Every finding on record at The Ambassador Nebraska City, Inc

Based on interview and record review the facility failed to notify the practitioner of significant weight loss for 1 (Resident 12) of 1 resident. The facility staff identified a census of 47. Findings are:A.Record review of facility's Weight Recording Policy dated 10/2025 revealed the following; Policy Statement -It is the policy of this facility to routinely monitor weight of all residents/patients. Procedure 1. All residents/patients are weighed upon admission and monthly thereafter, at a minimum. The admit weight will be recorded on the admission assessment.2. More frequent weights (i.e., weekly, daily) will be obtained when need is determined by physician, nursing or dietician. Weights will be recorded in the Electronic Health Record (EHR).3. The primary physician and dietician will be notified of any significant weight loss or gain of five percent (5%) or more in one month, seven- and one-half percent (7.5%) in three months and ten percent (10%) in six months. Nursing will notify the primary physician and document the notification in the medical record of the significant weight loss/gain, at the direction of the Dietician and or the Dietary Coordinator.4. Consideration for resident right refusals and terminal diagnosis will be made on an individual basis.5. In the case of significant weight change from one weight to another, this will result in an automatic re-weight. Significant weight change will be reported to the dietician and or dietary coordinator. B.Record Review of Resident 12's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool to determine a residents functional capabilities and helps nursing home staff identify health problems) dated 1-11-26 revealed the facility admitted the resident on 1-5-26 with diagnoses of Unspecified fracture of T11-T12 (thoracic spine) vertebra, Spinal Stenosis (a narrowing of the spinal canal, placing pressure on the spinal cord and nerves, usually caused by age related degeneration), other intervertebral disc degeneration, thoracolumbar region, and esophageal obstruction; a Brief Interview for Mental Status (BIMS, a standardized 0-15 point tool used in nursing homes to assess cognitive impairment) of 15/15, indicating intact cognition. Further review revealed a weight for Resident 12 of 134 pounds. Record review of EHR form titled vital signs: weights revealed on 1-5-26 Resident 12's weight was 134.4 pounds. Further review of Resident 12's weights revealed on 1-19-26 Resident 12 weighed 128.8 pounds, a loss of 5.6 pounds or a 4.17% weight loss compared to the weight on 1-5-2026. Record review of EHR form titled vital signs: weights revealed on 2-16-26 Resident 12's weight was 118 pounds a loss of 10.8 pounds or a 7.76% weight loss compared to the weight on 1-19-26 and a significant weight loss in 30 days with no evidence the resident was re-weighed. Review of a Nursing Facility Note Physician's Assistant Certified (PAC) with an encounter date of 2-18-26 revealed the practitioner identified a 10-pound weight loss for Resident 12 with a note that if there was no improvement to consider mirtazapine. Review of a form labeled Nutrition Fax sheet dated 2-23-26 revealed a recommendation from the Registered Dietician to the practitioner to add a magic cup or shake with meals due to weight loss. Further review revealed the practitioner signed the form and agreed with the recommendations which was noted by a facility nurse on 2-25-26. Review of the February, March and April 2026 Medication Administration Record (MAR) revealed Resident 12 had taken the magic cup starting February 28- March 5,2026 and refused the Magic Cup/or protein shake from 3-6-26 through 4-13-26 for a total of 38 days and a total of 114 occurrences with no evidence the facility notified the practitioner. Record review of EHR form titled vital signs: weights revealed on 3-11-26 Resident 12's weight was 112.4 a loss of 5.6 pounds or a 5.39% weight loss compared to the weight on 2-16-26 and a significant weight loss in 30 days. Review of Resident 12's medical record revealed there was no evidence the resident was re-weighed or the provider was notified of the significant weight loss. Record review of EHR form titled vital signs: weights revealed on 3-26-26 Resident 12's weight was 106.2 a loss of 6.2 pounds or a 5.18% weight loss compared to the weight on 3-11-26 and a significant weight loss in 30 days. Review of Resident 12's medical record revealed there was evidence the resident was re-weighed or provider was notified of the significant weight loss. Review of Resident 12's EMR revealed a form titled Event Report, Metabolic/Nutrition Events-Unplanned Weight Loss with an initiation date of 3-31-26 identified Resident 12 as having a loss of 5% or more in the last month or loss of 10% or more in the last 6 months with it marked yes, not on physician prescribed weight loss regimen. Section labeled Notification Guidelines Notify MD (Doctor of Medicine)/NP (Nurse Practitioner)/PA (Physicians Assistant) on or by the next working day for any of the following (May use fax, e-mail or voicemail) for weight loss greater than 5% in 1 month, 10% in 6 months or significant decrease in meal intake over the course of several days with no guideline or notification noted. Interview with Director of Nursing (DON) on 4-14-26 at 10:35 AM confirmed there was no evidence of notification of dietician or practitioner with weight loss event initiated on 3-31-26. Interview with the DON on 4-14-26 at 1:59 PM confirmed there was no evidence of physician notification of weight changes since 2-23-26 and should have been.

Based on interview and record review the facility failed to complete a nutritional assessment prevent significant weight loss for 1 (Resident 12) of 1 resident. The facility staff identified a census of 47. Findings are:A.Review of a Nutritional Assessment Policy dated 1-2-24 revealed the following: As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident.Policy Interpretation and ImplementationThe dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition.The nutritional assessment will be conducted by the multidisciplinary team and shall identify but are not limited to the following components:Usual body weight;Current height and weight;A description of the resident's usual intake and appetite;A history of reduced appetite or progressive weight loss or gain prior to admission;Current clinical conditions and recent events that may have affected a resident's nutritional status and risk factors;Advance directives that may influence decision-making regarding nutrition support;General appearance - a description of the resident's overall appearance;The resident's usual route(s) of intake (e.g., oral, enteral, parenteral);Usual meal and snack patterns;Food preferences and dislikes (including flavors, textures, and forms);Food restrictions, including food allergies and cultural or religious practices affecting food choices; andPreferred portion sizes.Current medication regimen, including a list of medications that affect nutrient absorption, appetite, level of consciousness, and/or gastrointestinal function.Current clinical conditions and recent events that may have affected a resident's nutritional status and risk factors;Current laboratory results related to fluid and electrolyte status (BUN, creatinine, serum osmolality); andThe presence of chewing or swallowing abnormalities, i.e., conditions of the mouth, teeth, gums pharynx or esophagus that affect the resident's ability to chew or swallow food.An estimate of calorie, protein, nutrient and fluid needs;Whether the resident's current intake is adequate to meet his or her nutritional needs; andSpecial food formulations. 4.The multidisciplinary team shall identify, upon the resident's admission, quarterly, and as needed due to change of condition the following situations that place the resident at increased risk for impaired nutrition Cognitive or functional decline Chewing or swallowing Pain Medication Environmental Increased need for calories and/or protein Poor digestion or absorption Fluid and nutrient loss Inadequate availability of food or fluids 6. Sources of information for the resident nutritional assessment may include the following: a. Standardized nutrition screening and assessment tools; b. Resident Assessment Instrument (RAI); c. Assessments from other disciplines; d. Observation; e. Resident and family interviews; and f. The resident's current medical record. B.Record review of facility's Weight Recording Policy dated 10/2025 revealed the following: -Policy Statement -It is the policy of this facility to routinely monitor weight of all residents/patients. Procedure 1. All residents/patients are weighed upon admission and monthly thereafter, at a minimum. The admit weight will be recorded on the admission assessment. 2. More frequent weights (i.e., weekly, daily) will be obtained when need is determined by physician, nursing or dietician. Weights will be recorded in Electronic Health Record (EHR). 3. The primary physician and dietician will be notified of any significant weight loss or gain of five percent (5%) or more in one month, seven- and one-half percent (7.5%) in three months and ten percent (10%) in six months. Nursing will notify the primary physician and document the notification in the medical record of the significant weight loss/gain, at the direction of the Dietician and or the Dietary Coordinator. 4. Consideration for resident right refusals and terminal diagnosis will be made on an individual basis. 5. In the case of significant weight change from one weight to another, this will result in an automatic re-weight. Significant weight change will be reported to the dietician and or dietary coordinator. C.Record Review of Resident 12's admission minimum Data Set (MDS, a federally mandated comprehensive assessment tool to determine a residents functional capabilities and helps nursing home staff identify health problems) dated 1-11-26 revealed the facility admitted the resident on 1-5-26 with diagnoses of Unspecified fracture of T11-T12 (thoracic spine) vertebra, Spinal Stenosis (a narrowing of the spinal canal, placing pressure on the spinal cord and nerves, usually caused by age related degeneration), other intervertebral disc degeneration, thoracolumbar region, and esophageal obstruction; a Brief Interview for Mental Status (BIMS, a standardized 0-15 point tool used in nursing homes to assess cognitive impairment) of 15/15, indicating intact cognition. Further review revealed a weight of 134 pounds. Record review of Resident 12's comprehensive care plan dated 1-18-26 revealed Resident 12 was identified as having a potential for altered nutrition, hydration and weight status related to history of multiple medication use, and complex medical history with a goal the resident to consume 50-75% of most meals and 75-100% of fluids offered. The approach on Resident 12's care plan to meet this goal dated on 1-18-26 was for staff to give a regular diet, weights per MD orders, milk only with cereal, likes cottage cheese, yogurt, mashed and sweet potatoes, fish and chicken, monitor meal intakes, appropriate alternates offered, Labs (laboratory) as ordered, resident refused starting oral supplement. Record review of Resident 12's Electronic Health Record (EHR) to include progress notes, physicians orders, care plan, and MDS revealed there was no nutritional assessment completed to include usual body weight, residents usual intake, history of reduced appetite or progressive weight loss or gain prior to admission, usual meal and snack patterns, current medication regimen, including a list of medication that affect nutrient absorption, appetite, level of consciousness, and or gastrointestinal function, preferred portion sizes, current laboratory results related to fluid and electrolyte status, the presence of chewing or swallowing abnormalities, and whether the resident's current intake is adequate to meet their nutritional needs until 4-9-26, a 3 month time span. Record review of EHR form titled vital signs: weights revealed on 1-5-26 Resident 12's weight was 134.4 pounds. Further review of Resident 12's weights revealed on 1-19-26 Resident 12 weighed 128.8 pounds a loss of 5.6 pounds or a 4.17% weight loss compared to the weight on 1-5-2026. Record review of EHR form titled vital signs: weights revealed on 2-16-26 Resident 12's weight was 118 pounds a loss of 10.8 pounds or a 7.76% weight loss compared to the weight on 1-19-26 resulted in a significant weight loss in 30 days. There was no evidence of the facility re-weighing the resident. Review of a Nursing Facility Note by the facility Physician's Assistant Certified (PAC) with an encounter date of 2-18-26 revealed the following-Weight Loss-10-pound weight loss over the last month, poor appetite and certain preferences for food consistency due to concern from Schatzki ring (a thin benign ring of tissue that forms in the lower esophagus, often causing difficulty swallowing or a sensation of food getting stuck, especially solid food) history -Depression concerns from nursing staff-Dietary Consult-Trial puree food consistency-Has had prior Speech Therapy (ST) consultation-If no improvement consider mirtazapine Review of a form labeled Nutrition Fax sheet dated 2-23-26 revealed a recommendation from the Registered Dietician to the practitioner to add a magic cup or shake with meals due to weight loss. Further review revealed the practitioner signed the form and agreed with the recommendations which was noted by a facility nurse on 2-25-26. Review of the February, March and April 2026 Medication Administration Record (MAR) revealed Resident 12 had taken the magic cup starting February 28- March 5,2026 and refused the Magic Cup/or protein shake from 3-6-26 through 4-13-26 for a total of 38 days and a total of 114 occurrences with no evidence the facility evaluated Resident 12. Record review of EHR form titled vital signs: weights revealed on 3-11-26 Resident 12's weight was 112.4 a loss of 5.6 pounds or a 5.39% weight loss compared to the weight on 2-16-26 and a significant weight loss in 30 days. Review of Resident 12's medical record revealed there was no evidence the resident was we-weighed or evaluation of nutritional needs for significant weight loss was completed. Record review of EHR form titled vital signs: weights revealed on 3-26-26 Resident 12's weight was 106.2 a loss of 6.2 pounds or a 5.18% weight loss compared to the weight on 3-11-26 and a significant weight loss in 30 days. Review of Resident 12's medical record revealed there was no evidence the resident was we-weighed or evaluation of nutritional needs for significant weight loss was completed. Record review of EHR form titled vital signs: weights revealed on 3-30-26 Resident 12's weight was 104.8 a loss of 1.2 pounds or 1.88% weight loss compared to the weight on 3-26-26. Review of Resident 12's EMR an Event Report sheet titled, Metabolic/Nutrition Events-Unplanned Weight Loss with an initiation date of 3-31-26 revealed Resident 12 was not on a physician prescribed weight loss regimen. Further review of the Event Report sheet revealed under the section identified as interventions-Immediate measures taken revealed supplements, and snacks was not identified as an intervention. Record review of EHR form titled vital signs: weights revealed on 4-8-26 Resident 12's weight was 110 pounds a weight gain of 5.2 pounds or a gain of 5.57% compared to the weight on 3-30-26. Record review of EHR form titled vital signs: weights revealed on 4-10-26 Resident 12's weight was 105 pounds a loss of 5 pounds or a 4.54% loss compared to the weight on 4-8-26. In an interview with the Administrator on 4-09-2026 at 2:15 PM revealed no nutritional assessment had been completed on Resident 12 until 4-9-26. In an interview with the Dietician on 4-13-26 at 1:07 PM it was revealed the admission nutritional assessment would be expected to be completed within 14 days of the resident's admission [DATE]) and had not been done for Resident 12. In an interview with Administrator on 4/14/26 at 8:15 AM it was confirmed the fax dated 2-23-26 would not meet the criteria of the Nutritional Assessment.

Licensure reference: 175 NAC 12-006.02(H) Based on interview and record review, the facility failed to ensure an allegation of potential misappropriation of medication was reported for 2 [Resident 1 and 3] of 5 sampled residents. The facility had a total census of 46 residents. Findings are: A review of facility investigation dated 2/12/25 revealed an allegation that a nurse was requesting medication aides sign out prn [as needed] controlled medications and provide them to the nurse to administer to Residents 1 and 3 instead of having the Medication Aide administer the medication directly to the resident. The investigative report revealed that an audit was conducted of narcotic logs, administration of as needed medications and frequent /early re-orders of prn medications with no concerns identified. Staff interviews were conducted on 2/12/25 and 2/13/25 revealed no concerns of misappropriation of medications. In an interview on 3/10/25 at 3:04 PM and 3:52 PM, the Administrator confirmed that the allegation that a nurse was requesting medication aides provide medication to the nurse to administer instead of administering the medication directly to the resident had not been reported as potential misappropriation of medications. The Administrator reported that the reporter had not alleged that medications were missing. The Administrator confirmed that the facility did investigate to ensure medications were not missing based on the reporter's statements. A review of facility policy titled Abuse Reporting and Investigation Policy dated 7/2024 revealed the following: -Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury; or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where State law provides jurisdiction in long-term care facilities).

Licensure reference: 175 NAC 12-006.02(H) Based on interview and record review, the facility failed to ensure a thorough investigation had completed regarding an allegation of potential misappropriation of medications from 1 [Resident 1] of 5 sampled residents. The facility had a total census of 46 residents. Findings are: A review of facility investigation dated 1/12/15 revealed an allegation that a nurse was requesting medication aides sign out prn [as needed] controlled medications and provide them to the nurse to administer to Residents 1 and 3 instead of having the Medication Aide administer the medication directly to the resident. The investigative report revealed that an audit was conducted of narcotic logs, administration of as needed medications and frequent/early re-orders of prn medications without concerns identified. According to facility investigations, staff interviews were conducted on 2/12/25 and 2/13/25 revealed no concerns of misappropriation of medications. A review of facility investigation revealed further staff interviews were conducted on 2/20/25 and 2/21/25 that revealed three staff members had been asked to provide prn [as needed] medications to a nurse for a resident instead of administering directly to the resident. In an interview on 3/10/25 at 10 AM, the Administrator confirmed that the investigation had revealed that staff were giving medications to other staff members instead of administering medications directly to a resident. In an interview on 3/10/25 at 11:04 AM, the Director of Nursing confirmed that the investigation had revealed with signing out medication on the Controlled Drug Record and not documenting that the medication was given on the medication administration record. A review of facility Performance Improvement Project with start date of 2/20/25 revealed education was being provided to staff regarding procedures for administering and documenting administration of prn medications and auditing of regular prn medications and controlled substance audits. A review of Resident 1's Controlled Drug Record for Hydrocodone [a controlled medication for pain] 10/325 mg take 1 tablet orally every 8 hours as needed revealed a count of 18 tablets on 2/4/25 at 6 AM. The 2/4/25 at 6 AM count was at the bottom of a page. A new Controlled Drug Record sheet was started for Resident 1's prn Hydrocodone with the first entry on 2/4/25 at 6 AM, the count started with 10 tablets which was a difference of 8 tablets. In interviews on 3/10/25 at 2:50 PM, 4:02 PM, and 4:31 PM, the Director of Nursing reported checking to ensure the number of medications on the Controlled Drug Record matched the medications available in the cart for that resident as part of the investigation. The Director of Nursing reported just discovering the discrepancy with the Controlled Drug Record for Resident 1 and didn't have an answer for where the medications had gone. In an interview on 3/10/25 at 3:52 PM, the Administrator confirmed that there was a documentation issue in accounting for controlled medications and acknowledged that further investigation was needed to determine if there were missing medications.

Licensure Reference Number 175 NAC 12.006.09(I) Based on interview and record review, the facility failed to ensure evaluations were completed for 5 (Residents 7, 12, 15, 47, and 205) of 8 sampled residents to ensure the safe use of a power lift chair recliner (lift chair)(a motorized chair that reclines and lift upward to assist the resident to stand up) to prevent accidents. The facility census was 52. Findings are: A record review of the facility's undated Fall Policy revealed it was the policy of the facility to provide a safe and healthful living environment for all residents. Fall risk assessments were to be completed by nursing staff following a fall event. The Care Plan would be reviewed/revised to determine effectiveness of current interventions and/or add additional interventions to prevent future falls. A record review of the facility's undated Fall Risk Prevention policy revealed it was the policy of the facility to review and identify residents at risk for falls. Upon admission, quarterly, and when there was a change of condition, a Fall Risk Assessment would be completed. If the resident was identified as high risk (a score greater than 10) a prevention protocol would be initiated immediately to include -Evaluation in the care planning process as a potential or actual problem. -Request for Evaluation by Physical Therapy (PT) or Occupational Therapy (OT) for interventions such as positioning, strengthening, assistive devices, coordination, education, as needed. -Evaluation of the resident's environment. -Evaluation for predisposing factors. -Evaluation for needed safety alarm devices. A. A record review of Resident 12's Resident Census dated 10/30/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 12's SNF (Skilled Nursing Facility) Continuity of Care Document (CCD) dated 10/30/2024 revealed the resident had diagnoses of Repeated falls, Dizziness and giddiness (off-balance and surroundings moving or spinning), Orthostatic hypotension (blood pressure drop after standing), Restless Leg Syndrome (disorder that causes uncomfortable legs and an urge to move them), Acute on chronic systolic (congestive) heart failure, Chronic kidney disease, Benign prostatic hyperplasia (enlarged prostate), and Irritable bowel syndrome. A record review of Resident 12's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 05/22/2024 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 12 out of 15 which indicated the resident was moderately cognitively impaired (confused). The resident required partial/moderate assistance with toileting, upper body dressing, and oral and personal hygiene (cleaning). The resident was substantial/maximal assistance with bathing, lower body dressing, and footwear. The resident needed partial/moderate assistance with rolling, lying, and sitting on side of bed, sit to stand positioning, toilet transfer, and chair to bed transfers. The resident used a walker and a wheelchair. The MDS revealed the resident had fallen in the last month. A record review of the facility's Monthly Patient Fall Tracking Record dated 01/01/24 - 10/22/2024 revealed Resident 12 had falls on 05/11/2024 and 06/09/2024 from the lift chair. A record review of Resident 12's Progress Note dated 05/11/2024 revealed Resident 12 was found on the floor in the room sitting in front of the lift chair. When asked what happened Resident 12 stated they raised the lift chair all the way up to help stand up. When Resident 12 raised the lift chair up, the resident's slid on the carpet and the resident slowly sat down on the floor. Resident 12 was assisted back to the lift chair with 2 staff members using the Hoyer lift (a full body lift). The immediate intervention was to place new gripper socks on the resident's feet and then a sign was placed on the dresser to remind the resident to wear gripper socks or shoes when the resident was up. A record review of the facility's Post Fall Observation for Resident 12 dated 05/11/2024 revealed: The detailed description of Resident 12's fall was the resident raised the lift chair all the way up to help the resident stand. The resident previously had gripper socks on, and the resident removed them and put regular socks on. When the resident raised the recliner up, the resident's feet slid on the carpet and slowly sat down on the floor. The resident was assisted back to the lift chair with 2 staff using the Hoyer lift. The resident was normally an assist of 1 staff with/without device for ambulation. A summary of potential factors that could have contributed to the fall was regular socks sliding on the carpet. A description of measures to be taken to prevent further falls was a sign placed on dresser to remind the resident to wear gripper socks or shoes while up. A record review of the facility's Falls Investigation Form for Resident 12 dated 5/11/2024 revealed an intervention of gripper socks placed on the resident. Resident 12 was putting recliner up and slid down to the floor. The lift chair was all the way up. The resident reported the resident was moving the resident's seat up and slowly slipped. A record review of Resident 12's Progress Note dated 06/09/2024 revealed Resident 12 fell from the recliner. The resident was sitting on the floor in front of the lift chair which was in the high raised position. The chair alarm was sounding, and the resident had gripper socks on. Resident 12 was helped back into the lift chair with a Hoyer lift. The staff added Dycem (a non-slip material) to the lift chair to prevent sliding and staff was to check on resident frequently. A record review of the facility's Post Fall Observation dated 06/09/2024 revealed: The detailed description of Resident 12's fall was the resident slid from the lift chair. The resident's usual ambulatory status was a staff assist of 1 with/without a device. It did not reveal there was a pattern to the resident's falls. The resident had raised the lift chair causing the resident to slide. A description of measures to be taken to prevent further falls was Dycem placed in the lift chair and staff was to check on resident frequently. A record review of the facility's Falls Investigation Form dated 06/09/2024 did not reveal an immediate measure put into place to protect the resident and ensure safety. Resident 12 stated the resident slid out of the lift chair. The lift chair tipped up and staff suggested keep chair controller out of reach, check on the resident frequently, and keep Dycem under the resident to prevent sliding. A record review of Resident 12's EMR and paper chart did not reveal a safety assessment had been completed to assess the resident's ability to safely use the lift chair. An observation on 10/30/2024 at 1:18 PM revealed Resident 12 was reclined in the lift chair with the resident's legs elevated. An observation on 10/31/2024 at 11:12 AM revealed Resident 12 was sleeping while reclined in the lift chair with the resident's legs elevated. The remote was in reach. In an interview on 10/30/2024 at 1:18 PM, Resident 12 confirmed the resident had a lift chair, the remote was in reach, and the resident was not supposed to use it, the resident was to call staff if needed. In an interview on 10/30/2024 at 3:27 PM, Registered Nurse (RN)-E confirmed the admitting nurse went over the room education with the resident but was unaware of any education provided to the resident on how to safely use the lift chair. In an interview on 10/31/2024 at 3:18 PM, RN-G confirmed that when a resident was admitted to the facility, the staff would ensure the resident was able to use a walker but didn't make ensure a resident knew how to use the lift chair controller. In an interview on 10/30/2024 at 11:28 AM, Occupational Therapist (OT)-F confirmed OT did not do safety assessments on the resident's ability to safely use a lift chair unless the facility specifically requested it. In an interview on 10/30/2024 at 1:34 PM, the Director of Nursing (DON) confirmed the staff did not complete safety assessments on the residents to ensure the residents were able to safely use a lift chair. B. A record review of Resident 7's Face Sheet dated 10/30/2024 revealed the resident was admitted to the facility on [DATE]. The resident had diagnoses of Bilateral primary osteoarthritis of knee (knee joint disease), Other forms of scoliosis, lumbar region (spine deformity of the lower back), Postural kyphosis, site unspecified (hunching of the back), Unspecified abnormalities of gait (walking pattern), and Alzheimer's disease (mental deterioration). A record review of Resident 7's MDS dated [DATE] revealed the resident had a BIMS score of 3 out of 15 which indicated the resident was severely cognitively impaired (confused). The resident required partial/moderate assistance with bathing, oral, and personal hygiene. The resident was substantial/maximal assistance with dressing and was dependent on staff for toileting and footwear. The resident needed substantial/maximal assistance with rolling, lying, and sitting on side of bed, sit to stand positioning, toilet transfer, and chair to bed transfers. The resident used a walker and a wheelchair. A record review of the facility's Monthly Patient Fall Tracking Record dated 01/01/24 - 10/22/2024 revealed Resident 7 had fallen on 10/27/2024 from the lift chair. A record review of Resident 7's Progress Note dated 10/27/2024 revealed Resident 7 had increased confusion overnight and kept getting out of bed and looking for the resident's spouse. The staff were eventually able to settle the resident in the lift chair. At 4:30 AM the resident's chair alarm sounded. The resident had slid out of the lift chair. The resident did not understand what the controller was and put the chair all the way up. Throughout the assessment process, the resident remained confused and kept asking what happened that the chair kept going up. The resident was assisted up with 2 assist, gait belt (belt that fastened around a resident for staff to hold to keep from falling), and walker. The staff was unable to use the Hoyer lift, as resident's legs were pushed up against the dresser and the staff was unable to get the Hoyer into place. The resident would be monitored for safety every hour in addition to the 5 R (reposition, restroom, rate pain, reach, and refresh) checks for 3 days. A record review of the facility's Post Fall Observation dated 10/27/2024 revealed: The detailed description of Resident 7's fall was the resident slid out of the recliner and did not understand the resident was raising it up with the controller. The resident landed on the buttocks with legs out in front of the resident, partially bent at the knees. The resident was normally an assist of 1 staff with/without device for ambulation. A summary of potential factors that could have contributed to the fall was the resident was confused and did not understand the resident was pushing the controller to raise the chair. A description of measures to be taken to prevent further falls was in addition to 5 R checks, safety checks to be done every hour for 3 days. A record review of the facility's Falls Investigation Form dated 10/27/2024 revealed an intervention of add every hour safety check to 5's for 3 days. Resident 7 said it just kept going up and that the resident was confused and didn't understand the resident raised the chair with the controller. The fall was unwitnessed. A record review of Resident 7's EMR and paper chart did not reveal a safety assessment had been completed to assess the resident's ability to safely use the lift chair. An observation on 10/28/2024 at 10:38 AM revealed Resident 7 was reclined in the lift chair with the resident's legs elevated, feet were off the end of the lift chair and the lift chair controller was on the floor. An observation on 10/29/2024 at 11:21 AM revealed Resident 7 was sitting reclined in the lift chair with the resident's legs elevated. The remote was on the floor. In an interview on 10/28/2024 at 1:34 PM, Resident 7's Power of Attorney (POA) confirmed the resident had a lift chair and slid out of the lift chair on Saturday, 10/27/2024. The intervention Resident 7's POA was told was the facility was going to place an alarm in the lift chair and bed. In an interview on 10/30/2024 at 3:27 PM, Registered Nurse (RN)-E confirmed the admitting nurse went over the room education with the resident but was unaware of any education provided to the resident on how to safely use the lift chair. In an interview on 10/31/2024 at 3:18 PM, RN-G confirmed that when a resident was admitted to the facility, the staff would ensure the resident was able to use a walker but didn't make sure a resident knew how to use the lift chair controller, but if the resident had to stand up, they had to use the lift chair. In an interview on 10/30/2024 at 11:28 AM, Occupational Therapist (OT)-F confirmed OT did not do safety assessments on the resident's ability to safely use a lift chair unless the facility specifically requested it. In an interview on 10/29/2024 at 1:19 PM, the Director of Nursing (DON) confirmed they do not have a safety assessment on Resident 7, and one was not done following the fall from the lift chair recliner. In an interview on 10/30/2024 at 1:34 PM, the DON confirmed the staff did not complete safety assessments on the residents to ensure the residents were able to safely use a lift chair. C. A record review of Resident 15's Resident Census dated 10/30/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 15's SNF CCD dated 10/30/2024 revealed the resident had diagnoses of Acute lymphangitis of right lower limb (infection in right leg), Acquired absence of limb (arm or leg removal), Unsteadiness on feet, Muscle weakness, Peripheral vascular disease (low blood flow in arms or legs), Need for assistance with personal care, and Chronic Obstructive Pulmonary Disease (COPD). A record review of Resident 15's MDS dated [DATE] revealed the resident had a BIMS score of 14 out of 15 which indicated the resident was cognitively aware. The resident required substantial/maximal assistance with bathing, oral, and personal hygiene. The resident was dependent on staff for toileting, dressing, and footwear. The resident was dependent on staff for all mobility and transfer needs. The resident used a wheelchair. A record review of the facility's Monthly Patient Fall Tracking Record dated 01/01/24 - 10/22/2024 revealed Resident 15 had fallen on 09/07/2024 from the lift chair. A record review of Resident 15's Progress Note dated 09/07/2024 revealed at 10:45 PM the Nursing Assistant (NA) called the RN into Resident 15's room and the resident was on the floor. The call light was on, and the NA went to answer it. The lift chair was elevated, and the resident was laying on the resident's left side. The resident's face had several cuts and was bleeding and the resident's nose was bleeding. The resident stated the resident was messing with the blanket and with what was on it. The chair was found elevated and tilted forward. The emergency room (ER) was called, and the facility got orders to transport to the hospital. A record review of the facility's Post Fall Observation dated 09/07/2024 revealed: The detailed description of Resident 15's fall was the resident fell out of lift chair onto their left face. It did not reveal any measures were in use at the time of the fall. The resident was normally an assist of 1 staff with/without device for ambulation. A summary of potential factors that could have contributed to the fall was the resident was messing with the blanket and what was on it (chair remote was on it) and the resident's lift chair was elevated when observed. A description of measures to be taken to prevent further falls was blank. A record review of the facility's Falls Investigation Form dated 09/07/2024 revealed Resident 15 had a significant injury and was sent to ER. The chair was lifted up, the resident was on the resident's left side, left face/eye/nose were bleeding because of a skin tear. The resident was attempting to grab the lift chair remote. The resident said the resident leaned to mess with chair remote and blanket and toppled over and hit her face on the floor. Immediate measure put in place to protect the resident and ensure safety was ER called. A record review of Resident 15's Rehabilitation Screen dated 09/09/2024 revealed following the fall, OT assessed the resident and recommended a non-lift recliner to prevent the risk of falls. A record review of Resident 15's EMR and paper chart did not reveal a safety assessment had been completed to assess the resident's ability to safely use the lift chair. An observation on 10/30/2024 at 12:26 PM revealed Resident 15's had a power recliner but was not a lift chair. In an interview on 10/30/2024 at 3:27 PM, Registered Nurse (RN)-E confirmed the admitting nurse went over the room education with the resident but was unaware of any education provided to the resident on how to safely use the lift chair. In an interview on 10/31/2024 at 3:18 PM, RN-G confirmed that when a resident was admitted to the facility, the staff would ensure the resident was able to use a walker but didn't make sure a resident knew how to use the lift chair controller. In an interview on 10/30/2024 at 11:28 AM, Occupational Therapist (OT)-F confirmed OT did not do safety assessments on the resident's ability to safely use a lift chair unless the facility specifically requested it. In an interview on 10/30/2024 at 1:34 PM, the DON confirmed the staff did not complete safety assessments on the residents to ensure the residents were able to safely use a lift chair. D. A record review of Resident 47's Resident Census dated 10/30/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 47's SNF CCD dated 10/30/2024 revealed the resident had diagnoses of Peripheral vascular disease, Muscle weakness, Unsteadiness on feet, Acquired absence of left toe, Fracture of unspecified part of neck of right femur (right hip), and Other abnormalities of gait. A record review of Resident 47's MDS dated [DATE] revealed the resident had a BIMS score of 6 out of 15 which indicated the resident was severely cognitively impaired. The resident required supervision/touching for oral and personal hygiene. The resident required partial/moderate assistance for bathing and upper body dressing. The resident required substantial/maximal assistance for lower body dressing and was dependent on staff for toileting and footwear. The resident needed substantial/maximal assistance to move from sit to lying and lying to sitting. The resident was dependent on staff for sit to stand, chair, toilet, and tub/shower transfers. The resident used a wheelchair. A record review of the facility's Monthly Patient Fall Tracking Record dated 01/01/24 - 10/22/2024 revealed Resident 47 had fallen on 10/05/2024 from the lift chair. A record review of Resident 47's Progress Note dated 10/05/2024 revealed the resident was found in the room sitting on the floor. The resident was positioned in front of the recliner. The resident states that the resident did not hit the resident's head, the resident slid on the buttocks. The recliner remote was underneath the resident, which caused the chair to raise up. A record review of the facility's Post Fall Observation dated 10/05/2024 revealed: The detailed description of Resident 47's fall was the Recliner remote was underneath of the resident, the recliner up button was being pushed. The resident slid to the resident's bottom. It did not reveal that any measures were in use at the time of the fall. The resident was normally an assist of 1 staff with/without device for ambulation. A summary of potential factors that could have contributed to the fall was blank. A description of measures to be taken to prevent further falls was make sure the recliner remote is not underneath the resident to make sure the resident did not hit the up button. A record review of the facility's Falls Investigation Form dated 10/05/2024 revealed the following -Resident 47 said I slid out of my chair. -Resident was attempting to continue sitting in recliner. Recliner tilted up. Sat on remote tip up button. Resident sat on remote slid under bottom over time and hit tilt-up button and slid out of chair. -Intervention was to make sure resident don't sit on recliner remote. It did not reveal immediate measure were put in place to protect the resident. A record review of Resident 47's EMR and paper chart did not reveal a safety assessment had been completed to assess the resident's ability to safely use the lift chair. An observation on 10/30/2024 at 10:18 AM revealed Resident 47's had a lift chair. In an interview on 10/30/2024 at 3:27 PM, Registered Nurse (RN)-E confirmed the admitting nurse went over the room education with the resident but was unaware of any education provided to the resident on how to safely use the lift chair. In an interview on 10/31/2024 at 3:18 PM, RN-G confirmed that when a resident was admitted to the facility, the staff would ensure the resident was able to use a walker but didn't make sure a resident knew how to use the lift chair controller, but if the resident had to stand up, they had to use the lift chair. In an interview on 10/30/2024 at 11:28 AM, Occupational Therapist (OT)-F confirmed OT did not do safety assessments on the resident's ability to safely use a lift chair unless the facility specifically requested it. In an interview on 10/30/2024 at 1:34 PM, the DON confirmed the staff did not complete safety assessments on the residents to ensure the residents were able to safely use a lift chair. E. A record review of Resident 205's Resident Census dated 10/30/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 205's SNF CCD dated 10/30/2024 revealed the resident had diagnoses of Unilateral Primary Osteoarthritis, right hip. Idiopathic scoliosis (curvature of spine without reason), Presence of right artificial hip joint, Alzheimer's disease, Unspecified dementia (confusion), Muscle weakness, Unsteadiness on feet, and Other abnormalities of gait. A record review of Resident 205's MDS dated [DATE] revealed the resident had a BIMS score of 6 out of 15 which indicated the resident was severely cognitively impaired. The resident required partial/moderate assistance for oral hygiene. The resident required substantial/maximal assistance for dressing and personal hygiene and was dependent on staff for toileting, bathing, and footwear. The resident needed substantial/maximal assistance for tub/shower transfers. The resident was partial/moderate assistance for mobility, toilet, and chair transfers. The resident used a walker. A record review of the facility's Monthly Patient Fall Tracking Record dated 01/01/24 - 10/22/2024 revealed Resident 205 had fallen on 02/10/2024 from the lift chair. A record review of Resident 205's Progress Note dated 02/10/2024 revealed the NA noted the resident was sitting on the floor in front of the lift chair. The leg rest of the lift chair was raised. The resident was sitting with the resident's back to the recliner, knees slightly bent in front and to the left. The resident was barefoot with sandals beside the lift chair. A record review of the facility's Post Fall Observation dated 02/10/2024 revealed: The detailed description of Resident 205's fall was the resident was sitting on the floor in front of the recliner. The footrest was up. The resident's legs were partially bent and toward the left. Bare feet. It did not reveal that any measures were in use at the time of the fall. The resident was normally an assist of 1 staff with/without device for ambulation. A summary of potential factors that could have contributed to the fall was the footrest of lift chair was raised, the resident scooted off of it. A description of measures to be taken to prevent further falls was Footrest not to be raised. A record review of Resident 205's EMR and paper chart did not reveal a Falls Investigation Form or a safety assessment had been completed to assess the resident's ability to safely use the lift chair. In an interview on 10/30/2024 at 3:27 PM, Registered Nurse (RN)-E confirmed the admitting nurse went over the room education with the resident but was unaware of any education provided to the resident on how to safely use the lift chair. In an interview on 10/31/2024 at 3:18 PM, RN-G confirmed that when a resident was admitted to the facility, the staff would ensure the resident was able to use a walker but didn't make sure a resident knew how to use the lift chair controller, but if the resident had to stand up, they had to use the lift chair. In an interview on 10/30/2024 at 11:28 AM, Occupational Therapist (OT)-F confirmed OT did not do safety assessments on the resident's ability to safely use a lift chair unless the facility specifically requested it. In an interview on 10/30/2024 at 1:34 PM, the DON confirmed the staff did not complete safety assessments on the residents to ensure the residents were able to safely use a lift chair.

Based on record review and interviews, the facility failed to ensure side effects for Adderall XR (a stimulant medication-a class of drugs that increase the activity of the brain) XR (extended release) were monitored for Resident 33. This affected 1 of 5 residents sampled for unnecessary medication use. The facility census was 52. Findings are: A review of Resident 33's Continuity of Care Document created 10/29/2024 revealed the resident was admitted on [DATE] with diagnoses of a stroke with left side weakness and paralysis, multiple sclerosis (a disorder of the central nervous system marked by weakness, numbness, a loss of muscle coordination, and problems with vision, speech, and bladder control), high blood pressure, and narcolepsy (a nervous system problem that causes extreme sleepiness and attacks of daytime sleep). A review of Resident 33's Quarterly Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) dated 10/03/2024 revealed 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) of 14, indicating intact cognition. A review of Resident 33's Orders printed 10/31/2024 revealed an order for Adderall 5 milligrams (mg) orally once a day at 11:30 AM with a diagnosis of narcolepsy. Further review of the Orders revealed no instruction to monitor for side effects (SE) of stimulant medications. A review of Resident 33'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) in the Electronic Health Record (EHR) and of the printed working care plan at nurse's station revealed no mention of Adderall XR, stimulants, or of the SE of that medication or class of medications to monitor. A review of the website https://www.webmd.com/drugs/2/drug-63163/adderall-oral/details under the Side Effects tab revealed that some SE of Adderall XR may be loss of appetite, weight loss, nausea/vomiting, dizziness, headache, nervousness, and elevated blood pressure. More serious SE listed were blood flow problems in the fingers and toes, mood/mental status changes such as agitation and aggression, and fast or pounding heartbeat. An interview on 10/31/2024 at 12:00 PM with the Director of Nursing (DON) confirmed that monitoring SE of medications was only documented in the Medication Administration Record and in the CCP, and that SE of a stimulant/Adderall was not listed in either place. The DON further confirmed that they should be monitoring for the SE of a stimulant medication. An interview on 10/31/2024 at 12:12 PM with Registered Nurse (RN) B confirmed the RN did not know the side effects of Adderall XR and that they were not listed on the MAR. An interview on 10/31/2024 at 12:23 PM with Medication Aide (MA) C confirmed the MA did not know what the side effects of a stimulant medication were. An interview on 10/31/2024 at 12:35 PM with RN E confirmed the RN did not know the side effects of a stimulant/Adderall.

Licensure Reference Number 175 NAC 12-006.18(B) Based on record review, observation, and interviews, the facility failed to put Enhanced Barrier Precautions (EBP) into place for Resident 43 to prevent the potential for cross contamination. This affected 1 of 4 residents sampled for skin conditions. The facility census was 52. Findings are: A review of the undated list titled Ambassador Health of Nebraska City Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes. EBP involves wearing a gown and gloves during high-contact resident care activities, such as wound care, for residents known to be colonized or infected with a MDRO as well as residents at increased risk of MDRO acquisition [for example, residents with wounds or indwelling medical devices]) provided by the facility on 10/28/2024 revealed three residents in EBP: Resident 15 for a wound, Resident 26 for a catheter, and Resident 9 for a feeding tube. Resident 43 was not on the list. A review of Resident 43's Continuity of Care Document created 10/29/2024 revealed the resident was admitted on [DATE] with diagnoses of heart failure, an irregular heartbeat, high blood pressure, and type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). A review of Resident 43's Significant Change of Status Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) dated 09/10/2024 revealed 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) of 11, indicating moderate cognitive impairment. A review of the Event Report dated 09/13/2024 revealed the facility had recorded an open area to Resident 43's gluteal cleft (the groove that runs between the upper buttocks) on 09/13/2024, and that the area remained open through 10/29/2024. A review of the facility's Enhanced Barrier Precautions policy dated 4/2024 revealed that EBP are indicated for a resident with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. An observation made on 10/31/2024 at 7:22 AM revealed no signage for EBP outside Resident 43's room and no gowns available for use either inside or outside the resident's room. An observation made on 10/31/2024 at 8:55 AM of Licensed Practical Nurse (LPN) A performing wound care for Resident 43 revealed no use of a gown during the procedure. An interview on 10/31/24 at 7:40 AM with Registered Nurse (RN) B confirmed the facility did not have Resident 43 in EBP because the wound was not draining, and the resident always had a brief on. An interview on 10/31/24 at 7:40 AM with the Director of Nursing (DON) confirmed the facility did not have Resident 43 in EBP because they were looking at the area as a short-term wound that would heal. An interview on 10/31/2024 at 1:37 PM with the DON confirmed that Resident 43 should be in EBP.

Based on record review and interview, the facility failed to ensure a new PASARR (Pre-admission Screening and Resident Review, a screening to determine the presence of a mental illness or intellectual disability) review had been completed after a diagnosis of a mental disorder was identified for 1(Resident 40) out of 1 reviewed for PASARR. The facility census was 45. Findings are: Review of the Resident 40's face sheet revealed Resident 40 admitted on [DATE]. Further review revealed that a diagnosis of Psychotic Disorder with delusions due to known physiological condition was added on 9/6/22. Review of Resident 40's admission PASARR I, completed on 7/22/22, revealed There was no signs of a serious mental illness, intellectual disability, or a related found during the Level I Screen. No further clinical review or onsite evaluation is needed. Review of Resident 40's electronic health record (EHR) and paper chart revealed no PASARR completed since new diagnosis of Psychotic Disorder with delusion due to known physiological conditions was added on 9/6/22. Record review of the PASARR policy dated 09/2018 revealed the following: -#8 The facility is required to notify the appropriate state mental health authority or state intellectual disability authority when a resident with a mental disorder (MD) or intellectual disability (ID) has a significant change in his/her physical or mental condition. Further review revealed that the policy did not address that a PASARR II to be completed for a resident being identified with newly evident or possible serious MD, ID or a related condition. Interview with Social Service Director(SSD)on 9/5/23 at 12:49 PM confirmed that a PASARR II should have been done and was not when Resident 40 received the psychotic disorder on 9/6/22.

Licensure Reference Number 175 NAC 12-006.09C1c Based on record review and interviews; the facility failed to include the resident or the resident's representative when performing a comprehensive care plan (CCP-written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) review and revision for 2 (Resident 3 and Resident 41) of 2 sampled residents. The facility census was 45. Findings are: A. An interview on 8/30/23 at 11:11 AM Resident 3 revealed that Resident 3 had not been invited to care plan conferences. Review of Resident 3's Electronic Health Record (EHR) revealed that Resident 3 readmitted to the facility after a hospitalization on [DATE] with a diagnosis of Pneumonia. Review of Resident 3's comprehensive Minimum Data Set (MDS- an assessment of each resident's functional capabilities used to develop a resident's plan of care), dated 7/14/23, revealed Resident 3 had 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) of 14. Review of Resident 3's Initial Care Plan-Description: readmit, dated 7/11/23, revealed that the initial care plan had not been reviewed with the resident or resident representative and that a copy was not provided or offered to the resident or resident representative. Review of the facility's Conference Minutes-Purpose of review: Initial, dated 7/19/23, for Resident 3 revealed, under the Signature of Resident/Family in Attendance section, no signature. An interview on 9/5/23 at 1:12 PM, the Social Services Director (SSD) confirmed that Resident 3 or a representative was not in attendance to the 7/19/23 care plan conference and that Resident 3 or a representative should have been. The SSD further revealed that there is no policy related to care plan conferences and that there is no documentation completed that would state why a Resident or representative were not in attendance to a care plan conference. 45613 B. Interview on 8/30/23 at 12:24 PM with Resident 41's representative confirmed they had not attended a recent careplan conference meeting. Record review of careplan conference meeting notes and attendance record sheets dated 6/22/23 and 8/30/23 revealed Resident 41 and represntatives were not in attendance for careplan meetings. Record review of Resident 41's progress notes revealed there is no documentation of careplan meetings. Interview on 9/6/23 at 01:57 PM with SSD confirmed there is no facility Care Plan meeting Policy. Interview on 09/06/23 at 01:58 PM with SSD confirmed Resident 41 or representatives did not attend the careplan meetings on 6/22/23 or 8/30/23, letters were mailed out to invite the families to the careplan meetings and it was not documented if the resident or the resident representative attended the careplan meeting.

Based on record review and interview, the facility failed to ensure a new PASARR (Pre-Admission Screening and Resident Review, a screening to determine the presence of a mental illness or intellectual disability) review had been completed after a [DIAGNOSES REDACTED]. The facility census was 45. Findings are: Review of Resident 39's Admission Level 1 PASARR completed on 1/11/21 revealed that Resident 39 exhibited no signs of a serious mental illness, intellectual disability, or a condition related during the Level 1 screen. No further clinical review or onsite evaluation was needed. Record review of Resident 39's Progress Notes between 1/25/21 and 1/27/21 revealed that Resident 39 exhibited several episodes of agitation, wandering, exit seeking and verbally expressed fixed delusional beliefs toward staff. Record review of Resident 39's Physician order [REDACTED]. Record review of Resident 39's [DIAGNOSES REDACTED]. Record review of Resident 39's significant change Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) dated 2/22/21 section A1500 for PASARR revealed that Resident 39 was not considered by the State level 2 PASARR process to have a serious mental illness or intellectual disability or a related condition. The MDS further identified Resident 39 to have a current psychiatric [DIAGNOSES REDACTED]. Record review of Resident 39's Electronic Medical Record revealed that a new PASARR had not been completed after 1/26/21 when the resident received a mental illness [DIAGNOSES REDACTED]. Interview on 3/8/21 at 3:18 PM with the facility Administrator confirmed that Resident 39 had a [DIAGNOSES REDACTED].

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3 Based on record review and interview; the facility failed to evaluate and implement a toileting program for 1 (Resident 5) of 1 sampled resident. The facility staff identified a census of 43. The findings are: Record review of MDS (Minimal Data Set; a federally mandated assessment tool used for care planning) dated 7/18/19 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) was a 13. According to the MDS Manual, a score of 13 indicates cognitively intact. - Extensive assistance with toileting and transfers. -Frequently incontinent of urine with no toileting program. Record review of Resident 5's medical record revealed no evidence of a bowel and bladder assessment. Record review of current plan of care revealed no problem identified with residents incontinence. Record review of the facility policy and procedure dated 9/2017 revealed the facility will maintain a program that provides assessment, treatment, and documentation of incontinent residents. An interview conducted with the DON (Director of Nursing) on 07/23/19 at 02:18 PM confirmed that Resident 5 had not been evaluated for a toileting program.

Licensure Reference Number 175 NAC 12-006.09C Based on record review and interview, the facility failed to develop a Comprehensive Care Plan (CCP) (a comprehensive interdisciplinary plan to ensure the provision of quality care for the resident) for 1 (Resident 18) of 13 residents reviewed. A CCP was not developed related to oxygen therapy for Resident 18. The facility census was 50. Findings are: Record review of Resident 18's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 01/19/18 revealed the facility staff acknowledged Resident 18 had previously required oxygen therapy for the last 14 days prior to admission. An Interview with Licensed Practical Nurse (LPN) A on 5/2/2018 at 9:45 AM revealed that Resident 18 wore oxygen every night for comfort. Record review of Resident 18's CCP dated 05/03/18 revealed no specific information related to oxygen therapy or the need for oxygen therapy or specific interventions to address oxygen therapy. An interview with Director of Nursing (DON) on 5/3/18 at 2:05 PM reveals that Resident 18 wore oxygen overnight and that oxygen had not been addressed in the CCP. The DON confirmed that oxygen therapy should be addressed in the CCP

Licensure Reference Number 175 NAC 12-006.17D Based on observations, interviews, and record reviews; the facility failed to cleanse scissors in a manner to prevent cross contamination and failed to perform hand hygiene between glove changes during wound care for 1 resident (Resident 26) of 2 residents sampled. The facility staff identified the census at 50. The findings are: A review of Resident 26's Face Sheet dated 5-7-18 revealed Resident 26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation conducted on 5-3-18 at 8:55 AM of wound care for Resident 26 by Licensed Practical Nurse (LPN) B revealed LPN B pulled a pair of scissors out of their pocket and washed the scissors in the bathroom using soap and water. LPN B used the scissors to cut open the soiled dressing on the resident's left leg and placed the scissors on the bedside table. When LPN B gathered up the trash and supplies after the dressing changed, LPN B without cleansing the scissors placed the scissors back in their uniform pocket. An observation conducted on 5-3-18 at 8:55 AM of wound care for Resident 26 by LPN B revealed that LPN B removed their gloves after removing the soiled dressing from Resident 26's leg, and without performing hand hygiene, applied clean gloves. LPN B cleansed the residents wounds and removed their gloves, and without performing hand hygiene, applied clean gloves. An interview conducted on 5-3-18 at 9:10 AM with LPN B confirmed that LPN B had put the scissors in their pocket without cleansing the scissors. LPN B confirmed they did not perform hand hygiene when changing gloves. An interview conducted on 5-3-18 at 2:45 PM with the Director of Nursing (DON) revealed that scissors used for resident's dressing changed were to be cleansed before and after use with disinfectant wipes according to the instructions on the wipe container. The DON reported that the staff were expected to wash their hands between glove changes. A review of the facility's policy Cleaning Resident Equipment and Supplies dated 2-15-08 revealed the following: Procedure: Nail Clippers and Scissors: 1. Nail Clippers and scissors will be cleaned after each use. 2. After each use, clippers/scissors will be cleaned with a disinfectant solution and stored in the appropriate area. A review of the facility's undated policy for Gloves: Non-sterile Application and Removal revealed the following: Procedure: 7. Dispose of gloves in proper container. 8. Wash hands.

Licensure Reference Number 175 NAC 12-006.11D Based on observation and interview, the facility failed to ensure that spices were dated and not expired. This had the potential to affect all but 1 resident that ate food served out of the facility kitchen. The facility census was 50. Findings are: Observation on 02/27/2017 at 8:33 AM revealed that the spices, present for use were not dated, or had an open date from 2014, and had expired. The spices included: Lemon Pepper, [MEDICATION NAME], Ginger, Chili Powder, Cumin, Thyme, Allspice, Celery Salt, Cloves, Cream of Tartar, Cayenne Pepper, Ground Mustard, and Nutmeg. Interview with the facility Dietary Manager confirmed that the spices were to be dated upon opening and were to be removed from use after 6 months. The Dietary Manager confirmed that the spices had not been dated upon opening, or had been dated with a date from the year 2014. The dietary manager confirmed that the spices would start to loose the flavor after 6 months.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on record review and interviews; the facility failed to develop a comprehensive care plan related to hospice care and services for 2 or 2 sampled residents (Resident 19 and 33), for behaviors for 1 of 5 sampled residents (Resident 49) and for skin breakdown for 1 of 1 sampled residents (Resident 17). The facility census was 50. Findings are: A. Review of resident 33's face sheet the resident admitted to the facility on [DATE]. An interview with Nurse Aide (NA) G on 3/1/17 at 7:30 am revealed Resident 33 was receiving hospice services for end of life care. Review of Resident 33's hospice admission and standing order sheet signed by the physician on 10-21-16 revealed Resident 33 had a terminal [DIAGNOSES REDACTED]. Review of Resident 33's Care Plan dated 11/1/16 revealed no Care Plan for the coordination of hospice care and end of life services. An interview conducted with the Director of Nursing (DON) on 03/01/2017 at 2:38 PM confirmed that Resident 33 was on hospice care and confirmed that there was no care plan for the coordination of hospice care and services and there should have been. Review of the facility Care PLans-Comprehensive Policy dated 5/2015 revealed: An individualized comprehensive care plan that includes meassurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 3. Each resident's comprehensive care plan is designed to: incorporate identified problem areas; reflect treatment goals, timetables and objectives in measurable outcomes, identify the professional services that are responsible for each element of care, and aid in preventing or reducing declines in the resident's functional status B. Review of Resident 17's face sheet revealed Resident 17 admitted to the facility on [DATE]. Review of a Skin Observation Assessment for Resident 17 dated 2-16-17 revealed Resident 17 had a Moist open area to the bottom of the left foot that measured 1 1/4cm (centimeters) x 1 1/4cm a dressing was applied, the physician was notified and Resident 17 was reminded not to file off bunions. An observation made on 3/1/17 at 9:12 am with Licensed Practical Nurse (LPN) E of Resident 17's left foot revealed an open area to the bottom of the left foot on the big toe, the area was noted to have a dark purple wound bed. LPN E revealed it was like dark dead tissue at the base and that Resident 17 has had many problems with (gender) feet. LPN E stated that Resident 17 will pick off bunions and leave open areas from time to time. Review of Resident 17's care plan with an intitiation date of 12-14-16 revealed no mention of the skin impairment to the bottom of the left foot nor that Resident 17 would pick off bunions and leave open areas. An interview with the Director of Nursing (DON) on 3.2.17 at 8 AM confirmed that Resident 17 did not have a care plan for the open area on the bottom of the left foot nor that Resident 17 would pick off bunions and leave open areas. The DON agreed this should have been care planned. C. Review of Resident 49's MDS dated [DATE] revealed Resident 49 had a [DIAGNOSES REDACTED]. Interview with Resident 49 on 2/27/2017 at 01:45 PM revealed Resident 49 had constant anxiety but did not like to take medication for it because of how it made Resident 49 feel. Interview with Medication Aide (MA) I on 03/01/2017 at 7:56 AM revealed that Resident 49 did have quite a bit of anxiety. When asked what could be done to alleviate Resident 49's anxiety, MA I stated they administered medication for that. Review of Resident 49's Care Plan revealed no problem or interventions to address Resident 49's complaint of ongoing anxiety. Interview with Registered Nurse (RN) B on 3/2/17 at 2:06 PM revealed that Resident 49 did not have care plan to address non pharmacological interventions for Resident 49's ongoing anxiety but that there probably should be. D. Record review of Resident 19's Face Sheet, dated 3/2/17, revealed that, Resident 19 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 19's Physician order [REDACTED]. Record review of Resident 19's Comprehensive Plan of Care revealed that Hospice was noted under the Nutritional focus. Record review failed to reveal a Comprehensive Plan of Care for the Hospice services that Resident 19 was recieving. Interview with Staff Member B confirmed that Resident 19's Comprehensive Plan of Care did not include Hospice involvement in Resident 19's care.

Licensure Reference Number: 175 NAC 12-006.17 Based on observation, interview and policy review; the facility failed to ensure the glucometer was sanitized between resident use for two residents (Residents 64 and 30) and failed to follow the recommended contact time for disinfecting the glucometer for one resident (Resident 78) which had the potential to affect five residents that shared the glucometers. The facility's census was 50. Findings are: A. Observation of Licensed Practical Nurse (LPN) E on 3/1/17 at 11:52 AM revealed LPN E removed the glucometer from the med cart, laid it directly on top of the med cart to gather supplies and took it into Resident 78's room laying the lactometer directly onto Resident 78's bedside table. LPN E proceeded to use the glucometer to test Resident 78's blood sugar and took the glucometer back out into the hall and placed it directly on top of the med cart. LPN E then used a Sani Cloth disposable wipe and cleansed all surfaces of the glucometer and laid it directly on top of the medication cart again. The glucometer was completely air dry within one minutes time. Interview with LPN E on 3/1/17 at 11:54 AM revealed the glucometer was used for more than one resident on that unit. B. Observation of LPN C on 3/1/17 at 4:35 PM revealed LPN C removed the glucometer from the medication cart and used a disposable Sani Cloth wipe to cleanse all surfaces of the glucometer. LPN C then laid down the glucometer directly on top of the medication cart, picked it up with in seconds and carried into Resident 30's room to test Resident 30's blood sugar. After completing the testing, LPN C carried the glucometer out of Resident 30's room and laid it directly onto the medication cart. LPN C did not sanitize the glucometer. C. Observation of LPN C on 3/1/17 at 4:46 PM revealed LPN C picked up the same glucometer machine and carried it into Resident 64's room to test Resident 64's blood sugar. LPN C laid down the glucometer directly onto Resident 64's bed side table before and after using it. Review of the instruction label on the Sani Wipe disposable cloths revealed, To disinfect thoroughly wet surface Allow treated surface to remain wet for a full two minutes Interview with LPN C on 3/1/17 at 4:50 PM revealed LPN C was unaware that the glucometer needed to remain wet for two minutes in order to be disinfected and further confirmed the glucometer was not sanitized after use on Resident 30 and before using it for Resident 64. Review of the facility's undated policy for the Blood Glucose Monitoring System revealed, 1. Assemble equipment. 2. Clean and Disinfect the meter with approved product. Allow to air dry for Recommended time. Review of an undated list provided by the Director of Nursing revealed their were five residents that used the glucometer machines used during the observations.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B3 Based on observations and interviews, the facility failed to ensure equipment and surfaces in resident rooms were cleanable for 3 of 7 resident rooms reviewed (Rooms 429-1, 514 and 505-1). The facility census was 50. Findings are: An environmental tour conducted on 3.2.17 at 8 am with the Administrator and the Maintenance Director revealed the following: - Room 429-1's bathroom had an adhesive bandage over the corner of the sink with a date on it of 9-3-16 that was visibly dirty and had an adhesive dressing to the bathroom door frame that was visibly dirty. -Room 514 revealed a bedside table that had the vinyl coating off in the corner exposing the under wood filler material revealing a non cleanable surface. -Room 505's bathroom revealed a grab bar on the wall next to the toilet that was wrapped in a blue bandage material that was visible dirty and had fuzz balls on it and was not a cleanable surface. Interview with the Maintenance Director on 3/2/17 at 8:30 AM confirmed that Room 429-1's bathroom had non cleanable surfaces and should not have had adhesive dressings stuck to the sink or door frame and that they were dirty. The Maintenance Director also confirmed that the bed side table in room 514 was not cleanable and needed replaced and that room 505's grab bar in the bathroom was wrapped in a bandage that was not cleanable and dirty and should not have been there.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B Based on record review and interviews, the facility failed to ensure the the MDS(Minimum Data Set- A federally mandated comprehensive assessment) was coded to reflect a terminal illness for 2 of 2 sampled residents (Residents 19 and 33). The facility census was 50. Findings are: A. Review of resident 33's face sheet the resident admitted to the facility on [DATE]. An interview with Nurse Aide (NA) G on 3/1/17 at 7:30 am revealed Resident 33 was receiving hospice services for end of life care. Review of Resident 33's hospice admission and standing order sheet signed by the physician on 10-21-16 revealed Resident 33 had a terminal [DIAGNOSES REDACTED]. Review of Resident 33's MDS dated [DATE] section J1400 Prognosis was marked that Resident 33 did not have a terminal condition. An interview conducted with the Director of Nursing (DON) on 03/01/2017 at 2:38 PM confirmed that Resident 33 was on hospice and had a terminal condition that should have been marked on the MDS. An interview conducted with the MDS Nurse B on 03/01/2017 at 3:50 PM revealed that Resident 33's MDS did not get marked for a terminal condition and thought it was maybe because MDS B didn't have the terminal illness paperwork at that time. MDS Nurse B agreed that the paperwork should have then been obtained and it should have been marked that Resident 33 had a terminal illness. B. Record review of Resident 19's Face sheet, dated 3/2/17, revealed that, Resident 19 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 19's Physician order [REDACTED]. Record review of Resident 19's Comprehensive Plan of Care dated 1/17/17 revealed that Resident 19 had a potential for alteration in nutritional status related to inconsistent meal intakes. Resident will consume food and fluid to comfort per Hospice Status. Record review of Resident 19's MDS dated [DATE] revealed that J1400 (Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months) was answered, No. Section O K (Hospice Care) was marked , confirming that the facility was aware that the resident was being provided Hospice. Interview with Staff Member B, on 3/1/17 at 3:50 PM confirmed that Resident 19 did have Hospice services. Staff Member B confirmed that the MDS did not have J1400 marked although the physician order [REDACTED]. Staff Member B confirmed that if a resident was receiving Hospice Services that the life expectancy was less than 6 months and that the Resident 19 did have a Terminal Diagnosis.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2 Based on observation, record review and interviews, the facility failed to monitor and ensure interventions were in place to promote healing for non-pressure skin breakdown for 1 of 2 residents reviewed (Resident 17). The facility census was 50. Findings are: Review of Resident 17's face sheet revealed Resident 17 admitted to the facility on [DATE]. Review of a Weekly Skin Observation Assessment for Resident 17 dated 2-16-17 revealed Resident 17 had a Moist open area to the bottom of the left foot that measured 1 1/4 cm (centimeters) x 1 1/4 cm a dressing was applied, the physician was notified and Resident 17 was reminded not to file off bunions. No further Weekly Skin Observation Assessments for Resident 17 were found upon record review conducted on 3/1/17. Review of Resident 17's Progress Notes dated 2/16/17 at 3:54 PM revealed that Resident 17 had an open area to the bottom of the left foot and Resident 17 was reminded not to file bunions off. Review of Resident 17's Progress Notes dated 2/21/17 at 2:37 PM revealed Resident 17 had a left foot bunion callous that was open with old yellow drainage and Resident 17 was reminded not to pick at it. The area was cleansed and clean gauze applied. Review of Resident 17's treatment sheets for February and March 2017 revealed no scheduled or as needed treatments to the Resident 17's foot. Review of Resident 17's care plan with an initiation date of 12-14-16 revealed no mention of the skin impairment to the bottom of the left foot nor that Resident 17 would pick off bunions and leave open areas and no interventions to protect Resident 17's skin. An observation made on 3/1/17 at 9:12 am with Licensed Practical Nurse (LPN) E of Resident 17's left foot revealed an open area to the bottom of the left foot on the big toe, the area was noted to have a dark purple wound bed. LPN E revealed it was like dark dead tissue at the base and that Resident 17 has had many problems with (gender) feet. LPN E stated that Resident 17 will pick off bunions and leave open areas from time to time. LPN E revealed there currently was no treatment staff are doing to the area and reported no interventions to protect the area and assist in healing. Resident 17 stated that Resident 17 has a lotion that the resident will put on the foot from time to time. An observation made on 3/1/17 at 10 AM with the Wound Nurse of Resident 17's left foot revealed the open area on the big toe. The wound nurse stated that it did not look like the wound bed was dark from dried blood. The Wound Nurse revealed that (gender) was not sure if the physician had been notified or not of the open area and confirmed there were no treatments being done to it. The Wound Nurse revealed that Resident 17 has had many problems with (gender) feet with bunions, poor circulation and vascular problems and picking off scabs and calluses. The Wound Nurse revealed that there should be weekly skin assessments completed on the residents An interview conducted on 3/1/17 at 11:07 AM with the Wound Nurse, revealed that Resident 17's doctor did not get notified that there was an open area to the bottom of Resident 17's left foot as areas open and close a lot her Resident 17's feet and the doctor should already know that about the resident. An interview conducted with Registered Nurse (RN) L on 03/02/2017 at 9:48 AM revealed that anytime an open area is discovered on a resident the physician is to be notified and a treatment is to be ordered. An interview conducted on 03/02/2017 at 9:10 AM with the Corporate Compliance nurse. When asked if staff should have notified the physician and gotten treatment orders for Resident 17's open area to the left foot the Corporate Compliance nurse nodded head yes and said there should have been interventions in place to promote the healing of the skin breakdown and that skin assessments were to have been completed weekly with measurements and descriptions of any open area for monitoring. Review of the facility policy for Wound Care: Prevention, Assessment, Treatment and Documentation dated 3/2015 stated: -The Ambassador will maintain a program that provides prevention, assessment, treatment and documentation for all wounds. -When a wound is identified, the nurse must notify the physician and an order for [REDACTED].>-Assessment of wound will be completed weekly and as needed, documentation will include: date of onset, location of impairment, size, exudate type, description of peri-wound skin, assessment of pain related to the wound or treatment.

Licensure Reference Number: 175 NAC 12-006.09D7b Based on observation, interview and record review; the facility failed to evaluate and implement fall interventions for 1 of 3 residents reviewed (Resident 55) and failed to evaluate and implement interventions for the safe use of a call bell for 1 of 1 resident reviewed (Resident 20). The facility had a census of 50. Findings are: A. Review of Resident 55's MDS (The Long-Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and/or Medicaid-certified long-term care facility.) dated 10/20/16 revealed Resident 55 had moderate cognitive impairment, required extensive assistance for transfers and had 2 or more falls with out injury since the previous assessment. Review of Resident 55's Care Plan dated 10/27/16 revealed Resident 55 had a potential for falls related to a forgetfulness, poor balance and a history of falls. Interventions to be in place to prevent falls included having a sensor alarm to the bed and the chair to alert staff to when Resident 55 was attempting to get up independently. Staff were also to make sure the alarms were on and working properly before leaving Resident 55's room. Review of Resident 55's Event Reports revealed, 1/5/17 Found on floor beside bed. States was trying to get to bed. Didn't' have gripper socks on. 2/6/17 Slid out of the wheelchair onto the floor. 2/7/17 Resident was agitated regarding the alarms, ripping them apart and refusing staff to put alarms in place. 2/8/17 Staff found an alarm pad that had been cut 2/19/17 Resident was attempting to self transfer from wheelchair to recliner and landed on buttocks. Resident was admitted to the hospital for hip fracture. Resident refuses to call for help at times and dismantles and throws chair alarms away. Review of the facility's internal investigation dated 2/19/17 of Resident 55's fall with resulting hip fracture on 2/19/17 revealed an undated handwritten witness statement from Nursing Assistant (NA) F that there were no alarms sounding at the time NA F entered Resident 55's room and found Resident 55 had fallen. Observation of Resident 55 on 02/28/2017 at 1:16 PM revealed Resident 55 laying down in bed. A sensor pad was noted to be in place to Resident 55's bed but did not appear to be activated. The screw to the back of the bed alarm was missing and the battery cover was not securely in place. Resident 55 moved around in the bed but no alarm sounded and Resident 55 reported the alarm on the bed had not been sounding during the day. Observation on 2/28/17 at 2:07 PM of NA G and NA H assisting Resident 55 from the bed to the bathroom revealed no alarm sounded when Resident 55 was being assisted out of the bed. Observation the next morning on 3/1/17 at 8:17 AM revealed NA I and NA J assist Resident 55 from the bed to the chair and no alarm sounded. Interview with NA I on 3/1/17 at 8:20 AM revealed the bed alarm should have sounded and that it appeared to not be working. NA I then removed the alarm and stated a new alarm was needed. Interview with the Corporate Clinical Nurse on 03/02/2017 at 1:49 PM revealed the aides should check the alarms at least once a shift to ensure they are functioning. B. Record review of Resident 20's Face Sheet, dated 3/2/17, revealed that, Resident 20 was admitted on [DATE] to the facility. The face sheet revealed that Resident 20's [DIAGNOSES REDACTED]. A record review of Resident 20's MDS (The Long-Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and/or Medicaid-certified long-term care facility.) dated 12/29/16, revealed a BIMS (A brief interview for mental status) score of 00, which revealed that Resident 20 was severely cognitively impaired. Section G of the MDS revealed that Resident 20 required extensive assist of two persons to physically assist, for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture), to transfer (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position), and to toilet. The MDS revealed that Resident 20 does not walk. A record review, of Resident 20's Physician Order, dated 11/25/16, revealed that, the call light was to be kept out of reach of Resident 20 related to safety concerns. A record review, of Resident 20's Comprehensive Plan of Care, dated 11/25/16 revealed that staff were to anticipate the needs of and to check on, Resident 20, every two hours, and to ensure that the needs were met, with special instructions, to keep the call light out of reach, for safety reasons, on every shift. A observation of Resident 20 on 2/28/17 at 2:17 PM, Resident 20 was in a recliner chair with the call bell present and with in reach. A observation of Resident 20 on 3/2/17 at 11:16 AM, Resident 20 was in a recliner chair with the call bell draped over the tray table beside the resident and with in reach. An interview with Licensed Practical Nurse (LPN) D revealed that the call bell was removed from Resident 20's reach when it had been found near or around her neck. LPN D was not the nurse who had witnessed this occur. An interview with Staff Member B, on 3/2/17 at 10:52 AM, revealed that, the Comprehensive Care Plan of the call light to be kept out of reach of Resident 20 had been based on LPN D informing Staff Member B that this had been care planned in the past and should have been added to present care plan. An interview with the Director of Nursing (DON), and the Nurse Consultant, on 3/2/17 at 10:52 AM , confirmed that there was no documentation, in Resident 20's medical record, to support that the call light was a safety risk. The DON and Nurse Consultant confirmed that there was a care plan and physician order [REDACTED]. The DON and Nurse Consultant confirmed that staff were to follow the plan of care, and physician orders, therefore Resident 20, was not to have the call light in reach. The DON and Nurse Consultant confirmed that another means, for Resident 20, to alert staff when assistance was needed, should have been provided.