/2019 at 7:03 PM revealed Resident 1's physician was notified of Resident 1's condition and transport to the hospital. Review of Resident 1's EMR revealed no follow up documentation on monitoring from 9:52 AM until 6:30 PM when Resident 1 was sent out to the hospital emergently and no documentation the physician was notified of Resident 1's change of condition at 9:52 AM. Review of letter dated 9/24/2019 received from the facility Medical Director revealed Resident 1 was admitted to the hospital with [REDACTED]. Interview on 9/23/2019 at 2:45 PM with the director of Nursing (DON) revealed RN-A did not document further monitoring for Resident 1. RN-A should have documented vital signs at the time they were assessed and not a summary on a late entry. DON revealed changes in Resident 1's condition should have been called to the physician. C. Record review of Resident 4's progress notes dated 9/17/19 at 6:13 AM revealed: - Resident 4 did not wake for supper the previous night and had snoring like breaths . - Resident 4 had heavier breathing at 4:30 AM and short panting breaths with abdominal accessory (indicating the presence of a disorder affecting a person's ability to breathe) usage. - at 5:20 AM Resident 4 was hot to the touch, sweaty, and vital signs revealed a temperature of 101.5 blood pressure of 170/70, pulse of 80 and respirations were 28 to 30 with abdominal accessory usage noted with breaths. -Resident 4 would not respond to verbal or tactile stimulation and only fluttered the eyes. Review of progress notes dated 9/17/19 at 7:12 AM revealed blood pressure was higher than previous, temperature and respiratory rate was still elevated above normal and O2 saturation rate was 92% (amount of oxygen in the blood). Resident 4 was sent to the emergency room via ambulance transport, admitted to the hospital and diagnosed with [REDACTED]. Review of progress notes dated 9/17/19 revealed that between the hours of 5:20 AM and 7:12 AM there were no vital signs documented for Resident 4. An interview conducted on 9/23/19 at 2:45 PM with the DON, revealed the DON agreed that there should have been more monitoring and assessments completed

Licensure Reference Number 175 NAC ,[DATE].05(4) Based on interview and record review, the facility failed to follow the cardiopulmonary resuscitation (CPR) directive for one resident (Resident 1). The facility census was 100. Findings are: Review of Resident 1's Resuscitation Orders dated [DATE] revealed that in the event of cardiac and/or respiratory arrest Resident 1 wanted CPR initiated. Review of Resident 1's Nurses Notes, dated [DATE], revealed that the resident was found at 7:05 PM with no vitals or respiration. CPR was initiated and 911 was called, Director of Nursing (DON) was notified. During an interview with Licensed Practical Nurse A (LPN A) on [DATE] at 2:40 PM, LPN A revealed that, on the evening shift of [DATE], LPN A came up to the nurses station on the central unit while LPN B and Registered Nurse C (RN C) were having a discussion that Resident 1 had died and that they were unsure of Resident 1's CPR status. LPN A informed them that Resident 1's directive was to initiate CPR and that 911 needed to be called. LPN A stated that LPN A got the crash cart (a mobile cart carrying medical equipment used for resuscitation) and went to Resident 1's room but didn't have the key to turn the oxygen tank on and had to go back to get it. LPN A said that this all took about 5 minutes. LPN B was interviewed by telephone on [DATE] at 2:10 PM. LPN B said that on [DATE] after supper, RN C came to the nurses station and told LPN B that Resident 1 had died . LPN B said that, We kinda thought (Resident 1) was a no code. LPN B said it was ,[DATE] minutes before CPR was started on Resident 1. On [DATE] at 5:31 PM, RN C was interviewed by telephone. RN C stated that RN C found Resident 1 in room and unresponsive at 7:05 PM. RN C went to the nurses station and called LPN B and checked the resident's chart for the code status. Asked how long from the time Resident 1 was found unresponsive until CPR was initiated, RN C said, about 10 minutes. Review of the facility's CPR policy, with an effective date of [DATE], revealed that: 1) CPR sequence was to: -Check patient for responsiveness -Check for breathing or no normal breathing -Call for help -Check a pulse for no more than 10 seconds -Give 30 compressions -Open airway and give 2 breaths -Resume compressions -No more than 10 seconds hands off time 2) Compressions should be initiated within 10 seconds of recognition of the arrest. Review of a document titled Verification of Investigation (VOI) dated [DATE] revealed that another resident (Resident 2) was admitted to the facility on [DATE]. Resident 2 was alert and oriented and signed a code status at that time indicating Resident 2 wanted CPR. Under Summary And Outcome of Investigative Findings on the VOI, it stated that, (Resident 2) had a [DIAGNOSES REDACTED]. The resident's health status declined and the resident was found with no pulse or respirations at 1:15 AM. Resident was not given CPR. On [DATE] at 11:41 the DON was interviewed about Resident 2 and how the facility responded to the resident not getting CPR. The DON said that education was provided to all nursing staff on CPR policies at that time and audits were done on all charts to ensure all CPR status' were current. On [DATE] at 5:15 PM the DON agreed to immediately implement the following: -Immediately educate all direct care staff currently on duty about what do and how to respond when a resident is found unresponsive/without vitals -Initiate a plan on how the facility would educate each shift and the remaining direct care staff before the staff began their work shift.

Licensure Reference Number: 175 NAC 12-006.09D2 Based on record review, observation and interview; the facility failed to prevent a pressure ulcer from occurring and implement interventions to promote healing for one resident (Resident 36). The facility had a census of 98 residents. Findings are: A. Review of Resident 36's admission Clinical Health Status dated 10/9/14 revealed Resident 36 was admitted with a surgical wound to the knee (with knee brace) and was at moderate risk of developing a pressure ulcer (an alteration to skin integrity caused by prolonged pressure over a bony prominence). Review of Resident 36's Immediate Plan of Care dated 10/10/14 revealed no plan of care regarding the risk of pressure ulcers or alterations in skin integrity. Review of a Consultation/Clinic referral for Resident 36 dated 10/15/14 revealed the following note from the physician, "please obtain new hinged knee brace (current brace worn and soiled)". Review of Resident 36's Admission Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 10/16/14 revealed Resident 36 required extensive staff assistance with mobility and hygiene tasks, had a surgical wound, no pressure ulcers but was at risk of developing pressure ulcers and had a [DIAGNOSES REDACTED]. Review of Resident 36's PT (Physical Therapy) Daily Treatment Notes revealed the following: -10/17/14 "measured and sized pt (patient) for new knee brace and placed order with supply clerk as per MD order. Instruction with nursing staff for proper placement of brace. -10/27/14 "adjustment to brace to ensure proper placement." Review of Resident 36's PT Progress report dated 10/23/14 revealed caregivers at the facility were educated on appropriate donning and doffing (applying and removing) of the knee brace. Review of Resident 36's physician orders [REDACTED]. Review of the facility's internal investigation dated 11/3/14 revealed a pressure area to Resident 36's left heel was noted measuring 3.0 cm x 3.0 cm and was dark purple in color. Resident 36 was unable to interview regarding underlying cause. Immediate interventions initiated included prevalon boot (a pressure relieving heel boot) to the lower extremities and to offload the heels in bed. Resident 36 to follow up with the wound doctor. Resident 36 has a brace and surgical wound to left leg with limited range of motion and recently some pain that also limited range of motion. Will continue to work with therapies for positioning and transfers. Review of Resident 36's care plan dated 11/5/14 identified that Resident 36 had an unstageable left heel ulcer with eschar (dead tissue) present with the following interventions identified: - Weekly skin inspection -do not massage over bony prominence -nutritional and hydration support -provide pressure reducing wheel chair cushion -provide pressure reduction/relieving mattress -air mattress -provide thorough skin care after incontinent episodes and apply barrier cream -toileting plan -treatments as ordered -weekly wound assessment -wound MD to eval/treat There was no notation of the order to offload heels or use a prevalon boot Review of Resident 36's PT Daily Treatment Notes revealed the following: -11/05/14 "noted a quarter size sore in L heel. Placed order for prafo boot (a pressure reducing heel boot used interchangeably with the term prevalon boot by the facility) to eliminate pressure and hopefully to hasten wound healing." -11/10/14 pt observed without new Prafo boot in place. Educated pt and staff (note posted in room) for appropriate wearing schedule and foot placement in boot to protect skin integrity on left heel. -11/13/13 2:35 PM Therapist repositioned left lower extremity brace for correct fit and placed Prafo boot on foot. Education with NA (Nursing assistant) as is a new staff working on pt's unit today. Review of Resident 36's December 2014 Treatment Administration Record revealed no documentation of the Prevalon/Prafo boot or of offloading the heels until 11/12/14 and no documentation that the resident had refused the intervention. Review of a Consultation/Clinic referral for Resident 36 dated 12/1/14 revealed staff were to continue to ensure the heel is offloaded at all times. Observation of Resident 36's room on 12/4/14 revealed two signs posted on the wall. The first sign was undated and read, "Please place leg brace on outside of clothing per therapy dept (department)" with red highlighting and underlined. The second sign was dated 11/10/14 and read, "Please have Prafo boot on (Resident 36) at all times. Ensure heel is placed in back of boot." Interview with the Director of Nursing (DON) on 12/9/14 at 3:16 PM revealed the DON had determined the pressure ulcer was caused by Resident 36's knee brace. Resident 36 came to the facility with a different brace that was leg length and was rubbing on the area the pressure ulcer occurred. PT ordered Resident 36 a new brace that does not cause pressure anymore. Observations of Resident 36 on 12/4/14 at 9:38 am and 12:22 PM revealed Resident 36 sitting in a wheelchair with socks on feet resting on foot pedals and the prafo/prevalon boot on a desk in the room instead of on Resident 36's foot. Observation of Resident 36 on 12/8/14 at 9:29 AM revealed Resident 36 in a wheelchair with out the prafo/prevalon boot on the left foot and a prevalon/prafo boot sitting on the desk in Resident 36's room. Interview with the Physical Therapy Assistant (PTA) and Director of Rehabilitation on 12/10/14 at 10:32 AM revealed Resident 36's brace was worn out on the fabric and the velcro and that Resident 36 was measured for a new brace after the physician ordered it on approximately 10/17/14. The PTA was asked about the signs posted in Resident 36's room and stated that the brace was found under the resident's clothing and had slid down on the leg at one point and the sign was posted to prevent that from occurring again. The PTA went on to say there were times when PTA noticed Resident 36 without the prafo/prevalon boot on so the PTA applied the boot without difficulty. When asked if the old brace caused the pressure ulcer both the PTA and the DON stated the old brace never came in contact with the resident's heel even when it slid down on the leg and could not have caused the pressure ulcer. The PTA reported the area was probably caused from prolonged pressure but not by the brace. Observation of Resident 36 on 12/9/14 at approximately 4:00 PM revealed Resident 36 was lying in bed but did not have either heel offloaded. No prafo boot was on and no pillows were under the ankles to offload the heels. LPN G came to room and confirmed this finding stating they should have been put on a pillow. Review of the facility's Skin Integrity Guideline revised November 2014 indicated residents would be assessed for risk of skin breakdown with in the first 24 hours of admission. If identified at risk the interventions will be implemented on either the Immediate plan of care or the comprehensive care plan at that time in order to prevent the development of pressure ulcers.