Good Shepherd Lutheran Home

Licensure Reference Number 175 NAC 12-006.11 E The facility failed to ensure hand hygiene and gloving were performed in a manner to prevent the potential for food borne illness and failed to maintain the cleanliness and condition of shelving units, serving windows, equipment, floors, ventilation systems, and storage carts in the facility kitchen. This had the potential to affect 66 residents in the facility that ate foods prepared in the facility kitchen. The facility census was 66. Findings are: A. Record review of a facility policy entitled Hand Washing dated 3/19/2020 revealed the following: Hand hygiene will be performed for a minimum of 20 seconds. Procedures: Guidelines on when to perform hand hygiene may include - before preparing or handling food. - - after removing personal protective equipment ( gloves) Perform hand hygiene as follows: a. If using soap and water, turn on faucet, holding fingertips downward to prevent water from running down the arm. Apply soap and work into a lather. b. Rub all surfaces of the hands for at least 20 seconds. c. i. Rinse hands under running…

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 12.006.18(B) Based on record review observation, and interview, the facility staff failed to implement measures to prevent the potential contamination of resident supplies that affect all residents in the facility, the facility staff failed to change oxygen tubing per practitioner's order for Resident 26, and the facility failed to follow enhanced barrier precautions for Resident 50. The facility identified a census of 66. Findings are: A. A record review of a facility provided policy titled Storage Areas, Maintenance, dated December 2009 revealed, all storage areas must be kept free from accumulation of trash, rubbish, oily rags, paper, etc., at all times. Record review of a receipt of payment to dated 5/8/2024 to a roofing company for the amount of $4000.00 related to work that applied a patch to the roof. A record review on 4/30/2025 revealed a facility provided email dated May 10, 2024, indicating the management company was aware of the functional damage the campus…

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 12-006.19A Based on record review, observation and interview, the facility failed to repair leaks in the facility's roof. This had the potential to affect all residents that resided in the facility. The Facility identified a census of 66. Findings are: A record review of a facility policy titled Storage Areas, Maintenance, dated December 2009 revealed, all storage areas must be kept free from accumulation of trash, rubbish, oily rags, paper, etc., at all times. A record review on 4/30/2025 of an email dated May 10, 2024 revealed the management company was aware of the functional damage the campus sustained. Record review of a receipt of payment to dated 5/8/2024 to a roofing company for the amount of $4000.00 related to work that applied a patch to the roof. An observation on 4/30/25 8:45 AM with the Administrator (ADM) revealed the office in the therapy gym had discolored water like stained ceiling tiles that are brown with black in the center, and the therapy gym above a TV that has portions of plaster substance missing with brick exposed behind…

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 12-007.04 D Based on observation, record review and interview; the facility failed to ensure a working ventilation system in 20 (302, 303, 304, 305, 306, 307, 308, 310, 311, 400, 401, 402, 404, 405, 406, 407, 408, 409, 410, 411) of 28 occupied resident rooms on the 300 and 400 halls in the facility. The total number of occupied resident rooms in the facility was 52. The facility census was 66. Findings are: Observations of the facility environment on 05/01/25 between 8:30 AM and 9:15 AM with the facility Maintenance Director [MD] revealed that the ventilation system in resident bathrooms in rooms 302, 303, 304, 305, 306, 307, 308, 310, 311, 400, 401, 402, 404, 405, 406, 407, 408, 409, 410, 411 did not draw a 1 ply square of tissue to the surface of the ventilation covers in resident bathrooms. The fact that the tissue square was not drawn to the cover indicated that the system was non-operational at the time of the observation. Interview on 05/01/25 at 09:15 AM with the MD confirmed the ventilation system did not draw in bathrooms on the 300 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.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on record reviews and interviews; the facility failed to notify the medical practitioner and family of 1 (Resident 52) of 5 residents sampled for refusal to take medications. The facility census was 66. Findings are: Record review of Resident 52's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 03/28/2025 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 99. The MDS manual identified a score of 99 as resident was unable to complete the interview. Record review of Resident 52's Order Summary dated 4/29/2025 revealed the following medications were prescribed by the practitioner: -Acetamin tab 325 milligrams (mg) twice daily for pain -Aspirin 81 mg for heart health -Atorvastatin 80 mg for hyperlipidemia (an elevated level of lipids - like cholesterol and triglycerides in your blood) -Carvedilol 10 mg extended…

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(G) Based on record reviews and interview; the facility failed to ensure a rationale was documented for the continued use of PRN (as needed) antianxiety medication for 1 (Resident 42) of 5 sampled residents. The facility staff identified a census of 66. The findings are: A record review of a facility policy entitled Documentation and Communication of Consultant Pharmacist Recommendations dated revised August 2024 revealed: -D. Psychotropic PRN (as-needed) medication order (excluding antipsychotics): Order for PRN psychotropic medication will be time limited (i.e., 14 days) and only for specific clearly documented circumstances. -a. Order may be extended beyond 14 days if the attending physician or prescribing practitioner: -b. Believes it is appropriate to extend the order -and -c. Documents clinical rationale for the extension -and -d. Provides a specific duration of use. -e. Rationale should include effectiveness, ongoing specific diagnosed conditions, indication, and duration. A record review of Resident 42's admission Record identified…

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(8) Based on record review and interview; the facility failed to report an allegation of resident-to-resident abuse within the required timeframe to Adult Protective Services (APS) for 1 (Resident 119) of 4 facility self-report investigations reviewed. The facility census was 66. Findings are: Record review of an undated facility policy entitled Abuse and Neglect Reporting revealed the following information: All staff members, residents, visitors are required to immediately report any incidents or suspected incidents of resident mistreatment, abuse, or neglect, exploitation, including injuries of unknown source and misappropriation of properties. Procedure: 1. Any alleged violations involving abuse or negligence neglect including injuries of an unknown source and misappropriation of resident property must be reported. 3. Staff members aware of an incident or suspected incident of abuse or neglect must immediately report knowledge of such incidents to the charge nurse, department head or administration. 5. The staff person receiving 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 12-006.05 Based on record review and interview; the facility failed to notify the resident and resident representative in writing of the reason for hospital transfer for 1 (Resident 20) of 1 sampled resident. The facility staff identified a census of 66. The findings are: A record review of a facility policy entitled Bed-hold Agreement dated Revised 05/2023 revealed: -2. When an emergency transfer is necessary (e.g. ER transfer), the facility will provide the resident or his/her representative with a copy of the bed-hold agreement at the time of transfer. -3. A copy of the bed-hold agreement will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all of the following: -a. The specific reason and basis for the transfer or discharge. A record review of Resident 20's admission Record revealed the facility admitted the resident on 09/29/2023. Further review of Resident 20's admission Record…

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(F)(ii) Based on record review and interview; the facility failed to develop a comprehensive care plan within 7 days of the completion of the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) for 1 (Resident 219) of 21 sampled residents. The facility staff identified a census of 66. The findings are: A record review of a facility policy entitled Care Plans, Comprehensive Person-Centered dated 2001 revealed: -The comprehensive, person-centered care plan is developed within seven days of the completion of the required MDS assessment (Admission, annual or sig change) and no more than 21 days after admission. A record review of Resident 219's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 06/05/2024 identified the facility admitted the resident on 05/29/2024…

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 12-006.10(D) Based on observation, interview, and record review; the facility failed to ensure a medication error rate of less than 5%. Observation of 25 medications administered revealed two errors resulting in a medication error rate of 8%. The medication errors affected 2 (Resident 39 and Resident 42) of 4 sampled residents. The facility staff identified a census of 66. The findings are: A. Record review of Resident 39's Medication Administration Record (MAR) printed on 04/30/2025 revealed the following medications to be administered at 7:00 AM: -insulin lispro (a rapid-acting insulin) inject 5 units -insulin lispro inject per sliding scale -Omeprazole 40 milligrams (mg) An observation on 04/30/2025 at 6:55 AM of Registered Nurse (RN)-Y administering medication for Resident 39 revealed the RN-Y obtained Resident 39's blood sugar reading of 107 from a continuous glucose monitor and determined that sliding scale insulin was not required. RN-Y administered the oral medication with water. At 7:01 AM RN-Y injected 5 units of insulin lispro…

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 12-006.10(D) Based on observation, interview, and record review; the facility failed to ensure residents were free of significant medication errors. This affected 1 (Resident 45) of 4 sampled residents. The findings are: A record review of a facility policy entitled Medication Administration - Insulin dated 06/22/2014 revealed: -Rapid-acting insulin (e.g., Novolog, Humalog) Onset 10-15 minutes, Peak 0.5-3 hours, Duration 3-6 hours. -Important Points: -RAPID-ACTING insulin (or a rapid-acting insulin mixed with either an intermediate or long-acting insulin) would be injected immediately prior to a meal, or administered concurrent with food such as graham crackers. A record review of Resident 39's Medication Administration Record (MAR) printed 04/30/2025 revealed the resident was to receive 5 units insulin lispro (a rapid-acting insulin used to aid blood sugar control) before meals. An observation on 04/30/2025 at 7:01 AM revealed that Registered Nurse (RN)-Y injected 5 units of insulin lispro into the right upper arm after oral medications were…

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.

Based on record review and interview; the facility failed to ensure that the designated infection preventionist was certified. This had the ability to affect all residents in the facility. The facility claimed a census of 70. Findings are: A record review of the facility Infection Control Program dated 7/2019 and revised on 10/11/2019 and 3/26/2020 revealed the following: Paragraph 2. A nurse (RN - Registered Nurse or LPN - Licensed Practical Nurse) will be designated as the facility Infection Preventionist and will complete required training related to the role of an Infection Preventionist. An interview on 04/22/2024 at 1:32PM with the designated Infection Preventionist (IP) revealed they are not currently a certified Infection Preventionist but expect to complete the required IP certification in May of 2024. An interview on 04/22/2024 at 3:34PM with the Facility Administrator confirmed the facility does not have a certified Infection Preventionist at this time but the designated IP is expected to be certified by May 2024.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.17B Based on observation, interview and record review; the facility failed to position a catheter bag in a manner to prevent the potential for cross contamination for 1 (Resident 20) of 2 residents observed with urinary catheters. The facility census was 70. Findings are: Record review of a facility policy entitled Catheter Care - Suprapubic [suprapubic catheter: a hollow flexible tube that drains urine from the bladder. It is inserted into the bladder through a cut in the stomach just below the navel] dated [DATE] revealed the following information: Residents with Suprapubic catheters will have routine catheter care performed in a manner to minimize the opportunities for infection. Policy Interpretation and implementation: Check the following items: Catheter bag is not laying on the floor. Record review of Resident 20's Clinical Census report revealed that Resident 20 was admitted [DATE]. Resident 20's Diagnoses report identified that Resident 20 had diagnoses that…

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: 175 NAC 12-006.04C3a(6). Based on record review and interview, the facility failed to notify responsible party of weight loss for 1 [Resident 3] of 3 sampled residents. The facility had a total census of 69 residents. Findings are: A review of Resident 3's admission Record revealed Resident 3 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. A review of Resident 3's 3/21/2024 annual MDS [Minimum Data Set; a comprehensive assessment used for care planning] assessment revealed a BIMS [Brief Interview for Mental Status is used to get a quick snapshot of how well you are functioning cognitively at the moment] was not completed. Resident 3 was identified as having short-term and long-term memory problems. Resident 3 was identified as having a weight loss of 5% or more in the last month or a loss of 10% or more in last 6 months. A review of Registered Dietitian annual assessment of Resident 3 dated 3/19/24 revealed the following: -Height 63 inches, weight 116.5 lbs.…

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.

175 NAC 12-006.04A3 Based on record review and interviews, the facility failed to ensure the required Background and Registry checks were performed prior to employees beginning to work independently in the facility. This affected 4 of 5 employees sampled for Background and Registry checks and had the potential to affect all residents. The facility census was 51. Findings are: A review of lists provided by facility titled New Agency Staff Since Jan. 1, 2023 and All New Hires Since 01/01/2023 provided a sample of 5 new employees to review. A. A review of the employee file for Nursing Assistant (NA) A revealed a hire date of 3/23/23. Further review revealed the employee file contained a Background Check dated 3/21/23 that revealed a misdemeanor from 2007. The employee file also contained a Nebraska Central Registry Request [a request to check the Nebraska Child Abuse and Neglect Central Registry (CAN Registry)/ Nebraska Adult Protective Services Central Registry (APS Registry) for information regarding the employee] dated 3/27/23. This form revealed an Agency Substantiated incident…

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 175 NAC 12-006.09B Based on record reviews and interviews, the facility failed to ensure the accuracy of the Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) regarding medications for Residents 10, 13, and 4, Pre-admission Screening and Resident Review [PASARR-a federal requirement to help ensure that residents are not inappropriately placed in nursing homes for long term care. Level II screening is triggered by evidence of a serious mental illness (MI), Intellectual or Developmental Disabilities (IDD) or condition related to IDD (RC) as defined by state or federal] for Resident 41 and falls for Resident 4. This affected 4 of 14 residents reviewed for MDS accuracy. The facility census was 51. Findings are: A. A review of Resident 10's active orders revealed orders for medications that include the following: METHENAM HIP (Methenamine Hippurate-an antibiotic) TAB (tablet) 1GM (gram) Take 1 table by mouth twice daily with a start date of 6/1/22. TRIPLE ANTIBIOTIC-OINT…

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 12-006.10A Based on observation, record review and interview, the facility failed to ensure a self-medication assessment had been completed prior to leaving medications at the bedside for 1 (Resident 41) of 1 resident sampled. The facility census was 51. Findings are: An observation on 4/30/23 at 1:25 PM revealed a tube of Diclofenac Gel 1% (a medication to help with pain control) in a basin on Resident 41's over bed table. An observation on 5/1/23 at 11:00 AM revealed a tube of Diclofenac Gel 1% in a basin on Resident 41's over bed table. A review of Resident 41's physician orders, dated 5/3/23, revealed an order for Diclofenac Gel 1%, apply topically (to skin) to affected area four times daily as needed may keep at bedside, start date 9/21/22. A review of the facilities Medication-Self Administration policy, dated 6/22/14, revealed the following: -The staff and/or practitioner will periodically reevaluate a resident's ability to continue to self-administer medications. It is recommended that this be done quarterly and with any significant change.…

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 175 NAC 12-006.05(5) Based on record reviews and interviews, the facility failed to provide a written notice of transfer to Resident 47 and/or their representative upon transfer to the hospital. The facility census was 51. Findings are: Record review revealed Resident 47 was hospitalized on [DATE], 10/30/22, 2/3/23, 3/16/23, and 5/1/23. Record review revealed that there was no documentation that the facility notified the resident and/or representative of the transfer in a written notice and the reason for the move in writing and in a language and manner they understand. On 5/2/23 at 3:03 PM Interview with Social Services Director (SSD) confirmed that a hospital written transfer notice was not given to resident 47 and/or personal representative when transferred to the hospital on 9/19/22, 10/30/22, 2/3/23, 3/16/23 and 5/1/23. SSD confirmed that the facility has not been doing this.

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 Resident 21. The facility census was 51. Findings are: Record review revealed PASARR I dated 12/22/22, 1/21/22 and 2/2/23 for Resident #21 with Diagnosis of Depressive Disorder and Anxiety Disorder. Record review revealed new diagnosis of Bipolar Disorder on 3/18/23. Interview on 5/2/23 at 2:50 PM with Social Service Director confirmed that the facility did not have a PASARR II for this resident. Record review of Pre-admission Screening and Resident Review Policy dated 6/22/19 revealed: 7) Any resident with newly evident or possible serious mental disorder, ID, or a related condition (see F644) shall be referred by the facility to the appropriate mental health or ID authority for review.

Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to attempt a non-pharmacological intervention (NPI) prior to administration of an as needed medication for 1 (Resident 4) of 5 sampled residents. The facility census was 51. Findings are: A review of Resident 4's physician orders, dated 5/2/23, revealed the following order: -Hydromorphon (a medication to treat pain) tab 2 milligram (mg) take ¼ tablet (0.5mg) by mouth every 1 hour as needed (PRN) A review of Resident 4's March 2023, April 2023, and May 2023 medication administration record (MAR) revealed that Resident 4 received the Hydromorphon 26 times with no NPI attempted prior to administration. An interview on 5/2/23 at 8:48 AM, Medication Aide (MA)-I revealed that prior to a PRN pain medication being administered a NPI must be attempted and charted in the medication administration record (MAR) or progress notes. An interview on 5/2/23 at 10:35 AM, the Director of Nursing (DON) confirmed that there was no NPIs charted in Resident 4's progress notes or MARs related to the PRN…

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 attempt a non-pharmacological intervention (NPI) prior to administration of an as needed (PRN) psychotropic medication (a medication that affects behavior, mood, thoughts or perception) for 1 (Resident 4) of 5 sampled residents. The facility census was 51. Findings are: A review of Resident 4's physician orders, dated 5/2/23, revealed the following orders: -Lorazepam (a medication to treat anxiety) Con 2 milligram (mg)/milliliter (ml) give 0.5ml by mouth/sublingually (under the tongue) every 1 hour as needed - Zolpidem (a medication to treat sleeplessness) tablet (tab) 5mg take 1 tab by mouth at bedtime as needed A review of Resident 4's March 2023, April 2023, and May 2023 medication administration record (MAR) revealed that Resident 4 received the PRN Lorazepam 39 times and PRN Zolpidem 50 times with no NPI attempted prior to administration. An interview on 5/2/23 at 8:48 AM, Medication Aide (MA)-I revealed that prior to a PRN psychotropic medication being administered a NPI…

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.

175 NAC 12-006.17B 175 NAC 12-006.17D Based on observation, record review, and interviews, the facility failed to prevent the potential for cross contamination during wound care for 1 resident (Resident 10) of 3 sampled for wound care, and the facility failed to ensure storage and cleaning of respiratory equipment in a manner to prevent the potential for cross contamination for 2 residents (Residents 4 and 41) of 2 sampled for Respiratory Care. The facility census was 51. Findings are: A. During an observation of a dressing change to the coccyx (tailbone) wound for Resident 10 on 5/2/23 from 1:28 PM to 1:45 PM, Licensed Practical Nurse (LPN) F gathered wound care supplies and assisted a Nursing Assistant to get Resident 10 in bed. LPN F then removed gloves, did not perform hand hygiene, and adjusted Resident 10's pillow. Without performing hand hygiene, LPN F put on new gloves, then assisted Resident 10 to turn on the left hip. LPN F touched the resident's wound. With the same soiled gloves, LPN F got a clean washcloth out of the bathroom, opened the bottle of sterile saline, poured…

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 12-006.18b The facility failed to ensure that the kitchen walk in refrigerator door and walk in freezer door was in a safe working condution. The facility census was 51. Findings are: Observation on 4/30/23 at 8:20 AM of the walk in freezer reveal upon entering the freezer, the door to the walk in freezer shut. Further observations revealed upon attempting to exit the walk-in freezer, the freezer door would not open requiring knocking on the inside of the freezer door to obtain the attention of dietary staff. Observation on 4/30/2023 at 8:30 AM revealed the walk in refrigerator door did not close requiring dietary staff to push forcefully in order to get the door to close. On 4-30-2023 at 8:45 AM an interview was conducted with Dietary Aid (DA) A. During the interview DA A reported both the walk-in freezer and the walk-in refrigerator had not been working or repaired. On 5-01-2023 at 7:58 AM an interview was conducted with the Dietary Manager (DM). During the interview the DM confirmed the walk-in freezer and walk-in refrigerator has not been…

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.