Crest View Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.11(D) Based on observation, record review, and interview; the facility failed to ensure nutritive value was maintained for 2 (Residents 24 and 28) of 2 sampled residents who received pureed meals. The facility census was 29.Findings Are: A record review of a facility provided document Dining Manager- Pureed Beef & Broccoli Stir Fry dated 2025 revealed serving size options for 5, 10, and 20 servings. The ingredients for preparing 5 servings of the dish were:-1 quart and 1 cup of Beef & Broccoli Stir Fry,-1 teaspoon of beef base, and-3/4 cup of water. A record review of a facility provided bag revealed the bag contained Trio Low Sodium [NAME] Gravy Mix. The back of the bag contained preparation instructions which stated to make 2 cups of gravy, 1/2 cup of gravy mix should be prepared with 2 cups of water. A record review of a facility provided bag revealed the bag contained Excel Gold Mashed Potatoes. The back of the bag contained preparation instructions which stated 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 12-006.09(H) Based on observations, interview, and record review, the facility failed to provide services to maintain the personal hygiene for 1 (Resident 3) of 4 sampled residents. The facility identified a census of 30. Findings are: A record review of an admission Record indicated the facility admitted Resident 3 on 6/8/2023 with diagnoses of Alzheimer's disease (a brain disorder that causes memory loss and other cognitive decline) and osteoarthritis (a chronic joint disease that causes pain and stiffness). A record review of Resident 3's quarterly Minimum Data Set (MDS- a standardized assessment tool used to evaluate the health of residents in nursing homes) with an Assessment Reference Date of 2/6/2025 indicated Resident 3 had a Brief Interview for Mental Status (BIMS- a structured evaluation aimed at evaluating aspects of cognition in elderly patients) score of 3/15, which indicated Resident 3 had severe cognitive impairment. The MDS also revealed Resident 3 was fully dependent on staff for personal hygiene and dressing. A record review 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 175 NAC 12-006.09(H)(iii)(2) Based on record reviews and interviews, the facility failed to provide monitoring of pressure ulcers (a localized injury to the skin and underlying tissue caused by prolonged pressure on a specific area of the body, often occurring over bony prominences like the heels, hips, or tailbone, leading to tissue damage and potential open sores if left untreated; this typically happens in people who are immobile or confined to a bed or wheelchair for extended periods) and treatments for the pressure ulcers as ordered for 1 (Resident 1) of 2 sampled residents. The facility identified a census of 30. Findings are: A record review of a facility policy Skin Program Policy with a last revised date of March 2019 revealed in the policy statement that care, and services would be provided to promote the healing of pressure ulcers that are present. The policy revealed procedures to complete a comprehensive wound assessment including site, stage, size, appearance of the wound bed, undermining, depth, drainage, and status of peri-wound tissue and the use…

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 12-006.11(E) Based on observation, interview, and record review; the facility failed to ensure sanitary conditions in the kitchen and that food was used or discarded before their expiration dates to prevent the potential for foodborne illness. This had the potential to affect all 31 residents who ate from the kitchen. The Findings Are: A record review of facility policy Sanitation Inspection with copyright date of 2024 revealed all food service areas would be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies, and other insects. An initial kitchen tour conducted on 8/28/24 at 9:06 AM revealed the following observations: -The metal shelving unit where the metal pots and pans were stored had gray fuzzy matter along the shelves and sides of the unit as well as brown and black debris on the bottom of the unit, just below bottom shelf. -On a shelf above the handwashing sink there was a plastic bin that contained an unopened bottle of PF Chang's Teriyaki sauce with a best by date of 12/5/2023. -On a shelf next 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.

Based on observation, interview, and record review; the facility failed to ensure there were no flying insects in the kitchen. This had the potential to affect all 31 residents who ate food prepared within the kitchen. The Findings Are: A record review of 2017 Nebraska Food Code, under section 6-501.111 revealed the premise shall be maintained free of insects. A record review of facility policy Pest Control Policy with revision date of March 2019 revealed that the environment would be monitored by facility staff and that there was to be an emphasis on the pest control program in the kitchen. A record review of facility policy Sanitation Inspection with copyright date of 2024 revealed that all food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies, and other insects. An observation on 9/3/24 at 9:54 AM in the kitchen revealed 4 insects flying around in the kitchen. The insects were observed landing on and walking on the steamtable, food prep counter, and other various surfaces in the kitchen. An observation on 9/3/24 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 175 NAC 12-006.04(B)(i) Based on record reviews and an interview, the facility failed to ensure five out of five sampled employees had completed initial orientation as required. This had the potential to affect all residents who resided at the facility. The facility identified a census of 31. Findings are: A record review of the Facility Assessment with a last updated date of 5/19/2024, under Section 3.4 Staff training/education and competencies, revealed training will be completed at orientation and refers to the orientation check list. A record review of Nurse Aide (NA) - G's personnel record provided by the facility revealed no evidence initial orientation had been completed. A record review of Licensed Practical Nurse (LPN) - H's personnel record provided by the facility revealed no evidence initial orientation had been completed. A record review of NA-I's personnel record provided by the facility revealed no evidence initial orientation had been completed. A record review of Registered Nurse (RN) - B's personnel record provided by the facility revealed no…

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 12-006.12(A)(vi) Based on record review and interview; the facility staff failed follow up on recommendations by the facility pharmacist and failed to obtain the rational for dosage reductions for 4 (Resident 6, 14, 19 and 27) of 5 sampled residents. The facility staff identified a census of 31. Findings are: A. A record review of an admission Record indicated the facility admitted Resident 6 on 6/17/2022 with diagnoses of Dementia and anxiety. A record review of Resident 6's Progress Notes with a date of 5/31/2024 revealed a monthly medication regimen review completed by the pharmacist with recommendation to check a vitamin D level. A record review of Resident 6's Progress Notes with a date of 3/31/2024 revealed a monthly medication regimen review completed by the pharmacist with a recommendation to recheck a thyroid-stimulating hormone (TSH) level due to a levothyroxine (thyroid medication) dose change on 1/29/2024. A record review of Resident 6's Progress Notes with a date…

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 Based on record review and interview; the facility staff failed to follow up on a gradual does reduction (GDR) for psychotropic medications for 2 (Resident 6 and 27) and failed to obtain the rational for the continued use of an as needed (PRN) medication that exceeded 14 days for 2 (Resident 17 and 27) of 5 sampled residents. The facility staff identified a census of 31. The Findings Are: A. A record review of facility policy Antipsychotic Use Policy and Procedure with revision date of November 2022, revealed a policy statement To ensure neuroleptics, hypnotics, sedative, antidepressant, anxiolytic, and antipsychotic medications will be used only when it is necessary to treat a specific condition. The policy also revealed that PRN (as needed) orders for anti-psychotic drugs were to be limited to 14 days and could not be renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication. B. A record review of Resident 27's Minimum Data Set (MDS), a federally mandated…

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 an interview, the facility failed to ensure 12 hours of continuing education had been completed for 3 of 5 sampled employees. This had the potential to affect all residents who resided at the facility. The facility identified a census of 31. Findings are: A record review of the Facility Assessment with a last updated date of 5/19/2024 indicated continuing competence of nurse aides of at lest 12 hours per year is to be completed. A record review of a Course Completion History for Nurse Aide (NA) - K revealed a total of 3.85 training hours. A record review of a Course Completion History for Medication Aide (MA) - L revealed a total of 11.85 training hours. A record review of a Course Completion History for MA-M revealed a total of 9.1 training hours. A record review of a facility provided employee listing revealed NA-K was hired on 5/22/23, MA-L was hired on 9/9/22, and MA-M was hired on 9/1/22. An interview on 9/4/2024 at 9:55 An with the Administrator confirmed NA-K, MA-L, and MA-M had not met the required…

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 12-006.05(S) Based on observation, interview, and record review; the facility failed to protect resident dignity and right to privacy by ensuring privacy during personal cares for 1 (Resident 13) of 4 sampled residents. The facility identified a census of 31. Findings are: A record review of a facility policy Resident Rights Policy with a last revised date of November 2019, under section 8. Privacy and Confidentiality, indicated the resident has a right to personal privacy during personal cares. A record review of an admission Record indicated the facility admitted Resident 13 on 6/8/2023 with a diagnosis of Alzheimer's disease. A record review of Resident 13's quarterly Minimum Data Set (MDS, a comprehensive assessment that includes medical, psychosocial, cognitive, and functional status to assist with developing care plans for individual residents) with an Assessment Reference Date (ARD) of 8/6/2024 revealed Resident 13 had a Brief Interview for Mental Status score of 3/15, which indicated Resident 13 had severe cognitive impairment. The MDS also…

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(F)(i)(5) Based on interviews and record reviews, the facility failed to notify the physician of significant weight loss for 2 (Resident 17 and 21) of 2 sampled residents. The facility identified a census of 31. Findings are: A. A record review of a facility policy Nutrition Unplanned Weight Loss Clinical Policy with a last revised date of March 2019 revealed a significant weight loss is 10% in six months. Under section Recording Weights and Follow-Up, the policy revealed nursing will notify the MD of the weight change. A record review of Resident 17's Vitals revealed Resident 17 weighed 164.5 pounds on 2/6/2024 and on 8/6/2024 Resident 17's weight was 143.5 pounds, which was a loss of 21 pounds or 12.77% loss since the weight on 2/6/2024. A record review of Resident 17's medical record did not reveal any evidence that Resident 17's physician was aware of the significant weight loss. An interview on 9/3/2024 at 2:24 PM with the Director of Nursing (DON) confirmed Resident 17's physician had not been notified of Resident 17's significant weight…

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(B) Based on record review and interview, the facility failed to accurately document falls with major injury for 1 (Resident 27) of 12 sampled residents and to accurately document antiplatelet use for 1 (Resident 6) of 12 sampled residents in their Minimum Data Set (MDS), a federally mandated comprehensive assessment tool used for care planning. The facility census was 31. The Findings Are: A. A record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities, revealed that major injuries were those that resulted in bone fractures, joint dislocations, closed head injuries with altered consciousness, and subdural hematomas. A record review of Resident 27's MDS, dated [DATE] revealed in Section J that Resident 27 had had two or more falls with major injury since their prior…

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 reviews and interview, the facility failed to develop interventions after falls for 1 (Resident 17) of 2 sampled residents. The facility identified a census of 31. Findings are: A record review of a facility policy Fall Prevention and Response Policy with a last revised date of October 2022 revealed post fall documentation included placing a new intervention after each fall. A record review of an admission Record indicated the facility admitted Resident 17 on 8/17/2022 with diagnoses of epilepsy and vascular dementia. A record review of Resident 17's quarterly Minimum Data Set (MDS, a comprehensive assessment that includes medical, psychosocial, cognitive, and functional status to assist with developing care plans for individual residents) with an Assessment Reference Date (ARD) of 7/9/2024 indicated Resident 17 had severe cognitive impairment. The MDS also revealed Resident 17 had two falls without injury, two falls with minor injury, and one fall with major injury. A record review of Resident 17's Progress Notes with a date of 3/2/2024 indicated Resident 17 had an…

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(H)(i)(3) Based on observations, interviews, and record reviews; the facility failed to provide assistance with toileting and incontinence care for 2 (Resident 13 and 17) of 2 sampled residents. The facility identified a census of 31. Findings are: A. A record review of a facility policy ADL Assistance Provided Per Care Plan with a revision date of September 2022 revealed incontinent residents shall be checked in accordance with their care plan. A record review of an admission Record indicated the facility admitted Resident 17 on 8/17/2022 with diagnoses of epilepsy and vascular dementia. A record review of Resident 17's quarterly Minimum Data Set (MDS, a comprehensive assessment that includes medical, psychosocial, cognitive, and functional status to assist with developing care plans for individual residents) with an Assessment Reference Date (ARD) of 7/9/2024 indicated Resident 17 had severe cognitive impairment. The MDS also indicated Resident 17 required extensive assistance with toileting. A record review of Resident 17's Care Plan with 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.

Licensure Reference 175 NAC 12- 006.09(I) Based on observations, interviews, and record reviews; the facility failed to ensure fall interventions were being implemented to prevent falls for 1 resident (Resident 17) and ensure safety during wheelchair locomotion with the use of footrests to prevent the potential for injury for 1 resident (Resident 13). The sample size was 3. The facility identified a census of 31. Findings are: A. A record review of a facility policy Fall Prevention and Response Policy with a last revised date of October 2022 indicated minimizing the risk for falls included to implement interventions to prevent falls. A record review of an admission Record indicated the facility admitted Resident 17 on 8/17/2022 with diagnoses of epilepsy and vascular dementia. A record review of Resident 17's quarterly Minimum Data Set (MDS, a comprehensive assessment that includes medical, psychosocial, cognitive, and functional status to assist with developing care plans for individual residents) with an Assessment Reference Date (ARD) of 7/9/2024 indicated Resident 17 had severe…

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) Licensure Reference Number 175 NAC 12-006.09(J)(i)(1) Based on observations, record review and interview; the facility staff failed to implement interventions to manage weight loss for 2 (Resident 12 and 21) of 3 sampled residents. The facility staff identified a census of 31. The Findings Are: A. A record review of a facility policy Nutrition Unplanned Weight Loss Clinical Policy with a last revised date of March 2019 revealed a 5% weight loss in one month was significant. Under section Recording Weights and Follow-Up, the policy revealed nursing would notify the MD (the resident's medical provider) of the weight change. The policy also revealed in the Treatment/Management section that the staff and physician would identify pertinent interventions based on identified causes and overall resident condition, prognosis, and treatment wishes. A record review of Resident 21's Minimum Data Set (MDS), a federally mandated comprehensive assessment tool used for care planning, dated 8/6/24 revealed that Resident 21 had a weight loss of 5% or…

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(H) Based on record review and interview, the facility staff failed to assess 1 (Resident 19) of 2 sampled resident's pain. The facility census was 31. The Findings Are: A record review of facility policy Pain Assessment and Management Policy with revision date of June 2021 revealed pain management is a multidisciplinary care process that includes assessing the potential for pain, effectively recognizing the presence of pain, identifying the characteristics of pain, addressing the underlying causes of the pain, developing and implementing approaches to pain management, identifying and using specific strategies for different levels and sources of pain, monitoring for the effectiveness of interventions, and modifying approaches as necessary. The policy also states to document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program. A record review of Resident 19's Minimum…

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(H) Based on record review and interviews, the facility failed to assess 1 (Resident 25) of 1 sampled resident's dialysis access port site daily. The facility census was 31. The Findings Are: A record review of a facility policy Dialysis with revision date of March 2019 revealed that the facility was to monitor the resident's access site for signs or infection at least daily. A record review of Resident 25's Minimum Data Set (MDS), a federally mandated comprehensive assessment tool used for care planning, dated 5/23/24 revealed Resident 25 had a diagnosis of end stage renal disease and was receiving dialysis (a treatment that removes waste and extra fluid from the blood when the kidneys are no longer functioning properly). A record review of Resident 25's care plan, with a last reviewed date of 8/26/24 revealed Resident 25 was receiving dialysis three times per week. There were no interventions in the care plan related to assessing Resident 25's dialysis port site. A record review of Resident 25's active physician's orders revealed an…

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 12-006.18(B) Based on observation, interview, and record review; the facility failed to ensure infection control practices were implemented for oxygen administration for 1 (Resident 6) of 1 sampled residents. The facility identified a census of 31. Findings are: A record review of 1st Class Medical's document The Importance of Changing Your Nasal Cannula with a date of 10/2/2018 indicated to disinfect oxygen nasal cannulas use an alcohol wipe then allow to dry to prevent the potential for bacteria buildup and infections. An observation on 9/3/2024 at 10:24 AM revealed Resident 3 had been ambulating from the dining room and down the hallway to their room. Resident 3 had been dragging their oxygen's nasal cannula on the ground during ambulation, dragging it through food debris and dirt. Further observation s revealed Nurse Aide (NA)-C intervened and placed the nasal cannula back in Resident 3's nose without first disinfecting it. An interview on 9/3/2024 at 10:28 with NA-C confirmed NA-C did not sanitize the nasal cannula before applying back into 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to submit their investigation of a fall with major injury to the state agency within five working days for 3 (Residents 1, 2, and 3) of 4 sampled residents. The facility census was 34. The Findings Are: A record review of the facility policy, Abuse Prevention Policy and Procedure dated December 2022, revealed in the investigation section that the facility will investigate all incidences such as falls, bruises, medication errors, resident complaints, etc. The Reporting and Response section revealed that the Administrator, DNS, or Nursing Supervisor will make sure that a report is filed, that the internal investigation begins immediately, and the appropriate reporting takes place. A record review of a document provided by the facility Administrator revealed the facility attempted to fax a 5-page Investigation Report to (402) [PHONE NUMBER] on 3/6/24 at 5:47 PM. The document stated pages not sent due to No…

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 12-006.09D7(3) Based on interviews and record reviews, the facility failed to implement interventions to reduce falls for 1 (Resident 1) of 3 sampled residents. The facility identified a census of 34. The findings are: A record review of the facilities' policy Fall Prevention and Response Policy with a last revised date of October 2022 revealed post-fall documentation includes root-cause analysis, interventions, response to interventions, and effectiveness of interventions. It also revealed the Interdisciplinary Team Fall Committee will meet and complete a fall review on each resident the following week where the care plan will be updated with a new or decided interventions. A record review of an admission Record indicated the facility admitted Resident 1 on 8/19/2021 with diagnoses of: epilepsy, vascular dementia, depression, anxiety, and osteoarthritis. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 1/23/2024 revealed Resident 1 was severely impaired with daily decision-making skills. Resident 1 required moderate assistance…

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 12-006.04B Based on interviews and record review, the facility failed to provide education/orientation/in-services specific to elopement. The failure had the potential to affect all facility residents identifies as at risk for elopement. The facility identified a census of 33 residents at the time of the survey. Findings are: A record review of the facility's Incident Reports revealed there had been resident elopements on 10/20/2022, 3/18/2023, 7/27/2023, and 8/3/2023. A record review of the facility's training schedule and courses for the year 2023 revealed Abuse, Neglect, and Exploitation were not included in the training schedule. In an interview on 8/15/23 at 9:30 AM with the Interim Administrator (IA)-A revealed they were not sure elopement staff education had occurred before or after residents had eloped from the facility due to changes in management. An interview on 8/15/23 at 11:38 AM with Maintenance (M)-revealed they did not receive education on elopements. An interview on 8/15/2023 at 10:00 AM with Nursing Assistant (NA)-C revealed 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 12-006.11E Based on observations, interviews, and facility policy and document review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety and to prevent foodborne illness. Specifically, the facility failed to keep the food items on the steam table at temperatures of 135 degrees Fahrenheit (F) or above, failed to ensure residents were not served food items from the steam table that were lower than 135 degrees F, failed to ensure food temperatures were recorded and food temperature logs were kept, and failed to date and label opened food items. This had the potential to affect all residents that received food items from the kitchen. Findings included: 1. Review of the facility's policy titled, Food: Preparation, revised 9/2017, revealed, 13. All foods will be held at appropriate temperatures, greater than 135 [degrees] F (or as state regulation requires) for hot holding, and less than 41 [degrees] F for cold food holding. 14. Temperature for TCS [time/temperature control…

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 12-006.09D7a Based on observation, record review, and interview, the facility failed to ensure staff observed residents take their medication to prevent accidents. This affected 1 (Resident #26) of 1 resident observed to have been given medication by a staff member who did not observe the resident take the medication before leaving the room. Findings included: A review of the facility's Medication Administration and Ordering Policy, dated 2019, revealed the policy did not address medications being left with a resident to administer without supervision of staff. A review of the admission Record for Resident #26 revealed the facility admitted the resident on 05/31/2023 with diagnoses that included type 2 diabetes mellitus, major depressive disorder, and cerebral infarction. A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/07/2023, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The resident required extensive…

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.