Emerald Nursing & Rehab Omaha

Licensure Reference Number 175 NAC 12.006.11(E)Licensure Reference Number 175 NAC 12.006.18(D) Based on observation, interview, and record review, the facility failed to ensure all kitchen staff performed hand washing for at least 20 seconds when preparing food, entering or re-entering the food service area, and before applying and when removing gloves. This had the potential to affect all 62 residents that consumed food from the kitchen. The total facility census was 62. Findings are:A record review of the facility's undated Handwashing Policy: Food Preparation Areas revealed that employees must wash their hands whenever entering or re-entering food preparation areas, before handling food, clean equipment, utensils, or serving items, after touching hair, face, body, or clothing, and before putting on gloves and after removing gloves. Hand washing should be performed for at least 20 seconds with soap and water. An observation on 01/20/2026 at 10:22 AM - 12:30 PM revealed Dietary Aide (DA)-N put hand in sleeve (hot pad) and got a pot off the stove, went to the dish room, came back 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 12-006.18 Based on observation and interview, the facility failed to maintain ventilation covers, water systems, fixtures, ceilings, doors, outlet covers and call systems in clean, good and working condition in 11 (rooms 204, 301, 304, 305, 306, 310, 502, 505, 511, 512, 514) of 42 occupied resident rooms. The facility census was 64.Findings are: Observation on 01/20/26 between11:35 AM and 12:13 PM with the facility Maintenance Supervisor and the facility Administrator, during the environmental tour of the facility , revealed the following environmental concerns: - There was no call string attached to the wall in the bathroom of room [ROOM NUMBER]. - The water pressure was very light in the sink in rooms [ROOM NUMBERS]. - Cobwebs were present along the walls and ceiling in room [ROOM NUMBER]. - The ventilation system covers were coated with a grey fuzzy substance that resembled dust in rooms 301, 304, 305, 306, 316, 502, 505, 511, 512, 514. - The bathroom light was out (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.05(G) Based on record review and interview, the facility failed to ensure that behavior monitoring was completed for the continued use of psychotropic medications for 2 (Resident 39 and Resident 31) of 7 residents reviewed for behavior management and unnecessary medications. The facility census was 64.Findings are: Record review of a facility policy titled Behavior monitoring dated January 2024 revealed the objective of the mood and behavior policy and procedure is to provide a plan of care that is individualized to the residents needs based upon the comprehensive assessment by the interdisciplinary team. Number 5.a. on the policy and procedure revealed mood and behavior tracking: Mood and behavior tracking documentation will be completed by front line staff, based upon comprehensive outcomes, to identify mood or behavior patterns, interventions attempted and outcomes of approaches. A. A record review of Resident 39's Clinical Census dated 01/15/2026 revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.02(A) Based on interview and record review, the facility failed to ensure the state agency was notified of Resident 39's elopement on 01/10/2026 and Resident 1's fall with major injury. This affected 2 (Resident 39 and 1) of 4 sampled residents. The facility census was 62. Findings are: A record review of the facility's Abuse, Neglect, and Exploitation policy last dated 1/2024 revealed the facility staff should have reported all allegations of Abuse, Neglect, and Exploitation including injuries of unknown source within 2 hours for serious bodily injury and 24 hours if no injury. The report of the investigation results should have been sent to the State Survey Agency within 5 working days of the incident. A. A record review of the facility's Elopement / Exit Seeking policy dated 09/02/2019 revealed: Elopement is defined as a resident leaving the physical structure of the facility without the knowledge of the facility staff. A record review of Resident 39's Clinical Census…

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 12-006.02(H) Based on record review and interview the facility failed to initiate and complete a thorough investigation related to a fall with a significant injury for Resident 1. The facility staff identified a census of 64. Findings are:A. Record review of facility policy titled Abuse, Neglect and Exploitation created 11-17 [no year] revealed the following information: Policy: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the residents' medical symptoms. Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. 7. Investigation of Alleged Abuse, Neglect 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 Based on record review and interview the facility failed to provide a bed hold information and a written reason for transfer at the time of hospitalization for Resident 1 on 5 occasions. The facility staff identified a census of 64.Findings are: A. A record review of a policy titled Bed Hold and Return to Facility Policy and Procedure created 5/17 and revised 1/2024 revealed the following information: Policy It is the policy of the facility that residents who are transferred to the hospital or go on a therapeutic leave are provided with written information about the State's bed hold duration and payment amount before and the transfer. Additionally, this facility permits residents to return to the facility after hospitalization or therapeutic leave if their needs can be met by the facility, they require the services provided by the facility and they are eligible for Medicaid or Medicare covered services or services covered by another payor. Residents and their representative will be provided with bed hold and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(H)(iii)Based on record review and interviews, the facility failed to provide surgical wound care as ordered by the physician for 1 (Resident 46) of 1 sampled resident. The facility staff identified a census of 64. Findings are:A record review of the facility's New/re-admission Process to be completed by the Licensed Nurse undated procedure revealed the following: 6. Licensed Nurse then to review admission orders. b. Wound orders to be inputted by the License Nurse (medication would be inputted by the Pharmacy, but the Licensed Nurse needs to input the order for the treatment. A record review Resident 46's Face Sheet revealed that the resident was admitted on [DATE] with a diagnosis of Encounter for surgical aftercare following surgery on the circulatory system. A record review of the hospitals after visit summary (AVS) for Resident 46 dated 12/19/2025 revealed the following: Wound care Location: Toe, fourth; Location orientation: Left; Wash area: soap and water, rinse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(H) (iii)Based on observation, interview and record review the facility failed to ensure that an air mattress was working and calibrated correctly for 1 resident (Resident 24). The facility reported a census of 64.A record review of Resident 24's undated care plan revealed Resident 24 had an admission date of 05/31/2025 and had the following diagnoses: Spastic Hemiplegia (brain damage disorder affecting one side of the body, causing stiffness, weakness and poor motor control in the affected arm and leg), quadriplegia (paralysis affecting all four limbs and the torso), cramps and spasms of muscle, amputation of left foot, amputation of right leg above the knee, and a history of wounds. A record review of Resident 24's Skin Observation Sheet, dated 1/13/2026 revealed Resident had a Stage III pressure ulcer (a deep crater where fat tissue is visible) to the sacrum (tailbone). Resident 24 also had a venous ulcer to the left lateral leg, a venous ulcer to the left anterior…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview, and record review, the facility failed to implement interventions to prevent potential accidents or elopements on 1 (Resident 39) of 4 sampled residents. The facility census was 62. Findings are:A.A record review of the facility's Elopement / Exit Seeking policy dated 09/02/2019 revealed: Elopement is defined as a resident leaving the physical structure of the facility without the knowledge of the facility staff. It was the policy of the facility to provide a safe and secure environment and be proactive in preventing elopement. A record review of Resident 39's Clinical Census dated 01/15/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 39's Medical Diagnosis dated 01/15/2026 revealed the resident had diagnoses of Personal History Of Traumatic Brain Injury (TBI), Unspecified Mood (effective) Disorder, and History Of Falling. A record review of Resident 39's Care Plan with an admission…

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)(g)Based on record review, observation, and interview, the facility failed to ensure oxygen tubing was connected from the oxygen concentrator to an oxygen humidification bottle to administer oxygen at the prescribed flow rate for 1 (Resident 6) of 1 sampled resident. The facility staff identified a census of 64.Findings are: Record review of Resident 6's admission Record revealed the facility admitted the resident on 11/20/2024. Further review of the admission record identified Resident 6 had conditions that included Chronic Obstructive Pulmonary Disease (COPD, pulmonary disease that is characterized by chronic typically irreversible airway obstruction resulting in a slowed rate of exhalation).Record review of Resident 6's annual Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 11/27/2025 revealed Resident 6 had a Brief Interview for Mental Status (BIMS, a brief screener that aids 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 Based on record review and interview, the facility failed to ensure 1 resident (Resident 7) received a Pre-Dialysis Assessment as ordered. The facility had a census of 64. Findings are:A record review of Resident 7's undated care plan revealed Resident was admitted to the facility on [DATE].A record review of Resident 7's care plan revealed the following diagnoses: End Stage Renal Disease (final stage of kidney disease where the kidneys have lost almost all of their ability to function) and dependence on renal dialysis (a life-sustaining treatment that filters waste, extra fluid and salt from the body).A record review of Resident 7's order summary revealed the following orders: Complete Dialysis Pre-Observation that includes vital signs. Fill out the dialysis communication form to send with resident, one time a day every Monday, Wednesday, Friday for Dialysis.A record review of Resident 7's Treatment Administration Record for January 2026 revealed a Pre-Observation was not completed on 1/5/2026, 1/7/2026 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 implement procedures to follow up on pharmacist recommendations for 1 (Resident 6) of 5 sampled residents. The facility staff identified a census of 64.Findings are: Record review of a facility policy titled Medication Regimen Review (MRR) dated reviewed 1/2024 revealed: - 1. Upon completion of the MRR, the facility designee and/or physician, will respond to the recommendations in a timely manner.Record review of a Lab Report with results dated 12/28/2024 showed Resident 6 had a Complete Metabolic Panel (CMP, a routine blood test that provides a snapshot of the body's chemical balance, metabolism, and organ function by checking sugar, electrolytes, protein, and liver and kidney enzymes) test performed. According to the lab report, the reference range for potassium was 3.5-5.3 millimoles (mmol) per (/) liter (l). Resident 6's potassium result was 3.2 mmol/l which indicated the result was low. Further review of the lab report revealed an order for potassium chloride 20 milliequivalents (mEq) by mouth once daily and to…

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

Based on record review and interview, the facility failed to obtain a Complete Metabolic Panel (CMP, a routine blood test that provides a snapshot of the body's chemical balance, metabolism, and organ function by checking blood sugar, electrolytes, protein, and liver and kidney enzymes) as directed for the monitoring and continued use of potassium chloride for 1 Resident 6) of 5 sampled resident. The facility staff identified a census of 64.Findings are:Record review of a facility policy titled Medication Regimen Review dated reviewed 1/2024 revealed: - 10. Each residents' drug regimen remains free of unnecessary drugs. An unnecessary drug is any drug when used: - a. In excessive doses, including duplicate therapy. - b. For excessive duration. - c. Without adequate monitoring.Record review of a Lab Report with results dated 12/28/2024 showed Resident 6 had a Complete Metabolic Panel (CMP, a routine blood test that provides a snapshot of the body's chemical balance, metabolism, and organ function by checking blood sugar, electrolytes, protein, and liver and kidney enzymes) test…

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

Licensure Reference Number 175 NAC 12-006.18(B & D)Based on record review, observation, and interview, the facility failed to complete hand hygiene prior to donning gloves and between glove changes to prevent the potential for cross contamination for 1 (Resident 16) of 7 sampled residents; the facility failed to change oxygen tubing and failed to ensure a filter was in place on a room oxygen concentrator to prevent the potential for cross contamination for 1 (Resident 6) of 1 residents sampled with oxygen; and the facility failed to ensure a bilevel positive airway pressure (BiPAP, a technique that is used for relieving breathing problems by pumping a flow of air through the nose to prevent the narrowing or collapse of air passages or to help the lungs expand and that differs from continuous positive airway pressure by pumping air at a reduced pressure during each exhalation) mask was hygienically stored between uses to prevent the potential for cross contamination for 1 (Resident 3) of 1 sampled residents with a BiPap. The facility staff identified a census of 64.Findings are:A. A…

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

Licensure Reference Number 175 NAC-006.04(B)(ii)(1) Based on record review and interview, the facility failed to ensure nurses aides had the required 12 hours of education yearly for 3 (NA/MA's G,H, and J) of 5 staff reviewed. Findings are:A. Record review of employee list revealed NA/MA G was hired on 12/12/2023. Record review of in-service education for NA/MA G had completed a total of 9.65 hours of training. B. Record review of employee list revealed NA/MA H was hired on 1/30/2023. Record review of in-service education for NA/MA H had completed a total of 8.0 hours of training. C. Record review of employee list revealed NA/MA J was hired on 3/29/2022. Record review of in-service education for NA/MA J had completed a total of 8.12 hours of training. D. Interview with the Regional Administrator on 1/21/26 at 9:52 AM confirmed the 12 hours of training had not been completed for NA/MA's G, H, & J.

Licensure Reference Number 175 NAC 12-006.05(H) & 175 NAC 12-006.02(H)Based on record review and interviews, the facility failed to protect residents from potential abuse for 1 (Resident 1) of 3 sampled residents. The facility staff identified a census of 56.The findings are:Record review of facility policy titled Abuse, Neglect and Exploitation dated 11/2017 revealed: -Resident Protection after Alleged Abuse, Neglect and Exploitation - The facility will make efforts to protect all residents after alleged abuse, neglect and/or exploitation. Examples of ways to protect a resident from harm during an investigation of abuse, neglect and exploitation may include, but are not limited to: -Reassignment of nursing staff duties. -Time off for nursing staff. -Response and Reporting of Abuse, Neglect and Exploitation - Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect or exploitation is suspected, the Licensed Nurse should: -Respond to the needs of the resident and protect them from further incident (document) -Notify the Director of Nursing…

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

Licensure Reference Number 175 NAC 12-006.02(H)Based on record review and interview, the facility failed to report an allegation of potential abuse to the State Agency within prescribed timeframes for 1 (Resident 1) of 3 sampled residents. The facility staff identified a census of 56.The findings are:Record review of facility policy titled Abuse, Neglect and Exploitation dated 11/2017 revealed: - Response and Reporting of Abuse, Neglect and Exploitation - Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect or exploitation is suspected, the Licensed Nurse should: -Respond to the needs of the resident and protect them from further incident (document) -Notify the Director of Nursing and Administrator (document) -Initiate an investigation immediately -Notify the attending physician, resident's family/legal representative and Medical Director. -Obtain witness statements, following appropriate policies. Suspend the accused employee pending completion of the investigation. Remove the employee from resident care areas immediately. -Contact 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 12-006.09(H)Based on record review and interview, the facility failed to ensure a process was in place to notify residents of scheduled appointments for 1 (Resident 2) of 3 residents sampled. The facility staff identified a census of 56.Record review of Resident 2's Clinical Census printed 9/29/25 showed the facility admitted the resident on 5/27/2025.Record review of Resident 2's Medical Diagnosis printed 9/29/25 revealed the resident had diagnoses which included carcinoma in situ (carcinoma in the stage of development when the cancer cells are still within their site of origin) of the cervix, anemia due to antineoplastic (inhibiting or preventing the growth and spread of tumors or malignant cells) chemotherapy, thrombocytopenia (persistent decrease in the number of platelets in the blood that is often associated with hemorrhagic conditions).Record review of Resident 2's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify…

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: 71-6022(1) Based on record review and interview, the facility failed to ensure 1 [Resident 1] of 7 sampled residents was provided with a 30-day notice of discharge that included a safe discharge location. The facility had a total census of 71 residents. Findings are: A. A review of Resident 1's admission Record revealed Resident 1 was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease [a progressive neurodegenerative disorder] with dyskinesia [involuntary uncontrolled movements]. A review of Resident 1's Progress Note dated 1/14/25 revealed Resident 1 was leaving the facility for a peg tube [a feeding tube insert through the skin and stomach wall] insertion that morning. A review of Progress Notes from 1/14/25-1/31/25 revealed Resident 1 remained in the hospital. A review of Resident 1 census in electronic medical record revealed Resident 1 was identified as being in the hospital on 1/14/25 and billing was stopped on 1/31/25. A review of undated Nursing 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(H)(iii) Based on observations, record reviews, and interview; the facility staff failed identify wound sizes and failed to re-evaluate treatment interventions for 1 (Resident 4) of 3 sampled residents. The facility staff identified a census of 71. Findings are: Record review of a Order Summary Report (OSR) dated 2-05-2025 revealed Resident 4 admitted to the facility on [DATE]. Further review of OSR dated 2-05-2025 for Resident 4 revealed Resident 4's practitioner on 5-20-2024 ordered a barrier cream to be applied to Resident 4's buttocks and perineal areas, 3 times a day related to Moisture Associate Skin Damage (MASD, caused by prolonged exposure to various sources of moisture, such as, urine, stool and perspiration). Record review of a Skin/Wound Weekly Observation (SWWO) sheet dated 1-01-2025 revealed the facility staff evaluated Resident 4's skin as having MASD. Resident 4's SWWO sheet dated 1-01-2025 revealed both buttocks had redness with scattered scratch marks…

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)(iv)(2) Based on observations record review and interview; the facility staff failed to evaluate a toileting program for 1(Resident 4) of 1 sampled resident. The facility staff identified a census of 71. Findings are: Record review of a Order Summary Report sheet dated 2-05-2025 revealed Resident 4 was admitted to the facility on [DATE]. Record review of Resident 4's Minimum Data Set (MDS, a federally mandated assessment to used for care planning) dated 11-23-2024 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) revealed the facility staff assessed Resident 4 with a BIMS score of 13. According to the MDS [NAME] a score of 13 to 15 indicates a person is cognitively intact. -Dependent on staff for toileting. -Required superviison or touch assistance with personal hygiene. -Required partial to moderate assistance with sitting to standing position. -Always incontinent of bladder and did not have a toileting…

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 12-006.17 Based on observations, record review and interviews; the facility staff failed to utilize handwashing and gloving techniques to prevent potential cross contamination and failed to implement Enhanced Barrier Precautions during the provision of care for 1 (Resident 4) of 3 sampled residents. The facility staff identified a census of 52. Findings are: Record review of the facility policy for Enhanced Barrier Precaution revised on 3-20-2024 revealed the following information: -Policy Statement: -Enhanced Barrier Precaution (EBP) are an infection control intervention designed to reduce the transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activity. -EBP maybe indicated for residents with any of the following: -Wounds, indwelling medical devices, infection or colonization with Multi-Drug Resistant Organism (MDRO). Record review of the facility policy for Handwashing revised on 3-20-2024 revealed the following: Policy Statement: This facility considers hand hygiene the primary means 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(H)(iii)(2) Based on observation, interview and record review the facility failed to ensure practitioner's orders for wound and skin care were followed for 2 (Resident 1 and 4) of 3 sampled residents. The facility census was 62. Findings Are: A. Record review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 09-23-2024 revealed the facility staff assessed the following about the resident: -A Brief Interview of Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) was scored as a 13/15. According to the MDS Manual a score of 13 to 15 indicate a person is cognitively intact. -The resident required total assistance with eating, dressing, bathing and bed mobility. -The resident had a diagnosis of Quadriplegia. -The resident had 3 pressure ulcers. Record review of Resident 1's Electronic Health Record (EHR, a digital version of a patient's paper medical chart) revealed Resident 1 was…

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

Licensure Reference Number 175 NAC 12.006.10(D) Based on record review and interview the facility failed to ensure residents were free of significant medication errors for 1 (Resident 1) of 5 sampled residents. The facility census was 65. Findings are:: Record review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 09-23-2024 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as a 15. According to the MDS manual a score of 13 to 15 indicate a person is cognitively intact. -Diagnosis of End Stage Renal Disease (ESRD) currently receiving dialysis. -had a heart transplant in the past. -recently had a blood clot in the veins in the left upper extremity. -required moderate assistance with toileting, bathing, dressing, and transfers. -currently taking an anticoagulant medication. Record review of Resident 1's progress notes revealed on 09-24-2024 Resident 1 was to have a PT/INR (a lab test that measures how long it takes the blood to clot) on 09-26-2024. An…

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

Licensure Reference Number 175 NAC 12.006.11(D) Based on observation, interview and record review, the facility failed to follow the standardized recipe for Shepard's Pie to maintain the taste and nutritional value of the food and in accordance with the facility policy. This had the ability to affect all residents that ate food prepared in the facility kitchen. The facility census was 68. Findings are: Record review of a facility policy entitled; Food and Nutrition Management, Preparation Guidelines dated 11/17 revealed the following: 1. The cook, or designee, should prepare menu items following the facilities written menu's and standardized recipes. Record Review of the planned facility Menu for Wednesday, 09/18/24, included Shepard's Pie as the entree. Observation on 09/18/24 between 10:30 AM and 10:55 AM revealed [NAME] D had began preparing Shepherds Pie for the lunch meal. Observation revealed that the Shepard Pie was partially done, with browned hamburger, onions and green beans layered into a large baking pan. [NAME] D prepared 1 large package of instant mashed potatoes with…

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

Licensure Reference Number 175 NAC 12-006.11 E Based on observation, record review and interview; the facility failed to perform hand washing and gloving during food preparation in the facility kitchen and failed to maintain equipment in a clean manner to prevent the potential for food borne illness. This had the potential to affect all residents that ate food prepared in the facility kitchen. The facility census was 68. Findings are: A. Observation on 09/18/24 between 07:15 AM and 07:45 AM revealed [NAME] D prepared egg and cheese biscuit sandwiches. [NAME] D left the food preparation area for a few minutes and, prior to returning to the food preparation area, performed hand washing for 10 seconds. Observation on 09/18/24 between 10:30 AM and 10:55 AM, during food preparation of the lunch meal entree revealed [NAME] D prepared the lunch meal entree. At 10:35 AM, [NAME] D left the food preparation area and the kitchen to bring juice to a resident at the request of a nurse. At 10:45 AM, [NAME] D returned to the kitchen, performed a 12 second hand wash , donned new gloves and returned…

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 12-006.19A Based on observation, interview and record review; the facility failed to maintain walls, floors, baseboards, fixtures, equipment, window blinds, light fixtures, door knobs, air conditioning unit and urine odors in 16 (Rooms 208, 209, 214, 301, 306, 312, 316, 405, 408, 409, 412, 415, 504, 507, 509 and 510 ) of 50 occupied resident rooms. The facility census was 68. Findings are: Observation on 09/23/24 between 9:15 AM and 10:46 AM, with the facility Assistant Administrator [AA] , Housekeeping Director [HD], and Maintenance Director [MD], identified the following environmental concerns during the environmental tour of the facility; - Toilets were stained with a dark brown, greasy substance resembling feces: Rooms 208, 301, 306, - Base of toilets were stained with a a dark brown greasy substance: Rooms 208, 209, 301, 312, 409, 412, 504, 507, 509 - Baseboards and bathroom floors were stained and wax covered with dust and particles of dirt present: Rooms 208, 306, 312,…

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 record review and interview, the facility failed to complete a thorough written investigation and report an allegation of staff to resident abuse within the required timeframe to the Department of Health and Human Services [DHHS] for 1 (Residents 125) of 3 facility self-report investigations reviewed. The facility census was 68. Findings are: Record review of facility policies and procedures entitled Abuse, Neglect, and Exploitation dated November 2017 revealed the following information: The facility must: 7. Investigation of alleged abuse, neglect and exploitation: When suspicion of abuse, neglect or exploitation, or reports of abuse. neglect or exploitation occur, an investigation is immediately warranted. Once the resident is immediately cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include: a. Interview the resident involved, if possible, and document all responses. c. Interview all witnesses separately. Include roommates, residents in adjoining…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(F) Based on record review and interview, the facility failed to develop a baseline care plan for 1 resident (Resident 177). The facility had a census of 68. Findings are: A record review of Resident 177's Electronic Health Record revealed Resident 177 was admitted to the facility on [DATE]. A record review of Resident 177's order summary revealed the following diagnoses: Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Heart Failure, Personal History of other Venous Thrombosis and Embolism, Hyperlipidemia, End Stage Renal Disease, Personal History of Transient Ischemic Attack (TIA), and Cerebral Infarction without Residual Deficits, Chronic Fatigue, unspecified, Type 2 Diabetes Mellitus with other skin ulcer, non-pressure Chronic Ulcer of other part of left foot with unspecified severity, Chronic Kidney disease, Heart Transplant status with long term (current) use of immunosuppressive biologic, primary Hypertension, dependence on Renal…

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)(a) Based on observation, interview and record review the facility failed to maintain a gastric feeding tube to prevent potential complications for 1 of 1 (Resident 65) sampled residents. The facility census was 68. Findings are: Record review of Resident 65's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 06-23-2024 revealed the facility staff assessed the following about the resident: -Diagnosis of CVA, with subsequent hemiplegia and dysphagia, HTN, and anxiety. - Brief Interview of Mental Status (BIMS, an assessment that aids in detecting cognitive impairment. A score of 0-7 equals severe impairment, 8-12 indicates moderate impairment and 13-15 indicates cognitively intact) of 12 which indicates moderate cognitive impairment. -Required set up assistance with eating. -Required extensive assistance with oral hygiene and upper body dressing. -Required total assistance with lower body dressing, toilet hygiene, bed mobility and transfers. -currently had a feed An interview was conducted…

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

Licensure Reference Number 175 NAC 12-006.09 Based on observation, interview and record review, the facility staff failed to evaluate a dialysis access's site for 1 (Resident 177) of 1 sampled residents who received dialysis treatments. The facility reported a census of 68. Findings are: A record review of Resident 177's order summary revealed the following diagnoses: Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Heart Failure, Personal History of other Venous Thrombosis and Embolism, Hyperlipidemia, End Stage Renal Disease, Personal History of Transient Ischemic Attack (TIA), and Cerebral Infarction without Residual Deficits, Chronic Fatigue, unspecified, Type 2 Diabetes Mellitus with other skin ulcer, non-pressure Chronic Ulcer of other part of left foot with unspecified severity, Chronic Kidney disease, Heart Transplant status with long term (current) use of immunosuppressive biologic, primary Hypertension, dependence on Renal Dialysis, Gangrene, Acute Embolism and Thrombosis of superficial veins of left upper extremity. 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 12.006.09 (H) Based on interview and record review the facility failed to ensure parameters were followed related to blood pressure medications resulting in unnecessary medication use for 1 (Resident 44) of 5 sampled residents. The facility census was 68. The findings are: Record review of Resident 44's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) revealed the facility staff assessed the following about the resident: - Brief Interview of Mental Status (BIMS, an assessment that aids in detecting cognitive impairment. A score of 0-7 equals severe impairment, 8-12 indicates moderate impairment and 13-15 indicates cognitively intact) score of 14 indicating intact cognition. -Diagnosis of orthostatic hypotension (also known as postural hypotension, is a sudden drop in blood pressure that occurs when standing up from a sitting or lying down position.), diabetes, bipolar disorder, left below the knee amputation. Record review of Resident 44's Medication orders revealed an order for Midodrine 5mg tablet (a medication…

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 License Reference Number 175 12.006.18(B), 12.006.18(D), and 12.006.19(A) Based on observation, interviews, and record reviews, the facility failed to perform hand hygiene in a manner to prevent cross contamination during skin care for Resident 1, failed to identify a resident on Enhanced Barrier Precautions for Resident 1, failed to provide bags to secure oxygen tubing in a manner that prevents the potential for cross contamination for 2 Residents (Residents 41 and 23), and failed to utilize PPE for a resident on Enhanced Barrier Precautions during wound care for Resident 48. The Facility identified a census of 68. Findings are: A. Record review of Facility Policy entitled: Isolation-Categories of Transmission-Based Precaution dated 1/2024- Enhanced Barrier Precautions (EBP): An infection control intervention designed to reduce transmission of multi-drug-resistant organisms (MDROs, microorganisms that are resistant to one or more types of antibiotics making them difficult to treat and spread quickly) in nursing…

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

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 failed to notify the medical provider of blood sugars that were outside of parameters and holding insulin based on blood sugars for 1 [Resident 1] of 4 residents. The facility had a total census of 62 residents. Findings are: A record review of Resident 1's admission record revealed Resident 1 was admitted to facility on 3/11/24 with a diagnosis of hyperglycemia [high blood sugar]. A record review of Resident 1's active orders revealed an order dated 3/11/24 to notify the provider of blood sugars of greater than 400 or less than 70. A review of Resident 1's 3/2024 MAR [Medication Administration Record] revealed an order dated 3/11/25 for Lispro [a medication to treat high blood sugars] insulin inject per sliding scale 4 times per day as follows based on blood sugar level: -blood sugar level of 180-250 administer 3 units of Lispro Insulin -blood sugar level of 251-300 administer 6 units of Lispro Insulin -blood…

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 ensure staff donned (put on) and doffed (took off) the required PPE (personal protective equipment) when in a resident's room that was positive for COVID-19, failed to ensure eye protection was worn that had side shields (shields attached to the sides of prescription glasses), and failed to ensure all staff required to wear a N-95 Respirator (N-95 mask) (a tight fitting mask designed to filter out very small particles) had a Fit-Test (a test to ensure the mask sealed) or medical evaluation to prevent the potential spread of COVID-19. This had the potential to affect all 59 residents in the facility. The facility census was 59. Findings are: A record review of the facility's COVID-19 Policy dated 09/28/2023 revealed, staff that entered a room of a resident with suspected or confirmed COVID-19 should have used a N-95 respirator, gown, gloves, and eye protection (goggles or a face shield that…

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

Licensure Reference 175 NAC 12-006.11C Based on observations and interviews, the facility failed to maintain overall kitchen sanitation and failed to store foods in a manner to prevent cross-contamination. This had the potential to affect 65 residents who received meals from the facility kitchen. Findings are: 1. A facility policy titled, General Kitchen Sanitation, dated 07/23/2014, indicated, The facility recognizes that food-borne illness has the potential to harm patients/residents. All Dietary employees will maintain clean, sanitary kitchen facilities in accordance with the county health department regulations and the current Federal and State Food Codes in order to minimize the risk of infection and food borne [sic] illness. Observations on 08/07/2023 beginning at 8:38 AM revealed a spot of dried red substance approximately six to eight inches in length on the floor of the walk-in refrigerator next to shelves with food stored on them. Multiple spice containers were observed on a shelf next to the oven with their lids open, exposed to the air. A pan holding a bag of dry rice…

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 12-006.02 (8) Based on interviews and record review, the facility failed to report incidents of elopement to administration and the state survey agency for 1 (Resident #65) of 4 sampled residents reviewed for wandering and elopement. Findings are: Review of a facility policy titled, Elopement/Exit Seeking, with a reviewed/revised date of 09/02/2019, revealed, Cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. The policy indicated, 7. Staff should promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. The policy also indicated, 9. When a departing individual returns to the facility, the Director of Nursing or Charge Nurse shall: d) Complete and file Report of Incident/Accident. Review of a facility policy titled, Incidents and Accidents Communication, with a reviewed/revised date of 09/01/2021, revealed, The facility will document,…

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 interviews and record review, the facility failed to ensure a resident's drug regimen was free from unnecessary drugs for 1 (Resident #43) of 5 residents reviewed for unnecessary medications. Specifically, the facility failed to follow a physician's order to hold Midodrine (used to treat low blood pressure) when a resident's systolic blood pressure (SBP) was greater than 120 millimeters of mercury (mmHg). Resident #43 received Midodrine ten times in July 2023 and eight times in August 2023 when the medication should have been held. Findings are: A facility policy titled, Physician Orders, dated December 2014, indicated, It is the policy of this facility to secure physician orders for care and services for residents as required by state and federal law. Physician orders will include the medication and/or treatment and a correlating medical diagnosis or reason. The policy provided did not address the facility's policy on following physician's orders. A review of Resident #43's admission Record revealed the facility admitted the resident on 09/16/2021, with diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference 175 NAC 12-006.10A Based on observations, interviews, and record reviews, the facility failed to ensure a resident was assessed for the self-administration of medications for 1 (Resident #33) of 1 sampled resident reviewed for self-administering medications. Findings are: A review of a facility policy titled, Self-Administration of Medication, with a reviewed/revised date of 12/15/2018, revealed, The self-administration of drugs may occur if ordered by the physician and the resident is competent to safely self-administer the medications as determined by the interdisciplinary team. A review of Resident #33's admission Record indicated the facility admitted the resident on 10/07/2022 with diagnoses that included cerebral vascular accident, pulmonary hypertension, and seizures. The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #33 had a Brief Interview for Mental Status (BIMS) of 13, which indicated the resident was cognitively intact. The MDS indicated 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 2. Review of an admission Record revealed Resident #65 was admitted to the facility on [DATE] with diabetes, osteoarthritis, Alzheimer's disease, chronic pain, cerebral infarction, and hypertension. Review of the annual Minimum Data Set (MDS), with an Assessment Reference Date of 06/24/2023, revealed Resident #65 had a Brief Interview for Mental Status (BIMS) score of 6, meaning the resident had severe cognitive impairment. The MDS indicated Resident #65 experienced continuous disorganized thinking. The resident was independent with locomotion on and off the unit and with walking in their room and the corridor. The MDS indicated the resident did not wander in the past seven days. Review of Resident #65's care plan, with an initiation date of 06/01/2023, revealed Resident #65 was at risk for elopement related to exit-seeking behaviors. The care plan indicated that on 07/13/2023, Resident #65 removed the wander monitoring bracelet and eloped. Review of an incident report for an elopement, dated 07/13/2023 at 2:15…

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 12-006.09C Based on record review and interviews, the facility failed to initiate and update a comprehensive care plan for a resident with wandering/exit seeking behaviors for 1 (Resident #65) of 4 sampled residents reviewed for elopement. Findings are: Review of a facility policy titled, Incidents and Accidents Communication, revised 09/01/2021, revealed, 6. Analysis, preventative plan, summary, determination and follow-up will be completed in a timely matter. 7. Care plan will be updated. Review of a facility policy titled, Resident Elopement Follow-Up Procedure, revised 09/02/2019, revealed, It is the policy of this facility to provide a safe and secure environment for our residents and to be proactive in preventing resident elopement. The policy indicated that following an elopement, the following actions would be initiated: 3. Plan of Care will be modified to incorporate an increased elopement risk and increased monitoring as needed based on behaviors. Review of an admission…

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 12-006.09D3 Based on interviews and record reviews, the facility failed to ensure a resident with a urinary catheter received treatment and services to prevent urinary tract infections for 1 (Resident #12) of 1 resident reviewed for catheters Findings are: Review of a facility policy titled, Indwelling Foley Catheter, Protocol, revised 04/29/2020, revealed, Indwelling catheters will not be changed on a routine basis, rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised unless otherwise ordered by a physician. Review of the admission Record revealed the facility admitted Resident #12 on 04/01/2021 with diagnoses which included quadriplegia and neuromuscular dysfunction of the bladder. Review of an annual Minimum Data Set (MDS), with an Assessment Reference Date of 05/05/2023, revealed Resident #12 scored 13 on a Brief Interview for Mental Status assessment, indicating 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 175 NAC 12.006.12B Based on interviews and record review, the facility failed to have a physician ordered treatment available for 1 (Resident #33) of 3 sampled residents who were reviewed for pain control. Findings are: A review of an undated facility document titled, Reordering Medications, revealed, 1. Once the supply on the current active card(s) reaches 5 doses left, a request for refill will be required by facility staff. A review of Resident #33's admission Record indicated the facility admitted the resident on 10/07/2022 with diagnoses that included cerebral vascular accident, pulmonary hypertension, and seizures. The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #33 had a Brief Interview for Mental Status (BIMS) of 13, which indicated the resident was cognitively intact. The MDS indicated the resident was independent with all activities of daily living. A review of the resident's active physician orders revealed an order, dated 04/28/2023, for a corn cushion to be…

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.