Good Samaritan Society - Atkinson

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(l)(i)(3) Based on record review and interview; the facility failed to revise current fall interventions and/or develop new interventions to prevent ongoing falls for Resident 6. The sample size was 6 and the facility census was 28.Findings are: A. Review of the Fall Prevention and Management policy with revised/reviewed date of 10/14/25 revealed the purpose of the policy was to promote resident well- being by developing and implementing a fall prevention and management program, identifying risk factors, and implementing interventions before a fall occurs. If a resident fall occurs, the following procedure was identified:-assess the resident and perform a full body examination.-notify the Primary Care Physician (PCP) and the resident's representative.-complete a Fall Scene Huddle Worksheet to determine causal factors and fall interventions.-document the incident in the Safe Event-Incident Report. B. Review of Resident 6's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 11/26/25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(J)(i)(1)Based on record review and interview; the facility failed to implement nutritional interventions to address a weight loss for 1 (Resident 28) of 2 sampled residents. The facility census was 28.Findings are:A. Review of the Weight and Height Policy with a reviewed/revised date of 9/30/25 revealed the purpose of the policy was to ensure residents maintained an acceptable parameter of nutritional status, accurately measure weights and monitored weight loss or gain in residents. The facility was to inform the resident, the resident's representative, the Primary Care Physician (PCP), and the Registered Dietician (RD) when there was a significant change in the resident's weight. The policy further indicated if a weight varied by more than 3 percent (%) staff were to reweigh the resident. B. Review of Resident 28's Minimum Data Set (MDS, federally mandated comprehensive assessment tool used to develop resident care plans) dated 10/22/25 revealed diagnoses of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on record reviews and interviews; the facility failed to notify Resident 1's practitioner of the residents increased lethargy, decreased appetite, lowered blood glucose levels and staff failure to administer insulin; and Resident 3 and 4's practitioner and/or responsible parties of ongoing falls. The sample size was 5 and the facility census was 33. A. Review of the facility policy Notification of Change with a revision date of 12/23/2024 revealed the purpose of the policy was to identify when regulation required notifications to occur. The policy further revealed the facility must immediately inform the resident, the resident's physician and the resident representative when there was:-an accident involving the resident which resulted in an injury and had the potential for requiring physician intervention.-a significant change occurred in the resident's physical, mental or psychosocial status.-there was a need to alter treatment significantly, a need to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to report an injury of unknown origin and to submit an investigation to the State Agency within 5 working days for 1 (Resident 3) of 5 sampled residents. The facility identified a census of 31. Findings are: A. Review of the facility Abuse and Neglect Policy with a reviewed/revised date of 4/7/25 revealed the policy of the facility was to ensure all alleged or suspected violations involving any mistreatment. neglect, exploitation or abuse, including injuries of unknown origin were to be reported immediately to the Administrator or a delegated individual. The purpose of the policy was to: -ensure employees were knowledgeable regarding reporting and investigating the process of abuse and neglect allegations in the facility. -ensure the facility had an effective system in place that, regardless of the source, prevented mistreatment, neglect, exploitation, and abuse of residents and misappropriation of their property. -ensure residents were not subjected to abuse by anyone including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to thoroughly investigate allegations of potential abuse for Residents 1 and 2 and to report an allegation of potential abuse for Resident 2 within the required timeframe. The sample size was 5 and the facility census was 31. Findings are: A. Review of the facility Abuse and Neglect Policy with a reviewed/revised date of 4/7/25 revealed the policy of the facility was to ensure all alleged or suspected violations involving any mistreatment. neglect, exploitation or abuse, including injuries of unknown origin were to be reported immediately to the Administrator or a delegated individual. The purpose of the policy was to: -ensure employees were knowledgeable regarding reporting and investigating the process of abuse and neglect allegations in the facility. -ensure the facility had an effective system in place that, regardless of the source, prevented mistreatment, neglect, exploitation, and abuse of residents and misappropriation of their property. -ensure residents were not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY C. Review of Resident 16's MDS dated [DATE] revealed the resident was cognitively impaired, had Diabetes, had a dementia diagnosis, and received substantial assistance with bathing. Review of Resident 16's Care Plan with a revision date of 12/27/24 revealed the resident had impaired cognitive function and confusion, self-care deficits and requested one bath weekly and needed staff assistance to bathe. Review of Resident 16's Bathing Records from December 1st, 2024, through January 15th, 2025, revealed the following: -Bathing occurred on the following days in December 2024: December 4th, 11th, and 18th. -Bathing occurred on the following days in January 2025: No documented baths as of January 2025. -There was no evidence of bathing from December 18th, 2024, and January 15th, 2025 (28 days). During an interview on 1/15/25 at 10:15 AM RN-G confirmed Resident 16 was not receiving baths at least weekly as care planned. D. Review of Resident 3's MDS dated [DATE] revealed the resident had severe cognitive impairment,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(H) Based on observation, record review and interview; the facility failed to meet the Activities of Daily Living (ADL) needs for Resident 20 and the bathing needs for Resident's 3, 11, 16 and 24. The sample size was 20 with a census of 31. Findings are: A. Review of Resident 20's Minimum Data Set (MDS-federally mandated comprehensive assessment use to develop resident care plans) dated 12/12/24 revealed the resident received substantial to maximal assistance with toileting cares and transfers and was frequently incontinent of bowel and bladder. The resident had a diagnosis of non-traumatic brain dysfunction, Alzheimer's Dementia with short- and long-term memory loss with severely impaired decision-making skills. Review of Resident 20's Care Plan with a revision date of 11/27/24 revealed the resident required extensive assist to use the toilet, was dependent on staff for perineal hygiene and required extensive assist with transfers. The resident did not recognize the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09D7 Based on record review and interviews; the facility failed to develop new interventions and/or revise current interventions to prevent ongoing falls for Residents 182 and 26. The sample size was 4 and the facility census was 31. Findings are: A. Review of the Fall Prevention and Management Policy with a revision date of 7/29/24 revealed the purpose of the policy was to promote the resident's well-being by developing and implementing an individualized fall prevention and management program. Staff were to identify risk factors and implement interventions before a fall occurred. The following procedure was identified: -observe the fall scene. -determine if there may be a suspected injury. -if the fall was not witnessed then staff are to complete neurological checks per policy. -review the resident's current interventions to determine if a revision is needed or new interventions developed. -if any teaching is done as an intervention, then to document in the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.09(J)(i)(1) Based on record review and interviews; the facility failed to revise nutritional interventions and/or develop new interventions to address ongoing weight loss for 1 (Resident 14) of 2 sampled residents. The facility census was 31. Findings are: A. Review of the facility policy Weight and Height with a revision date of 10/15/2024 revealed the following regarding weighing the residents and monitoring weight loss. The policy indicated the purpose of weighing the resident was to: -ensure the resident maintained acceptable parameters of nutritional status regarding weight. -report a significant weight change to the physician, family, and resident. -monitor weight loss in a resident. The policy indicated residents at nutritional risk were to be weighed weekly and the facility was to immediately inform the resident, consult with the resident's physician and notify the resident's legal representative when there was a significant change in the residents' weight. The following procedure was identified for weighing the resident: -weigh the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.09(A) Based on record review and interview; the facility failed to ensure a documented rationale for the use of an anti-depressant for Resident 4. The sample size was 5 and the facility census was 31. Findings are: Review of the facility policy Psychotropic Medications with a revision date of 12/30/24 revealed the following: -the resident would be free from any chemical restraint imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms, -each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose or duration, without adequate monitoring or without adequate indications for use, in the presence of adverse consequences that indicated the dose should be reduced or discontinued, or any of the above combination of the reasons above, -after reviewing the mood and behavior documentation, the behavior committee and/or care plan team determines psychotropic medications may be necessary, the reduction team would be notified, -Gradual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.17 Based on observation, record review, and interview, the facility failed to implement hand hygiene at appropriate intervals and utilize Personal Protective Equipment (PPE) in a manner to prevent the potential spread of infection for Resident 15. The sample size was 16 and the facility census was 31. Findings are: A. Review of the facility policy Standard and Transmission-Based Precautions, last revised 4/2/24 revealed: -Enhanced Barrier Precautions (EBP) expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated ad refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing, -EBP is needed for resident with chronic wounds, and residents with indwelling medical devices (catheters, indwelling urinary catheters), -EBP are intended for the duration of the resident's stay, -EBP's are also needed for residents with CDC-targeted and MDRO infections and colonization's, -High-Contact Care Activities included:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.18(A) Based on record review and interview; the facility failed to offer Resident 16 the recommended Pneumococcal vaccines in accordance with facility policy and Center for Disease Control (CDC) guidelines. The sample size was 5 and the facility census was 31. Findings are: Review of the facility policy Immunization/Vaccinations for Residents, Pneumococcal, Influenza, COVID-19, Other with a revision date of 9/21/23 revealed the facility provided residents the opportunity to receive immunizations as they fit into their healthcare goals. -Upon admission, each resident and/or their representative received Vaccination Information Statements for influenza and pneumococcal vaccines. -The facility reviewed immunization records for all residents each year and residents' vaccine eligibility was reviewed on an ongoing basis as immunization recommendations changed. -Each time eligibility was determined education, consent, and screening were provided prior to each vaccine given. -All Residents received pneumococcal vaccination per CDC guidelines. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.04 Based on observation, record review, and interview; the facility failed to have staff adequate to meet the bathing needs of residents, respond in a timely fashion to call lights and to meet the housekeeping needs of residents. The sample size was 6 and the facility census was 33. Findings are: A. Review of the facility bathing records from 8/1/24 through 9/24/24 for Residents 1,2,4, and 5 revealed the following: -Resident 4 was bathed on 9/15/25 (1 bath in 55 days) -Resident 2 was bathed on 8/5/24, 8/19/24, 9/2/24 and 9/16/24 (4 bathes in 55 days). -Resident 1 was bathed on 8/5/24, 8/8/24, 8/29/24, 9/2/24, 9/12/24, and 9/20/24 (6 baths in 55 days). -Resident 5 was bathed on 8/1/24, 8/7/24, 8/8/24, 8/20/24, 8/29/24, 9/3/24, 9/7/24, and 9/15/24 (8 baths in 55 days and resident desired 2 baths weekly per the resident's care plan). B. Review of the facility Staff Posting dated 9/25/24 revealed the facility had 2 Registered Nurses, 2 Nurse Aides, and 1 Bath Aide scheduled from 6:00 AM until 2:30 PM. During an interview on 9/25/24 at 1:30 PM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.19 Based on observation, record review and interview; the facility failed to maintain the cleanliness of the resident's rooms and bathrooms and to maintain a safe and odor free environment. This affected 12 (rooms 98, 99, 103, 104, 105, 106, 205, 300, 301, 305, 306 and 309) out of 33 resident rooms. The facility census was 33. Findings are: Review of the facility policy Housekeeping Resource Packet with a revision date of 8/30/24 revealed the following regarding cleaning of resident rooms and common areas: -clean surfaces as often as necessary to keep furniture and equipment free from dust, dirt, debris, or food particles. -develop a daily schedule for cleaning floors that includes more thorough cleaning on a routine basis. -damp wipe with neutral cleaner or mild disinfectant high touch areas such as handrails, and/or door handles on a frequent basis. -empty waste baskets daily or as needed and then clean and disinfect the inside of the containers as needed to prevent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(H) (i)(1) Based on interview and record review, the facility failed to provide bathing assistance for 4 (Residents 1, 2, 4, and 5) of 6 sampled residents who were dependent with bathing. The facility census was 33. Findings are: A. Review of the facility policy Bathing with a revision date of 9/3/24 revealed the facility promoted cleanliness and general hygiene to stimulate skin circulation, promote comfort, relaxation, and well-being, to observe the resident's condition, to assist the resident with personal care, and to promote safety for the resident in the bath. B. Review of Resident 4's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/4/24 revealed diagnoses of cerebral palsy, depression, and schizophrenia. The assessment further indicated the resident had severe cognitive impairment, functional limitation of range of motion to both sides of the resident's upper and lower extremities and was dependent for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(4) Based on observation, record review, and interview; the facility failed to ensure 1 (Resident 3) of 6 sampled residents call light was accessible. The facility census was 33. A. Review of the facility policy Call Light with a revision date of 7/29/24 revealed the facility ensured residents always had a method for calling for assistance and prompt answering of call lights. Review of Resident 3's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 9/16/24 revealed the resident was admitted to the facility on [DATE], was dependent for dressing, all hygiene, bathing, and transfers. The resident's urinary continence was not rated due to the presence of a catheter. Review of Resident 3's Care Plan with a revision date of 9/17/24 revealed the resident received Hospice services for a terminal diagnosis, was dependent for toileting and had an indwelling urinary catheter in place. During an observation on 9/25/24 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.04(F)(i) Based on record review and interview; the facility failed to ensure the resident's family or responsible party were notified of orders, appointments, and/or procedures for 1 (Resident 1) of 5 sampled residents. The facility census was 33. Findings are: Review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool used in care planning) dated 8/1/24 revealed the resident was cognitively intact; had diagnoses of diabetes, heart failure, anxiety, depression, and respiratory failure; and needed assistance with toileting, dressing, hygiene, bathing, and transfers. Review of Resident 1's Care Plan, last revised 7/31/24 revealed the resident required assistance with toileting, dressing, hygiene, bathing, and transfers. Review of Resident 1's Progress Notes revealed the following: -on 8/8/24 at 10:44 AM an entry revealed a fax was received with a new order to decrease the gabapentin (a medication used to treat nerve pain) to 300 milligrams (mg) 4 times per day. The facility was unable to reach the responsible party, on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(H)(iv)(1) Based on observation, record review and interview; the facility failed to ensure potential infection/complication with Resident 3's urinary catheter (tube used to drain urine from the bladder and collected in a sterile closed system drainage bag). The sample size was 3 and the facility census was 33. Findings are: Review of the facility policy Catheter: Care, Insertion and Removal, Drainage Bags, Irrigation, Specimen dated 7/30/24 revealed the following: -Catheter tubing and drainage bags were kept covered and out of sight, catheters were always properly secured, connected and maintained using a sterile closed drainage system. -Catheter tubing was secured to the resident's leg, coiled on the bed with no kinks or obstructions and kept in straight line to the urinary drainage bag. In addition, the tubing should never be allowed to touch the floor. Review of Resident 3's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.18 Based on record review and interview; the facility failed to implement an ongoing system for tracking antibiotic use to identify trends in infections for 1 (Resident 1) of 4 sampled residents. The facility census was 33. Findings are: Review of the facility policy Infection Prevention and Control Program, last revised 10/30/23 revealed the following: -the infection prevention and control program prevented, identified, reported, investigated, and controlled infections for all resident's, staff, and visitors, -the components of the infection prevention and control program included: program oversight, policies and procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infections, immunizations, and employee heath and safety, -the facility would establish a system for surveillance based on standards of practice, -the facilities surveillance system included a data collection tool and the use of a nationally recognized surveillance criteria to define infections, -resident infection surveillance would…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY D. Review of a facility investigation report dated 12/4/23 related to a fall incident for Resident 5 revealed the following: -12/3/23 at 5:45 AM, staff were assisting the resident to the bathroom. The resident stood from the toilet to transfer into the wheelchair, the resident's knee buckled, and staff then lowered the resident to the floor. -12/3/23 at 7:30 AM the resident complained of left knee pain and had increased swelling to the knee. -12/3/23 at 1:30 PM the resident continued to complaint of left lower leg pain and was unable to bear weight on the leg. -12/4/23 at 10:00 AM the resident's knee was swollen, and the resident was unable to bend the left knee. The physician was notified, and the resident was sent for an x-ray. The resident was admitted to the hospital with a fracture of the femur, fibula and the fifth toe of the left leg/foot. -the incident was reported to APS on 12/4/23 at 11:51 AM. There was no evidence the facility submitted a written investigation related to the fall with injury and a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09B Based on record review and interview; the facility failed to code the Minimum Data Set (MDS-federally mandated assessed used to develop resident care plans) to reflect the resident's status at the time of the assessment regarding nutritional approaches for Residents 10, 2, 84, and 16 and medication use for Resident 17. The sample size was 17 and the facility census was 33. Findings are: A. Review of Resident 10's MDS dated [DATE] revealed the following: -diagnoses of: anemia, high blood pressure, peripheral vascular disease, diabetes, anxiety, and respiratory failure. -received 25% or less of total calories through parental or tube feeding. -received 500 cubic centimeters (cc) or less of average fluid intake by Intravenous (IV) or tube feeding. -did not receive parental or IV feeding. B. Review of Resident 2's MDS dated [DATE] revealed the following: -diagnoses of: non-traumatic brain dysfunction, schizoaffective disorder, atrial fibrillation, high blood pressure,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09D Based on observations, record review and interviews; the facility failed to: 1) obtain orders for management of a blood glucose monitoring device and to ensure assessments and ongoing monitoring were completed for wound care and blood glucose levels for Resident 184; 2) reposition Resident 16 in accordance with the plan of care to prevent the potential for skin breakdown; and 3) follow physician orders regarding fluid restriction and weight monitoring for Resident 5. The sample size was 3 and the facility census was 33. Findings are: A. Review of Resident 5's Minimum Data Set (MDS-a comprehensive assessment tool used to develop a resident's care plan) dated 10/15/23 revealed diagnoses of anemia, coronary artery disease, end stage renal disease, diabetes, heart failure and anxiety. The resident was assessed as cognitively intact, the resident's weight was 223 pounds, and the resident was identified as taking a diuretic (medication used to reduce fluid buildup in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.05(21) Based on observation, interview and record review, the facility failed to ensure Resident 16's dignity was maintained by not putting pants on the resident when staff assisted [gender] to dress for the day. The sample size was 1 and the facility census was 33. Findings are: A. Review of the undated facility policy Resident's Rights For Skilled Nursing Facilities revealed residents have the right to a dignified existence and the facility must protect and promote the rights of each resident. Residents are to be treated with dignity and have the right to retain and use personal possessions, including furnishings, and clothing unless to do so would infringe upon the rights or health and safety of other residents. B. Review of Resident 16's Minimum Data Set (MDS- a federally mandated comprehensive assessment used for the development of resident care plans) dated 12/20/23 indicated the resident had diagnoses of: Cerebral Palsy, dementia, high blood pressure, weakened bladder control and depression. The MDS further indicated the resident had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-00605(8) Based on observations, record review and interview; the facility staff failed to evaluate the use of a seatbelt as a restraint for 1 (Resident 84) of 1 sampled resident. The facility staff identified a census of 33. Findings are: A. Review of the facility policy Restraints with a revision date of 12/5/23 revealed the purpose of the policy was to ensure the appropriate use and application of restraints and to prevent residents from self-injury or injury to others. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. If a device or equipment (defined as waist, arm, wrist, leg or ankle restraint, waist belt or a safety belt) cannot be easily removed by the resident then this is a restraint. B. Record review of Resident 84's Minimum Data Set (MDS-a federally mandated assessment tool used for care planning) dated 12/12/23 revealed diagnoses of: quadriplegia, diabetes, neurogenic bladder, anxiety, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09A Based on record review and interview; the facility failed to ensure a new PASRR (Pre-admission Screening and Resident Review- a tool used to ensure residents receive the care they require for mental illness) had been completed after a diagnosis of mental illness was identified for 2 (Residents 2 and 29) out of 2 reviewed for PASRR. The facility census was 33. Findings are: A. Review of the facility policy Pre-admission Screening and Resident Review with a revision date of 12/11/23 revealed the purpose of the policy was to ensure residents with retardation, serious mental disorder or intellectual disability received the care and services they required in the most appropriate setting. During a residents stay, if the resident is diagnosed with a mental disorder the designated state agency will be contacted for a Level II screening. B. Review of Resident 2's admission PASRR completed on 11/5/21 at 12:25 PM revealed the resident was evaluated as a level I. The rationale…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09D2b Based on record review and interview; the facility failed to provide assessment and monitoring of a pressure ulcer to ensure healing for Resident 84. The sample size was 1 and the census was 33. Findings are: A. Review of a Wound and Pressure Ulcer Management policy dated 5/29/23 revealed the purpose of the policy was to provide consistent standards of practice in wound care management. This was to ensure the promotion of healing, pain management and prevention of complications, accurate assessment, and documentation. If a pressure ulcer was present, staff were to assess/evaluate the wound weekly. Observations of the ulcer's characteristics were to be documented by the licensed nurse and should include the following: -measurements (width, length, and depth). -characteristics including wound bed, undermining (separation of the wound edges from the surrounding (opening beneath the surface of the skin) health tissue creating a pocket under the wound surface) and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.04 Based on record review and interviews, the facility failed to ensure sufficient direct care nursing staff were available to answer call lights in a timely manner for Resident 26. The sample size was 17 and the facility census was 33. Findings are: A. Review of Resident 26's Minimum Data Set (MDS- a federally mandated comprehensive assessment used to develop the resident's plan of care) dated 12/11/23 revealed: -The resident was admitted on [DATE] and had diagnoses of: anemia, heart failure, high blood pressure, pneumonia, diabetes, high cholesterol, and lung disease. -Resident had mild cognitive impairment and required substantial assistance with bed mobility, transfers, toileting, personal hygiene and dressing. During an interview with Resident 26 on 01/03/24 at 11:40 AM, the resident indicated [gender] call light had not been answered for approximately 30-45 minutes at times and there was no specific day or time of day this occurred. In addition, the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference 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 long term use of an antibiotic medication for Resident 10. The antibiotic did not specify a duration and had no supporting documentation for clinical use based on laboratory results. The sample size was 1 and the facility census was 33. Findings are: A. Review of the facility policy Antibiotic Stewardship Program with a review date 12/15/22 revealed the following: -The purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. -The Infection Control Preventionist oversees the program, and the Medical Director serves as a liaison between the facility and other medical staff members. The Consultant Pharmacist reviews antibiotics prescribed to residents during their medication regimen review and is a resource for questions. The Attending Physician prescribes appropriate antibiotics in accordance with standards of practice and facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to ensure 1 (Resident 16) of 5 sampled residents were free from unnecessary psychotropic (a type of psychoactive medication which alters chemicals in the brain to affect changes in behavior, mood and emotion) medications related to 1) as needed anti-psychotic and anti-anxiety medications without a specified duration, 2) no evidence of ongoing evaluations completed by the physician, and 3) a diagnosis not indicated for an anti-psychotic medication. The facility census was 33. Findings are: A. Review of the facility policy Psychotropic Medications dated 12/6/23 revealed the following: - The purpose is to evaluate behavior interventions and alternatives before using psychotropic medications and eliminate unnecessary psychotropic medications. - An unnecessary drug is any drug when used; in excessive dose including duplicate drug therapy, for excessive durations, without adequate monitoring, without adequate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.17B Based on observation, record review and interview; the facility failed to implement transmission-based precautions to prevent the potential for cross contamination as staff failed to initiate contact precautions for Resident 84 when the resident returned from the hospital with a diagnosis of Methicillin Resistant Staphylococcus Aureus (MRSA-a type of staph infection which is difficult to treat due to resistance to many antibiotics). The total sample size was 17 and the facility census was 33. The findings are: A. Review of the facility policy Standard and Transmission Based Precautions with a reviewed/revised date of 12/7/23 revealed the purpose of the policy was to explain the use of transmission-based precautions and to assist staff with determining the appropriate type and duration of precautions for residents. The policy further revealed Contact Precautions were to be used in addition to Standard Precautions for residents with known or suspected infections with an increased risk for contact transmission. Staff entering a resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.