Prestige Care Center of Nebraska City

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(I)(i)(3)Based on record review and interview, the facility failed to implement interventions to prevent falls for 1 (Resident 3) of 3 sampled residents; and the facility failed to investigate causal factors and implement interventions to prevent skin tears for 1 (Resident 2) of 1 sampled resident. The facility staff identified a census of 41.The findings are:A. Record review of a facility policy entitled Fall Prevention Program dated revised 7/2025 revealed: -9. When any resident experiences a fall, the facility will: -a. Assess the resident. -b. Complete a post-fall assessment. -c. Complete an incident report. -d. Notify physician and family. -e. Review the resident's care plan and update as indicated. -f. Document all assessment and actions. -g. Obtain witness statements in the care of injury.Record review of Resident 3's admission Record revealed the facility admitted the resident on 12/2/2015. Further review of the admission record showed Resident 3 had diagnoses…

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 complete a thorough investigation for an allegation of abuse for 1 (Resident 1) of 3 sampled residents. The facility staff identified a census of 43.The findings are:Record review of a facility policy entitled Abuse, Neglect and Exploitation dated revised 01/2025 revealed: -A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. -B. Written procedures for investigations include: -1. Identifying staff responsible for the investigation; -2. Exercising caution in handling evidence that could be used in a criminal investigation. -3. Investigating different types of alleged violations; -4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; -5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; 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.

Based on record review and interview, the facility failed to provide federally required transfer documentation to the receiving health care institution for 2 (Resident 1 & 2) of 3 sampled residents. The facility staff identified a census of 43.The findings are:Record review of a facility policy entitled Transfer and Discharge (including AMA) dated revised 2/2025 revealed: -8. For a transfer to another provider, for any reason, the following information must be provided to the receiving provider: -a. Contact information of the practitioner who was responsible for the care of the resident; -b. Resident representative information, including contact information; -c. Advance directive information; -d. All other information necessary to meet the resident's needs, which includes but may not be limited to: -i. Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; -ii. Diagnoses and allergies; -iii. Medications (including when last received); and -iv. Most recent relevant labs, other diagnostic tests, and recent…

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(I)Based on observation, interview, and record review, the facility failed to implement interventions to prevent potential falls for 1 (Resident 2) of 3 sampled residents. The facility staff identified a census of 43.The findings are:Record review of a facility policy entitled Fall Prevention Program dated revised 7/2025 revealed: -Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. -6. High Risk Protocols: -c. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. d. Provide additional interventions as directed by the resident's assessment, including but not limited to: -i. Assistive devices -ii. Increased frequency of rounds -iii. Sitter, if indicated -iv. Medication regimen review -v. Low bed -vi. Alternate call system access -vii. Scheduled ambulation or toileting assistance -viii. Family/caregiver…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.18 Based on observation, interview and record review, the facility failed to maintain the cleanliness and condition of walls, floors, fixtures, doors, carpets, bathroom ceiling ventilation covers in 17 (rooms 104, 106, 108, 110, 111, 213, 214, 215, 216, 217, 218, 219, 220, 221, 222, 319 and 324) of 28 occupied resident rooms in the facility. The facility census was 40. Findings are: Observation on 11/06/24 between 8:00 AM and 4:00 PM, during the initial pool observations of resident rooms, revealed the following environmental concerns: - The caulking surrounding the base of the toilet was cracked and broken in resident bathrooms for rooms 104, 106, 108,110, 111, 217, 219, and 319. - There were scrapes present in the drywall on walls in resident bathrooms in rooms [ROOM NUMBER]. - There were stained, brown areas present around the base of the toilet in resident bathrooms and on the linoleum in rooms 108, 110, 214, 216, 217, 218, 219, 220, 221, 222 and 319. - The baseboard…

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(J)(i)(1 Based on record review and interviews, the facility failed to initiate interventions to prevent further weight loss for 1 (Resident 193) of 1 sampled resident. The facility identified a census of 40. Findings are: Record review of Resident 193's admission record revealed the resident admitted on [DATE] with the following diagnoses: unspecified dementia, anxiety, muscle weakness, need for assistance with personal care, cognitive communication deficit, attention and concentration deficit. Record review of Resident 193's admission Minimum Data Set (MDS) (a federally mandated assessment used to determine cares for a resident) dated 8/28/2024 revealed under Section C, a Brief Interview for Mental Status (BIMS) (an interview used to determine a resident's cognition) a score of 3. A score of 3 indicated severe mental cognition impairment. Section K revealed no concerns with swallowing, nutrition, or an altered diet. Record review of Resident 193's Care Plan 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 175 NAC 12-006.09 Based on observation, record review and interview, the facility failed to provide a trauma-based assessment for 2 (Resident 24 and 34) of 2 sampled residents who were diagnosed with Post Traumatic Stress Disorder. The facility had a census of 40. Findings are: A. A record review of Resident 24's Electronic Health Record revealed the Resident was admitted to the facility on [DATE]. A record review of Resident 24's Minimum Data Set (MDS - a federally mandated assessment tool used in nursing homes to evaluate the health of residents) dated 8/19/2024, revealed the resident had a Brief Interview for Mental Status (BIMS - a mandatory tool used to identify cognitive impairment in long-term care residents) of 3, indicating the resident had severe cognitive impairment (had problems with the ability to think, learn, remember, use judgement and made decisions). A record review of Resident 24's Medical Diagnosis sheet revealed Resident 24 had a diagnosis Post-Traumatic Stress…

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 record review and interview, the facility staff failed to notify the practitioner of a change in condition and to update the practitioner as ordered for 1 [Resident 3] of 3 sampled residents. Facility had a total census of 46 residents. Findings are: A. A review of Resident 3's admission Record revealed Resident 3 was admitted to the facility on [DATE] with a diagnosis of congestive heart failure [a chronic condition in which the heart is unable to pump blood efficiently enough to meet the body's needs]. A review of Resident 3's admission orders dated 7/31/24 revealed an order for daily weights. A review of Resident 3's Care Plan revealed a focus area identifying Resident 3 had congestive heart failure dated 8/14/24 with the following interventions: -Encourage adequate nutrition and offer small frequent feedings -Give cardiac medications as ordered -Monitor lab work including potassium, sodium, blood urea nitrogen, and creatinine…

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 NAC 12-006.04C2 Based on record review and interview, the facility failed to ensure a Registered Nurse was present in the facility for a continuous period of 8 hours a day, 7 days a week. This had the potential to affect all residents who reside in the facility. The facility had a census of 48. Findings are: An interview on 9/13/2023 at 11:41 AM with the Human Resources/Scheduler (HR/S) confirmed (gender) is responsible for filling out the 24hour staffing sheets. HR/S confirmed there are no RNs (Registered Nurse) in the building on the weekends. An interview on 9/13/2023 at 2:45 PM with the HR/S confirmed the HR/S was aware of the requirement for an RN to be in the facility for 8 consecutive hours, 7 days a week. An interview on 9/13/2023 at 12:02 PM with the Administrator confirmed that there is not an RN on site on the weekends. The Administrator confirmed an RN is on call during the weekends and the RN on call responsibility is rotated between the Administrator and the Director of Nursing. An interview on 9/13/2023 at 2:35 PM with the Administrator…

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 12-006-11 E Based on observations, interviews and record reviews; the facility failed to utilize proper hand hygiene practices during the preparation and serving of food to prevent foodborne illness. This had the potential to affect all residents in the facility who eat food from the kitchen. The facility census was 48. Findings are: Record Review of Prestige Healthcare Management Food Safety Requirements Revised on 8/23 revealed the following information: -Policy: It is the policy of this facility to procure food from sources approved or considered satisfactory by the federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. -Policy Explanation and Compliance Guidelines: -Section 1. Food safety practices shall be followed throughout the facility's entire food handling process. -This process begins when food is received from the vendor and ends with delivery of food to the resident. -Section 7. Staff shall adhere to safe hygienic practices to prevent…

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 12-006-18 B Based on observation, interview and record review; the facility failed to maintain the cleanliness and condition of ventilation systems, fixtures and floors in 7 resident bathrooms (rooms 316, 317, 318, 320, 321, 322 and 325) of 10 occupied resident rooms on the secured unit of the facility. The facility census was 48. Findings are: Observation on 09/13/23 between 1:00 PM and 1:30 PM with the facility Director of Maintenance [DM] revealed the following concerns with the facility environment: - The surface and interior of the ventilation systems in resident bathrooms in rooms 316, 317, 318, 320, 321, 322 and 325, on the secured unit of the facility, were heavily coated with a gray fuzzy substance that resembled dust. - The surrounding base of the toilets and the linoleum in resident bathrooms in rooms 316, 317, 318, 321 and 325, on the secured unit of the facility, had a brown, greasy substance that corroded the base of the toilets. The linoleum that surrounded the base of the toilets' was gray and spongy from water damage and was pulled away…

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 D7a Based on observation, record review and interview, the facility failed to ensure that chemicals were secured and not accessible to 2 (Residents 23 and 43) residents that were independent with ambulation, exhibited wandering behaviors [movement with no purpose or safety awareness], had poor safety awareness, and resided on the secured unit of the facility. The facility had 10 residents that resided on the secured unit of the facility. The facility census was 48. Findings are: A. Record review of a facility policy entitled Environmental Services Safety Procedures dated 5/23 revealed the following guidelines: - 3. Staff will ensure equipment (e.g., chemicals) is properly stored and not left unattended in areas that are accessible to residents. When not in use, equipment will be stored in a locking closet, cabinet, or storage area for safety. B. Continuous observation on the ACU [secured unit] unit on 09/12/23 between 8:45 AM and 1:00 PM revealed an unlocked bathhouse door…

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 12-006.18Ea1 LICENSURE REFERENCE NUMBER 175 NAC 12-00618Ea2 Based on observations, record reviews and interview; the facility staff failed to ensure bathing water temperatures were maintained at a level to prevent the potential of scalding. This had the potential to affect all residents in the facility. The facility failed to ensure hand sink water temperatures were maintained to prevent the potential for scalding for 1 (Resident 36) of 16 residents on the initial pool and failed to ensure a clutter free environment to prevent falls for 1(Resident 13) of 2 sampled residents. Findings are: A. Record review of a Bathing Resident Policy and Procedure revised on 10/2020 revealed the following information: -It is the practice of this facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues. -The water temperature should be 98.6 degrees to 100 degrees. Record review of the facility Policy and Procedure for safe water temperatures dated 4/2019 revealed the following information: -It is the policy of this facility…

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 Based on observations, record reviews and interview; the facility management failed to utilize its resources to attain or maintain the highest practicable physical, and psychosocial well-being of each resident as identified by the deficient practices cited. The facility staff identified a census of 38. Findings are: -F565. The facility failed to address resident council grievances, housekeeping, maintenance, food, activities and staff concerns. -F582. The facility staff failed to provide liability notice to 1 (Resident 39). -F584. The facility failed to maintain residents room lighting, floors, walls, light fixtures, doors, outdoor fencing in a clean manor and in good repair. -F609. The facility staff failed to submit an investigation to the required state agency within 5 working days of an investigation of an injury of unknown source for 1 (Resident 36). This is a repeated citation from the prior annual survey. -F623. The facility staff failed to give written notice of the reason for transfer and failed to notify the Ombudsman of the…

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

Licensure Reference Number 175 NAC 12-006.17A(2) Licensure Reference Number 175 NAC 12-006.17B Based on observation, interview, and record review, the facility failed to ensure staff and visitors' COVID-19 screening questions were completed and evaluated prior to entrance into the facility and failed to ensure oxygen tubing was changed and stored to prevent the potential for contamination for Resident 39 and 2. This had the potential to affect all residents in the facility. Total census was 38. Findings are: A. An interview with Social Services Director (SS)-J on 05/31/2022 at 08:40 AM confirmed staff and visitors that entered the facility were to just complete the Employee/Visitor COVID-19 Screening Sign-In sheets and leave the sheets on the left side of the book. SS-J said the staff will collect the sheets at the end of the day. An observation on 06/02/2022 at 01:00 PM revealed a Vendor was allowed entrance into the facility without an Employee/Visitor COVID-19 Screening Sign-In sheet being completed. Record review of the Employee/Visitor COVID-19 Screening Sign-In sheets 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 12-006.17 Based on observation, interview, and record review, the facility failed to prevent the spread of COVID-19 as evidenced by the following: -1). Failure to complete contact tracing and perform outbreak testing accordingly. -2). Failure to perform COVID-19 testing in accordance with manufacturer's directions. These failures had the potential to affect all residents residing in the facility. At the time of the survey, a total of 4 residents and 1 staff member had tested positive for COVID-19 since the start of the outbreak. The facility had a total census of 36 residents. The findings are: A. In an interview on 8/17/22 at 10:10 AM, the DON (Director of Nursing) reported the facility currently had 2 residents positive for COVID-19. Both lived in the secured unit and both tested positive on 8/12/22. The DON reported all residents (9) in the secured unit were tested on [DATE] and were only being tested again if they showed symptoms of COVID-19. In an interview on 8/17/22 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.

Based on observations, interviews, and record review; the facility failed to fully implement the facility COVID-19 Contingency Plan for staff with exemptions. Less than 25% of staff were unvaccinated. Total census was 38. Findings are: Record review of the facility's Employee COVID-19 Vaccinations Policy with a Reviewed date of 05/2022 revealed the facility would require addition precautions to prevent the transmission and spread of COVID-19 for all staff that are not fully vaccinated against COVID-19. Those precautions would include the use of a N-95 or higher- level respirator (a device designed to achieve a very close fit to the face and very efficient filtration of airborne particles). An interview on 05/31/2022 with the Social Services Director (SS)-J confirmed the facility was not in an outbreak status and had not been since January 2022. Record review of the COVID-19 Staff Vaccination Status for Providers dated 01/2022 revealed that Licensed Practical Nurse (LPN)-L had not been vaccinated against COVID-19. An observation on 06/02/2022 at 07:43 AM revealed LPN-L was wearing 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 12-006.05(17) Based on observation, interview, and record review, the facility failed to address Resident Council grievances (complaint or protest) regarding housekeeping, maintenance, food, activities, and staff concerns. This had the potential to affect 32 residents on the 100 and 200 hallways. Total census was 38. Findings are: Observation on 06/01/2022 at 10:30 AM revealed the Resident Council (RC) attendance was Resident16, 8, 10, 9, and 39. Record review of the 01/25/2022 RC meeting minutes revealed the RC voiced the following concerns: o Greeting cards and stamps should be available for purchase at the business office. o The kitchen was still not reading menu tickets and the residents are getting items they are allergic to or do not want. o The laundry is not coming back fast enough. o Maintenance needed help around the building. o Nurses are short staffed. Record review of the 02/22/2022 RC meeting minutes revealed the RC voiced the following concerns: o No activities o A lot of staff changes, and the residents are not sure who is 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.18 Based on observation, interview and record review; the facility failed to ensure the negative ventilation system was working and maintain residents room lighting, floors, walls, light fixtures, doors, outdoor fencing clean and in good repair. This had the potential to affect all 38 residents in the facility. Total census was 38. Findings are: A. An observation on 05/31/2022 on 09:42 AM of rooms 104, 106, 108, and the restroom that connects room [ROOM NUMBER] and 110 revealed all the overhead lights in the resident rooms and the restroom were not working. Resident 20 in room [ROOM NUMBER] had pulled the light partially off the wall and triggered the electrical circuit breaker (an electrical switch designed to protect an electrical circuit from damage caused by short circuit). The light switches in room [ROOM NUMBER] had tape over the switches. No bare wires were observed. No alternative light sources were observed in any of the rooms. Interview with Resident 38 on…

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 Based on record review and interview; the facility staff failed to provide written notice of the reason for transfer and failed to notify the Ombudsman of the residents who discharged from the facility for 3 (Resident 2, 20 and 40) of 5 residents. The facility staff identified a census of 38. Findings are: A. Record review of Resident 40's medical record revealed Resident 40 had discharged to the hospital on 5-03-2022. Record review of a Bed Hold Notice dated 5-04-2022 revealed Resident 40's responsible party was given the notice for holding Resident 40's bed. Further review of the bed hold notice dated 5-4-2022 revealed it did not identify in writing why Resident 40 had transferred to the hospital. On 6-07-2022 at 10:43 AM an interview was conducted with the Regional Director of Operations (RDO). During the interview the RDO confirmed a written notice for the reason for transfer had not been provided to Resident 40's responsible party. B. Record Revied of the undated Office of the Long-Term Care Ombudsman (an official appointed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on observations, record review and interview; the facility staff failed to evaluate and implement interventions to promote healing for skin breakdown for 1 (Resident 22) of 1 sample resident. The facility staff identified a census of 38. Findings are: Record review of Resident 22's Comprehensive Care Plan (CCP) printed on 6-01-2022 revealed Resident 22 was at risk for skin breakdown related to impaired mobility. The goal identified for Resident 22 was to have intact skin. Record review of Resident 22's Minimum Data Set (MDS: a federally mandated assessment tool used in care planning) dated 3-23-2022 revealed the facility staff assessed the following about the resident: -Brief interview of Mental status (BIMS) was 0. According to the MDS [NAME] a score of 0 to 7 indicates severe cognitive impairment. -Required extensive assistance of 1 person for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. -No skin breakdown was identified on 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 12-006.09D9 Based on observations, record review and interview; the facility staff failed to ensure water was within reach or available for 3 (Resident 22, 25 and 36) of 3 sampled residents, failed to implement assessed interventions to prevent further weight loss for 1 (Resident 20) and failed to obtain weekly weights for 1(Resident 2) of 5 sampled residents. The facility staff identified a census of 38. Findings are: A. Record review of Resident 22's Nutritional Assessment (NA) dated 3-14-2022 revealed Resident 22 admitted to the facility on [DATE]. Further review of Resident 22's NA revealed Resident 22's daily fluids needs was 1400 milliliters. Observation on 5-31-2022 at 10:15 AM revealed Resident 22 was in a wheelchair in (gender) room and did not have water within reach. Observation on 6-01-2022 at 9:16 AM revealed Resident 22 was up in a wheelchair in (gender) room with water out of reach for the resident. Observation on 6-02-2022 at 10:16 AM revealed Resident 22 was up…

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

Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview; the facility failed to implement non pharmacological interventions prior to the administration of antianxiety medications for Resident 242, failed to address the use of an antianxiety as needed medication in excess of 14 days per regulation for Resident 26 and failed to complete a sleep study for Resident 40. Findings are: A. Review of Resident 26's physician orders revealed an order for Lorazepam (a psychotropic medication) injection 2 milligrams per milliliters to be given every 4 hours as needed for 6 months, with a start date of 4/21/2021. Interview with the Director of Nurses on 06/08/22 at 01:04 PM revealed the PRN lorazepam was ordered for 6 months and should have only been ordered for 14 days. B. Record review of Resident 242's Medication Administration Record (MAR) for August 2021 revealed Resident 242's practitioner ordered medications that included Lorazepam ( an anti-anxiety medication) as needed every 8 hours. Further review of Resident 242's MAR for August 2021 revealed Resident 242…

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 12-006.11D Based on observation and interview, the facility staff failed to ensure that food was being served at temperatures to prevent foodborne illness. The facility had a census of 38. Findings are: Observation on 6/2/22 at 11:44 AM revealed a drink cart in the dining room with pitchers of drinks on ice. The lemonade was at 45 degrees and the milk at 45 degrees per the Dietary Manager (DM). Interview with the DM on 6/2/22 at 11:45 confirmed the drinks should have been at 41 degrees or below. Observation on 06/02/22 at 12:28 PM of a sample room tray brought to the administrators office for a sample tray for temperature testing with the DM. Temperature of food: -Broccoli 118* -Mashed potatoes 120* -Salisbury steak 112* Interview on 06/02/22 at 1:00 PM with DM revealed no facility policy on temperature regulation of room tray.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-007.03I5 Based on observation and interview, the facility failed to ensure each resident in a semiprivate (a room shared by 2 people) room had individualized closet space. This had the potential to affect 32 of 38 residents in the facility. Total census was 38. Findings are: An observation on 05/31/2022 at 10:14 AM of Resident 20's room revealed the room was set up as a semiprivate room, but only had 1 closet without shelves or dividers. An observation of 3 rooms that are shared by 2 residents, (room [ROOM NUMBER]. 105, and 108) on 06/07/2022 at 03:01 PM with the Maintenance and Housekeeping Director (MD)-D revealed there was only 1 closet in the rooms and that closet did not have shelves or dividers to give each resident their own private closet space. In an interview with MD-D on 06/07/2022 at 03:01 PM, MD-D confirmed all rooms in the facility are the same size and layout. MD-D confirmed all rooms in the facility only had 1 closet and did not have shelves or dividers. MD-D…

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 staff failed to issue the Advanced Beneficiary Notice (ABN) to 1 (Resident 39) of 3 sampled residents which did not give the resident/resident representative the opportunity to appeal the facility's decision to discontinue Medicare A benefits. The facility had a census of 39. Findings are: A review of Resident 39's Notice of Medicare Non-coverage revealed that Resident 39's Medicare A services ended on 12/15/2021 and Resident 39 was notified on 12/15/2021. Interview on 06/06/22 at 01:24 PM with the Social Services Director confirmed that the ABN was not filled out within 48 hours prior to Medicare Services ending and that the facility had no policy for issuing the ABN.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview; the facility staff failed to submit a investigation of an injury of unknown source to the required state agency within 5 working days for 1 (Resident 36) of 7 investigations reviewed. The facility staff identified a census of 38. Findings are: Record review of Resident 36's Comprehensive Care Plan (CCP) printed on 6-01-2022 revealed Resident 36 was admitted to the facility on [DATE]. Record review of Resident 36's Progress Note dated 9-24-2021 revealed Resident 36 was evaluated as having a quarter of an inch slit with a fifty cent piece bruise to the right scapula. According to Resident 36's progress note dated 9-24-2021 it was unknown how the injury occurred. On 6-07-2022 at 10:40 AM an interview was conducted with the Regional Director of Operations (RDO). During the interview the RDO confirmed a investigation into Residents 36's injury of unknown source to the right Scapula had not been submitted to the required state agency.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09D6(7) Based on observation, interview, and record review, the facility failed to obtain an oxygen order for Resident 23. This affected 1 of 3 sampled residents. Total census was 38. Findings are: Record review of the facility's Oxygen Concentrator (a machine used to separate the oxygen from other gases in the air and send the oxygen to a resident) Policy dated 10/2020 revealed that oxygen is administered under orders of the attending physician. An observation on 05/31/2022 at 09:28 AM of Resident 23 revealed the resident was wearing oxygen from an oxygen concentrator. An observation on 06/01/2022 at 09:41 AM revealed Resident 23 was on 2 liters per minute (L/M) of oxygen from an oxygen concentrator. Record review of the Minimum Data Set (MDS)(a comprehensive assessment of each resident's functional capabilities) dated 02/02/2022 revealed that Resident 23 was on oxygen prior to admission and while a resident at the facility. Record review of the MDS dated [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 Based on observation, interview, and record review, the facility staff failed to evaluate and obtain treatment for Depression (a mental health disorder the presents as persistent depressed mood or loss of interest in activities, causing significant impairment to daily life) for Resident 191. This affected 1 of 2 sampled residents. Total census was 38. Findings are: An observation on 05/31/2022 at 04:07 PM revealed that Resident 191 was upset and emotional. The resident cried 3 times during the observation and interview. In an interview on 05/31/2022 at 04:07 PM, Resident 191 confirmed the resident's spouse passed away recently. The resident wanted to go home, but stated not sure why, nobody was there anymore. Resident 191 stated Resident 191 wanted to go home to die but confirmed the resident would not harm self. Resident confirmed loss of appetite and no interest in activities. An observation on 06/01/2022 at 07:05 AM revealed Resident 191 was sleeping in the recliner. In an interview on 06/02/2022 at 07:08 AM…

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

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observations, record review and interview; the facility staff failed to ensure a medication error rate of less than 5%. Observations of 25 medications administered revealed 4 errors resulting in an error rate of 16%. The errors effected 1 (Resident 10) of 3 residents sampled. The facility staff identified a census of 38, Findings are: Record review of Resident 10's Order Summary Report printed on 6-02-2022 revealed Resident 10's practitioner ordered medications that included the following: -Flonase (used for sinus type of issues) 1 spray each nostril. -Levo thyroxine (used for thyroid treatment) to be given 30 minutes before a meal. -Linzess ( medication used in the treatment for bowl issues) to be given 30 minutes before the first meal of the day. -Omeprazole ( medication to reduce stomach acid) to be given 60 minutes before a meal. Observation on 6-01-2022 at 9:25 AM revealed Licensed Practical Nurse (LPN) G prepared Resident 10's medication. LPN G took Resident 10's medications to the resident room. LPN G without cueing…

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.