Cascades at Skyview

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09 Based on record review and interviews, the facility failed to provide and report timely laboratory services for 4 (Residents 7, 8, 14, and 17) of 7 sampled residents and failed to perform blood glucose monitoring per the provider's orders for 3 (Residents 7, 14, and 17) of 3 sampled residents. The facility census was 25.A. A record review of Resident 7's face sheet revealed Resident 7 was admitted on [DATE] with diagnoses of congestive heart failure, Type 2 diabetes mellitus (a disease in which the body cannot regulate blood sugar effectively), obesity, hypertension, and atrial fibrillation (an abnormal heart rhythm that is irregular in the chambers of the heart are out of sync). A record review of a facility document scanned into Resident 7's electronic medical record dated 10/3/25 revealed a new provider order from the Nurse Practitioner (NP) to obtain a BMP (Basic Metabolic Panel, a blood test that measures 8 substances in the blood that relate to chemical balance…

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 12-006.10(D) Based on record review and interviews, the facility failed to ensure significant medication errors did not occur for 2 (Residents 10 and 14) of 14 sampled residents. The facility census was 25.A.A record review of Resident 10's admission Record revealed the resident was admitted to the facility on [DATE] and had diagnoses of postlaminectomy syndrome (a complication after spinal surgery involving persistent pain), chronic pain syndrome and muscle spasms of the back. A record review of Resident 10's Provider Visit note dated 10/23/2025 revealed the resident was seen due to recent drowsiness and dizziness. The resident had described these symptoms as emerging after their Baclofen (a muscle relaxer) dose was increased from 10 milligrams (mg) to 15 mg, in addition to their ongoing use of tizanidine (a muscle relaxer). In the treatment section of this note, it stated the provider was going to change the resident's Tizanidine 2 mg to PRN (as needed) every 6 hours. 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 12-006.18 Based on observations, interviews, and record review; the facility failed to prevent the potential for cross contamination during wound care for 2 (Residents 3 and 6) of 3 sampled residents. The facility census was 25.Findings Are: A record review of the facility policy Wound Care with revision date of December 2011 revealed in the Steps in the Procedure section that Step 1 was to use a disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. A.A record review of Resident 3's Order Summary Report dated 11/12/2025 revealed the resident was admitted to the facility on [DATE]. The report also revealed the resident had the following wound care orders:-Cleanse right posterior thigh proximal and distal sites with wound cleanser, apply skin prep, apply hydrogel, cover with border dressing. This order had a start date 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.

Licensure Reference Number 175 NAC 12-006.18(B)Licensure Reference Number 175 NAC 12-006.18(D) Based on observation, interview, and record review, the facility failed to: a) implement contact precautions as ordered by the physician, b) implement Enhanced Barrier Precautions (EBP) and adhere to infection control standards during wound care, c) and adhere to infection control standards during medication administration for 3 residents (Residents 3, 12 and 18.) These lapses created a risk of cross-contamination and potential transmission of infection to all residents residing within the facility. The facility identified a census of 28.Findings are: A. A record review of the Center for Disease Control's (CDC) article Carbapenem-resistant Pseudomonas Aeruginosa: A Serious Public Health Threat revealed pseudomonas aeruginosa bacteria are a common cause of infection in the healthcare setting. They can cause pneumonia, bloodstream infections, urinary tract infections (UTI), and surgical site infections, and they are particularly dangerous for patients with chronic lung disease. The bacteria…

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 12-00604(D)Nebraska Revised Statute 71-6018.02(a) Based on record reviews and interviews, the facility failed to maintain acceptable documentation (timecards, time sheets, payroll information) that a Registered Nurse (RN) was on duty for a minimum of 8 consecutive hours a day, 7 days a week, as required. This had the potential to affect all 28 residents by limiting access to RN-level assessment, oversight, and decision-making related to resident care.Findings are: A record review of a facility provided document SCARAB (Skyview Care and Rehab at Bridgeport) Facility Assessment- 2025 dated 6/4/2025 revealed under the staffing type section, nursing services of the Director of Nursing (DON), RN, Licensed Practical Nurse (LPN), Nurse Aides (NA), and Medication Aides (MA) were needed to provide support and care for the facility's residents. Under the staffing plan section, it was revealed that a total of 5 licensed nurses providing direct care were needed. There was no evidence…

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)(3) Based on observations, record review, and interview; the facility failed to ensure residents received assistance with their Activities of Daily Living per their plan of care for 6 (Residents 1, 2, 3, 4, 12, and 19) of 6 sampled residents. The facility identified a census of 36. Findings Are: A record review of the facility policy Activities of Daily Living (ADL), Supporting with a revision date of March 2018 revealed that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. An interview on 6/7/25 at 10:14 PM with Nursing Assistant ( NA)-L and NA-M revealed both NA's worked the night shift. NA-M stated that three nights earlier, it was after midnight before the staff finished getting the residents into bed for the night due to the lack of staff that had been available to provide cares for the residents on the evening shift. A. 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 12-006.09(I) Based on record review and interview the facility failed to prevent the potential for serious harm or injury while performing transfers via Hoyer or sit-to-stand mechanical lifts, this had the potential to affect 11 (Residents 1, 4, 6, 9, 10, 11, 12, 13, 14, 15, and 16) of 11 residents sampled. The facility identified a census of 36. Findings Are: A record review of the facility policy Lifting Machine, Using a Mechanical with revision date of July 2017 revealed in the General Guidelines that at least two nursing assistants are needed to safely move a resident with a mechanical lift. The policy also revealed that the types of lifts that may be available in the facility are a floor-based full body sling lift, an overhead full body sling lift, and a sit to stand lift. A record review of the facility provided Resident List dated 6/7/25 revealed Residents 4, 9, 10, 14, and 16 were marked as utilizing a Hoyer lift. The list also revealed Residents 1, 6, 11, 12, 13, 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 12-006.09(H)(iii)(3) Based on observations, interviews, and record review; the facility failed to implement interventions of repositioning and failed to re-evaluate and revise ineffective interventions for 1 (Resident 9) of 1 sampled resident with Moisture Associated Skin Damage (MASD, a condition that occurs when skin is repeatedly exposed to various sources of bodily secretions or effluents, often leading to irritant contact dermatitis with inflammation, with or without denudation of affected skin). The facility identified a census of 28. Findings are:A record review of the facility policy provided when the policy related to skin assessments was requested, Prevention of Pressure Injuries with a revision date of April 2020, revealed in the Mobility/Repositioning section the staff were to reposition all resident with or at risk of pressure injuries on an individualized scheduled, as determined by the interdisciplinary team. The policy also revealed in the Monitoring section,…

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 observations, record reviews and interview; the facility staff failed to ensure a medication error rate of less than 5%. Observations of 25 opportunities of medication administration revealed 5 medication errors resulting in a medication error rate of 20%. The medication errors effected 2 (Resident 4 and 17). The survey had a total sample size of 19. The facility identified a census of 36. Findings are: A record review of a facility policy Administering Medications with a last revised date of April 2019 revealed medications are to be administered in accordance with prescriber orders, including any required time frame. The individual administering the medication should check the label three times to verify the right resident, medication, dosage, time, and route prior to administering the medication. A record review of a facility policy, Adverse Consequences and Medication Errors with a last revised date of February 2023 revealed examples of medication errors include omission (when a drug is ordered but not administered),…

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 record review and interview, the facility failed to ensure three doses of an intravenous (IV) antibacterial medication were not omitted for 1 (Resident 7) of 1 sampled resident. The facility identified a census of 36. Findings are: A record review of a facility policy, Adverse Consequences and Medication Errors with a last revised date of February 2023 revealed examples of medication errors include omission (when a drug is ordered but not administered), unauthorized drug (when a drug is administered without a physician's order), wrong dose, wrong route, wrong drug, wrong time, or failure to follow manufacturer's instructions and /or accepted professional standards. The policy defined signification medication-related errors as the requirement for the medication to be discontinued or modified, required hospitalization, resulting in disability, requiring treatment with a prescription medication, resulting in cognitive deuteriation, life threatening, or resulting in death. A record review from AstraZeneca Pharmaceuticals (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 175 NAC 12-006.04(A)(iii)(2)(a) Based on record reviews and interview, the facility failed to complete a nurse aide registry check prior to hire as required for 5 [Nurse Aide (NA) - E, NA-O, Assistant Director of Nursing (ADON), Dietary Aide (DA) - A, and Dietary Supervisor (DS)] of 5 sampled employees. This had the potential to affect all residents who reside within the facility. The census was 36. Findings are: A record review of a facility policy, Background Screening Investigations with a last revised date of March 2019 revealed for any individual applying for a position of a NA, the state NA registry is contacted to determine if any findings of abuse, neglect, mistreatment, or theft have been entered into the applicant's file. There was no evidence of a nurse aide registry check being completed prior to hire if the employee has direct, unsupervised access to residents. A record review of a facility staff list, with a date of 3/10/2025, revealed the following: -NA-E was hired on 12/6/2024. -NA-O was hired on 10/30/2024. -The ADON was hired on 11/20/2024.…

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 175 NAC 12-006.04(B)(ii)(1) Based on record reviews and interview, the facility failed to ensure 12 hours of ongoing training had been completed for the year for 5 [Nurse Aide (NA) - G, NA-H, NA- F, MA-I, and NA- K] of 5 sampled employees. This had the potential to affect all residents who reside within the facility. The facility identified a census of 36. Findings are: A record review of the facility's SCARAB Facility Assessment with a last revised date of 1/15/2024 revealed nurse aides will complete at least 12 hours of ongoing training per year, including dementia and abuse. A record review of a facility staff list, with a date of 3/10/2025, revealed the following: - NA-G was hired on 8/11/1989. - NA-H was hired on 9/1/2018. - NA-F was hired on 8/30/2023. - MA-I was hired on 1/13/2023. - NA-K was hired on 12/17/2018. A. A record review of an In-Service Quiz - Infection Control with a date of 3/8/2024 had been completed by NA-G, however, at the time exit, the facility had not provided evidence of hours completed for this training. A record review of in-services…

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 12-006.11(E) Based on observation, interview, and record review, the facility failed to dispose of expired foods, clean dry storage area and freezer, failed to implement hand hygiene practices to prevent the potential for cross contamination, use hair and beard restraints, and obtain food temperatures prior to serving to prevent the potential for foodborne illness. This had the potential to affect all residents who ate from the kitchen. The facility census was 36 . Findings are: A. An observation during the initial kitchen tour on 3/10/2025 from 7:30 AM to 8:18 AM revealed the two upright freezers with dried old food particles in the bottom and dark stains with black smears on the outside of the freezers. One freezer with approximately 3 inch ice build up around inside on the sides and top, the inside of the door with yellow stains from a food spillage and dried old food particles on the bottom. The dry food storage area revealed 1 bag of spiral rotini unsealed and no date, 1…

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 12-006.09(H)(i)(3) Based on observations, interviews, and record reviews, the facility failed to provide assistance with bathing services in order to maintain good hygiene for 3 (Residents 13, 15, and 16) of 3 sampled residents. The facility identified a census of 36. Findings are: A record review of a facility policy, Activities of Daily Living, Supporting with a last revised date of March 2018 revealed appropriate care and services will be provided for residents who are unable to carry out Activities of Daily Living (ADLs), including hygiene (bathing, dressing, grooming, and oral care) independently, with consent of the resident and in accordance with the plan of care. A. A record review of an admission Record revealed the facility admitted Resident 16 to the facility on 1/20/2017 with diagnoses of a cerebral aneurysm (a weakened area in the wall of a blood vessel in the brain that bulges.) Resident 16 also had diagnoses of dementia, Chronic Obstructive Pulmonary Disease (a group 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 175 NAC 12-006.09 (I) Licensure Reference 175 NAC 12-006.19(A) Based on observations, interviews, and record reviews, the facility failed to: develop and implement interventions for Resident 32's falls, failed to ensure Resident 17's carpet was free from buckling to prevent the potential for an avoidable accident. The sample size was 4. The facility identified a census of 36. Findings are: A. A record review of a facility policy, Assessing Falls and Their Causes with a last revised date of October 2010 revealed after a resident falls, appropriate interventions to prevent future falls will be recorded in the resident's medical record. A record review of an admission Record revealed the facility admitted Resident 32 on 8/4/2023 with a diagnosis of Chronic Myeloid Leukemia (a caner of the blood and bone marrow.) Resident 32 also had diagnoses of paroxysmal atrial fibrillation (a heart rhythm disorder that can cause rapid, irregular heartbeats, shortness of breath, dizziness, and fatigue),…

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 175 NAC 12-006.02(H) Based on record reviews and interviews, the facility failed to report allegations of staff-to-resident abuse to the required State agency within 2 hours involving 1 (Resident 33) of 1 sampled resident. The facility identified a census of 36. Findings are: A record review of a facility policy, Abuse Investigation and Reporting, with a last revised date of July 2017, revealed all alleged violations involving abuse will be reported to the State agency and Adult Protective Services (APS) within two hours of the alleged violation. A record review of a facility policy, Identifying Types of Abuse, with a last revised date of September 2022, revealed mental abuse is the use of verbal or non-verbal conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability…

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 Based on record review and interview, the facility failed to notify 1 (Resident 17) of 1 sampled resident's representative in writing, as required, of the reason for Resident 17's transfer to the hospital. The facility census was 36. Findings Are: A record review of the facility policy Transfer or Discharge, Facility-Initiated with revision date of October 2022 revealed in the Policy Statement, Facility-Initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification. A record review of Resident 17's Progress Notes dated 3/7/25 revealed the resident had a change in condition, the facility had received an order from the provider to transfer the resident to the hospital for evaluation, and the facility called the resident's Power of Attorney (POA) and notified them that Resident 17 was being transferred. The Progress Notes also revealed that Resident 17 was admitted to the hospital on [DATE] with sepsis. A record review of Resident 17's electronic…

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 Based on record review and interview, the facility failed to notify 1 (Resident 17) of 1 sampled resident's representative of the facility's bed hold policy at the time of Resident 17's transfer to the hospital. The facility census was 36. Findings Are: A record review of the facility policy Bed-Holds and Returns with a revision date of October 2022 revealed that all residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence. Residents, regardless of payer source, are provided written notice about these policies at least twice: -notice 1: well in advance of any transfer; and -notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours). A record review of Resident 17's Progress Notes dated 3/7/25 revealed the resident had a change in condition, the facility had received an order from the provider to transfer the resident to the hospital for evaluation, 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 175 NAC 12-006.09(F)(i) Based on record reviews and interview, the facility failed to develop a baseline care plan (BCP, a document that serves as initial instruction and guidance for the resident's care) within 48 hours as required by state regulations for 1 (Resident 139) of 7 sampled residents. The facility identified a census of 36. Findings are: A record review of an undated facility policy, Care Plans - Baseline revealed BCPs should be developed for each resident within 48 hours of admission and include initial goals, physician's orders, dietary orders, therapy services, social services and Pre-admission Screening and Resident Review (PASRR, a process which requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have Serious Mental Illness or Intellectual Disability) recommendations - if applicable. A record review of an admission Record revealed the facility admitted Resident 139 on 3/4/2025 with diagnoses of cancer of the tongue and Chronic Obstructive Pulmonary Disease (COPD,…

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 12-006.09(H)(iv)(5) Based on record reviews and interviews, the facility failed to follow their bowel protocol orders to prevent constipation for 2 (Residents 16 and 27) of 5 sampled residents. The facility identified a census of 36. Findings are: A. A record review of an admission Record revealed the facility admitted Resident 16 to the facility on 1/20/2017 with a diagnosis of a cerebral aneurysm (a weakened area in the wall of a blood vessel in the brain that bulges.) Resident 16 also had diagnoses of dementia and constipation. A record review of Resident 16's quarterly 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) with an Assessment Reference Date (ARD) of 1/22/2025 revealed Resident 16 had a Brief Interview for Mental Status (BIMS, a brief screening that aids in detecting cognitive impairment) score of 9, which indicated Resident 16 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09 (H)(vi)(3) Based on interviews and record review, the facility failed to administer oxygen as ordered by the physician to 1 of 1 (Resident 19) residents. The facility identified a census of 36. Findings are: A review of Resident 19's admission Record revealed they were admitted to the facility on [DATE] with a primary diagnosis of respiratory failure. A record review of Resident 19's physician orders revealed an order dated 2/11/25 for oxygen to be administered by nasal cannula at 1 liter per minute continuously. Record review of Resident 19's care plan revealed an entry dated 2/12/25 which read, Continuous oxygen via nasal cannula at 1 liters per minuete. An observation of Resident 19 on 3/12/25 at 11:05 AM revealed the resident not wearing oxygen by nasal cannula or any other means. An interview with Resident 19 on 3/12/25 at 12:27 PM confirmed they have not been wearing oxygen in the facility continuously. An interview on 3/12/25 at 12:14 PM with the Director 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.

License Reference Number 175 NAC 12-006.02 (H) Based on record review and interview, the facility failed to submit their investigation of an incident within 5 working days as required for 1 (Resident 1) of 2 sampled residents. The facility identified a census of 37. Findings Are: A record review of a facility document titled Abuse, Neglect, or Misappropriation and dated 10/23/24, revealed Resident 1 had a fall with injury on 10/15/24 at 10:00 PM. The document further revealed the investigation was submitted to the State Agency on 10/23/24. An interview on 1/6/25 at 1:15 PM with the Administrator confirmed the facility did not submit their investigation of Resident 1's fall with injury that occurred on 10/15/24 to the State Agency within 5 working days as required.

Licensure Reference175 NAC 12-006.09(I) Based on record reviews and interview, the facility failed to develop new interventions for falls for 1 (Resident 2) of 3 sampled residents. The facility identified a census of 37. Findings Are: A record review of a facility policy, Falls and Fall Risk, Managing, with a last revised date of March 2018 indicated if falls recur despite initial interventions, staff will implement additional or different interventions. A record review of an admission Record indicated the facility admitted Resident 2 on 5/27/2022 with diagnoses of history of falling, dystonia (a brain condition that causes uncontrollable muscle movement,) hemiplegia (weakness on one side of the body,) muscle weakness, unsteadiness on feet, and abnormalities of gait and mobility. A record review of Resident 2's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning), with an Assessment Reference Date of 11/8/2024 indicated Resident 2 had a Brief Interview for Mental Status (BIMS, a brief screening that aids in detecting cognitive…

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 175 NAC 12-006.11D Based on observations, interviews, and record reviews, the facility failed to prepare foods following the recipe to ensure nutritive value. This had the potential to affect all 41 facility residents that ate food prepared in the kitchen. The facility identified a census of 41. Findings are: A continuous observation of meal preparation of French Onion Pork Chop on 4/23/2024 from 7:09 AM to 8:00 AM revealed the following: - The Dietary Supervisor (DS) had measured three boneless pork chops. The first porkchop was six ounces, the second was three ounces, the third was three ounces. - The DS did not measure the remaining prepared porkchops - The DS had grabbed four fresh onions from the pantry. Once the DM had began to cut the onions, threw away two of the onions, which were bad. - The DS had placed a bag of French onion soup mix on top of porkchops - No stock chicken and soup base had been used An interview on 4/23/2024 at 7:15 AM with the DS revealed the porkchops were to be about four ounces. An interview on 4/23/2024 at 7:52 AM with the DS…

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 12-006.11E Based on observations, interviews, and record review, the facility failed to ensure foods were labeled, dated, and served within best by dates, and prepare food under sanitary conditions, the facility failed to ensure potentially hazardous foods of meat and dairy products were held at 135 degrees or higher on the steam table. This had the potential to affect all 41 residents that ate food prepared in the kitchen. The facility identified a census of 41 residents. Findings are: A. An initial kitchen observation on 4/18/2024 at 7:02 AM revealed the following in the kitchen: - Several saran wrapped pieces of cornbread, without preparation or use by dates on the kitchen counter - A bin of sugar with a label including a prepared date of 2-1-24 but no use by date - A bin of flour with a label including a prepared date of 2-1-24 but no use by date An initial kitchen observation on 4/18/2024 at 7:02 AM revealed the following in the refrigerator in the kitchen: - An opened Sysco chicken base…

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 12-006.10D Based on observations, interviews, and record reviews; the facility failed to maintain a medication error rate less than 5%, which affected 3 (Resident 8, Resident 16, and Resident 34) of 9 sampled residents. The medication error rate was 11.11%. The facility census was 41. A record review of facility policy Administering Medications with a last revised date of April 2019 revealed the following: - Medications are administered within one hour of their prescribed time. - Verify the right resident, right medication, right dosage, right time and right route. - The charge nurse must accompany new nursing personnel on their medication rounds for minimum of 3 days to ensure established procedures are followed and proper resident identification methods are learned. A. An observation on 4/22/2024 at 12:17 PM revealed Medication Aide (MA)-D had administered Resident 8's Sinemet at this time. A record review of Resident 8's Medication Administration Record revealed the medication was scheduled for 1100. B. An observation on 4/22/2024 at 12:35 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.

Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review and interview; the facility failed to ensure to notify the physician of low blood pressures for 1 (Resident 2) of 5 residents who was on blood pressure medication. The facility census was 41 at the time of survey. Findings are: A record review of Resident 2's undated facility admission Record revealed an admission date of 11/15/16 to the facility with a primary diagnosis of Chronic Obstructive Pulmonary Disorder (COPD). A record review of Resident 2's Annual Minimum Data Set (MDS -a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 10/10/23 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) score of 2 which indicated severe cognitive impairment. Record review of Resident 2's Comprehensive Careplan initiated on 11/21/19 revealed: -problem Cardiovascular/Circulatory: I have an altered cardiovascular…

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 12-006.09B Based on record review and interview, the facility failed to ensure completion of the admission Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) within the required time for 1 (Resident 95) resident. This affected 1 of 6 residents reviewed for MDS accuracy. The facility census at the time of the survey was 41. Findings are: A record review of Resident 95's undated facility admission Record revealed an admission date of 3/26/24 to the facility with a primary diagnosis of unspecified dementia. A record review of Resident 95's admission MDS revealed an admission date of 3/26/24 and an Assessment Reference Date (ARD) of 4/5/24. A record review of Resident 95's admission MDS revealed an ARD (marks the end of a 7 day period during which a resident is observed and assessed) of 4/5/24. A record review of Resident 95's admission MDS revealed a completion date of 4/23/24. Record review of the Resident Assessment Instrument manual (RAI- instruction manual 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 12-006.09C1a Based on record review and interview; the facility failed to ensure that the written summary of the baseline care plan (written plan required to be developed within 48 hours of admission detailing the instructions needed to provide initial effective and person centered care of the resident that meet professional standards of quality care) for 1 (Resident 94) of 6 sampled residents. The facility census at the time of survey was 41. Findings are: Record review of Resident 94's undated Comprehensive Care Plan (CCP- written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) revealed an admission date to the facility on 4/15/24 with a primary diagnosis of Osteomyelitis. Record review of Resident 94's Electronic Medical Records revealed no baseline careplan. Interview on 04/23/24 at 5:51 PM with the MDS coordinator confirmed there was not a baseline careplan completed for Resident 94 and there should have been, it was also confirmed that the resident was 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.

Licensure Reference 175 NAC 12-006.09D7b Based on interviews and record reviews; the facility failed to identify causative factors and implement new interventions to prevent falls for 1 (Resident 13) of 2 sampled residents. The facility identified a census of 41. Findings are: A record review of an admission Record indicated the facility admitted Resident 13 on 5/26/2015 with diagnoses of muscle weakness, edema, Obstructive Sleep Apnea, hypertension, and Major Depressive Disorder. A record review of a significant change Minimum Data Set with a date of 5/15/2023 revealed Resident 13 had a Brief Interview for Mental Status score of 12/15, which indicated Resident 13 had moderate cognitive impairment. Resident 13 also required moderate assistance with bathing, supervision with oral hygiene, and was dependent from toileting and dressing. A. A record review of Resident 13's Care Plan with a date initiated of 9/18/2019 revealed Resident 13 was at risk for falls. Interventions were as follows: - Anticipate and meet my needs (initiated on 9/18/2019) - Be sure my call light is within reach…

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 175 NAC 12-006.17 Based on observations and record review, the facility failed to implement infection control practices during medication administration for 3 (Resident 16, Resident 31, and Resident 95) of 9 sampled residents. The facility identified a census of 41. An observation on 4/22/2024 at 12:02 PM revealed Registered Nurse (RN) -C had prepared a insulin syringe with 6 units of insulin. RN-C then applied gloves. RN-C then touched the inner rim of the trash to throw away an empty box of gloves and did not change gloves after touching the inner rim of the trash can. RN-C then injected the insulin into Resident 16. An observation on 4/22/2024 at 12:12 PM revealed RN-C had dialed a insulin pen with 10 units of insulin. RN-C then applied gloves. RN-C had knocked and attempted to enter the room by turning the doorknob with the gloved hand. RN-C was asked to wait one minute by nursing. While waiting, RN-C touched RN-C's hair. The nursing staff then stated they were ready. RN-C had again opened the door with RN-C's gloved hand. RN-C then injected Resident 31'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.