Every finding on record at Sutton Community Home, Inc.

Licensure Reference Number 175 NAC 12-006.09 (F) Based on record review and interview, the facility failed to revise the Care Plan (Comprehensive -CCP - written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care), to add interventions for a fall for one Resident (Resident 6) and to update Care plan with new interventions for 2 Residents (Resident 1, and Resident 3 ) of 6 sampled residents. The facility census was 22.Findings are: A. A record review of the admission record revealed that Resident 6 was admitted to the facility on [DATE] with the diagnosis of Anxiety Disorder (the body's natural response to stress, characterized by feelings of unease, worry, or fear), Atrial Fibrillation (an irregular, often rapid heart rhythm (arrhythmia) where the heart's upper chambers (atria) quiver out of sync with the lower chambers), Dementia with psychotic Disturbance (involves cognitive decline combined with delusions (false beliefs) or hallucinations (seeing or hearing things not there) , Urinary Tract Infections (bacterial infection in any part of your urinary system (kidneys, bladder, ureters, or urethra), and Major Depression (a serious mood disorder characterized by a persistent feeling of profound sadness, hopelessness, and a loss of interest in daily activities) . A record review of the Brief Interview for Mental Status (BIMS) (a test used to get a quick snapshot of a residents cognitive function, scored from 0-15, the higher the score, the higher the cognitive function), dated 4/1/2026 revealed Resident 6 BIMS score was a 6 meaning severely impaired. A record review of the progress notes dated 6/6/26 revealed Resident 6 was on the floor near the bathroom with a laceration to head and Resident stating that Resident 6 must of hit the door jam and then the floor. It was noted that Resident 6 has dementia. Resident 6 was transported to the hospital. A record review of the progress notes dated 6/6/26 revealed a nurse from the hospital called facility to inform the facility that Resident 6 had a mildly displace 5th rib and that Resident 6 was having delusions. A record review of a Post-Fall assessment form with no date revealed: -investigate, and record fall for proper interventions, circumstances, resident outcomes, and staff response to the fall in Risk Management on Point Click Care (PCC) (a comprehensive network for long-term and post-acute care providers to manage patient history, medical assessments, and care planning). -implement immediate interventions -document interventions in the notes tab under Risk Management -enter fall and interventions in Care Plan on PCC with fall date and date interventions was implemented. -be sure intervention matches what caused the fall A record review of the Care plan dated 6/6/26 for Resident 6 revealed: 6/6/26 unwitnessed fall with injury with no new intervention in place to prevent further falls. An interview on 6/25/26 with the Assistant Director of Nursing confirmed that there were no new interventions to prevent further falls for Resident 6 and there should be new interventions in place. B. A record review of Resident 1's admission Report identified an admit date of 11/01/2023 with diagnosis of difficulty walking related to prior stroke (blood flow to the brain is blocked or severely restricted). The Brief Interview for Mental Status (BIMS-a test to get a quick snapshot of a resident's cognitive function, scored 0-15, the higher the score, the higher the cognitive function) revealed Resident 1 had a score of 15, which indicated the resident is cognitively intact. A review of Resident 1's Progress Notes dated 05/19/2026 at 2:45 PM revealed Resident 1 was observed on her knees on top of a blanket. No apparent injury was noted and Resident 1 was assisted up safely. A record review of Resident 1's Progress Notes dated 05/20/2026 at 1:30 PM revealed a follow up note for the 05/19/2026 fall and further revealed Resident 1 was encouraged to remove blankets from her lap before standing and encouraged to use a lighter blanket while in the recliner. Review of Resident 1's Care Plan initiated on 03/01/2024 revealed Resident 1 is a high risk for falls and fell on [DATE]. No new interventions for 05/19/2026 fall were identified in the care plan. During an interview with the Assistant Director of Nursing (ADON) on 06/24/2026 at 11:08 AM when discussing Resident 1's Care Plan in the electronic medical record, confirmed Resident 1 did not have updated interventions for fall on 05/19/2026 and should have. C. A review of an admission Record revealed the facility admitted Resident 3 on 04/08/2026 with diagnoses repeated falls and an age-related cognitive decline. The Brief Interview for Mental Status (BIMS-a test to get a quick snapshot of a resident's cognitive function, scored 0-15, the higher the score, the higher the cognitive function) revealed Resident 1 had a score of 13, which indicated the resident has moderate cognitive impairment. A review of Resident 3's Progress Notes dated 05/09/2026 at 8:20 AM revealed the resident had a fall last night when trying to use the restroom. No documented fall on 05/08/2026. Review of Resident 3's Care Plan initiated on 04/08/2026, revealed Resident 3's care plan was updated on 05/13/2026 which included 05/10/2026 Gripper tape on the floor in front of toilet. The intervention was added to the Care Plan three days after the intervention was to start and five days after the fall on 05/08/2026. During an interview with the Assisted Director of Nursing (ADON) on 06/24/2026 at 11:15 AM when discussing Resident 3's Care Plan in the electronic medical record (EMR) confirmed Resident 3 did not have revised interventions on Resident 3's care plan for 05/08/2026 fall until five days had past and should have been documented same day as fall.

Licensure Reference Number 175 NAC 12.006.7(C) Based on interviews and record review, the facility failed to identify hand washing as a systemic issue prior to the survey, and to correct previously cited quality issues. This had the potential to affect all 20 residents residing at the facility at the time of the survey. The facility census was 20.Findings are:In a record review of the facility's Medicare.Gov. Nursing Home Compare website (A public website that provides information to help consumers find and compare the quality of Medicare and/or Medicaid certified nursing homes across the country) on 12.22.2025 at 9:32 AM, revealed prior infection control deficiencies on 6.11.2021, 7.26.2022, 9.14.2023, and 9.12.2024. In a record review of the facility Quality Assurance & Performance Improvement Program (QAPI) dated 8.13.2013 with a revised date of July 2025 revealed a focus area to include monitoring the efficacy and outcomes for the Infection Prevention (IP) program. The guiding principles included: Uses QAPI to make decisions and guide day-to-day operations. Focuses on systems and processes, rather than individuals. Makes decisions based on data, which includes the input of caregivers, residents, health care providers, families, and other stakeholders. Meeting times and scope included reviewing the plan of correction with review of correction compliance and IP data. In a record review of the facility Infection Prevention and Control Risk assessment dated 9/2025 revealed: Staff non-compliance with hand hygiene was rated as having a low probability of occurrence. In a record review of the facility provided active PIP's dated November 2025 revealed Dignity and Wound Assessments and Documentation as the current PIP's. In a record review of the facility QAPI Meeting dated 12.11.2025 revealed Old Business which included: Infection Control; infections and Monthly Infection Surveillance. Nursing; Fall Interventions and Care Planning. Social Services; Grievances, Dignity PIP, Resident Rights and Satisfaction Survey Results. Record review of the facility QAPI Meeting dated 11.13.2025 revealed hand hygiene and handling soiled linen audits with 100% of completed audits in compliance. Record review of the facility QAPI Meeting dated 10.9.2025 revealed hand hygiene and catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care audits with 100% of completed audits in compliance. Record review of the facility QAPI Meeting dated 9.11.2025 revealed hand hygiene and enhanced barrier precaution (infection control steps to stop germs from spreading beyond standard care) audits with 100% of completed audits in compliance. During an interview on 12.17.2025 at 8:54 AM with the Licensed Practical Nurse-Infection Prevention (LPN-IP) confirmed no active PIP for hand hygiene and the facility only completed hand hygiene audits based on the recommendation from The Nebraska Infection Control Assessment and Promotion Program (Nebraska ICAP) recommendations. Further confirmed that staff will bring issues or concerns to leadership when identified and the committee will change an intervention (action or process of intervening) after a lack of improvement. During an interview on 12.17.2025 at 11:53 AM with the Assistant Director of Nursing (ADON) confirmed QAPI oversight. Further confirmed the current PIP's included dignity and wound documentation and no current hand hygiene PIP. During an interview on 12.18.2025 at 8:19 AM with the Administrator (ADM) confirmed facility had repeat issues with hand hygiene on previous state surveys, and the facility currently does not have an active PIP for hand hygiene and only completed hand hygiene audits. Further confirmed the hand hygiene audit results have always been 100% and the staff are aware they are being monitored, which could improve the outcome of the audits.

Licensure Reference Number 175 NAC 12-006.18Based on observations, interviews, and record reviews, the facility staff failed to ensure hand hygiene was performed during meal service, during catheter cares for Resident 15, and during wound care for Resident 7. This practice had the potential to affect all residents in the facility. The facility census was 20 at the time of survey. Findings are: Record review of facility policy titled Service Staff and Serving the Meal, dated 2/9/2010 revealed the Infection Preventionist will provide staff with training on hand hygiene and PPE. Record review of the facility policy titled Hand Hygiene, dated 8/17/25 revealed hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR) and to perform hand hygiene before putting on gloves and after glove removal. A. During an observation on 12/16/2025 at 11:47 AM Dietary Aide (DA) – D served lunch trays in the dining room, holding tray with hands around the bottom of the tray then returned to dining room with same gloves on and no hand hygiene performed. During an interview on 12/16/2025 at 11:55 AM DA – D confirmed that (gender) usually just washes (gender) hands and puts gloves on before serving and then when finished (gender) removes them, it was also confirmed that (gender) goes in and out of resident rooms with the same gloves on. During an interview on 12/17/2025 at 11:20 AM Medication Aide (MA) – E stated that staff is supposed to wash their hands for 20 seconds before putting on gloves and always hand hygiene with glove changes. During an observation on 12/17/2025 at 11:40 AM MA – E did not perform hand hygiene before putting on gloves in the dining room to help serve lunch trays. B. During an observation on 12/17/2025 at 9:11 AM Nursing Assistant (NA) – B completed foley catheter cares and peri cares. Hand hygiene was not performed when changing gloves between tasks. During an interview on 12/17/2025 at 12:25 PM NA – B confirmed that (gender) usually has hand sanitizer with (gender) but was nervous and forget to use it during glove change. During an interview on 12/17/2025 at 12:31 PM Licensed Practical Nurse Infection Preventionist (LPN-IP) confirmed that staff is supposed to perform hand hygiene before gloving, in between glove changes and after removing gloves. It was also confirmed that hand washing audits are completed for all departments. C. A record review of Resident 7's admission Record dated 12/16/2025 revealed Resident 7 was admitted on [DATE] and had diagnoses of arthritis, high blood pressure, malnutrition, mild intellectual difficulties and a Stage 4 pressure ulcer of the sacral region (a deep injury to tissue caused by prolonged pressure to an area. Stage 4 is full thickness and exposes the underlying muscle, bone, or tendon. The sacral region is the triangular area at the base of the spine, above the buttocks.) A record review of Resident 7's Order Summary dated 12/16/2025 revealed an order for a daily wound dressing change. A record review of the facility's Hand Hygiene (HH-cleaning the hands using either soap and water or an alcohol-based hand rub[ABHR]) policy reviewed/revised 08/17/2025 revealed that HH should be performed under the conditions listed in, but not limited to the attached hand hygiene table, that HH using either ABHR or soap and water should take at least 20 seconds, and that if the task requires use of gloves, HH should be performed prior to putting on gloves, and after removing them. A record review of the undated Hand Hygiene Table copyright 2023 revealed that HH should be performed before applying and after removing PPE, after handling items potentially contaminated with blood or body fluids, and when moving from a contaminated site to a clean site on a resident. A record review of the facility's Personal Protective Equipment (PPE-special equipment, including gloves, gown, masks, and eye protection, worn to prevent exposure to hazards such as infectious materials) policy reviewed/revised 07/25/2025 revealed HH should be performed before putting on and after removing gloves, and that gloves should be changed and HH performed between clean and dirty tasks, when moving from one body part to another, and when heavily contaminated or torn. An observation of Resident 7's dressing change done on 12/17/2025 an 9:32 AM revealed Licensed Practical Nurse (LPN) A and Nurse Aide (NA) B entered Resident 7's room. NA B did not perform HH, went to the PPE holder and took out two gowns. While holding one gown in their hand, the NA put on the second gown and reached up to tie the neck ties of the first gown, causing the second gown to rub on their hair. After handing the gown to LPN A, NA B did not perform HH and put on gloves. LPN A cleaned the overbed table, washed their hands with soap and water for 25 seconds, put on the gown NA B had been holding then put on gloves. An observation 12/17/2025 at 9:40 AM revealed LPN A removed the old dressing, removed their gloves, performed HH, and put on new gloves. The LPN then cleaned the wound and patted it dry, then changed gloves without performing HH and applied the clean dressing. An interview on 12/17/2025 at 9:50 AM with LPN A confirmed the LPN had not performed HH when changing gloves between cleaning the wound and applying the new dressing and should have. An interview on 12/17/2025 at 9:50 AM with NA B confirmed they had not performed HH before putting on gloves when entering the room and should have. The NA further confirmed they should not have been holding the gown up by their head when tying the neck ties on the gown. An interview on 12/17/2025 12:37 PM with the LPN Infection Preventionist (LPN IP) confirmed that staff should perform HH when entering a resident room. LPN IP further confirmed the expectation is that HH should be done before putting on, when changing, and after removing gloves, and that gloves should be changed between removing an old dressing, cleaning the wound, and applying a new dressing.

Licensure Reference Number 175 NAC 12-006.9(D)Based on record reviews and interviews, the facility failed to ensure the Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) was coded accurately for 1 (Resident 8) of 5 sampled residents for PASARR's (Preadmission Screening and Resident Review -that is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. Level 2 screening is triggered by evidence of a serious mental illness (MI), Intellectual or Developmental Disabilities (IDD) or condition related to Intellectual or Developmental Disabilities (RC) as defined by state and federal). The facility census was 20. Findings are: Record review of Resident 8's annual MDS dated [DATE] revealed the resident was admitted to the facility on [DATE], had a PASARR (Preadmission Screening and Resident Review) Level 1 preliminary screening (federally mandated screening for all residents entering a Medicaid certified nursing facility, designed to identify individuals who might have a Serious Mental Illness or an Intellectual/Developmental Disability), and a Brief Interview for Mental Status (BIMS - a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 14 indicating cognitively intact, with diagnosis of schizoaffective disorder (a serious mental illness blending psychosis and mood disorder), and bipolar disorder (a serious mental illness causing extreme shifts in mood, energy and activity levels). Record review of Resident 8's Level II PASARR (an in depth person centered evaluation for individuals flagged by the initial Level 1 screening, to assess their need for nursing facility placement and specialized services) dated 10/22/18, revealed Serious Mental Illness (MI). The resident met state medical necessity criteria due to a diagnosis of schizoaffective disorder, needing medication to help manage the symptoms, and had a history of psychiatric hospitalization and seeing a psychiatrist. Record review of Resident 8's Comprehensive Care Plan (CCP - written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) focus date revision 8/9/2022 revealed that the resident had a Level 2 PASARR. During an interview on 12/16/2025 at 3:44 PM the Assistant Administrator (AA) - C confirmed that the annual MDS should have been coded as a Level 2 PASARR. During an interview on 12/17/2025 at 1:11 PM the Director of Nursing (DON) confirmed the facility did not have an MDS policy, it was also confirmed that the facility uses the RAI (Resident Assessment Instrument) manual (the official guide for nursing facilities, detailing how to use the RAI process) to ensure accuracy of the MDS.

Based on record review and interviews, the facility failed to post daily staffing information to include the total number and the actual hours worked by discipline, that are directly responsible for resident care per shift. This had the potential to affect all 20 residents residing in the facility at the time of the survey. The facility census was 20. Findings are: In a record review of the facility Daily Staffing Logs dated 7.3.2025, 7.13.2025, 7.19.2025, 8.24.2025, 8.31.2025, and 9.27.2025, the Daily Staffing Logs did not include the total number of hours by discipline or include total hours worked by shift of the staff responsible for resident care. In a record review of the Daily Staffing Logs revealed: Date 12.15.2025- hours not totaled by shift or for the 24-hour period. No changes to indicate actual hours worked. Certified Nurse Aide (CNA) column indicating hours worked was left blank. Date 12.16.2025- hours not totaled by shift or for the 24-hour period. No changes to indicate actual hours worked. CNA column indicating hours worked was left blank. Date 12.17.2025- hours not totaled by shift for the 24-hour period. One change indicating a call in and the staff member that replaced them. CNA column indicating hours worked was left blank. During an interview on 12.15.2025 at 1:30 PM with the Registered Nurse (RN), it was confirmed the facility Daily Staffing Log is updated by the night shift only and does not include the total number of hours worked by shift of the staff responsible for resident care. During an interview on 12.17.2025 at 12:34 PM with the Assistant Director of Nursing (ADON), it was confirmed the facility does not have a Daily Staff Posting policy. During an interview on 12.17.2025 at 1:25 PM with the ADON, it was confirmed the facility Daily Staff Logs did not separate staff by discipline or include total hours worked by shift of staff responsible for resident care.

Licensure Reference Number 175NAC 12-006.04 (A)(ii) Based on record reviews and interviews, and observations; the facility and failed to ensure that pre-employment health history screenings were reviewed to prevent the potential for the transmission of contagious diseases for 4 of 4 sampled staff. The facility census was 23. Findings are: A record review of an undated and untitled list of facility employees revealed that Dietary Aide-H (DA-H) had a hire date of 6/24/2024. A record review of a document titled Medical History and Screening Form that was undated revealed that it was signed by DA-H. A record review of a document titled Medical History Questionnaire revealed the document listed DA-H's name and had a date of 6/24/2024. A record review of an undated and untitled list of facility employees revealed that Nurse Aide-I (NA-I) had a hire date of 6/24/2024. A record review of a document tilted Medical History and Screening Form that was undated revealed that it was signed by NA-I and not dated. A record review of a document titled Medical History Questionnaire revealed the document listed NA-I's name and had a date of 6/24/2024. A record review of an undated and untitled list of facility employees revealed that Dietary Aide-G (DA-G) had a hire date of 6/24/2024. A record review of a document titled Medical History and Screening Form that was undated revealed that it was signed by DA-G. A record review of a document titled Medical History Questionnaire revealed the document listed DA-G's name and had a date of 6/24/2024. A record review of an undated and untitled list of facility employees revealed that Nurse Aide-J (NA-J) had a hire date of 6/24/2024. A record review of a document tilted Medical History and Screening Form that was undated revealed that it was signed by NA-J. A record review of a document titled Medical History Questionnaire revealed the document listed NA-J's name and had a date of 6/24/2024. In an interview conducted on 9/11/2024 at 9:45 AM with the facility Infection Control Coordinator (ICC), the ICC confirmed they did not review the Medical History and Screening Form or the Medical History Questionnaire that were completed and turned in by all facility employees. In an interview conducted on 9/11/2024 at 10:00 AM with the Facility Administrator (FADM), the FADM confirmed that the ICC was responsible for prevention of potential transmission of contagious disease by staff.

Licensure Reference Number 175NAC 12-006.11(E) Based on observation, record review, and interview; the facility failed to ensure food items were stored and labeled per the Food Code, and failed to perform hand hygiene as required during meal service to prevent the potential for foodborne illness. This had the potential to affect all residents who ate food prepared in the kitchen. All residents residing in the facility received food and used dishes from the kitchen. The facility census was 23. Findings are: A. A record review of a facility policy titled Food Receiving and Storage and dated 2014 revealed all foods stored in the refrigerator or freezer will be covered, labeled, and dated. The policy also stated that wrappers of frozen foods must stay intact until the time of thawing. In an observation on 9/9/2024 from 9:15 AM to 9:40 AM the following was observed in the kitchen food storage areas: -In the main kitchen double door refrigerator: a clear round plastic container 3/4 full of light [NAME]-pink moist half-moon shaped food items. A lid was on the container and there was not date written on the container. -In the main kitchen double door refrigerator: a tall, clear, round plastic container 1/4 full of light [NAME]-pink moist half-moon shaped food items with the manufacture's label intact which read Grapefruit Sections. There was no opened on or use by date written on the container. -In the 4-door freezer: a square frozen food item that was light brown in color with orange, light cream, and green specks throughout. This substance was surrounded by clear plastic and written on the plastic was Turkey Noodle. There was no date written on the plastic surrounding the frozen substance. -In the 4-door freezer, in a cardboard box that had been opened then had the top folded loosely shut was a clear, white plastic bag that was open and exposed to the elements of the freezer and contained round, yellow 1/4 inch thick patties. The manufacture's label on the outside of the cardboard box read Egg Patties. -In the outdoor walk-in refrigerator area were limp brown, green leafy stalks in a plastic bag that was opened at the top, exposing the item to the elements of the refrigerated area. There was no label stating what the item was and there was no date on the plastic surrounding the limp discolored stalks. -In the outdoor walk-in refrigerator area there was thin-sliced dark pink food items in a plastic bag sitting on the top shelf. On the shelf below this, there was a food item covered with clear plastic and labeled Bread Pudding, there was no date present on the label. In an interview on 9/9/2024 at 9:40 AM with the DM, the DM confirmed that the items in the double door refrigerator, the item labeled Turkey Noodle, and the item labeled Bread Pudding were not labeled or dated properly. The DM confirmed the limp brown, green leafy stalks were celery and it was not labeled or stored properly, and that the thin-sliced dark pink food items were raw sliced ham and should not have been stored above any other food item in the refrigerator. B. A record review of the Nebraska Food Code dated 2017 revealed food employees shall clean their hands after handling soiled equipment or utensils, when switching between working with raw food and working with ready to eat food, before donning gloves to initiate a task that involves working with food and after engaging in other activities that contaminate the hands. In an observation of meal service completed on 9/11/2024 from 11:21 AM through 12:05 PM the following was observed: -Dietary Manager (DM), with gloved hands used a gray scoop to scoop red apple sauce from a clear container and place in white foam dishes on a brown tray. DM then gave the tray to Dietary Cook-H (DC-H). The DM removed the gloves from both of their hands, walked over to the counter, reviewed paperwork on the counter, then returned to the meal service area and placed gloves on both of their hands and proceeded to assist DC-H with meal service. -DC-H, with gloved hands, walked from the steam table over to the counter and opened the cabinet doors and obtained a clear plastic bag with sliced bread in it. DC-H, with their gloved hands, reached into the clear plastic bag, took out slices of bread with their gloved hand, and then placed the slices of bread into the toaster sitting on the counter. DC-H then closed the clear plastic bag and placed it back into the cupboard and shut the cupboard door with their gloved hand. DC-H then returned to the meal service area and with the same gloved hands began scooping food items from containers and placing items on a place on a tray. In an interview on 9/11/2024 at 11:30 AM the DM confirmed that they did not complete hand hygiene between glove changes when they were assisting with meal service. In an interview on 9/11/2024 at 12:00 PM, DC-H confirmed they should have completed hand hygiene and changed gloves when going from opening the cupboard and handling the bread to returning to serving the meal.

Licensure Reference Number 12-006.09(I) Based on record reviews, interviews, and observations the facility failed to develop, evaluate, and monitor interventions to prevent further elopement for 2 residents (Resident 11 and 12) of 5 sampled resident. The facility census was 23. Findings Are: Record review of a facility policy titled Elopements and Wandering Residents dated 6/20/2023 revealed interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident). A record review of an Admission Record dated 9/9/2024 revealed the facility admitted Resident 12 on 10/13/2021 with diagnoses that included mild cognitive impairment (when a person had trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and cerebrovascular disease (a condition affecting the blood flow to a person's brain). A record review of Resident 12's Annual Minimum Data Set (MDS) (a mandatory comprehensive assessment tool that measures the health status of nursing home residents and is used for care planning), dated 7/17/2024 revealed Resident 12 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 4/15 which indicated the resident was severely cognitively impaired. The resident was coded to have not exhibited the behavior of wandering during the look back period of the assessment and was independent with ambulating throughout the facility without an assistive device. Resident 12 was coded to have a wander guard device present. A record review of Resident 12 Care Plan dated 9/9/2024 revealed a Focus of the resident tended to wander aimlessly at times and had made requests to go home, placing the resident at risk for elopement due to a diagnosis of dementia. Also, that the resident had an actual elopement on 12/10/2023. This section was dated 9/22/2023 and revised on 12/14/2023. Interventions were listed as: -The resident would be calm and self-assured, dated 9/22/2023. -Staff were to ensure the lighting was adequate for the resident and the resident had on proper fitting clothing and shoes, dated 9/22/2023. -Staff were to intervene as needed to protect the rights and safety of others and approach the resident in a calm manner, divert their attention and remove or take the resident to another location as needed, dated 9/22/2023. -A wander guard bracelet was placed and was to be checked twice daily and changed per expiration guidelines, dated 9/22/2023. There were no new interventions or changes in interventions listed on Resident 12's care plan on or after the elopement that occurred on 12/10/2023. A record review of Resident 12's Progress Notes revealed: -12/10/2023 at 1:44 PM the resident was actively exit seeking in the afternoon looking for children believing they were missing outdoors. Redirection by multiple staff members was ineffective and the nurse sat with the resident for several minutes and was able to calm the resident down. -12/10/2023 at 10:50 PM the resident was exit seeking and telling staff to leave the resident alone. The resident would stick their tongue out at staff when staff would not allow the resident to open the front door. No interventions were documented being attempted to assist with this behavior. -12/10/2023 11:29 PM the resident was observed/found walking outside the facility across the lawn. Staff were able to get the resident to return into the facility without incident. The resident had no injuries. -12/10/2023 2:35 AM the resident continued to be upset at staff. The resident did finally go to bed and rest with their eyes closed at that time. A record review of Resident 12's medical records revealed no evidence of new interventions being implemented to assist in preventing the resident from eloping from the facility after the resident was identified to be actively exit seeking. There was also no evidence of any changes to current interventions or new interventions being put into place after the resident eloped from the facility to prevent the resident from eloping again. In an interview on 9/11/2024 at 1:48 PM with the Director of Nursing (DON), the DON confirmed that Resident 12 had been actively exit seeking and then eloped from the facility on 12/10/2023 and no new intervention were implemented to prevent the resident from eloping from the facility when they were actively exit seeking and at risk for eloping from the facility.

Licensure Reference Number 175 NAC 12-006.09(H) Based on record reviews and interviews, the facility failed to ensure 1 (Resident 12) of 5 sampled residents were monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being while taking an antipsychotic medication. The facility census was 23. Findings are: A record review of a facility policy titled Use of Psychotropic Medications and dated 12/04/2022 revealed residents who receive an antipsychotic medication will have an Abnormal Involuntary Movement Scale (AIMS, a test that measures for extra pyramidal or involuntary body movements which is a side effect of taking an antipsychotic medication), performed on admission, quarterly, with a significant change in condition, change in antipsychotic medication and as needed. A record review of an Admission Record dated 9/9/2024 revealed the facility admitted Resident 12 on 10/13/2021 with diagnoses that included mild cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and dementia (a term for several diseases that affect memory, thinking, and the ability to perform daily activities). A record review of Resident 12's Annual Minimum Data Set (MDS, a mandatory comprehensive assessment tool that measures the health status of nursing home residents and is used for care planning), dated 7/17/2024 revealed Resident 12 had a Brief Interview for Mental Status (BIMS, a brief screening tool that aids in detecting cognitive impairment) score of 4/15 which indicated the resident was severely cognitively impaired. The resident was coded to have not exhibited any behaviors during the look back period and received routine antipsychotic medication. A record review of Resident 12's Care Plan dated 9/9/2024 revealed a Focus of Resident 12 used psychotropic medications due to behavior management, dementia, mood disturbance and anxiety dated 7/24/2024. Interventions were listed as: -Administer psychotropic medications as ordered and monitor for side effects and effectiveness every shift, dated 7/24/2024. -Consult with the pharmacy and provider to consider dosage reduction when clinically appropriate or at least quarterly, dated 7/24/2024. -Educate the resident, family, and/or caregivers about risks, benefits and side effects, dated 7/24/2024. -The resident was being seen by a provider for behavioral medication management, dated 7/24/2024. -Staff were to monitor, document, and report any adverse reactions of psychotropic medications such as unsteady gait, tardive dyskinesia, and extra pyramidal effects, dated 7/24/2024. - Staff were to monitor and record occurrences of target behaviors of nervousness, irritability and on-edge, delusions, thinking people are talking about them or taking the residents items, and the resident looking for their husband or kids, dated 7/24/2024. A record review of Resident 12's Electronic Medical Health Record on 9/10/2024 at 9:30 AM revealed Resident 12 had an AIMS assessment completed on 7/18/2024. There was no evidence of any other AIMS assessments being completed for Resident 12. A record review of Resident 12's physician orders revealed Resident 12 started receiving Olanzapine (and antipsychotic medication) 2.5 milligram (mg) every night at bed time on 1/22/2024. In an interview on 9/11/2024 at 2:30 PM with the facility Director of Nursing (DON), the DON confirmed that Resident 12 started receiving a routine antipsychotic medication on 1/22/2024 and that no AIMS assessment had been completed until 7/18/2024. The DON confirmed the facility policy was for an AIMS assessment to be completed with a change in antipsychotic medication and this was not done for Resident 12.

LICENSURE REFERENCE NUMBER 175 NAC 12.006.17 Based on observation, record review and interview: the facility failed to prevent potential cross contamination between residents as hand hygiene was not completed during the provision of cares for Resident 6. In addition, staff failed to cleanse/sanitize re-useable care equipment between residents use. This practice had the potential to affect 6 residents (Residents 8, 12, 14, 15, 4 and 2) who routinely used the lift. The facility census was 24 and the total sample size was 20. Findings are: A. Review of the facility policy titled Hand Hygiene with revision/reviewed date of 8/2/23, revealed the facility considered handwashing/hand hygiene the primary method of preventing the spread of infections and included the following situations in which handwashing/hand hygiene was to be completed: -before and after direct contact with residents; -when hands are visibly soiled or dirty (with soap and water); -before and after assisting a resident with personal cares; -before and after assisting a resident with toileting; -before handling soiled equipment; and -before putting on clean gloves and after removing soiled gloves. B. During an observation on 9/12/23 at 9:09 AM, Nurse Aide (NA)-B and NA-A assisted Resident 15 to transfer into the bathroom with a mechanical sit/stand lift (a device used to safely transfer a resident from one location to another). After the resident cares were completed, NA-B exited the room with the mechanical sit/stand lift. NA-B failed to cleanse and/or sanitize the lift before positioning the lift in the corridor. C. During an observation of toileting/incontinence care for Resident 6 on 9/12/23 at 12:52 PM, NA-J and NA-D washed hands and placed on clean gloves. Resident 6 remained in bed and the staff proceeded to remove the resident's disposable urinary incontinence brief. Further observations revealed the resident was wearing 2 incontinence products and both were heavily soiled with feces and urine. NA-J provided the resident with perineal hygiene using 6 pre-moistened cleansing cloths to clean the resident's buttocks as the feces had started to dry and was clinging to the resident's skin. NA-J completed cares and removed gloves but failed to complete hand hygiene. NA-J placed 2 clean incontinence products on the resident and assisted to reposition the resident in bed. Still without performing hand hygiene, NA-J adjusted the resident's bed linens and gave the resident the call light and the remote for the bed. NA-J moved the resident's bed and the bedside table before washing hands in the resident's sink. Interview with NA-J on 9/12/23 at 1:15 PM confirmed NA-J failed to wash hands or to use hand sanitizer when soiled gloves were removed after performing perineal hygiene for Resident 6. D. Interview with the Director of Nursing (DON) on 9/12/23 at 4:27 PM confirmed staff members were expected to wash hands or perform hand hygiene after removing soiled gloves. In addition, staff were to cleanse/sanitize the lift between resident uses and before storing in the corridor. The DON identified Residents 8, 12, 14, 15, 4 and 2 routinely used the mechanical lift for transfers.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E1 Based on observation, record review and interview; the facility failed to provide safe storage of medications for 1 (Resident 6) of 20 residents sampled. The facility census was 24. Findings are: A. Review of the facility policy Medication Storage with a revised/reviewed date of 6/9/23 revealed the following: -all drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms); -only authorized personnel will have access to the keys to the locked compartments; and -during a medication pass, medications must be under direct observation of the person administering medications or locked in the medication storage area/cart. B. During an observation on 9/12/23 at 8:16 AM, Resident 6 remained in bed in the resident's room. The resident had received a breakfast meal tray and the tray had been placed on a bedside table next to the resident. Prepared medications consisting of Colace (medication used to treat constipation), Effexor (medication used to treat depression), Lasix, Multivitamin, Omeprazole (medication used to treat conditions where there is too much acid in the stomach), Plavix (used to prevent blood clots), Vitamin D, Baclofen (relieves cramping and tightness of muscles), Coreg (used to treat high blood pressure), and Vasotec (used to treat high blood pressure) were observed in a clear medication cup next to the meal tray. The medications had been left unattended in the resident's room. Interview with Resident 6 on 9/12/23 at 8:45 AM revealed the staff frequently brought in the morning medications and left for the resident to take after the resident had eaten the breakfast meal. During an interview on 9/12/23 at 4:27 PM, the Director of Nursing (DON) confirmed medications were not to be left unsupervised and/or unattended in the resident's room. In addition, the Charge Nurses were to observe the residents as they swallowed the medications to assure all medications were received in accordance with physician orders.

Licensure Reference Number 175 NAC 12-006.10 Based on interview and record review; the facility failed to follow practitioner orders related to administration of blood pressure (bp) medications in accordance with indicated parameters. The total sample size was 20 and the facility census was 24. Findings are: Review of Resident 6's Medication Administration Record (MAR) dated 8/2023 revealed the following orders: -Norvasc (medication used to treat high bp 5 milligrams (mg) daily. Hold if systolic bp (bp is measured in 2 numbers. The first number is called the systolic and measures the pressure in your arteries when you heart beats. The second number, the diastolic, is the pressure in the arteries between heartbeats) is less than 90 and the diastolic is less than 60. Further review revealed the medication was administered despite these parameters on 8/7/23 (bp was 127/59) and on 8/16/23 (bp was 107/50); and -Coreg (medication used to treat high bp) 25 mg twice a day. Staff were to hold the medication if systolic bp was less than 90 and diastolic bp was less than 60 and if heart rate was less than 50. Further review revealed during the morning medication pass the medication was administered despite ordered parameters on 8/7/23 (bp was 127/59) and on 8/16/23 (bp was 107/50). The medication was administered during the evening medication pass despite ordered parameters on 8/14/23 (bp was 131/57). Review of Resident 6's MAR dated 9/2023 revealed the following: -Coreg 25 mg to be administered twice a day with directions to hold the medication if the systolic bp was less than 90 and the diastolic bp was less than 60. Further review revealed the medication was given despite these parameters during the evening medication pass on 9/1/23 (bp was 103/49) and on 9/2/23 (bp was 132/58). An interview with the Director of Nurses (DON) on 9/12/23 at 4:27 PM confirmed staff should be following the physician orders related to parameters for holding medications ordered for Resident 6's high bp.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on observations, record review and interview; the facility failed to provide timely toileting assistance/incontinence management for 1 (Resident 6) of 2 sampled residents who required assistance with activities of daily living. The facility census was 24. Findings are: Review of Resident 6's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 7/26/23 indicated the resident was admitted [DATE] with diagnoses of anemia, heart failure, diabetes, respiratory failure and depression. The assessment further indicated the resident required extensive assist for bed mobility, dressing, and toileting and was always incontinent of bowel and bladder. Review of Resident 6's undated current Care Plan revealed the resident had a self-care deficit related to an amputation above the right knee. The following interventions were identified: -extensive staff assist with bed mobility and dressing; -total staff assistance with toilet use; -total assist of 2 staff with a full body lift for all transfers; and -uses large disposable incontinence brief. During observations on 9/12/23, the following was observed for Resident 6: -8:16 AM the resident was awake and alert and lying in bed eating the breakfast meal; -9:12 AM to 12:08 PM the resident remained in bed in the resident's room. The resident's noon meal was delivered at 12:08 PM, and the resident consumed while remaining in bed; and -12:52 PM the resident remained in the room and in bed. Nursing Assistant (NA)-D and NA-J entered the resident's room and proceeded with incontinence cares. The resident was wearing 2 disposable incontinent products which were both heavily soiled with urine and feces. During an interview on 9/12/23 at 1:04 PM, NA-D and NA-J confirmed Resident 6 was wearing 2 incontinence products which were both soiled with urine and feces. In addition, Resident 6 had not been assisted with toileting and/or incontinence management since the resident had first awakened around 7:00 AM (5 hours and 52 minutes since cares were last provided for the resident).

Licensure Reference Number 175 NAC 12-006.17 Based on observation, record review and interview; the facility staff failed to prevent the potential spread of COVID 19 (a mild to severe respiratory illness that is caused by a coronavirus) related to screening documentation not being completed and failed to prevent the potential for cross contamination related to staff putting a dish of watermelon on the floor. This had the potential to affect all residents. The facility identified a census of 22 at the time of survey. Findings are: A. An observation on 7/20/22 at 2:15 PM revealed a sign on the door that all staff and visitors must wear a mask and complete hand hygiene, and must screen into the facility. A record review of COVID 19 Facility Visitor Screening logs from dates 5/18/22 through 7/20/22 revealed 145 undated entries, 10 entries without having completed the temperature check, and 10 entries without having completed the questions for symptoms of COVID 19. A record review of COVID 19 Facility Staff Screening Log from dates 5/27/22 through 7/20/22 revealed 9 entries with the question of cough answered yes, 3 entries with no temperatures recorded and 4 entries with COVID 19 symptoms answered yes. In an Interview on 7/25/22 at 1:00 PM with the Infection Preventionist (IP) confirmed there should not be any blanks on the screening logs in order to prevent the spread of COVID 19 and communicable diseases. B. During an observation on 7/26/22 at 12:25 PM Certified Nursing Assistant (CNA) G, was observed placing a bowl of watermelon on the floor outside of room [ROOM NUMBER] in order to put on Personal Protective Equipment (PPE). Then picked up the bowl of watermelon and took it into the resident's room. In an interview on 7/26/22 at 12:46 with Licensed Practical Nurse (LPN) E confirmed that CNA G picked up the watermelon off the ground and took into room and should not have. In an interview on 7/26/22 at 12:52 with Registered Nurse (RN) D it was confirmed that the CNA G should not have put the food on the floor, then picked the food up and taken the food into the resident's room.

Licensure Reference Number 175 NAC 12-006.11E Based on observation, record review and interview; the facility failed to prevent the potential spread of foodborne illness by not ensureing that dishware and kitchen were sanitized at the needed temperature. This had the potential to affect all residents. The facility identified a census of 22. Findings are: Observation of the kitchen on 7/20/22 at 2:32 PM revealed Ecolab was used for the maintenance and chemicals of the dish machine. A record review of the dish machine temperature logs dated July 14 through July 21, 2022. Wash and rinse temperatures were all 140 degrees. A record review of the Nebraska Food Code 4-501.112, confirmed stationary rack, dual temperature machine shall be 150 degrees Fahrenheit or above. A record review of Pots and Pans sink log wash temperatures dated July 11 through July 22, 2022. All wash temperatures were 130 degrees, and all sanitize temperatures were 120 degrees. A record review of the Nebraska Food Code 4-501.111, confirmed if immersion in hot water is used for sanitizing in a manual operation, the temperature shall be maintained at 171 degrees Fahrenheit or above. In an interview on 07/26/22 at 09:16 AM with Dietary Manager (DM) F confirmed the temperatures on the dish machine log sheet are lower than they should be in order to be sanitized.

LICENSURE REFERRENCE NUMBER 175 NAC 12-006.12B(5) Based on record review and interview, the facility failed to ensure that prn (as needed) antianxiety medication was given for the indicated use for Resident 9 and failed to identify target behaviors for Resident 6 and 9 for the use of [CONDITION(S)] medications. FINDINGS ARE: A. A record review of the MAR (Medication Administration Record) dated July 2022 revealed Resident 9 had been given PRN [MEDICATION(S)] 7 times in July 7/1, 7/4, 7/5, 7/6, 7/10, 7/15, 7/20. A record review of the Progress Notes for Resident 9 dated 7/1/22 through 7/24/22 revealed no documentation related to why [MEDICATION(S)] had been given. A record review of the task charting titled Behavior Symptoms for July 2022 revealed an answer of none of the above observed on 7/1, 7/4, 7/5, 7/6, 7/10, 7/15, 7/20 for Resident 9. During the interview on 07/25/22 at 10:14 AM with the DON (Director of Nursing), after review of the behavior task charting by the NA's, (Nurse Aides) confirmed that the expectation is that a nurse assessment should occur with use of the PRN [MEDICATION(S)] and did not. An interview on 07/25/22 at 10:14 AM with the DON confirmed that target behaviors should be on the CCP for each resident and is not. During the interview, the DON confirmed that the NA's had some behavior documentation in task charting however no follow up regarding behaviors from the nurses existed and should have. B. A record review of orders for Resident 6 revealed the following orders for medications affecting mood and behavior: -[MEDICATION(S)], an antipsychotic medication with an order date of 2/2/22 -[MEDICATION(S)], an antidepressant medication with and order date of 1/28/22 A record review of Resident 6's Comprehensive Care Plan (written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) revealed no target behaviors for antipsychotic or antidepressant medication use. An interview on 7/25/22 at 10:01 AM with the Director of Nurses (DON) confirmed there are no target behaviors listed anywhere in the Resident 6's medical record and should have been.

LICENSURE REFERRENCE NUMBER 175 NAC 12-006.09D8b Based on record review and interview, the facility failed to ensure nutritional assessments were completed and recommendations communicated to staff for residents with weight loss for Resident 8 and 14 and after removal of an enteral feeding tube for Resident 9. The sample size was 5. The facility identified a census of 21. FINDINGS ARE: A. A record review of the demographic information in the Electronic Medical Record for Resident 8 revealed an admitted [DATE]. A record review of the weights for Resident 8 for the last 6 months were as follows: -07/21/22 01:39 PM weights as follows: -6/7/2022 11:21 139.0 Lbs (pounds) Bath -6/3/2022 11:13 146.0 Lbs Bath -5/24/2022 13:40 146.0 Lbs Bath -5/17/2022 12:54 146.0 Lbs Bath -5/10/2022 11:20 146.0 Lbs Bath -4/29/2022 11:16 146.0 Lbs Bath -4/26/2022 12:54 148.0 Lbs Bath -4/22/2022 11:41 148.0 Lbs Bath -4/19/2022 13:59 148.0 Lbs Bath -4/15/2022 11:00 149.0 Lbs Bath -4/12/2022 13:44 149.0 Lbs Bath -4/6/2022 13:08 150.0 Lbs Bath -3/23/2022 11:51 152.0 Lbs Bath -3/15/2022 13:20 153.0 Lbs Sitting -3/1/2022 11:26 156.0 Lbs Bath -2/25/2022 11:30 157.0 Lbs Bath -2/22/2022 11:39 156.0 Lbs -2/18/2022 11:22 155.0 Lbs Bath -2/15/2022 10:48 155.0 Lbs Bath -2/11/2022 10:54 154.0 Lbs Bath -2/8/2022 13:29 155.0 Lbs On 04/26/2022, the resident weighed 148 lbs. On 06/07/2022, the resident weighed 139 pounds which is a -6.08 % Loss in less than 60 days. A record review of the Nutritional Progress Notes dated 6/18/22 did not indicate a weight loss but read as follows: Nutrition Assessment -MedPass (a liquid nutritional supplement) 2.0 60 cc QID-240 kcal, 30 g protein -No noted Food Allergies/intolerances. -Ht: (height) 69 in. -Wt: (weight) (6/7/22) 139 lbs (63.1 kg) -BMI: (Body Mass Index) 20.5 -IBW: 149 lbs (BMI 22) -Wt history: -6/3/22: 146 lbs (-7 lbs; -4.8%) -5/10/22: 146 lbs (-7 lbs; -4.8%) -3/15/22: 153 lbs (-14 lbs; -9 %) (This represents significant weight loss over past 90 days) -12/7/21: 160 lbs (-21 lbs; -13%) (This represents significant weight loss over past 180 days) -Estimated nutritional needs: -1900-2200 Kcal (30-35 kcal/kg - increased needs due to PI ) 95 g protein (1.5 g/kg increased due to multiple PI) 1900-2200 ml (1 mL/kcal) -Dental/chewing/swallowing Status: no issues found in chart -Requiring more assistance with meals over past few days -[CONDITION(S)]: none noted -No Diarrhea/Constipation/Nausea/Vomiting noted in chart. -Documented PO intake varies from 0-75%, typically <50% with several refusals -Multiple pressure injuries: wounds on bilateral feet and toes. -Labs: no recent labs noted Nutrition Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] -Inadequate energy/protein intake rt multiple wounds/increased needs for healing aeb dx, wound notes, poor po intake, significant weight loss. Nutritional Interventions: -Continue regular diet, regular texture, regular consistency -Continue MedPass 2.0 2 oz QID (or as desired by resident and family) Increasing volume could help meet additional needs. -Encourage po intake at meals -Offer snacks as desired by resident between meals/at hs -Honor food preferences and resident's wishes for when and how much to eat. Nutritional Goals: -Weight maintenance over next 90 days. -PO (oral) intake >50% at most meals -MedPass 2.0 - 240 ml/day -Monitor and Evaluate: -Weight changes -PO intake -Supplement intake An interview on 7/25/22 at 11:00 AM with the DON (Director of Nursing) revealed that all dietary staff, including the Registered Dietician (RD) were contracted staff and the RD completed all assessments and documentation remotely. An interview on 7/25/22 at 3:00 PM with DM (Dietary Manager)-F confirmed that nutritional assessments were completed by the RD. B. During an interview on 07/21/22 at 10:01 AM, Resident 14 voiced having continuous nausea and vomiting upon admission and until recent weeks which has resulted in a 14 pound weight loss. Resident 14 is unable to voice the cause of the vomiting but stated the doctor told me it was old age, but my nurse gave me those pills and I am feeling much better. A record review of the weights for Resident 14 are as follows: -7/22/2022 13:21 129.0 Lbs Bath -7/19/2022 13:18 128.0 Lbs Bath -7/15/2022 12:28 131.5 Lbs Bath -7/12/2022 12:18 129.0 Lbs Bath -7/5/2022 14:38 130.0 Lbs Bath -7/5/2022 09:30 130.0 Lbs Bath -6/28/2022 13:09 132.0 Lbs Bath -6/24/2022 13:21 133.0 Lbs Bath -6/21/2022 13:32 142.0 Lbs Bath -6/17/2022 11:12 140.0 Lbs Bath -6/14/2022 13:03 141.0 Lbs Bath -6/10/2022 10:43 139.0 Lbs Bath -6/7/2022 11:21 142.0 Lbs Bath -6/3/2022 11:12 140.0 Lbs Bath -5/31/2022 12:55 138.0 Lbs -5/24/2022 13:39 139.0 Lbs Bath -5/20/2022 13:19 140.0 Lbs Bath -5/17/2022 12:53 139.0 Lbs Bath -5/10/2022 11:19 140.0 Lbs Bath -5/3/2022 13:25 137.0 Lbs Bath -4/29/2022 11:14 138.0 Lbs Bath -4/26/2022 12:52 139.0 Lbs Bath On 04/26/2022, the resident weighed 139 lbs. On 07/22/2022, the resident weighed 129 pounds which is a -7.19 % Loss. A record review of the document titled Nutritional Evaluation-SCH and dated 7/14/22 revealed that it did indicate a significant weight loss at 1 month and 3 months post admission with recommendations as follows: May consider Ensure BID between meals for an additional 440 kcal w/ 18 g protein. An interview on 07/25/22 0 at 4:28 PM revealed that the recommendation from the Registered Dietician for Ensure had not been relayed to Nursing staff until today, 7/25/22 and a request had been sent to the physician to obtain the order. C. A record review of the Progress Notes dated 7/21/21 through 7/21/22 revealed Resident 9's PEG (percutaneous endoscopic gastrostomy which is a type feeding tube) tube had been removed on 6/12/22 due to no longer being needed to maintain recommended nutritional status. A record review of the Progress Notes dated 7/24/21 through 7/24/22 revealed no nutritional notes or assessment had been completed since removal of the PEG tube for Resident 9. An interview on 07/25/22 0 at 4:28 PM confirmed that the expectation was that the RD would be monitoring Resident 9's nutritional status since removal of the PEG tube and was not.

LICENSURE REFERRENCE NUMBER 175 NAC 12-006.09D Based on record review and interview, the facility failed to ensure residents were free from unnecessary medications related to duplicate blood pressure meds for Resident 9. The sample size was 3. The facility census was 21. FINDINGS ARE: On 07/24/22 at 12:17 PM a record review of the active orders for Resident 9 revealed the following medications which required some type of monitoring or follow up: -[MEDICATION(S)] Tablet 10 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Administer 1 tablet via peg tube once daily -[MEDICATION(S)] Tablet 20 MG Give 1 tablet by mouth one time a day related to [CONDITION(S)], UNSPECIFIED (E78.5) Administer 1 tablet via peg tube once daily -[MEDICATION(S)] Tablet 20 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) 1 tablet via peg tube daily -[MEDICATION(S)] Tablet 30 MG Give 1 tablet by mouth one time a day related to ANXIETY DISORDER, UNSPECIFIED -Potassium Chloride Solution 10 % Give 15 ml by mouth one time a day related to MODERATE PROTEIN-CALORIE MALNUTRITION -[MEDICATION(S)] Tablet 25 MG Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Administer 1 tablet via peg tube twice daily with meals -Acetaminophen Tablet 325 MG Give 2 tablet by mouth three times a day for pain Administer 2 tablets (650mg) via peg tube 3 times daily -[MEDICATION(S)] Sprinkles Capsule Delayed Release Sprinkle 125 MG ([MEDICATION(S)]) Give 1 capsule by mouth three times a day related to ANXIETY DISORDER, UNSPECIFIED A record review of the Orders Summary Report dated 7/28/22 revealed Resident 9 was taking 4 medications for Hypertension ([CONDITION(S)]) with no blood pressure parameters ordered to indicate when the medication should not be given. A record review of the blood pressures for Resident 9 for the last 60 days revealed the following blood pressures with a SBP (systolic blood pressure or top number) of less than 100 or DBP (diastolic blood pressure or bottom number) of below 60 with medications given: -85/44 on 7/23/22, -90/50 on 7/17/22, -105/57 on 7/16/22 -110/44 on 7/15/22 -100/53 on 7/10/22 -96/53 on 7/6/22 -76/30 on 6/18/22 -97/56 on 6/6/22 -89/40 on 6/5/22 -92/50 on 6/5/22 An interview on 07/25/22 at 10:14 AM with the DON (Director of Nursing) after review of the blood pressures documented for Resident 9 and the current 3 medications being given for [CONDITION(S)], confirmed that the blood pressure medications should have parameters ordered. During the interview on 07/25/22 at 10:14 AM with the DON, after review of the blood pressures for Resident 9, confirmed that nursing staff should have addressed the low blood pressures with the physician and obtained parameter orders and did not.

LICENSURE REFERRENCE NUMBER 175 NAC 12-006.09D7b Based on record review and interview, the facility failed to ensure causative factors were identified related to falls for Resident 15. The sample size was 3. The facility identified a census of 21. FINDINGS ARE: A record review of the Assessments tab revealed Resident 15 had assessments labeled post fall assessments 10 times in the last 10 months. A record review of the facility Incident log dated 7/21/21 through 7/20/22 revealed Resident 15 had had 10 falls in the last 1 year A record review of the Progress Notes dated 7/23/21 through 7/24/22 for Resident 15 revealed the following: -no follow up charting after the 8/13/21 fall existed -an entry for the 9/18/21 fall read the same as the 8/13/21 fall and then had been crossed out with no other fall charting surrounding the 9/18/21 fall listed on the incident log -no POA (Power of Attorney) notification documentation existed for the 9/26/21 or 9/27/21 falls -a fall on 11/20/21 had been documented with no follow up assessment documentation. A record review of the running Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) for Resident 15 revealed the problem/goal/interventions statement related to falls revealed no new interventions had been initiated for any fall within the last 1 year except one dated 3/22/22. An interview on 07/25/22 at 10:14 AM with the DON (Director of Nursing) revealed that no special forms are used related to falls and determining causative factors. After review of the falls over the last year for Resident 15 and the CCP, the DON confirmed that new interventions and causative factors had not been addressed after each fall and should have been addressed.

LICENSURE REFERRENCE NUMBER 12-006.09B Based on record review and interview, the facility failed to ensure the MDS (Minimum Data Set, a comprehensive assessment of each resident's physical and mental functional capabilities) related foot ulcers and wounds for Resident 8 reflected the resident's status at the time of MDS. The sample size was 2. The facility census was 21. FINDINGS ARE: A record review of the Orders Summary with a run date of 7/21/22 revealed 3 different treatment orders to open areas on Resident 8's bilateral (bil) feet. The record review revealed the following treatment orders were in place: -#2 Rt, dorsal great toe. Monday, Wednesday, Friday (M/W/F) and PRN (as needed). Cleanse with normal saline, cleanse peri-wound (tissue surrounding the wound) with soap and water. Paint with iodine/[MEDICATION(S)] (a topical antiseptic) daily and cover with gauze/kerlix, paper tape. -Wound #4 left Dorsal great toe. M/W/F and PRN. Cleanse with Normal Saline, cleanse peri-wound with soap and water. Paint with iodine/[MEDICATION(S)] daily and cover with gauze or Kerlix, paper tape. -Wound #5 Left Dorsal second toe. M/W/F and PRN cleanse wound with normal saline, cleanse peri-wound skin with soap and water, with iodine/[MEDICATION(S)] daily and cover with gauze or kerlix, and paper tape. A record review of the running diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] dated 3/8/22 -[CONDITION(S)], UNSPECIFIED dated 1/4/22 -NON-PRESSURE CHRONIC ULCER OF OTHER PART OF RIGHT FOOT WITH FAT LAYER EXPOSED and dated 1/4/22 On 07/25/22 at 09:00 AM an observation of wound care was completed by LPN (Licenses Practical Nurse)-E to the wounds on Resident 8's bilateral feet. The wound to the right lateral foot with maceration surrounding wound and large skin tag remaining attached to side of wound bed. An interview with LPN-E during the observation of wound care, revealed Resident 8 did not see any wound specialist and treatment orders were received from the attending physician. A record review of the MDS dated [DATE] and titled Significant Change in Status, section M titled Skin Conditions for Resident 8, revealed the following questions and answers: -M0100 A. Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device?, with an answer of NO -M0210. Does this resident have one or more unhealed pressure ulcers/injury? with an answer of Yes. -M0300.Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage Stage 3 Pressure Ulcers with an answer of 1. -Unstageable-Slough and/or eschar F1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar with an answer of 1. An interview on 7/25/22 at 3:30 PM with MDS-C, after review of the MDS dated [DATE] and titled Significant Change in Status, section M titled Skin Conditions for Resident 8, confirmed that it did not reflect the resident's current status at the time of the MDS and that the MDS and contained conflicting answers related to having pressure ulcers.

Licensure Reference Number 175 NAC 12-006.09D7b Based on observation, record review and interview; the facility failed to protect one (Resident 7) from injury of burn from a heat blanket. This had the potential to affect all 30 residents due to all residents have the order for heat packs as desired for generalized discomfort. The facility census was 30 with a sample size of 27 residents. Findings are: Observation of Resident 7 at 3:05 PM on 5/31/11 revealed this resident in the dining room in motorized wheelchair waiting for nails to be polished. This resident had glasses on and was dressed in a blouse and shorts. Had ankle socks on with legs supported by bilateral wheelchair leg supports. Left lower leg wrapped with with clean, dry dressing. Interview of the Resident 7 at 4:30 PM on 5/31/11 revealed that this resident stated, "No" when asked if had pain at this time. Resident was up in motorized wheelchair in dining room watching birds in aviary. Resident pointed to left lower leg dressing and stated, "It feels better now." Resident had slow, garbled speech and was asked to repeat "It feels better now" for proper understanding. Record Review on 5/31/11 of the Physician order [REDACTED]. --original order date of 9/28/10 was for the Heat Packs BID (two times a day) and PRN (when required). May use heat packs one hour after Ketoprofen (Topical medication used for pain on left knee, lower back, left shoulder, and right forearm); --[DIAGNOSES REDACTED]. --another order with original order date of 3/2/11 was for the Heat Pack to the left hand PRN for 30 minutes for comfort and keep a minimum of 30 minutes between the applications; --Heat Pack treatment for [REDACTED]. --No order for lavender spa heat blanket. Record Review on 5/31/11 of Resident 7's MDS (Minimum Data Set federally mandated comprehensive assessment tool used for care planning, version 3.0) dated 4/11/11 revealed: --type of assessment was Annual Assessment; --sometimes makes self understood with the ability limited to making concrete requests; --understands others with clear comprehension; --summary score for repetition of three words, temporal orientation, and recall was 13 total out of 15 questions; --bed mobility was rated at the need for total dependence with assistance of two staff members for the moving to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture; --transfers was rated at the need for total dependence with assistance of two staff members for the Resident 7 to be moved between surfaces including to and from: bed, chair, and wheelchair; --mobility device that was used was the wheelchair; --[DIAGNOSES REDACTED]. --pain management in the last five days stated that Resident 7 had been on a scheduled pain medication regimen, received PRN medication, and had received non-medication intervention for the pain; --pain assessment interview was done with the Resident 7 and Resident 7 had frequent pain or hurting at anytime in the last 5 days and the pain did not affect this resident on the ability to sleep at night and did not cause this resident to limit day-to-day activities because of the pain; --pain intensity was rated by this resident at a numeric scale of 5 with moderate intensity. Record Review on 5/31/11 of the Resident 7's Plan of Care updated on 4/28/11 revealed: A) --a goal of Resident 7 will have no complaints of pain by the next review with the following approaches: 1. Offer massage to me when I am uncomfortable. Typically I like the same person to give my massage when I want it. I become "uncomfortable" when unfamiliar staff give my massage. 2. When I have pain, I am able to point to the appropriate Wong-Baker face (a picture graphic face for rating pain scale); --no further approaches or revision were stated in Resident 7's Plan of Care for use of pain approaches involving medication, non-medication or treatments. B) --a goal of Resident 7 to be able to maintain the ability to independently reposition self while in the bed during the night by next review with the following approaches: 1. When assisted to bed at night, position me on my stomach at the foot of the bed. 2. Attach my call light to my bedding with the attached clip. 3. Ensure that my back side rail is padded and in up position. 4. Use a contour mattress on my bed as a boundary marker. 5. Use the Hoyer lift with two assist for transfers. 6. One person total assist with personal hygiene. 7. One to two person total assist with dressing. 8. I am independent with locomotion throughout the facility in my motorized wheelchair with set up help only. 9. Ensure my safety belt is fastened on my motorized wheelchair, commode, and the foot pedal per my request and my Guardian's order. 10. Place a small pillow under my left armpit and slightly behind per my request and Guardian's request. 11. Place a gel cushion under my contracted toes and feet when in the bed. 12. Encourage me to report any mouth sores or mouth pain and report this to the charge nurse; Record Review on 5/31/11 of Resident 7's Treatment Sheets revealed: A) Heat packs BID and PRN for back pain with Reheater pack to back before arising and at HS (Given after 7 PM) and also PRN. May use heat packs one hour after Ketoprofen for [DIAGNOSES REDACTED]. --hours stated on the treatment sheet for May 2011 were PM (afternoon after 4 PM), NOC (night), and PRN; --no PM heat pack treatments were initialed by nursing staff for the months of May 2011 or March 2011; --one time on April 20th 2011, the PM heat pack treatment was recorded as given for this April 2011; --NOC for the heat pack treatment sheet for March 2011 were initialed as given, except on March 18th, March 20th, and March 24th; --NOC for the heat pack treatment sheet for April 2011 were initialed as given; --NOC for the heat pack treatment sheet for May 2011 were initialed as given, except on May 25th, May 26th, May 29th, and May 30th; B) Heat pack to the left hand PRN for 30 minutes for comfort and keep a inhuming of 30 minutes between applications for treatment of [REDACTED]. --the recorded PRN treatment was recorded as start date of 3/2/2011 with no record of receiving any in the month of March 2011 --received one time for this PRN treatment on April 18th, 2011; --no PRN treatment received for May 2011. Observation (Copies obtained) of Heat Packs (TheraBeads) on 5/31/11 that were used on Resident 7 revealed: --Heat Packs were titled TheraBeads which were in a standard pack of 12"x12"; --Instruction on the TheraBead heat pack stated "When using a Therabead Heating Unit Press code 1," and "When using a conventional microwave unit heat to approximately 2 minutes, refolding and rotating in the oven after half the indicated time increment in 30 second intervals until the skin temperature monitor indicates Therapeutic Range." --the skin temperature monitor is on the heat packs and indicated "Correlated Skin Temperature Therapy Range." On the one end of the temperature monitor is the word of "re-heat" with the Celsius of 40 degrees to 45 degrees and on the right of this is the word "Do not apply." --the heat packs are put into a terry cloth cover before being put on the resident. --4 out of 6 of these heat packs had multiple dark brown areas on each side of them and 3 out of 6 of these had skin temperature monitors that were cracked and peeling; --4 out of the 6 of these heat packs had edges that were frayed. Observation of the Heat Blanket (TheraBeads) on 5/31/11 that was used on Resident 7 revealed: --Heat Blanket was titled TheraBeads and was a Lavender Spa blanket with size of 18"x44" --this heat blanket did not have a skin temperature monitor on it for indicating heating range; --heat blanket had a terry cloth cover to put it before contact with the resident; --microwave instructions on this Heat Blanket stated, "Warning!" Microwaves vary in power. Start at 30 seconds full power. Add time in 10 second increments until desired temperature is reached. "Do Not Overheat To Avoid Risk Of Fire." --WARNING: FOLLOW INSTRUCTIONS TO AVOID INJURY: Cleanse treatment area from body lotions, oils or gels prior to the application of the pad. Contact with lotions, oils or gels can alter the effectiveness of the TheraBeads. Interview with Director of Nursing, Administrator, and Assistant Director of Nursing at 5:25 PM on 5/31/11 revealed: A) The incident was discovered in the morning of 5/28/11 by the NA (Nurse Aide) 1 when Resident 7 was up on the commode and pointed to a red area on left lower leg. NA 1 alerted LPN (Licensed Practical Nurse) 3 and this nurse assessed the wound which at that time was a blister on the left lower leg and notified the Administrator and physician on call. New order from the physician was obtained for the burn and covered. A message was left for the guardian of Resident 7 initially via voice mail but not recorded by the Administrator. The order for the heat pack was to be done BID (twice daily) and PRN (when necessary). The heat packs were stored in the treatment room and warmed up in the microwave and covered with the terry clothes. The heat blanket (Lavender Spa blanket) was stored in Resident 7's room and heated up in the microwave in the treatment room then it was brought back into Resident 7's room with a terry cloth cover on it. There were no orders from the physician on using the heat blanket (Lavender Spa Blanket) and no temperature to heat this too. There was a therapy range for heat indicator on the heat packs, but no heat indicator on the heat blanket. The heat blanket was brought in because of its larger size of 18x44" to cover resident 7's shoulders to lower back when in bed. The treatment times were in the PM (evening) and NOC (early morning around 5 or 6 AM). B) Interview with the Administrator revealed that this person had brought in the Sonoma Lavender Spa Blanket. No order was obtained for use of this blanket. There was no policy and procedure on the use of the heat blanket. C) Interview with the DON and ADON revealed that there was no policy or procedure on the heat blanket and the only guideline on the heat packs was posted in the treatment room on the bulletin board and stated: "Heat Pack Guidelines." 1) Check list of residents for skin sensitivity. 2) Heat ALL heat packs for 1 minute on high. DO NOT EXCEED 1 MINUTE. 3) Check heat pack for hot spots. Twist and roll to distribute heat evenly. Test temperature on bare skin of the employee's arm. 4) Wrap in Terry cloth cover. 5) Chart date, time, heat pack number and initials on clipboard sheet by microwave. 6) Apply heat pack to resident for 15-20 minutes at a time. Keep a minimum of two hours between applications to the resident. Chart time, initial and put results on Treatment Medex for each resident and application. 8) Information: a) Heat packs can only be used four (4) times in any 24 hour period. Please check the heat pack number to see what times it was last used, must keep six (6) hours of rest time between the use of the heat pack. --there were no other policies or procedures on the heat blanket or heat packs as of the date 5/27/11. Interview with Staff Development LPN on 5/31/11 revealed: --no inservices were done on policy and procedure for the use of the heat blanket or the heat packs; --following the burn to Resident 7 a "Heat or Cold Pack Therapy Policy Statement," was done with a note for staff to read and initial the policy with no one-on-one inservices for the staff to check competency; --as of the date of 5/31/11 only four staff had signed the policy statement indicating they read and understood the policy. Observation of Resident 7's left lower leg burn treatment at 8:10 AM on 6/1/11 revealed: --LPN 1 in room with Resident 7 up in motorized wheelchair for dressing change to left lower leg; --non-adherent gauze dressing removed with wound cleaned with sterile water and approximately 3 x 2 cm circular wound with no drainage but this wound did have redness around total circumference; --treatment of [REDACTED]. --Resident 7 complained of discomfort with cleaning of wound; --Resident 7 was watching television in room during treatment. Interview with LPN 1 at 9:00 AM on 6/1/11 revealed that there was no redness yesterday, but the blister on the left lower leg was raised up with fluid in it. Resident 7 was seen by the physician on 5/31/11. Observation of Resident 7 at 8:32 AM on 6/1/11 ; revealed this resident up in motorized wheelchair with a tray on it with food and drink on table eating and drinking without difficulty. Had glasses on and was dressed in a blouse and shorts. Wearing ankle socks. Had intact, clean dressing on left lower leg. Pillow behind left lower shoulder for positioning. Interview with the Administrator at 11:10 AM on 6/2/11 revealed: --the incident with Resident 7 getting a burn on 5/28/11 resulted in an investigation when called by the charge nurse LPN 3 at 7:39 AM; --incident report was filled out and the Administrator came into the facility to look at the burn and investigate what had happened; --the family (guardian) was called and a message was left due to no answer; --the heat blanket had caused the burn and not the heat packs. Interview with the ADON at 11:30 AM on 6/2/11 revealed that Resident 7 had not had the Care Plan updated under the pain management approaches since the date of 5/4/2010 and it is the responsibility of all professional nursing staff to updated the resident care plans. The resident care plans are kept at the nurses station. This violation was abated at the time of survey and the scope & severity was lowered to a 'F'. The facility put the following action into place: -All thermal packs were disposed of. -All heat therapy was suspended. -All current RNs and LPNs were trained by the Nurse Consultant. -All residents' physicians were notified of new procedures and the need for specific instructions and the use of warm compresses for each resident.