Emerald Nursing & Rehab Lancaster LLC

Statute 71-6018.02 Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) was present in the facility for at least 8 consecutive hours on 1/4/25 and 1/5/25. This had the potential to affect nursing care for all the residents that reside in the facility. The facility census was 174 at the time of survey. Finding are: Record review of nursing staffing schedules from 11/1/24 through 1/30/25 revealed no RN scheduled to work the weekend on 1/4/25 and 1/5/24. During an interview on 1/30/25 at 7:35 AM Nursing Assistant (NA) - M who was working as the staffing coordinator, confirmed that nursing staff titles were not listed on the staffing schedules and was unaware of which staff were RN's. Record review of the nursing schedule dated 1/4/25 revealed there was no RN in the building. Record review of the nursing schedule dated 1/5/25 revealed there was no RN in the building. Record review of daily posted nursing schedule for 1/4/25 revealed there were no RN hours marked. Record review of daily posted nursing schedule for 1/5/25 revealed there were no RN…

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

Licensure Reference Number 175 NAC 12-006.04(B)(ii) Based on record review and interview, the facility failed to provide the required 12 hours of ongoing training for 5 (Nursing Assistants (NA): NA-N, NA-O, NA-P, NA-R and Unit Director: UD-Q) of 5 sampled direct care staff. This had the potential to affect all the residents in the facility. The facility had a census of 174. Findings are: Record review of the facility policy titled Training Requirements dated 1/2024 revealed: -the staff Development Coordinator will maintain a training schedule and documentation system for completed training of the required individuals, -documentation of the required training will be forwarded to the HR Department to be placed into the individual's personnel file, -an individuals failure to complete required training will result in termination. Record review of the facility policy titled Required Training, Certification and Continuing Education of Nurse Aides dated 1/2024 revealed: -documentation of in-services will be maintained in the employee's personal file, -the in-services are required 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 12-006.11C Based on interviews, observations, and record reviews, the facility failed to perform hand hygiene for 20 seconds and wear a hair restraint while in the kitchen to prevent the potential for food-borne illness. The facility failed to ensure the ice machine was clean, food items were sealed, labeled, and dated, and outdated food were disposed of. The facility failed to ensure the scoop was not left in an ice cooler to prevent cross contamination. Facility reported that 173 residents receive food from kitchen. The facility census was 174. Findings are: A. Observation on 1/27/25 at 7:30 AM in the kitchen revealed the following: Foods found that were undated and/or opened or out of date: -In the dry storage area - chicken breaded powder not sealed and no date. - bag of macaroni open and not dated. In the walk-in freezer - 2 pieces of cake uncovered and not dated. - turkey patties opened and not dated. - grilled chicken breast fillets open and not dated. - Precooked pork breaded patties open and undated. In the walk-in refrigerator -5 bowls…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.18(B) Based on record review, interviews, and observations, the facility failed to transport laundry in a way to prevent cross contamination, place dirty linens into a soiled linen container, ensure Continuous Positive Airway Pressure (CPAP, a single pressure machine used to treat sleep apnea) and Bilevel Positive Airway Pressure (BiPAP, an inspiratory and expiratory pressure machine used to treat sleep apnea) cleaning for Resident 101, and change oxygen tubing for Residents 60 and 66 to prevent cross contamination. Findings are: A. On 1/29/25 at 9:19 AM observation of laundry aide (LA) that took clean gowns out of linen cart and held against [gender] uniform, then placed the gowns in another clean linen cart. LA dropped a clean towel on the floor, picked it up and placed the towel in the clean cart. Interview on 1/29/25 at 9:21 AM with LA confirmed that [gender] should not have linens against their body and if any linens fall to floor, they need placed in the dirty…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.19(A) Based on observation, interview, and record review, the facility failed to ensure the wall mounted oscillating (moved back and forth) fans' shrouds (cage around the blades) and blades in Rooms 204, 210, 213 and 233, the vent above the whirlpool in the Station 2 bathhouse, and the pivot stand (a device used to assist with resident transfers) in the Station 2 hallway were clean from lint and debris. The facility census was 174. Findings are: A record review of the facility's Cleaning and Disinfection - Environmental Infection Control policy dated 1/2024 revealed environmental surfaces would be disinfected (or cleaned) on a regular basis (e.g. (for example), daily, three times per week), and when surfaces were visibly soiled. A record review of the facility's Survey Readiness Environmental Checklist log sheets did not reveal it included the bathhouses, pivot stand, or room fan cleaning. A record review of the facility's undated Environmental Service Associate…

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 12-006.04J(i) Based on record review and interview, the facility failed to have a qualified Activity Professional. The failure to have an Activity Professional had the potential to affect all residents that participate in activities in the facility. The facility had a census of 174. Findings are: During an interview on 1/30/25 at 9:19 AM the Activity Director (AD) confirmed that (gender) has not had any activity training. Record review of the AD's credentials revealed no Activity training. Record review of the undated Facility Assessment revealed the nursing facilities will conduct, document, and annually review a facility wide assessment which includes the facility needs to care for their residents. Record review of the facility policy titled, Facility Responsibilities dated 1/2024 revealed that the facility must ensure that staff members are educated on the rights of residents and the responsibilities of the facility to properly care for the residents. Interview on 1/30/25 at 12:29 confirmed that the Manager of Operations (MOO) is the activities…

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 reviews and interviews, the facility failed to provide written notice of transfer to residents or their representatives prior to a transfer for 4 (Residents 16, 85, 99, and 115) of 4 sampled residents for hospitalizations. or their representatives prior to a transfer to the hospital. The facility census was 174. Findings are: A record review of the facility's Transfer and Discharge from the Facility Policy dated 1-2024 revealed the following: The facility should provide notice in writing and in a manner and language that is understood. The notice should include at minimum the reason and effective date of the discharge/transfer, the location where the resident was transferred, a statement of the resident's appeal rights, the name, mailing address, email address and telephone number of the agency that receives discharge appeal requests, information about how to obtain an appeal form, title of the facility staff who will assist the resident to complete and submit the form, and the name, mailing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09B Based on record review and interview; the facility failed to ensure the Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) reflected the current number of unhealed pressure ulcers/injuries (injury to the skin and underlying tissue resulting from prolonged pressure on the skin) for one (Resident 153) of 34 sampled residents. The facility census was 174. Findings are: A review of Resident 153's tissue analytics, dated 1/8/25, revealed the following: -Wound 4: Right hand; primary etiology: pressure ulcer-unstageable; eschar (thick dark brown or black dead tissue that adheres to a wound): fully covered A review of Resident 153's MDS, dated [DATE], revealed the following: -Does this resident have one or more unhealed pressure ulcers/injuries? Marked Yes -Current number of unhealed pressure ulcers/injuries at each stage: All stages marked 0 including unstageable-slough (yellow/white dead…

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)(2) Based on observations, interview and record review the facility failed to ensure activities were provided to meet the resident's needs for 3 (Residents 109, 133, and 168) of 3 sampled residents on the Alzheimer's Unit. The facility had a total census of 174. Findings are: Observation on 1/27/24 at 10:10 AM of station 5 with no activities written on the activity board and there were no activities going on noted on station 5. Record review of activity calendar for station 5 revealed that café cart and Catholic Mass activity should have been going on station 5 at this time and observation of no activity. During an interview on 1/27/25 at 9:38 AM Nursing Assistant (NA) - K revealed that there is not an activity person, a bath aide or a restorative aide scheduled to be on station 5 and the residents don't do scheduled activities. Observation on 01/27/25 at 2:25 PM of no activities being done on station 5. Record review of activity calendar for station 5 revealed…

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)(vi)(3) Based on observation, interview and record review; the facility failed to ensure a complete, valid prescription was obtained for a Continuous Positive Airway Pressure (cpap-a machine used to deliver positive airway pressure to a resident's airway to prevent it from closing during sleep) for 1 (Resident 60) of 3 sampled residents. The facility census was 174. Findings: A. An observation on 1/27/25 at 12:33 PM revealed a cpap machine on Resident 60's bedside stand. An interview on 1/27/25 at 12:33 PM with Resident 60 confirmed that [gender] wears the cpap every night. In a review of Resident 60's Order Summary Report, dated 1/28/25, revealed the following: -CPAP at current setting with oxygen. Connect O2 (oxygen) tubing to mask, apply at night and fill chamber with distilled water to the fill line. In an interview on 1/29/25 at 3:42 PM, the Director of Nursing (DON), confirmed that there was not a complete, valid prescription with the current settings for Resident 60's cpap.

Licensure Reference Number NAC 12-005.06(H) Based on interviews and record review the facility failed to employ an Infection Preventionist (IP). This had the potential to affect all the residents living at this facility. The census of the facility was 178. Findings are: Record review of Infection Prevention and Control Program Policy dated 5/20/2017 revealed: -The designated Infection Preventionist serves as a consultant to our staff on infectious diseases, resident room placement, implementing of isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. Record review of Antibiotic Stewardship and Infection Control Surveillance Record revealed no documentation for November 2024. Interview on 11/20/24 at 6:58 AM with Director of Nursing (DON) revealed the facility has not had an IP since mid-October 2024. The facility has hired a new nurse and will have them trained for IP. DON confirmed that infection control duties had not been done since October 2024. Interview on 11/20/24 at 8:26 AM with 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 Based on record review and interviews the facility failed to assess and monitor for potential signs and symptoms of a urinary tract infections for 1 (Resident 2) of 3 sampled residents. The census of the facility was 178. Findings are: Record review of Resident 2's census record dated 11/19/24 revealed the resident admitted to the facility admitted on [DATE]. Record review of Resident 2's Minimum Data Set, MDS, a comprehensive assessment of each resident's functional capabilities) dated 11/3/24 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) was 15, which means the resident is cognitively intact. Record review of Resident 2's Physician orders dated 11/19/24 revealed: -Cephalexin Capsule 500 milligram (mg). Take one capsule by mouth every 6 hours for 5 days-indications for use: Urinary Tract Infection (UTI) -Start 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number NAC 12.005.06(D)(E) Based on observations, interviews and record review the facility failed to perform hand hygiene for 20 seconds and wear personal protective equipment (PPE) throughout wound care for 1 (Resident 9) of 1 sampled residents. The facility census was 178. Findings are: Record review of MDRO PPE-Enhanced Barrier Precautions policy dated 1/2023 revealed: Policy Statement-Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. Record review of Infection Control Standard Precautions-Handwashing policy dated 1/2024 revealed: Policy Statement-The facility considers hand hygiene the primary means to prevent the spread of infections. Procedure: -Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. Record review of Resident 9's November 2024's Medication Administration Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.05(E) Based on observations, record reviews, and interviews, the facility failed to honor preferences for religious practices for Resident 2 and bathing preferences for 5 residents (Residents 1, 4, 5, 6, and 7). This affected 6 of 7 residents sampled for choices. The facility census was 175. Findings are: A. A record review of the facility policy Quality of Life-Resident Self Determination and Participation revised December 2016 revealed that each resident was allowed to choose activities and schedules consistent with their interests and values, including religious affiliation and worship preferences. A record review of the facility policy Resident Rights created 11-17 revealed that the resident had a right to participate in activities, including religious, that did not interfere with the rights of other residents in the facility. A record review of Resident 2's admission Record printed 09/19/2024 revealed the resident was admitted to the facility on [DATE] 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.02(G) and (H) Based on record review, observation, and interviews; the facility failed to ensure a formal investigation was completed and the State Agency was notified for 2 (Residents 1 and 2) of 3 sampled resident's elopement. The facility census was 198. Findings are: A record review of the facility's undated Missing Resident/Elopement Procedure revealed all nursing staff were responsible for knowing the whereabouts of residents for which they were assigned. Each resident was required to advise the nurse in charge when the resident left the building. Residents were not permitted to leave the building alone unless a physician order was present. Residents identified as cognitively impaired and assessed as an elopement risk were to be provided with an elopement prevention device and all personnel were responsible for promptly going to the location and determining the cause of an activated audible door alarm. In the event a resident cannot be located the charge nurse of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review and interviews, the facility failed to notify the physician of change of condition for 1 (Resident # 1) of 3 sampled residents. The facility census was 210. Findings are; A record review of the admission Record indicated the facility admitted Resident # 1 on 8/7/2023 with diagnoses of Urinary tract infections (an infection in your urinary system), Type 2 diabetes Melllitus (is a chronic condition that happens when you have persistently high blood sugar levels. Insulin resistance is the main cause), Bacterial Infection (microorganisms that invade tissue), Other Specified Disorders of Kidney and Ureter (urinary tract infections, kidney stones, bladder control problems, and prostate problems), Dysphagia (Difficulty swallowing), Unspecified Cognitive Communication Deficit (Reduced awareness and ability to initiate and effectively communicate needs), Unspecified Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance,…

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 Based on record review and interview the facility failed to provide an escort and or family member to a Cat Scan appointment for 1 (Resident #2) out of 3 sampled residents. The facility census was 210. Findings are: A record review of admission Record revealed that Resident #2 was admitted to the facility on [DATE] with diagnoses of Aphasias following Cerebral Infarction (trouble talking or understanding what other people are saying when they're talking. They may also struggle to communicate in other ways like writing), Unspecified Sequelae of Cerebral Infarction (cognitive functions following cerebral infarction. Speech and language deficits following cerebral Infarction), Epilepsy, unspecified, not intractable, without status Epilepticus ( may have seizures again and again. May have status epilepticus if you have a seizure that lasts longer than 5 minutes, or if you have more than one seizure without returning to a normal level of consciousness between episodes),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09D Based on observation, interview, and record review; the facility failed to ensure interventions were in place as care planned for one (Resident 1) of three sampled residents. The facility censure was 209. Findings are: Review of Resident 1's admission record, dated 3/13/24, revealed that Resident 1 admitted to the facility on [DATE] and had the following diagnoses: senile degeneration of the brain (also known as late onset dementia), nontraumatic subarachnoid hemorrhage (bleeding in the area between the brain and thin tissues that cover and protect it) and restlessness and agitation. Review of Resident 1's Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care), dated 2/26/24, revealed the following: -Severely impaired for decision regarding tasks of daily life -Was dependent for all Activities of Daily Living (ADLs) and transfer from chair to bed -Sit to standing and ambulation 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 Number 175 NAC 12-006.05(4) Based on interview and record review, the facility failed to provide bathing preferences for 1 (Resident 4) of 7 sampled residents. The facility census was 216. Record review of Resident 4's undated admission Record revealed that Resident 4 admited to the facility on 7/20/22. Record review of Resident 4's Minimum Data Set (MDS -a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 12/20/23 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) of 15, which indiciated the resident was cognitively intact. In an interview on 2/12/24 at 12:05 PM with Resident 4 revealed they wanted a bath twice weekly and they have not been recieving that preference. A record review of Resident 4's bathing tasks documented in Electronic Medical Records for December 2023 baths were documented on 12/5/23 and 12/29/23. The resident was in the hospital 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 12-006.11E Based on observation, interview, and record review; the facility kitchen staff failed to label, and date opened packages of food and failed to dispose of expired food and fluids from the walk-in refrigerators and walk in freezer to prevent the potential for food borne illness. This had the potential to affect 206 residents. The facility census was 207. Findings are: Observation on 1/17/2024 at 7:15 AM of the walk-in refrigerator in the main kitchen closest to the dry storage room revealed: - three opened containers of coleslaw dated 1/5/2024, 1/7/2024, and 1/8/2024, - container of prepared yellow jello dated 1/3/2024, - pan of cooked sweet potatoes dated 1/7/2024, - bowl of cooked hamburger dated 1/9/2024, - container of what appears to be tomato soup with no date, - pan of pork gravy dated 1/12/2024, - 2 jugs of Sparky's Wing and Dippin sauce that says opened 1/1/2024 but expiration date of 7/28/2023, - jug of opened picante sauce with expiration date of 9/1/2023, - a packaged of opened tomato slices covered in saran wrap dated…

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 F. A record review of the untitled and undated list provided by the Director of Nursing (DON) revealed that the facility had 19 residents that had tested positive for Covid-19 (a mild to severe respiratory illness that is caused by a coronavirus) and that Station 5 had 3 residents in room isolation due to testing positive for Covid-19. An observation on 01/17/24 at 10:43 AM revealed NA-W to be standing at the nurses' desk with an isolation mask below (gender) nose. During the observation, the Unit Manager had instructed NA-W to wear (gender) mask correctly. An observation on 01/18/24 at 8:08 AM revealed MA-X to be standing at the medication cart with an isolation mask below (gender) nose. An interview on 01/18/24 at 8:08 AM with MA-X confirmed that staff are to wear their isolation masks above their nose. During the interview, MA-X voiced getting COVID-19 (a mild to severe respiratory illness that is caused by a coronavirus) training and education just last week and voiced that ongoing Covid-19 training occurred…

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 12.006.18A1 Based on record review, observations, and interviews, the facility failed to ensure that station 2's clean utility refrigerator, microwave, and icemaker were clean, open items in the refrigerator were dated, exhaust vent fans were cleaned in resident restrooms 234, 214, 216, 211, 204, 231, 306 and 431, and that the wall fans were clean in resident rooms 214, 204, 231, 228, 228, 315, 306, 424, and 431. The total facility census was 207. Findings are: A. A record review of the facility's Food Safety Requirements policy dated 05/2017 revealed food that required refrigeration would be received by the facility designee for proper and immediate storage including labeling and dating. A record review of the facility's undated Cleaning Instructions: Refrigerators policy revealed the refrigerators would be washed thoroughly inside and out with a detergent followed by sanitizer at least once every other month or as needed. Spills and leaks would be wiped up as they were…

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

Licensure Reference Number 175 NAC 12-006.05(21) Based on record review, observation, and interview, the facility failed to treat 1 resident (Resident 18) of 2 sampled with dignity and respect by failing to provide privacy while performing peri-care. The facility census was 207. Findings are: Record review of Resident 18's Clinical Resident Profile dated 1/18/2024 revealed that [gender] admitted to facility on 7/20/2006 with diagnoses of: cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), hemiplegia (paralysis of one side of the body) affecting left nondominant side, cerebral infarction (disrupted blood flow to the brain), contracture (fixed tightening of muscle, tendons, ligaments, or skin) of right knee, pain, and bilateral hearing loss. A record review of the Quarterly MDS (Minimum Data Set) (comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 11/11/2023 revealed: -Brief Interview for Mental Status (BIMS) (a test used to get a quick snapshot of a resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.02(8) Based on interview and record review, the facility failed to ensure Adult Protective Services (APS) and the State of Nebraska Department of Health and Human Services (DHHS) were notified of a resident-to-resident abuse incident on 11/17/2023 between 2 (Residents 88 and 140) of 4 sampled residents. The total facility census was 207. Findings are: A record review of the facility's Abuse, Neglect and Exploitation Policy dated 11/2017 revealed the that abuse meant the willful infliction of injury, unreasonable confinement, intimidation, or punishment. Physical abuse included hitting, slapping, pinching, and kicking. The facility must report all allegations (claims) of abuse to APS within 2 hours for events that caused serious bodily injury, or not later than 24 hours for events that did not result in serious bodily injury and must send the report to DHHS within 5 working days. A record review of Resident 140's Clinical Census dated 01/18/2024 revealed the resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY B) A record review of Resident 143's undated Face Sheet revealed, that Resident 143 was admitted on [DATE] with the diagnosis of Mood disorder, Major depressive disorder, Bipolar disorder, and anxiety disorder. Resident 143 had a score of 14 on the BIMS indicating Resident 143 is cognitively intact. A record review of Resident 143's PASSAR II (is a comprehensive evaluation required as a result of a positive level I screening. A level II is necessary to confirm the indicated diagnosis noted in the level I screening and to determine whether placement or continued stay in a Nursing Facility is appropriate.) dated 2/28/23 revealed: The PASRR reported Resident 143 has a reported mental health diagnosis of anxiety, bipolar disorder, and major depressive disorder. A record review of the Minimum Data Set, (MDS), (a comprehensive assessment of each resident's Functinal capabilities) annual dated 10/26/23 revealed, in section 1500 reads: Is the resident currently considered by the state level II PASRR process to have…

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 Based on record review, observations, and interviews, the facility failed to ensure blood pressures, pulses, and labwork were completed as ordered for 1 (Resident 140) of 1 sampled resident, failed to maintain wheelchair positioning for 1 (Residents 62) of 2 sampled residents, and failed to ensure Dycem (a material used to prevent sliding) was placed on wheelchair, scoop mattress provided, failed to unsure the recommeded lift was used during transfers, and did not provide built up silverware for 1(Resident 34) of 1 sampled residents. The total facility census was 207. Findings are: A. A record review of Resident 140's Clinical Census dated 1/18/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 140's Medical Diagnosis dated 1/18/2024 revealed the resident had diagnoses of: Paroxysmal Atrial Fibrillation (irregular heart rate), Other Supraventricular Tachycardia (SVT)(irregular rapid heart rate), Fluid Overload, Venous…

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 12-006.12E1 Based on observations, interviews and record review, the facility failed to ensure that medications were secured in a locked compartment for 1 (Resident 92) of 1 sampled resident for medication storage. The facility census was 207. Findings are: A review of Resident 92's admission Record revealed the resident was admitted on [DATE] with diagnoses of: cellulitis (skin infection) of the left leg, diabetes (a chronic health condition that affects how the body turns food into energy), and a recent left second toe amputation (removal of a body part). A review of the resident's admission and 5-day Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) dated 12/23/23 revealed Resident 92's Brief Interview of Mental Status (BIMS-an assessment used in long-term care to evaluate a person's cognitive [thinking] abilities) was 09, indicating moderate cognitive impairment. An observation of Resident 92's room on 01/17/2024 at 9:57 AM revealed 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 NUMBER 175 NAC 12-006.12E1 Based on observations, record reviews and interviews; the facility staff failed to secure 4 of 10 medication storage carts when unattended. The facility staff identified a census of 213. Findings are: Observation on 8-24-2023 at 7:20 AM revealed medication storage carts were unlocked and unattended on station 3 A and 3 B. On 8-24-2023 at 7:40 AM an interview was conducted with Registered Nurse (RN) G. During the interview RN G confirmed the medication storage carts on station 3 A and 3 B were unlocked and unattended. RN G reported medication carts are to be locked. Observation on 8-27-2023 at 7:45 AM revealed the medication storage cart was unlocked and unattended on Station 4. On 8-27-2023 at 7:45 AM during the observation The Director of Nursing confirmed the medication cart was unlocked and unattended. Observation on 8-27-2023 at 8:42 AM revealed the medication storage cart on station 5 was unlocked and unattended. On 8-27-2023 at 8:42 AM an interview was conducted with Licensed Practical Nurse (LPN) F. During the interview LPN F…

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 12-006.181(1) Based on observations, and interviews: the facility staff failed to ensure 2 (station 4 and 5) of a total of 5 stations were clean and in good repair. The facility staff identified a census of 213. Findings are: A. Observation on 8-27-2023 at 7:20 AM revealed a a brown liquid that had an odor of stool was dripping from a residents wheelchair as the resident wheeled in-between the nurses station and the dining room on station 4. A another facility resident informed Nursing Assistant (NA) C of the mess on the floor. NA C was able to obtain assistance for the resident in the wheelchair, however, the brown stool smelling liquid was not clean up. Further observations revealed 3 random staff walked through the brown liquid and 3 residents were wheeled through the brown liquid on the floor. B. Observations during a tour of station 4 and station 5 on 8-27-2023 at 2:02 PM and ending at 2:31 PM with the facility Administrator and Company Director (CD) revealed the following…

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 12-006.04C3a(6) Based on record review and interview; the facility staff failed to notify the resident's representative of falls for 2 ( Resident 1 and 4) and failed to notify the residents representative of being transported to the hospital for 1( Resident 7) of a total of 7 sampled residents. The facility staff identified a census of 213. Findings are: A. Record review of Resident 1's Minimum data set (MDS, a federally mandated assessment tool used for care planning) dated 6-30-2023 revealed the facility staff assessed Resident 1 with a Brief Interview of Mental Status) BIMS of a 5. According to the MDS [NAME] a BIMS score of 0 to 7 indicate severe cognitive impairment. Record review of Resident 1's Comprehensive Care Plan (CCP) revised on 12-30-2022 revealed Resident 1 was at risk for falls. The goal identified for Resident 1 was to be free of major or injury. Interventions identified on Resident 1's CCP to meet this goal included keeping items within reach, using wheelchair…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observations record review and interviews; the facility staff failed to implement assessed interventions for fall prevention for 3 (Resident 1, 3 and 4) of 4 sampled residents. The facility staff identified a census of 213. Findings are: A. Record review of Resident 1's Minimum data set (MDS, a federally mandated assessment tool used for care planning) dated 6-30-2023 revealed the facility staff assessed Resident 1 with a Brief Interview of Mental Status) BIMS of a 5. According to the MDS [NAME] a BIMS score of 0 to 7 indicate severe cognitive impairment. Record review of Resident 1's Comprehensive Care Plan (CCP) revised on 12-30-2022 revealed Resident 1 was at risk for falls. The goal identified for Resident 1 was to be free of major or injury. Interventions identified on Resident 1's CCP to meet this goal included keeping items within reach, using wheelchair and bed alarms and ensuring the residents call light is within reach. Observation on 8-24-2023 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D4 Based on observations, record review and interview; the facility staff failed provided incontinence care for 1(Resident 1) of 3 residents sampled. The facility staff identified a census of 213. Findings are: Record review of Resident 1's Minimum data set (MDS, a federally mandated assessment tool used for care planning) dated 6-30-2023 revealed the facility staff assessed Resident 1 with a Brief Interview of Mental Status) BIMS of a 5. According to the MDS [NAME] a BIMS score of 0 to 7 indicate severe cognitive impairment. Record review of Resident 1's Comprehensive Care Plan (CCP) revised on 1-26-2023 revealed Resident 1 is incontinet of bladder. The goal identified for Resident 1 was to be continent at all time. The intervention listed on Resident 1's CCP was to change Resident 1 frequently and as needed. Observation on 8-27-2023 at 7:10 AM revealed Resident 1 was laying in bed with a sheet covering the abdominal area and in between the legs. Further observations…

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 12-006.11E Based on observation and interview, the facility failed to prevent the potential for cross contamination related to food that was not dated upon opening and dietary staff that did not have hair/beard coverings in place during food handling. This had the potential to affect 184 of 186 residents that received food from the kitchen. The facility census was 186. Findings are: An observation on 02/21/23 at 08:31 AM of the kitchen revealed Cook-M to be completing meal prep with no beard cover in place and dread locks not in a hair cover. The walk through of the walk-in fridge on 02/21/23 at 08:31 AM revealed a container of shredded cheese with no open date, a container, opened and half used of whipped cream with no open date, and a gallon of milk, half used with no open date. The walkthrough of the walk-in freezer revealed a ready to serve container of pureed sausage with no date, pureed oats with no date, and pureed eggs with no date. An interview on 02/21/23 at 08:31 AM with the FSD (Food Service Director), confirmed that all food is to be dated…

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 12-006.17A(1) Based on observation, record review and interviews, the facility failed to ensure all dietary staff wore facial coverings in a manner to prevent the potential spread of COVID-19 (a mild to severe respiratory illness that is caused by a coronavirus) to 184 of 186 residents that consumed food from the kitchen, failed to ensure staff wore masks covering the nose and chin, failed to clean and store a nebulizer kit (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) for Resident 441, failed to ensure staff doffed (removed) PPE (Personal Protective Equipment) prior to exiting a COVID-19 positive isolation room, failed to disinfect eye protection when exiting an isolation room to prevent the potential spread of COVID-19, failed to ensure doors of COVID-19 isolation rooms were kept closed, and failed to deliver laundry in a covered cart in resident care areas. This had the potential to affect all 186 residents in the facility. 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.

175 NAC 12-006.12E1 Based on observations, record review, and interviews, the facility failed to ensure medications were securely stored for Resident 46 and the facility failed to ensure medication carts on Stations 2 and 3 were secured when not in use. This had the potential to affect 43 residents on Station 2 and 19 residents on Station 3. The facility census was 186. Findings are: A. An observation made on 2/21/23 at 3:52 PM revealed that Resident 46 had a roll-on container of Icy Hot on the overbed table next to the recliner. An observation made on 2/22/23 at 8:00 AM revealed that Resident 46 had a roll-on container of Icy Hot on the overbed table next to the recliner. An observation made on 2/27/23 at 7:40 AM revealed that Resident 46 had a roll-on container of Icy Hot on the overbed table next to the recliner. A review of the Resident 46's active orders revealed an order for pain relieving cream 4 times a day that the resident may keep at bedside. A review of Resident Self-Administration of Medication policy created 11-17 revealed the following: 7. Bedside medication storage…

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

175 NAC 12-006.16E Based on record reviews and interviews, the facility failed to provide notice to Medicaid recipients when their Resident Trust Account (RTA) balances were within $200.00 of the maximum allowed in cash assets. This had the potential to affect 2 Residents (27 and 34) of 3 sampled for Personal Funds. The facility census was 186. Findings are: A. A review of Resident 27's Clinical Census revealed that the resident's payment source was Medicaid. An interview conducted with the Business Office Manager (BOM) on 2/28/23 at 9:19 AM revealed that Resident 27 did have a Resident Trust account. B. A review of Resident 34's Clinical Census revealed that the resident's payment source was Medicaid. An interview conducted with the Business Office Manager (BOM) on 2/28/23 at 9:19 AM revealed that Resident 34 did have a Resident Trust account. C. A review of The Nebraska Department of Health and Human Services Medicaid Eligibility website (https://dhhs.ne.gov/Pages/Medicaid-Eligibility.aspx) revealed that cash resources should not exceed $4000.00 for one person. An interview…

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 provide written notice of transfer to Resident 24 and 34 or their Representatives upon transfer to the hospital. This affected 2 of 3 residents sampled for hospitalizations. The facility census was 186. Findings are: A. A review of Resident 24's Progress Notes from 10/22/22 to 2/23/23 revealed that the resident had gone to the emergency room (ER) on 10/26/22 for leg pain, on 12/16/22 for abdominal pain, and on 2/18/23 for a fall. An interview conducted with the Clinical Consultant (CC) on 2/23/23 at 2:20 PM confirmed that no written notices of transfer were provided to Resident 24 or the resident's representative for the ER visits on 10/22/22, 12/16/22, or 2/18/23. An interview conducted with the Director of Social Services (SW) L on 2/23/23 at 2: 56 PM confirmed that written notices of transfer were not provided to the resident or their representative for the ER visits on 10/22/22, 12/16/22, or 2/18/23. L further confirmed that the Ombudsman was not notified of those transfers. B. A review of Resident 34's Progress Notes…

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 provide notice of the Bed Hold Policy to Resident 24 or their Representative upon transfer to the hospital. This affected 1 of 3 residents sampled for hospitalizations. The facility census was 186. Findings are: A review of Resident 24's Progress Notes from 10/22/22 to 2/23/23 revealed that the resident had gone to the emergency room (ER) on 10/26/22 for leg pain, on 12/16/22 for abdominal pain, and on 2/18/23 for a fall. An interview conducted with the Clinical Consultant (CC) on 2/23/23 at 2:20 PM confirmed that no notices of the Bed Hold Policy were provided to Resident 24 or the resident's representative for the ER visits on 10/22/22, 12/16/22, or 2/18/23. An interview conducted with the Director of Social Services (SW) L on 2/23/23 at 2: 56 PM confirmed that notices of the Bed Hold Policy were not provided to the resident or their representative for the ER visits on 10/22/22, 12/16/22, or 2/18/23.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) accuracy related to the ADL (Activities of Daily Living) ability for Resident 97 and a diuretic medication (a medication used that causes the kidneys to make more urine) use for Resident 153. The sample size was 4. The facility identified a census of 186. Findings are: A. A record review of the MDS dated [DATE], Section G, for Resident 97, read as follows: A. Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture with a response of 0 Independent for Self Performance and 0 Independent for physical assist. A record review of the MDS dated [DATE], Section G, for Resident 97, read as follows: B. Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet) with a response reading : 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.

Based on interview and record review, the facility failed to complete a new Preadmission Screening and Annual Resident Review (PASARR)(a screening for mental illness) for Resident 146 following a new Bipolar Disorder (a disorder associated with episodes of mood swings) diagnosis. Total census was 186. Findings are: A record review of the Preadmission Screening and Annual Resident Review Policy dated 05-17 revealed the facility would refer all residents with a newly evident or possible serious mental disorder for a level II PASARR review to the State PASARR representative. A record review of the facility's Pharmacy Note To Attending Physician/Prescriber dated 10/01/2022 revealed that Resident 146 was started on Depakote (a medication that can be used to treat Bipolar Disorder) was started on 09/29/2022. The Pharmacy requested an associated medical diagnosis. The provider's response was Bipolar Disorder. A record review of Resident 146's Medical Diagnosis dated 02/22/2023 revealed a diagnosis of Bipolar Disorder was added during the resident's stay on 10/27/2022. 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 Number 175 NAC 12-006.04C7 Based on interview and record review, the facility failed to ensure 1 (Resident 12) of 1 sampled resident was treated for constipation in a timely manner. Total census was 186. Findings are: A record review of the facility's undated Admission/Ancillary Orders revealed the facility's Bowel Protocol per the facility's policy was to administer (give) a Dulcolax Suppository (a medication inserted into the rectum to dissolve and soften stools) as needed to residents with no bowel movement on day 4. In an interview on 02/21/2023 at 01:02 PM, Resident 12 confirmed that the resident had gone greater than 3 days with no bowel movement and had not received treatment from the staff. A record review of the facility's Medication Administration Report (MAR) dated 02/01/2023 -02/28/2023 revealed Resident 12 had an order for a Bisacodyl Suppository (brand name Dulcolax) on day 4 of no bowel movement. A record review of Resident 12's 30 Day Bowel Elimination Task dated 01/01/2023 - 02/28/2023 revealed the resident did not have a bowel movement from 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 12-006.09D4 Based on observation, record review and interview; the facility failed to ensure a restorative nursing program was provided per therapy recommendation, to maintain and/or to prevent potential decline and/or complications of contractures (a condition of shortening and hardening of muscles, tendons, or other tissue often leading to deformity and/or rigidity of joints), mobility, or range of motion (ROM) for Resident 60 and Resident 146. The sample size was 4 and the facility census was 186. Findings are: A. A record review of Resident 60's medical diagnoses, dated 8/27/21, revealed a diagnosis of hemiplegia and hemiparesis (weakness on one side of the body) following cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area) affecting right dominant side. A record review of Resident 60's Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a resident's care plan), dated 2/6/23,…

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 12-006.07a Based on observation, interview, and record review, the facility failed to ensure Resident 146 was assisted to bed after mealtime to prevent accidents, failed to ensure safe storage of Resident 153's cigarettes and lighter, and failed to ensure residents smoke in designated areas. This affected 2 of 2 sampled residents. Total census was 186. Findings are: A. A record review of the facility's Accidents and Incidents Policy dated 05-01-2017 revealed the facility strives to ensure residents will not experience undue discomfort due to an unusual occurrence such as an accident or incident. In an interview on 02/22/2023 at 09:24 AM, Resident 146 confirmed that the resident had fallen a couple of times since January 1, 2023. A record review of the facility's Incident Audit Report with an Incident date of 12/31/2022 at 04:15 PM revealed Resident 146 had an unwitnessed fall on 12/31/2022 at 04:15 PM. During the fall investigation, A Situation, Background, Assessment, 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 12-006.04C7 Based on observation, interview, and record review, the facility failed to ensure the facility was staffed sufficiently to prevent potential accidents. This affected 1 (Resident 146) of 2 sampled residents. Total census was 186. Findings are: A record review of the facility's Accidents and Incidents Policy dated 05-01-2017 revealed the facility strives to ensure residents will not experience undue discomfort due to an unusual occurrence such as an accident or incident. In an interview on 02/22/2023 at 09:24 AM, Resident 146 confirmed that the resident had fallen a couple of times since January 1, 2023. A record review of the facility's Incident Audit Report with an Incident date of 12/31/2022 at 04:15 PM revealed Resident 146 had unwitnessed fall on 12/31/2022 at 04:15 PM. During the fall investigation, A Situation, Background, Assessment, and Recommendation (SBAR) Communication Form and Progress Note had been completed and dated 12/31/2022 at 06:30 PM by Registered…

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.