Life Care Center of Elkhorn

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.19(C), 12-006.18(B)Based on observation, record review and interview, the facility failed to ensure soiled linen did not come into contact with staff clothing for Residents 5 and 15, ensure nebulizer kits were cleaned after use for Residents 27 and 63, ensure Resident 6's PAP and PAP mask were clean and off the floor, and ensure Resident 6's PAP machine contained a filter; and the facility staff failed to wear enhanced barrier precautions when providing catheter care for Resident 12. The facility census was 86.Findings are: A. Record review of a facility policy dated 7/5/25 entitled Laundry Services revealed the following information: Facility staff should handle all laundry as potentially contaminated and use standard precautions with the appropriate Personal Protective Equipment. Soiled linen should be handled as little as possible and with a minimum of agitation to prevent gross microbial contamination of the air and of persons handling linen. -Never carry soiled…

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 and interview, the facility failed to ensure that ventilation systems were operational in resident bathrooms in 4 (Rooms 106, 108, 114 and 115) of 15 occupied resident rooms on the 100 hall of the facility. The facility census was 86. Findings are:Observation on 12/4/25 between 9:00 AM to 9:30 AM with the facility Maintenance Supervisor [MS] revealed that the ventilation system did not draw a 1 ply square of toilet paper to the surface of the ventilation cover in resident bathrooms in resident rooms 106, 108, 114 and 115. This indicated that the ventilation system was not working properly on the 100 hall of the facility at the time of the observation. Interview on 12/4/25 at 9:25 AM with the MS confirmed that the ventilation system did not draw a 1 ply square of toilet paper in resident bathrooms in rooms 106, 108, 114 and 115 which indicated that the ventilation system was not working properly on the 100 hall of the facility. The MS confirmed that no routine checks of the ventilation system had been completed 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 12-006-05(A)(B)(C)Based on record review and interview, the facility failed to provide notice of resident rights on admission for 1 (Resident 95) of 1 sampled resident. The facility staff identified a census of 86.The findings are:Record review of a facility policy entitled admission Policy dated reviewed 8/28/2025 revealed: - Resident Rights - Before or upon admission the facility will ensure that the resident and/or the resident's representative or interested family member has been informed of the resident's rights and all facility policies governing resident conduct and responsibilities in a language and manner they can understand. - 1. The resident's rights are communicated both orally and in writing with adaptations made to account for visual and hearing impairments (i.e., sign language, large print, Braille copies). - 2. The facility will provide language assistance services such as qualified interpreters for individuals with limited English proficiency, and appropriate auxiliary aids and services to comply with Section 1557. - 3. Written…

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

Licensure Reference Number 175 NAC 12-006.02(H)Based on interview and record review, the facility failed to protect 1 of 1 resident surveyed (Resident 14) during the investigation of an abuse allegation. The facility had a census of 88.Findings are:A record review of Resident 14's undated care plan revealed the following diagnoses: Type 1 Diabetes Mellitus with hyperglycemia (consistently high blood sugar levels due to insufficient insulin production), Anxiety Disorder, Diabetes insipidus ( a kidney disorder causing excessive thirst and large amounts of urine), Chronic pain, Adrenocortical insufficiency (a condition where the adrenal glands do not produce enough hormones), spinal stenosis with claudication (a narrowing of the spinal canal that puts pressure on the spinal cord and nerves causing pain, numbness or weakness), depression, suicidal ideation (thoughts of suicide), other speech and language deficits following cerebral infarction (stroke).A record review of Resident 14's Minimum Data Set (MDS - a federally mandated assessment tool that measures the health status in nursing…

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 review and interview, the facility failed to ensure an anti-psychotic medication [a class of medications used to manage symptoms of psychosis such as delusions and hallucinations] was used to treat a medically accepted, diagnosed, specific condition for 1 (Resident 10) of 5 residents reviewed for unnecessary medications. The facility census was 86.Findings are:A. Record review of a facility policy dated 11/19/24 entitled Psychotropic Medication Management revealed the following information:A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:Anti-psychotic, Anti-depressant, Anti-anxiety, and Hypnotic.Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. With regards to psychotropic medications, the regulations additionally require:Giving psychotropic…

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 12-006.2(H)Based on interview and record review, the facility failed to ensure that an abuse allegation for 1 of 1 resident surveyed (Resident 14) was reported to officials within the required time limits. The facility claimed a census of 88.Findings are:A record review of Resident 14's undated care plan revealed the following diagnoses: Type 1 Diabetes Mellitus with hyperglycemia (consistently high blood sugar levels due to insufficient insulin production), Anxiety Disorder, Diabetes insipidus (a kidney disorder causing excessive thirst and large amounts of urine), Chronic pain, Adrenocortical insufficiency (a condition where the adrenal glands do not produce enough hormones), spinal stenosis with claudication (a narrowing of the spinal canal that puts pressure on the spinal cord and nerves causing pain, numbness or weakness), depression, suicidal ideation (thoughts of suicide) and other speech and language deficits following cerebral infarction (stroke).A record review of Resident 14's Minimum Data Set (MDS - a federally mandated assessment tool…

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 12-006.2(H)Based on interview and record review, the facility failed to investigate an allegation of abuse for 1 of 1 residents surveyed (Resident 14). The facility had a census of 88.Findings are:A record review of Resident 14's undated care plan revealed the following diagnoses: Type 1 Diabetes Mellitus with hyperglycemia (consistently high blood sugar levels due to insufficient insulin production), Anxiety Disorder, Diabetes insipidus ( a kidney disorder causing excessive thirst and large amounts of urine), Chronic pain, Adrenocortical insufficiency (a condition where the adrenal glands do not produce enough hormones), spinal stenosis with claudication (a narrowing of the spinal canal that puts pressure on the spinal cord and nerves causing pain, numbness or weakness), depression, suicidal ideation (thoughts of suicide) and other speech and language deficits following cerebral infarction (stroke).A record review of Resident 14's Minimum Data Set (MDS - a federally mandated assessment tool that measures the health status in nursing home…

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(E)(i)Based on record review and interview, the facility failed to develop a Comprehensive Care Plan (CCP, a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) related to prophylactic antibiotic use for Resident 8 and anticoagulant [a blood thinner medication which can increase the risk of bleeding] for Resident 14. The facility sample size was 25. The facility census was 86.Findings are:A. Record review of Resident 8's Face Sheet revealed that Resident 8 was admitted on [DATE] with diagnoses that included urinary tract infection [UTI], chronic kidney disease, and bladder neck obstruction. Record review of Resident 8's significant change Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 10/21/25 revealed that Resident 8 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 11 which indicated that Resident 8…

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.

The facility failed to administer tube feeding as ordered by the physician for 1 (Resident 7) of 1 sampled residents. The facility staff identified a census of 86.Record review of facility policy entitled Enteral Nutrition Therapy (Continuous) dated reviewed 9/5/2025 revealed: - The facility will provide continuous enteral nutrition therapy in accordance with physician orders and professional standards of practice.Record review of Resident 7's admission Record revealed the facility admitted the resident on 7/24/2025. Further review of the admission record identified Resident 7 had diagnoses which included encephalopathy (brain dysfunction often caused by an underlying condition such as infections, toxins, liver or kidney failure, or nutritional deficiency) and severe protein-calorie malnutrition.Record review of Resident 7's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 11/13/2025 revealed the facility staff assessed the following about…

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)(g) Based on observation, interview, and record review, the facility failed to obtain valid positive airway pressure (PAP) device (a machine used to treat sleep apnea) orders for 2 (Residents 6 and 63) of 3 sampled residents and oxygen orders for 1 (Resident 63) of 3 sampled residents. The facility census was 86. Findings are:A record review of the facility's BIPAP (bilevel positive airway pressure) / CPAP (continuous positive airway pressure) Administration Policy with a reviewed date of 09/24/2025 revealed the facility would ensure each resident received respiratory care and services in accordance with professional standards of practice. When a PAP was ordered, the mode, pressure setting, size and type of mask, liters of oxygen if ordered, and frequency of use must be included in the written order. A.A record review of Resident 6's Clinical Census dated 12/02/2025 revealed the resident was admitted [DATE]. A record review of Resident 6's Medical Diagnosis…

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 interview and record review, the facility failed to evaluate for and identify situational triggers for post-traumatic stress disorder (PTSD) for 1 (Resident 9) of 1 sampled resident. The facility staff identified a census of 86.The findings are:Record review of facility policy entitled Trauma Informed Care dated reviewed 9/2/2025 revealed: - 1. Screening and assessment - The facility will use a multi- pronged approach to identifying a residents with PTSD or history of trauma. This approach would include assessing the residents for indicators of trauma upon admission/readmission and with change in condition. This assessment will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event. - a. The facility will utilize the Trauma-Informed Care Assessment in PCC to assess the resident's experience of seventeen possible negative life events. - b. If the residents responds to any of the seventeen possible negative life events with an answer other than…

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(D)(i) Based on observation, interview, and record review, the facility failed to provide secured storage for medications stored in the residents' rooms for 2 (Residents 6 and 43) of 2 sampled residents. The facility census was 86. Findings are:A record review of the facility's Self-Administration of Medications policy with a last revised date of 06/01/2024 revealed the care plan would reflect that the resident could self-administer medications. The staff would document in the resident's care plan if the resident or the facility staff were responsible for storage of the resident's medications. The facility should provide a secured compartment for the storage of the resident's medications. The storage compartment would be stored in the resident's room and locked when not in use. A.A record review of Resident 6's Clinical Census dated 12/02/2025 revealed the resident was admitted [DATE]. A record review of Resident 6's Medical Diagnosis dated 12/04/2025 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.

Based on record review and interview, the facility failed to complete admission paperwork for 1 (Resident 95) of 1 sampled resident. The facility staff identified a census of 86.The findings are:Based on record review and interview, the facility failed to complete admission paperwork for 1 (Resident 95) of 1 sampled resident. The facility staff identified a census of 86.The findings are:Record review of a facility policy entitled admission Policy dated reviewed 8/28/2025 revealed: - Resident Orientation - 1. Prior to, or upon admission, the resident is orientated, but not limited to: - a. Privacy Practices - b. Antidiscrimination policy - c. Grievance policy - d. Resident Rights. - e. A nursing facility that is a composite distinct part as defined in section 483.5 must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations - f. Resident Trust Fund. - g. Financial Agreement. - h. Smoking policies and procedures. -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on interview and record review the facility failed to update the medical practitioner of changes in daily weights for 1 (Resident 1) of 3 resident sampled. The facility census was 83. The findings are:Record review of the Facility Policy titled Changes in Resident's Condition or Status dated 08-29-2025 revealed the facility will notify, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status. The facility must immediately inform the resident and consult the resident's physician when there is a need to alter treatment significantly (That is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment.Record review of Resident 1's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 09-19-2025 revealed the facility staff assessed the following about the resident:-date of admission [DATE].-Brief…

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 12-006.09(H)(vi)(3)(g). Based on observation, interview and record review the facility failed to ensure residents were assisted with respiratory equipment and treatments for 1(Resident 1) of 3 residents sampled. The facility census was 83. The findings are:Record review of Resident 1's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 09-19-2025 revealed the facility staff assessed the following about the resident:-date of admission [DATE].-Brief Interview of Mental Status (BIMS) was scored as a 15. According to the MDS Manual a score of 13-15 indicates a person is cognitively intact. -required extensive assistance with dressing, hygiene and bed mobility.-required total assistance with transfers, toileting and bathing. -had a diagnosis of Heart Failure. Record review of Resident 1's Clinical Physician Orders (CPO) printed 11-06-2025 revealed an order dated 07-31-2025 for Oxygen with Bilevel Positive Airway Pressure (BiPAP: a treatment for sleep…

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 all food items in the kitchen's refrigerators and freezers were sealed, labeled, and dated, ensure food preparation (prep) was completed in a sanitary manner and per the menu, and ensure all kitchen equipment was cleaned to prevent foodborne illness. This had the potential to affect all 86 resident that consumed food from the kitchen. Findings are: A. A record review of the facility's Food Safety policy dated 05/01/2024 revealed all leftovers must be covered, labeled, and dated. An observation on 08/07/2024 at 7:03 AM revealed the following: The reach-in refrigerator in the kitchen: -1 open bag of a purple shredded substance was not sealed, labeled, or dated. -1 open zip lock style bag of a white chunk was not sealed or labeled. -1 bag of yellow slices not sealed. -1 clear cup of a liquid substance not sealed, labeled, or dated. -1 large zip lock style bag of a shredded green substance not labeled or dated. -1 opened package of bologna not sealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on record review and interviews, the facility failed to update and revise Care Plans for straight catheterization, wound care, tube feeding, and dental care for 4 (Resident 6, 68, 34, and 14) of 4 residents sampled. The facility census was 86. Findings are: A. Record review of Resident 6's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 6/18/24 revealed the resident's admission date was 6/7/24. Resident was unable to participate with the Brief Interview for Mental Status (BIMS, a brief screener to determine cognition) due to being rarely/never understood. According to the MDS, Resident 6 required supervision/touching assist with eating and was dependent for bed mobility, toileting, and transfers. The MDS also revealed the resident was always incontinent of urine and frequently incontinent of bowel. Resident 6's primary diagnosis was stroke. Other diagnosis included on the MDS were aphasia (non-speaking), 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 1.009.04(D) Based on observation and interview the facility failed to ensure safe water temperatures in resident bathrooms for rooms 101, 102, 109,113, 114, 117, 118, 120,122 and 123. This had the ability to affect 14 of the residents that reside at the facility. The facility census was 86. Findings are: Observation on 08-07-2024 at 9:00 AM of resident rooms revealed water temperatures in resident bathrooms were as follows: -room [ROOM NUMBER] of 132.4 degrees Fahrenheit (F). -room [ROOM NUMBER] of 131 degrees F. -room [ROOM NUMBER] of 126.5 degrees F. -room [ROOM NUMBER] of 125.4 degrees F. -room [ROOM NUMBER] of 129.4 degrees F. -room [ROOM NUMBER] of 124.9 degrees F. -room [ROOM NUMBER] 124.3 degrees F. -room [ROOM NUMBER] 123.4 degrees F. -room [ROOM NUMBER] 125.1 degrees F. -room [ROOM NUMBER] 124.5 degrees F. An interview was conducted with the facility Maintenance Supervisor (MS) on 07-08-2024 at 10:00 AM revealing the MS had taken a water temperature in room [ROOM…

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) Licensure Reference Number 175 NAC 12-006.18(C) Based on observations, record review and interview; the facility staff failed to ensure Resident 26, 38, and 42's respiratory equipment and supplies was cleaned and sanitized to prevent cross contamination, failed to implement enhanced barrier precautions during ADL care for Resident 14, and during catheter care for Resident 37, and failed to provide enhanced barrier signage for 1, Resident 68. The total sample size of the survey was 18. The facility staff identified a census of 86. Findings are: A. A record review of the facility's Bilevel Positive Airway Pressure (BiPAP)/Continuous Positive Airway Pressure (CPAP)(machines used to treat apnea) Administration Policy with a reviewed date of 09/26/2023 masks should be cleaned with soap and water as needed. A record review of the facility's Oxygen Administration policy with a revised date of 02/27/2024 revealed the exterior of the oxygen concentrators (a machine 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.

Licensure Reference Number 175 NAC 12-006.19(B) Based on record review, observation and interview the facility failed to maintain flooring in good repair for 12 resident rooms. This had the potential to affect 13 residents. The facility identified a census of 86. Findings are: A record review of the Facility policy titled Resident Belongings and Home Like environment, dated 06/12/2024. The policy states the facility will provide a safe, clean, and comfortable homelike environment. The policy included a section titled The facility must provide-This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. A tour with Mantenence Suppervisior (MS) on 8/13/2024 at 11:20 AM revealed 104, 105, 106, 108, 109, 111, 113, 114, 121, and 122. rooms did not have a transition strip between the hall carpet and the flooring in the resident's room. A tour with MS on 8/13/24 at 11:20 AM revealed 104, 113, 114, 122, 123, and 207 resident rooms had cracked or bubbled linoleum in…

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

Licensure Reference Number 175 NAC 12.006.09(J)(i)(1) Based on interview, and record review the facility failed to notify the resident's physician of a significant weight loss for 1 (Resident 37) of 1 resident sampled. The facility census was 86. The Findings are: Record Review of Resident 37's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 06-28-2024 revealed an admission date of 06-25-2024 following hospitalization for surgery of a diaphragmatic Hernia with Obstruction (is a protrusion of abdominal contents into the thoracic cavity due to a defect within the diaphragm), other diagnosis included Gastro Esophageal Reflux Disease (GERD, is a long-term condition that occurs when stomach acid flows back up into the esophagus), Benign Prostatic Hypertrophy (BPH, a non-cancerous condition that causes the prostate gland to enlarge in men), Barrett's Esophagus (is a condition in which the flat pink lining of the swallowing tube that connects the mouth to the stomach (esophagus) becomes damaged by acid reflux, which causes the lining to thicken 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 12.006.02(H) Based on observation, interview and record review the facility failed to report a fall resulting in serious bodily injury to the state agency for 1 (Resident 2) of 1 residents sampled. The facility census was 86. Findings are: Record Review of Resident 2's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 06-21-2024 revealed Resident 2 had diagnosis of Dementia, Chronic Obstructive Pulmonary Disease (COPD), anxiety and depression.The MDS also indicated Resident 2 needed staff to set up and supervise bathing and was independent with bed mobility, dressing, hygiene, and ambulation. Record Review of Resident 2's Progress Notes (PN) dated 08-08-2024 revealed Resident 2's roommate yelled for help and staff found Resident 2 on the bathroom floor, curled up on the right side. The PN also indicated the resident was crying and had bleeding from the right cheek. The facility staff called 911 and Resident 2 was transferred to 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 12.006.09(D) Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 57) of 1 sampled resident's tube feeding was on the Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 07/12/2024 and Insulin and Insulin injections were excluded from the 7/12/24 MDS. The facility census was 86. Findings are: A record review of the facility's Resident Assessment Instrument (RAI) & (and) Care Plan Development policy with a reviewed date of 08/22/2023 revealed the facility would follow the procedures in the RAI User's Manual 3.0 when completing the MDS and the facility must make a comprehensive (complete) assessment of the resident's needs, strengths, goals, life history, and preferences using the RAI. A record review of Resident 57's Clinical Census dated 08/08/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 57's Medical Diagnosis dated 08/08/2024 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.09(H)(vi)(3)(g) Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 26) of 5 sampled resident's oxygen order was followed and failed to ensure 1 (Resident 42) of 5 sampled residents had valid oxygen orders. The facility census was 86. Findings are: A record review of the facility's Physician Orders policy with a revised date of 02/26/2024 revealed a Physician, Physician's Assistant, or Nurse Practioner must provide orders for the resident's immediate care and ongoing care of the resident. A. A record review of Resident 26's Clinical Census dated 08/13/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 26's Medical Diagnosis dated 08/08/2024 revealed the resident had diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Morbid (severe) Obesity Due To Excess Calories (overweight), Chronic Respiratory Failure With Hypoxia (low oxygen), End Stage Renal Disease (kidney failure), Pleural…

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 observation, interview, and record review, the facility failed to ensure 2 (Resident 26 and 57) of 2 sampled resident's shunt site (an access point to a major artery) was assessed before and after each dialysis (mechanical treatment of the blood to clean it of impurities) treatment. The facility census was 86. Findings are: A record review of the facility's Hemodialysis Offsite Policy dated 04/17/2023 revealed the facility assures each resident received care and services for the provision of services which includes ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility and ongoing communication and collaboration with the dialysis facility. A. A record review of Resident 57's Clinical Census dated 08/08/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 57's Medical Diagnosis dated 08/08/2024 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.02(8) Based on interviews and record review, the facility failed to report abuse allegations to the facility's Administrator and state survey agency within the required timeframe of two hours and failed to submit final investigation reports to the state survey agency within five working days of the occurrences involving 5 (Residents #39, #149, #57, #66, and #53) of 5 residents reviewed for abuse, neglect, and misappropriation of property. Findings included: A review of the facility's undated policy titled, Area of Focus: Abuse & Neglect, revealed, 483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or…

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 interviews, record reviews, and facility document and policy review, the facility failed to thoroughly investigate allegations of abuse involving 5 (Residents #39, #149, #57, #66, and #53) of 5 residents reviewed for abuse, neglect, and misappropriation of property. Findings included: A review of the facility's undated policy titled, Area of Focus: Abuse & Neglect, revealed, 483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. 1. A review of Resident #39's admission Record revealed the facility admitted the resident on 04/30/2019 with diagnoses that included congestive heart failure (CHF), type two diabetes mellitus, atrial fibrillation, and major depressive disorder. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/16/2022, revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively…

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 12-006.12E1 Based on observations, interviews, and facility policy review, the facility failed to ensure medication and treatment carts were locked when not within line of sight for 4 (two treatment carts on the 100 Hall, one treatment cart on the 200 Hall, and one medication cart on the 200 Hall) of 8 carts in the facility. Findings included: Review of a facility policy titled, 5.3 Storage and Expiration Dating of Medications, Biologicals, revised 07/21/2022, revealed, 3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. During an observation on 07/12/2023 at 8:06 AM, there were two unlocked treatment carts (one light brown in color and the other dark brown in color) on 100 Hall, approximately 143 inches from the nurse at the medication cart who was administering medications. Licensed Practical Nurse (LPN) E was…

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 12-006.09D1c Based on observation, interviews, and record review, the facility failed to provide incontinence care to Resident #84 to ensure that no bowel movement remained on the resident before starting to put a new incontience brief on the resident. Findings included: Review of a facility policy titled, Pressure Injury Prevention, dated 05/04/2023, indicated, If diarrhea develops or if the patient is incontinent, follow these steps: Change underpads and briefs after soiling; and clean the skin with a no-rinse skin cleanser that has pH [acidity] similar to normal skin. A policy that specifically addressed incontinence care was requested but not provided. A review of Resident #84's admission Record revealed the facility initially admitted the resident on 10/26/2022 and readmitted the resident on 11/11/2022 with diagnoses that included malignant poorly differentiated neuroendocrine tumors, protein-calorie malnutrition, end stage renal disease, and dependence on renal dialysis. A review of the quarterly Minimum Data Set (MDS), with an Assessment…

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 observations, interviews, and record review, the facility failed to ensure a resident (Resident #9), who was not a candidate for self-administration, did not have a medication brought into the facility by a family member available for use at the resident's bedside. Findings included: A review of Resident #9's admission Record revealed the facility admitted the resident on 05/20/2022 with diagnoses that included enterocolitis, atrial fibrillation, chronic obstructive pulmonary disorder (COPD), peripheral venous insufficiency, heart disease, spontaneous migraine, typical atrial flutter, gastroenteritis and colitis, gastro-esophageal reflux disease (GERD), chronic kidney disease, long-term use of anticoagulants, and history of malignant neoplasm of the large intestine (colon cancer). The admission Record indicated the resident had a pacemaker. A review of the annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/21/2023, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 9, which…

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.