Emerald Nursing & Rehabilitation Mercy

Licensure Reference Number 175 NAC 12-006.18(B)Based on record review, observation, and interview, the facility failed to change a tube feeding pump set at the required intervals to prevent the potential for cross contamination for 1 (Resident 101) of 3 sampled residents. The facility staff identified a census of 103.Findings are:Record review of facility policy entitled Care and Treatment of Feeding Tubes dated revised 01/2024 revealed: - 7. Direction for staff on how to provide the following care will be provided. - d. Use of infection control precautions and related techniques to minimize the risk of contamination.Record review of Kangaroo ePump Enteral Feed and Flush Pump with Pole Clamp, Programmable dated Revised 04/2020 revealed: - The pump set usage warning indicator will blink on the running screen if a pump set has been used for 24 or more hours (hours actually running). It is recommended to replace pump sets after this length of usage.Observation on 05/05/2026 at 12:54 PM revealed Resident 101's Kangaroo ePump was running at the ordered rate. The machine display blinked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.04(F)(i)(5). Based on interview and record review the facility failed to update the resident's representative of changes in condition for 1(Resident 3) of 3 residents sampled. The facility census was 117. The findings are:A.Record review of the facility policy titled Notification of Changes Policy dated 01-2024 revealed it is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or resident representative, according to their authority, and reported to the attending physician or delegate. The resident and/or resident representative will be educated about treatment options and supported to make an informed choice about care preferences when there are multiple care options available. The objective of the notification policy is to ensure that the facility staff makes appropriate notification to the physician and immediate notification to the resident and/or resident representative when there is a change…

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(J)(i)(1). Based on observation, interview and record review the facility failed to accurately record meal intakes, implement interventions to prevent a significant weight loss, and failed to implement practitioner orders to ensure adequate nutrition after a bariatric surgery for 1 (Resident 3) of 1 residents sampled. The facility census was 117. The findings are: A. Record review of the facility policy titled Weight Monitoring dated 10-06-2025 revealed based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this not possible or resident preferences indicate otherwise. Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(H). Based on observation, interview and record review the facility failed to evaluate, monitor and implement interventions for severe pain and failed to ensure pain medications were available for use for 1(Resident 3) of 3 residents sampled. The facility census was 117. The findings are:Record review of the facility's policy titled Pain Management dated 01-2024 revealed the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The facility utilizes a systematic approach for recognition, assessment, treatment and monitoring of pain. Evaluate the resident for pain upon admission, during periodic scheduled assessments, and with change in condition or status. Behavioral signs and symptoms that may suggest the presence of pain include but are not limited to:-change is gait-loss of function-decline…

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, interview and record review the facility failed to monitor daily fluid intake, and failed to ensure medications and treatments were coordinated with the provision of dialysis services for 1 (Resident 5) of 1 residents sampled. The facility census was 117. The findings are:A.Record review of the facility policy titled Special Needs-Dialysis Policy dated 01-2024 revealed the policy is to outline care and services for dialysis residents in order to reduce the risk of infections, complications, and to provide for ongoing monitoring and interventions. An assessment of the resident will be performed on admission and quarterly and will include the location of the dialysis shunt, when dialysis is performed and where, and what to monitor. This information will be included as part of the resident's plan of care. The facility will ensure medications and meals are provided as ordered. Physician referral may be needed in order to adjust medication times or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.04(1). Based on interview and record review the facility failed to develop and implement interventions and arrange services for behavioral management for 1 (Resident 3) of 3 residents sampled. The facility census was 117. The findings are:A.Record review of the facility policy titled Mood and Behavior Policy and Procedure dated 01-2024 revealed it is the policy of the facility that each resident must receive and the facility must provide the necessary behavioral health care and services and medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. B.Record review of Resident 3's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-had diagnosis of Bipolar Disorder and Anxiety Disorder -Brief Interview of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.10(D). Based on interview and record review the facility failed to ensure residents were free from significant medication errors for 1(Resident 5) of 5 residents sampled. The facility census was 117. The findings are:A.Record review of Medication Errors in Nursing Homes Fact Sheet from the Long-Term Care Community Coalition dated 01-2023 revealed a medication error means an observed or identified preparation or administration of medications which is not in accordance with the prescriber's order, the manufacturer's specifications, or accepted professional standards or principles. A significant medication error is an error which causes the resident discomfort or jeopardizes their health and safety. Common medication errors include taking medication dose late, omitted dose, dispensing the wrong medication, giving the medication through the wrong route, and a wrong or extra dose of medication. B. Record review of Resident 5's Minimum Data Set (MDS: a federally mandated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview, the facility failed to include enough information to ensure a thorough investigation had been completed into an injury for 1 (Resident 1) of 3 reviewed with an injury. The facility census was 115. Findings are:A. Record review of a facility policy entitled Accidents and Incidents dated 1/2024 revealed the following information: Incident report, investigation and follow-up protocol:1. The facility strives to ensure residents will not experience undue discomfort and / or have their health and safety placed in jeopardy due to an unusual occurrence (accident / incident).2. The facility defines an accident / incident as an event, occurrence or happening that may produce an actual or potential undesirable outcome.3. The event may be an accident or a situation that could result in an accident. Accidents may include, but are not limited to, the following:- Falls / suspected falls- Injuries of unknown origin4. Should an accident /…

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 observations, interviews and record reviews, the facility failed to ensure interventions (what was put in place to prevent it from happening again) were implemented for falls on 2 (Resident 3 and 4) of 3 sampled residents. The facility census was 115. Findings are:A record review of the facility's Falls Management policy with a revision date of 1/2024 revealed the following: Fall Injury Prevention - Post Fall 1. Assess the resident/patient and immediately implement appropriate measures to prevent injury. a. EX. Wipe up spills, improve lightening [sp], call light in reach, appropriate footwear. b. Document in medical record 2. Initiate and complete the Incident Event documentation including pertinent witness statements 3. Review Fall Risk Assessment for any changes in fall risk, reassess post fall. 4. Review and Revise Pain Assessment. 5. Discuss findings and interventions with the resident/patient/family for inclusion in the Interdisciplinary Plan of Care…

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: 12-006.11(E)Based on observations, interviews, and record review, the facility failed to ensure temperatures of food on the steam table were hot enough to protect from potential food borne illness. This has the potential to affect 40 of 41 residents residing on the second floor of the facility. Findings are:Observations on second floor at 3/16/26 between 11:58 AM-12:02 PM revealed the lunch food arrived on the floor at 11:58 AM inside a heated cart. The BBQ pork was taken from the cart and placed in the steam table and the temperature was measured as 125 F [Fahrenheit] by [NAME] F.A review of second floor Daily Food Temperature log for lunch 3/16/26 revealed meat entree temperature was recorded as 125 F.In an interview on 3/16/26 at 12:02 PM, Food Service Director reported pork had been cooked and BBQ sauce added. The Food Service Director reported that the sauce had been cold when added to the cooked pork. The Food Service Director reported that the initial cooked pork temperature on the steam table should be 165 F.Observations at 3/16/26 at 12:17 PM revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure reference: 12-006.10A(i)Based on observation, interview, and record review, the facility to ensure 1 [Resident 3] of 6 sampled residents was evaluated for ability to self-administer laxative medication. The facility had a total census of 115 residents.Findings are:Findings are:A review of Resident 3's admission Record revealed Resident 3 was admitted to the facility on [DATE] with a diagnosis of hemiplegia [paralysis], unspecified affecting right dominant side.A review of Resident 3's MDS [Minimum Data Set; a comprehensive assessment used for care planning] dated 3/2/26 revealed a score of 8 on the Brief Interview for Mental Status which a score of 8-12 means moderate problems with thinking and memory.A review of Resident 3's Care Plan did not reveal any focus area related to self-administration of medication.A review of Resident 3's Self-Medication Administration Evaluation dated 3/3/26 revealed Resident 3 had been evaluated and determined Resident 3 could self-administer the medication nystatin…

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 failed to notify the provider of new pressure ulcers for 1 (Resident 2) of 2 residents sampled. The facility census was 115. The findings are:A.Record review of the facility policy titled Notification of Changes dated 01-2024 revealed it is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or resident representative, according to their authority, and reported to the attending physician or delegate. Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or resident representative, and the resident's physician to ensure best outcomes of care for the resident. The objective of the notification policy is to ensure that the facility staff makes appropriate notification to the physician and immediate notification to the resident and/or resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09F(iii). Based on record review and interview, the facility failed to review and revise the care plan related to pressure ulcers, amputation, and infection for 1 (Resident 2) of 3 residents sampled. The facility census was 115. The findings are:A.Record review of the facility's policy titled Care Plan Process revealed the plan of care must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and social well-being. Interim care plans are developed within 24 hours of admission for high-risk problems, including major medications and diagnosis. The resident's family or legal representative is involved if the resident is unable to participate and/or the resident approves. High risk areas such as falls, skin/wounds, pain, safety and weight loss must be care-planned immediately upon identifying risk via evaluation. The interdisciplinary team reviews the plan of care quarterly, annually, significant change 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 Based on interview and record review, the facility failed to evaluate weight changes according to practitioner orders and failed to monitor and provide ongoing PICC line care for 1 (Resident 2) of 1 residents sampled. The facility census was 115. The findings are:A.Record review of the facility's undated policy titled Overview of Infusion Therapy revealed for a Peripherally Inserted Central Catheter (PICC) the patient's upper arm circumference is measured on insertion, admission to the facility and whenever clinically indicated. The external catheter length is measured on admission and weekly to monitor for outward migration of the catheter. B.Record review of Resident 2's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 01-04-2026 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-Brief Interview of Mental Status (BIMS) was scored as 13. According to the MDS Manual a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure reference: 12-006.12(D)(i)Based on observation, interview and record review, the facility failed to ensure medication was stored securely in accordance with facility policy for 2 [Resident 2 and 3] of 6 residents. The facility had a total census of 115 residents. Findings are:A. A review of facility policy revised 8/2024 and titled Centralized medication storage in the long-term care facility revealed the following policy: -Medications are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier, and in accordance with federal and state laws and regulations. The medication supply is accessible only to authorized personnel. B. Observations on 3/17/26 at 8:14 AM revealed a container of Gavilyte-G solution [laxative] with pharmacy label for Resident 3 located on the bathroom sink in Resident 3's bathroom. The container had approximately 1 inch of solution in the bottom. In an interview on 3/16/26 at 10:47 AM, Wound and Infection Nurse confirmed that 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 12-006.18(B) Based on observation, interview and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP) during wound care for 1 (Resident 2) of 2 residents sampled. The facility census was 115. The findings are:A.Record review of the facility policy titled Enhanced Barrier Precautions (EBP) dated 01-2024 revealed EBP are infection control interventions designed to reduce the transmission of resistant organisms that employs targeted gown and glove use during high contact activities. EBP may be indicated for residents with any of the following: -wounds, or indwelling medical devices regardless of Multi-Drug Resistant Organism (MDRO) colonization status, -residents known to be infected or colonized with an MDRO;will be placed on EBP and signage on the door placed. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident activities:-dressing-bathing/showering-providing hygiene-changing linens-changing…

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)(3)Based on observation, interview and record review, the facility failed to use the prescribed wound dressing for 1 (Resident 2) of 3 residents and failed to conduct weekly skin evaluations for 1 (Resident 1) of 4 residents sampled. The facility census was 101. The findings are:A.Record review of Resident 2's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 09-23-2025 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 indicates a person is cognitively intact. -Required limited assistance with upper body dressing-Required extensive assistance with bathing, lower body dressing, hygiene and bed mobility.-Required total assistance with toileting and transfers. Record review of Resident 2's Treatment Administration Record (TAR) for October 2025 revealed the following order:-Right lower extremity…

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 12-006.04(F)(i)(5) Based on record review and interview, the facility failed to ensure notification of physician of sliding scale insulin not being administered to 1 [Resident 4] of 6 sampled residents. The facility had a total census of 92. Findings are:A review of Resident 4's admission Record revealed Resident 4 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus and dependence on renal dialysis. A review of Resident 4's 7/2025 Medication Administration Record (MAR) revealed orders for sliding scale insulin 3 times per day per the following sliding scale: 150-200=1 unit; 251-300=3 units; 301-350=4 units; 351-400=5 units; 401-450=6; greater than 450=7 units and call provider. A review Resident 4's 7/2025 between 7/1/25 and 7/28/25 revealed Resident 4's sliding scale insulin not provided at 5 PM on the following days:-Wednesday 7/2/25 noted to be out of facility,-Monday 7/7/25 noted to be out of the facility,-Wednesday 7/9/25 noted to out of facility,-Friday…

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 12-006.10 (A)(ii) Based on observation, interview, and record review, the facility failed to ensure insulin was administered in accordance with standards of practice for 3 [Residents 1, 3, and 4] of 6 sampled residents. The facility had a total census of 92 residents. Findings are:-A review of Resident 1's 7/2025 MAR [Medication Administration Record] revealed an order for Lispro insulin 5 units to be given 3 times daily with meals scheduled for 8 AM 12 PM, and 5 PM. Observations on 7/28/25 at 7:27 AM revealed LPN [Licensed Practical Nurse] A dialing up 5 units of insulin without priming the insulin pen. LPN A administered insulin into back of Resident 1's right arm. In an interview on 7/28/25 at 8:10 AM, LPN confirmed insulin pen was not primed before dialing insulin to be administered. -A review of Resident 3's 7/2025 MAR revealed an order for Novlog flex pen inject per sliding scale 4 times a day at 8 AM, 12 PM, 5 PM, and 8 PM per sliding scale as follows: 150-199 =1 units; 200-249=2 units, 250-299=3 units; 300-349=4 units; 350-399=5 units; 400-999=6…

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 failed to notify the resident's physician of a change of condition for 2 (Resident 1 and 3) of 4 sampled residents. The facility census was 101. The findings are: A. Record review of the Resident 3's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 05-22-2025 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 13-15 indicates a person is cognitively intact. -required total assistance with bathing and removing footwear. -required extensive assistance with lower body dressing. -was at risk of developing pressure ulcers. -had one or more unhealed pressure ulcers. Record review of Resident 3's Skin-Wound Weekly Observation (SWWO) dated 05-28-2025 revealed Resident 3 had a deep tissue injury (a pressure ulcer where the skin and underlying tissue are damaged…

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 evaluate, monitor and implement interventions for pressure ulcer prevention and to promote wound healing for 1 (Resident 3) of 4 resident sampled. The facility census was 101. The findings are: Record review of the Resident 3's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 05-22-2025 revealed the facility staff assessed the following about the resident: -admitted to the facility on [DATE]. -Brief Interview of Mental Status (BIMS) was scored as a 15. According to the MDS Manual a score of 13-15 indicates a person is cognitively intact. -required total assistance with bathing and removing footwear. -required extensive assistance with lower body dressing. -was at risk of developing pressure ulcers. -had one or more unhealed pressure ulcers. Record review of Resident 3's Comprehensive Care Plan (CCP) dated 05-29-2025 revealed the following about…

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

Licensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview the facility failed to perform pre and post dialysis (a life-sustaining treatment used when kidneys fail to filter waste and excess fluid from the blood) assessments for 2 (Residents 2 and 3) of 3 sampled residents, failed to assess the dialysis access sites (the locations where a dialysis machine can access the blood stream to perform dialysis) on each shift for 2 (Residents 2 and 3) of 3 sampled residents who had a dialysis access site, and failed to ensure the physician was notified of missed dialysis treatment for 1 (Resident 1) of 3 sampled residents. The facility had a census of 108. Findings are: A record review of the facility's Special Needs policy dated 11-17; 1-2024 revealed the following information: This policy pertains to the following needs: parenteral fluids, respiratory care, prostheses and dialysis, colostomy, urostomy, ileostomy. - Policy Explanation and Compliance Guidelines: - 7. Medical conditions will be monitored and managed to prevent complications. - b. Registered Nurses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 1-005.04 Based on record review and interview the facility failed to investigate and resolve grievances for 2 (Resident 5 and 6) of 3 residents sampled. The facility census was 105. The findings are: A. Record review of Resident 5's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 3-6-2025 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored at a 15. According to the MDS Manual a score of 13-15 indicates a person is cognitively intact. -Required total assistance with toileting. -Required substantial assistance with wheelchair mobility. -Required limited assistance with hygiene and transfers. Record review of the facility's grievance log revealed Resident 5 had submitted a grievance on 03-21-2025. Record review of the facility's Grievance Policy dated 01-2024 revealed it is the policy of this facility that each resident has the right to voice grievances to the 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 12-006.09(H)(iv)(5) Based on record review and interview the facility failed to monitor bowel movements for 1(Resident 4) of 3 residents sampled. The facility census was 105. Record review of Resident 4's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 04-04-2025 revealed the facility staff assessed the following about the resident: -BIMS was scored as a 15. -required total assistance with toileting, lower body dressing, bed mobility, and transfers. -required extensive assistance with upper body dressing. -was always incontinent of bowel and bladder. -a trial toileting plan was not attempted. Record review of Resident 4's progress note dated 3-29-2025 revealed Resident 4 had been readmitted to the facility after hospitalization for a small bowel obstruction. Record review of Resident 4's progress notes from 03-30-2025 to 04-16-2025 did not address the small bowel obstruction, an abdominal assessment or bowel movements. Record review of Resident 4's Comprehensive Care Plan (CCP) dated 03-12-2025 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 12-006.09(H)(iv)(2) Based on record review and interview the facility failed to implement a toileting program for 2 (Resident 1 and 4) of 3 sampled residents. The facility census was 105. The findings are: Record review of Resident 1's admission bladder assessment dated [DATE] revealed the following about Resident 1: -was currently incontinent of bladder, -had impaired mobility -had urine leakage on the way to the bathroom -the incontinence was new and occurred after an injury Record review of Resident 1's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 03-30-2025 revealed the facility staff assessed the following about the resident: -admitted to the facility on [DATE]. -Brief Interview of Mental Status (BIMS) was scored as a 15. According to the MDS Manual a score of 13-15 indicates a person is cognitively intact. -admitted with a right fractured femur (upper leg). -required total assistance with lower body dressing. -required moderate…

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 12-006.11(E) Based on observations, interviews, and record reviews, facility failed to label and date foods and to ensure food is disposed of in accordance with facility policy to ensure food safety. This has the potential to effective 110 of 111 residents residing in the facility. Findings are: A. Observations on 3/18/25 at 5:39 AM and 6:05 AM revealed the following items in the 4th floor refrigerator: -2 unlabeled bottles of a green substance -an undated jar of Miracle Whip -an undated jar of mustard -an undated jar of salsa -a bottle of white chocolate sauce with no label and an expiration date of 3/7/25 -a bottle of BBQ sauce with no label or date -orange juice concentration dated 2/25 In an interview on 3/18/25 at 6:05 AM, the Dietary Director confirmed foods in the refrigerator need to be labeled and dated and the white chocolate sauce was outdated. The Dietary Director confirmed that foods needed to be disposed of 7 days after opening. Observations on 3/18/25 at 5:56 AM and 6:11 revealed the following items in the third floor refrigerator: -yogurt…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 1-005.06(D, E & F) Licensure Reference Number 175 NAC 12-006.18(B) Based on observation, interview and record review; the facility failed to perform hand hygiene between glove changes during toileting care for 1 (Resident 84) of 4 sampled residents. The facility failed to utilize enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition [e.g., residents with wounds or indwelling medical devices]) during wound cares for 1 (Resident 75) of 4 sampled residents. The facility failed to ensure EBP was in place for 23 resident rooms in the facility with residents who had orders for EBP (Rooms 208, 211, 212, 224, 308, 402, 403, 404, 405, 408, 424, 426, 429). A total of 25…

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

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on interview and record review; the facility failed to notify the family of the development of a new wound and new treatment orders for 1 (Resident 108) of 4 sampled residents reviewed for wounds. The facility identified a census of 111. Findings are: A record review of Resident 108's Skin/Wound Weekly Observation dated 7/19/24, 7/28/24, and 8/5/24 revealed an existing wound to the left toes with a wound vac (medical device that removes drainage and assist with wound healing) treatment in place and no other skin conditions. A record review of Resident 108's Tissue Analytics dated 7/24/24 revealed a new trauma wound to the right great toe with treatment orders dated 7/25/24 to continue to paint the wound with betadine. A record review of Resident 108's medical record including progress notes revealed that there was no documentation regarding the resident's family member being notified of the new wound or new treatment. On 3/20/25 at 8:10 AM the Director of Nursing confirmed that the expectation would be to notify 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: 12-006.09(H)(i)(3) Based on interview and record review, the facility failed to ensure baths were provided in accordance with resident choice for 2 [Resident 68 and 75] of 37 sampled residents and failure to ensure assistance with eating for 1 [Resident 84 ] of 37 sampled residents. The facility had a total census of 111 residents. Findings are: A. A review of Resident 68's admission Record revealed Resident 68 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure [lungs are unable to adequately exchange oxygen and carbon dioxide] with hypoxia [low blood oxygen levels]. A review of Resident 68's MDS [Minimum Data Set; a comprehensive assessment used for care planning] revealed Resident 68 had a Brief Interview for Mental Status score of 8 indicating moderately impaired cognitive function. Further review of MDS revealed Resident 68 was dependent for bathing self. A review of Resident 68's Care Plan revealed Resident 68 was dependent for bathing and preferred two…

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 Based on interview and record review; the facility failed to obtain an order prior to administration of the Covid-19 vaccine for 1 (Resident 84) of 6 sampled residents. The facility identified a census of 111. Record review of facility policy entitled Quality of Care - Immunizations Vaccination of Residents Dated revised 1/2024 revealed: -All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated, or the resident has already been vaccinated. -7. Certain vaccines (e.g., influenza and Pneumococcal vaccines) may be administered per the physician approved facility protocol (standing orders) after the resident has been assessed by the physician for medical contraindications for each vaccine. The resident's attending physician must provide a separate written order for any other vaccination, and such orders shall be recorded in the resident's medical record. Record review of Resident 84's Medical Diagnoses printed 3/18/25 revealed diagnoses of anoxic brain damage (loss of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(H)(iii)(2) Based on observations, record reviews and interviews, the facility failed to provide a pressure ulcer treatment as ordered for 1 one (Resident 112) of 5 residents reviewed for wound management. The facility census was 111. Findings are: Record review of Resident 112's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 03/11/2025 revealed the resident was dependent for toileting hygiene, needs substantial assistance to roll left and right, to move from a sitting to lying position, and needs substantial assistance to transfer from the bed to the chair. The MDS revealed Resident 112 had an unhealed pressure ulcer at Stage 1 (intact skin with a localized area of non-blanchable erythema (redness) or higher, and two unstageable(full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer…

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, record review and interview; the facility failed to implement interventions to prevent falls for 1 (Resident 119) of 4 residents. The facility census was 111. Findings are: Record review of Resident 119's clinical census revealed an admission date of 03/06/2025. Record review of Resident 119's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 3-12-2025 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15. According to the MDS [NAME] a score of 13 to 15 indicates a person is cognitively intact. Further review of Resident 119's MDS dated [DATE] revealed Resident 119 had lower extremity impairment on one side, the use of a walker and a wheelchair for mobility, and the resident required supervision or touching assistance when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.12(A)(vi) Based on record review and interviews, the facility failed to ensure recommendations for pharmacy requests were reviewed and actions taken related to Gradual Dose Reduction (GDR, Stepwise tapering of a dose to determine whether or not symptoms, conditions, or risks can be managed by a lower dose or whether or not the dose or medication can be discontinued), discontinued medications, and stops dates not updated for Resident 46, and failed to follow up on pharmacy recommendations for gradual dose reduction for antidepressant medications used for Resident 47. This affected two (Residents 46 and 47) of five residents reviewed for unnecessary medications. The facility census was 111. Findings are: A. Record review of a facility policy entitled Medication Regimen Review (MRR, includes medication reconciliation, a review of all medications a resident is currently using, and a review of the drug regimen to identify, and if possible, prevent potential clinically…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility to identify target behaviors to ensure adequate monitoring for 1 [Resident 68] of 4 sampled residents receiving antipsychotic medications. The facility had a total census of 111 residents. Findings are: A review of Resident 68's admission Record revealed Resident 68 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure [lungs are unable to adequately exchange oxygen and carbon dioxide] with hypoxia [low blood oxygen levels]. A review of Resident 68's MDS [Minimum Data Set; a comprehensive assessment used for care planning] revealed Resident 68 had a Brief Interview for Mental Status score of 8 indicating moderately impaired cognitive function. Further review revealed Resident 68 received an antipsychotic medication on a routine basis. A review of Resident 68's 3/2025 MAR [Medication Administration Record] revealed an order for Quetiapine [an antipsychotic medication] 25 mg 1 tablet by mouth twice per day for major depressive…

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

Licensure Reference Number 175 NAC 12.006.04(G)(i) Based on record review and interviews; the facility failed to ensure 4 of 4 nursing staff sampled had competency evaluations. This had the ability to affect all residents that reside in the facility. The facility census was 101. The findings are: Record review of the facility's list of staff with position revealed the following: -Nursing Assistant (NA) C was hired on 09-13-2022. -NA D was hired on 05-28-2024. -NA E was hired on 04-09-2024. -NA F was hired on 10-01-2024. Record review of the facility's competencies for Nursing Assistants revealed the absence of competency evaluations for NA C, D, E, and F. An interview with the Interim Director of Nursing (IDON) was conducted on 11-14-2024 at 2:15 PM confirmed that competency evaluations were not completed for NA C, D, E, and F.

Licensure Reference Number 175 NAC 12-006.10 Based on record review and interview, the facility failed to follow the medical provider's orders for 1 (Resident 2) of 3 sampled residents. The facility identified a census of 106. Findings are: Record review of Resident 2's admission orders dated 7-30-2024 revealed, Resident 2's practitioner order the medications be administered through the G-tube (A tube that is inserted into the gastrointestinal tract to provide nutrition or medication). Record review of an practitioners order dated 9/04/2024 revealed Resident 2's Medical Practitioner had changed the medication route from G-tube to oral (consumption by mouth). Record review of the Resident 2's Medication Administration Record (MAR) for September 2024 revealed that the facility discontinued the medications on 9/4/2024 and restarted the medications on 9/06/2024 for the following: - Pantoprazole 2 MG/ML, give 20 Milliliters (ML) orally in the morning related to Gastro-Esophageal Reflux (Inflammation of the esophagus). - Amiodarone 200 Milligram (mg) Tablet, give 1 tablet orally in 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 12-006.04(F)(i)(5) Based on interview and record review the facility failed to notify the resident's physician prior to transfer to the hospital for 1(Resident 5) of 3 residents sampled. The facility census was 99. Findings are: Record Review of Resident 5's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 7-11-2024 revealed Resident 5 had the diagnosis of Acute Cystitis, Dementia, Bipolar Disorder, Chronic Obstructive Pulmonary Disease, and had a Multi Drug Resistant (MDRO, bacteria that is resistant to more than 1 antibiotic), and a 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 12 indicating moderate cognitive impairment. The MDS also indicated Resident 5 was occasionally incontinent of bladder and frequently incontinent of bowel and required moderate…

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 71-71-6022 (1) Based on record review and interview, the facility failed to document the basis for transfer and failed to provide a report the receiving provider for 1 (Resident 5) of 3 residents sampled who had transferred to the hospital. The facility census was 99. Findings are: Record Review of Resident 5's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 7-11-2024 revealed Resident 5 had a diagnosis of Acute Cystitis, Dementia, Bipolar Disorder, Chronic Obstructive Pulmonary Disease, and had a Multi Drug Resistant (MDRO, bacteria that is resistant to more than 1 antibiotic), and a 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 12 indicating moderate cognitive impairment. The MDS also indicated Resident 5 was occasionally incontinent of bladder and frequently…

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 Nebraska Statute 71-6022(2) Based on interview and record review the facility failed to provide a discharge notice 30 days prior to a facility-initiated discharge for 1 of 3 (Resident 5) sampled residents. The facility census was 99. Record Review of Resident 5's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 7-11-2024 revealed Resident 5 had diagnosis of Acute Cystitis (an infection in the bladder), Multi Drug Resistant Organism (MDRO, a bacteria that is resistive to treatment by more than 1 antibiotic), Dementia, Bipolar Disorder(a mental health conditions characterized by periodic, intense emotional states affecting a person's mood, energy, and ability to function), Chronic Obstructive Pulmonary Disease (COPD, is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe), and a Brief Interview of Mental Status (BIMS, an assessment that aids in detecting cognitive impairment. A score of 0-7 equals severe…

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

Licensure Reference Number 175 NAC 12-006.09(I)(i)(1) Based on observation, interview, and record review the facility failed to implement fall interventions for 1 (Resident 1) of 3 sampled residents. The facility census was 99. The Findings are: Record Review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 04-07-2024 revealed a diagnosis of intervertebral disc degeneration in the lumbar region Intervertebral disc disease is a common condition characterized by the breakdown (degeneration) of one or more of the discs that separate the bones of the spine (vertebrae), causing pain in the back or neck and frequently in the legs and arms ), ataxia (Ataxia describes poor muscle control that causes clumsy movements), anemia (Anemia is a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), osteoarthritis (Osteoarthritis is a degenerative joint disease, in which the tissues in the joint break down over time) of bilateral hips, hypertension, and peripheral vascular disease…

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 observation, interview and record review the facility failed to ensure residents were free of significant medication errors for 1 of 5 (Resident 6) sampled residents. The facility census was 99. Findings are: Record Review of Resident 6's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 07-02-2024 revealed diagnosis of Heart Failure, Peripheral Vascular Disease (PVD, is the reduced circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel), Right Below the Knee Amputation (surgical removal of a limb), Renal insufficiency (gradual decline in kidney function over time), and Diabetes Mellitus. The MDS also revealed Resident 6 had a 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 8 and required moderate assistance from staff for upper body dressing, maximal…

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 12-006.04D2 Based on record review and interview, the facility failed to employ a qualified dietary manager. This has the potential to affect all residents residing at the facility. The facility census was 89. The findings are: Review of the Dietary Manager's (DM) personnel file revealed no certification for the DM position. Record Review staff contact list on 2/14/23 at 9:37 am revealed the current DM is listed as DM on the staff contact list. Interview with Registered Dietician (RD) on 2/14/23 at 9:37 AM revealed the RD is in the building one time a week for oversite. The RD revealed the DM was in class and will complete in the fall to become certified. On 2/14/24 at 9:46 AM an interview with the Administrator confirmed the DM has until the fall to complete the required classes for the DM position.

Licensure Reference Number 175 NAC 12-006.11A1 Based on observation, record review and interview, the facility failed to ensure an approved recipe was followed to meet the nutritional needs of the residents. This had the ability to affect 88 of the 89 residents served food from the kitchen. The facility identified a census of 89. Findings are: Observation on 2/14/24 at 8:39 AM through 9:45 AM revealed [NAME] C prepared the hamburger stew for the noon meal by placing 1/1/2 rolls of packaged ground beef into the large cooking roaster. Cook C was following a recipe that was hand-written on a notepad, the following was on the notepad: HamburgerStew = Ground meat-1 1/2 Sliced carrots-boil half Diced potatoes-1 can Gravy Brown Do not boil the zucchini. Record review of the facility recipe for hamburger stew was as follows: Beef, ground 19 pounds 3 ounces-(Cook C used 15 pounds). Onion-4 cups- (Cook C used none). Water-hot 2 gallon- (Cook C used indeterminate amount with the gravy). Carrots-fresh diced 1 gallon, 2 quart- (Cook C used indeterminate amount of frozen carrots). Celery, fresh,…

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

Licensure Reference Number 175 NAC 12-006.11E Based on observation, record review, and interview, the facility failed to provide clean and sanitary conditions for food preparation and failed to prevent the potential for food borne illnesses due to expired food and improper hand hygiene during food preparation. This had the potential to affect 88 of 89 resident served food from the kitchen. The facility identified a census of 89. Findings are: An observation on 2/12/2024 at 7:10 AM during the initial kitchen tour revealed the following: - a cart with coffee dispensers, clean plates, and bananas on it. The cart had dirt and food crumbs, spilled red liquid and dried coffee on all three shelves, the ice machine had a scoop inside laying on the ice, two large coffee dispensers and one large drink dispenser with a drain across the front of the cart which had a dried dark build-up of unidentifiable substance. The floor around the prep station and stove was sticky with a greasy substance. -A large roaster/pan where large quantities of food are cooked and sits on pedestals had thick dried…

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 12-006.17a(2) LICENSURE REFERENCE NUMBER 175 NAC 12-006.17b Based on observations, record reviews and interviews; the facility staff failed to identify organisms for infection in their infection control program in real time and failed to utilize handwashing and gloving techniques during the provision of cares for 2 (Resident 33 and 26) of 4 sampled residents. The facility staff identified a census of 89. Findings are: A. Record review of the facility policy for Infection Prevention and Control Program (IPCP) dated 1/2024 revealed the following information: -Policy: -It is the policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable disease and infections. Record review of the facility Antibiotic Tracking Sheet (ATS) for the months of 12-18-2023 through 1-10-2024 revealed the ATS did identify the organisms that…

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

Licensure Reference Number 175 NAC 12-006.09D1d(1) Based on record review and interview, the facility failed to assist in scheduling an eye appointment for 1 (Resident 57) of 3 sampled residents. The facility census was 89. Findings are: Record Review of Resident 57's Care Plan dated 05-27-2022 revealed Resident 57 had impaired visual function related to glaucoma (an eye disease that can cause vision loss and blindness by damaging a nerve in the back of your eye) and the facility was to arrange consultation with an eye care practitioner. Record Review of Resident 57's medical record revealed Resident 57's responsible party signed a request for medical eye care on 02-09-2023. An interview conducted with Resident 57's legal guardian on 02-12-2024 at 2:35 PM revealed that an eye appointment had been requested over a year ago. Record Review of the facility grievance log revealed Resident 57's guardian filed a grievance on 11-20-2023 about Resident 57 not having an eye appointment. Record review of Resident 57's medical record revealed the absence of records from an eye care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09D4 Based on record review and interview; the facility staff failed to evaluate 1 (Resident 44) of 3 sampled residents for a Restorative Nursing Program (RNP). The facility identified a census of 89. Findings are: Record review of Resident 44's Order Summary sheet printed on 2-13-2024 revealed Resident 44 admitted to the facility on [DATE] with the diagnoses of: a right Femur fracture, Dementia, and Cerebral Infarction (commonly known as a stroke). Record review of Resident 44's Comprehensive Care Plan (CCP) dated 10-23-2023 revealed Resident 44 had functional deficits with current Activities of Daily Living (ADL's) related to the right hip fracture, stroke and Dementia. The goal identified for Resident 44 was to maintain current level of ADL function. Intervention to achieve this goal was for Occupational Therapy (OT), Physical Therapy (PT) and Speech Therapy (ST). Record review of Resident 44's Minimum Data Set (MDS, a federally mandated assessment tool used for care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09D4 Based on observations, record review, and interview; the facility staff failed to complete catheter (tube placed into bladder) care for 1 (Resident 33) and failed to complete incontinence care for 1 (Resident 44) of 4 sampled residents. The facility staff identified a census of 89. Findings are: A. Record review of a Order Summary Report (OSR) printed on 2-13-2024 revealed Resident 33 admitted to the facility on [DATE]. Further review of Resident 33's OSR revealed Resident 33 had a suprapubic catheter (tube place usually through lower abnormal area into the bladder to drain urine). Record review of Resident 33's Treatment Administration Record (TAR) for February 2024 revealed Resident 33 had treatment orders to cleanse the supra pubic site twice a day with soap and water. Observation on 2-14-2024 at 8:20 AM with Assistant Director of Nursing (ADON) E of suprapubic catheter care by Licensed Practical Nurse (LPN) F. LPN F gathered the required equipment, placed 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 Number175 NAC 12-006.09D8a Based on interviews, record review, and observation, the facility failed to provide nutritional interventions for continued weight loss on 1 (Resident 84) and failed to have a method of accurately and consistently obtaining weights for 1 (Resident 44) of 3 sampled residents. The facility has a census of 89. The findings are: A. Record review of Resident 84's Face Sheet revealed the resident was admitted on [DATE] with the following diagnoses: non-pressure chronic ulcer of other part of left foot with unspecified severity, cellulitis of left lower limb, and mild protein-calorie malnutrition. Record review of Resident 84's Discharge summary dated [DATE] from the hospital revealed the resident had an albumin level (a laboratory test measuring the amount of protein in your blood and if measure is low it can indicate malnutrition) of 2.7 and normal results should be 3.5 to 5.5. Record review of Resident 84's Minimum Data Set (MDS) (federally mandated assessment tool for…

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, observation, and interviews, the facility failed to identify, assess, and monitor a fistula site for 1 resident (Resident 25) of 1 sampled resident. The facility identified a census of 89. Findings are: Observation on 2/12/24 at 11:05 AM of Resident 25 revealed a dressing on the resident's right antecubital and right upper forearm, with dried blood underneath the dressing. The dressing was loose around the edges. Interview on 2/12/24 at 11:05 AM with Resident 25 revealed that resident had been on dialysis over a month and that resident had a fistula created about a week ago and the facility staff had not looked at the fistula since it was created. Record review of Resident 25's, quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C Brief Interview Mental Status (BIMS) (a test to evaluate the resident's cognition) revealed a score of 11. A score of 11 indicated the resident was mildly cognitively impaired. Section GG revealed the following: Eating is set up assist, bed mobility…

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 12-006.09D5 Based on observations, record review and interview; the facility staff failed to evaluate and implement interventions to manage triggers for 1 (Resident 33) of 1 resident with a diagnosis of Post Traumatic Stress Disorder (PTSD). The facility staff identified a census of 89. Findings are: Record review of Resident 33's Minimum Data Set (MDS, a federally mandated assessment tools used for care planning) dated 11-27-2023 revealed the facility staff assessed Resident 33 with a Brief Interview of Mental Status (BIMS) of a 15. According to the MDS [NAME] a score of 13 to 15 indicates a person is cognitively intact. Further review of Resident 33's MDS dated [DATE] revealed Resident 33 had the diagnoses of PTSD. Record review of Resident 33's Comprehensive Care Plan (CCP) revised on 1-04-2023 revealed the facility staff had identified Resident 33 had the diagnosis of PTSD. Further review of Resident 33's CCP revised on 1-04-2023 revealed there were no indications of what…

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 12-006.14 Based on record review and interview, the facility failed to ensure dental services were provided for 1 of 4 sampled residents (Resident 57). The facility census was 89. Findings are: An interview with Resident 57's legal guardian on 02-12-2024 revealed Resident 57 has not had a dental appointment in over a year. Record Review of Resident 57's medical record revealed a consent for 360 dental services signed by Resident 57's guardian on 02-09-2023 and an absence of records for dental services provided. Record Review of the facility's grievance log revealed Resident 57's guardian requested a dental appointment on 11-20-2023. An interview with the facility's Nurse Consultant confirmed Resident 57 had not been seen for dental services.

Licensure Reference Number 175 NAC 12.006.05(4). Based on record review and interview: the facility failed to ensure that bathing was provided according to the comprehensive plan of care for 2 (Resident 2 and 3) of 6 sampled residents. The facility staff reported a census of 86. Findings are: Record Review of an undated Policy and Procedure of Resident Rights revealed that the resident has the right to participate in the development and implementation of the resident's person-centered plan of care. The policy also revealed that the resident has the right to choose schedules including bathing. A. Record review of Resident 2's comprehensive plan of care revised on 9/12/2023 revealed that Resident 2 was to be given a shower two times a week. A record review of tasks in Resident 2's electronic health record (EHR) for October 7, through November 7, 2023, revealed Resident 2 received three bed baths out of nine times Resident 2 should have received a bath/shower. An interview conducted on 11/07/2023 at 7:45 AM with Resident 2 revealed that the resident wasn't being bathed as often as…

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 staff failed to ensure the Facility Assessment (tool used to identify all the resources needed to meet the needs of the facility residents) identified if the facility Administrator, Director of Nursing (DON), Assistant Director of Nursing's, Social Services Director, Human Resources Director, Minimum Data Set,(MDS, a federally mandated assessment tool use for care planning) Coordinator, Business Office Manager, Environmental Services/Maintenance Director and the Dietary Manager were full or part time, failed to identify the needs for an Activities Director or Infection Control Preventionist and the amount of time needed to meet all the facility resident's needs. This had the potential to effect all residents in the facility. The facility staff identified a census of 94. Findings are: Record review of the Facility assessment dated [DATE] and updated 10-11-2022 revealed the following information: -Facility Assessment tool: -Purpose: -The purpose of the assessment…

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

Licensure Reference Number 175 NAC 12-006.04B2a Based on record review and interview; the facility staff failed to ensure 6 Nursing Assistants (NA D, NA E, NA G, NA H, NA I and NA J) of 8 NAs employed a year or longer received the required 12 hours of training yearly. The facility staff identified a census of 94. Findings are: Record review of a sheet provided on 9-20-2023 by the facility Administrator of the facility Nursing Assistant hire dates revealed the following: -NA D was hired on 9-13-2022. -NA E was hired on 1-07-2020. -NA G was hired on 4-05-2022. -NA H was hired on 12-28-2021. -NA I was hired on 9-11-1984. -NA J was hired on 7-15-2020. On 9-20-2023 at 3:40 PM an interview was conducted with the Regional Nurse Consultant (RNC). During the interview the RNC reported the the facility was not able to provide the 12 hour education for NA D, NA E, NA G, NA H, NA I or NA J.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.17A1 Licensure Reference Number 175 NAC 12-006.17D Licensure Reference Number 175 NAC 12-006.17B Licensure Reference Number 175 NAC 12-006.18B Licensure Reference Number 175 NAC 12-006.18C1 Based on observation, interview, and record review, the facility failed to ensure staff wore surgical masks above the nose and below the chin while serving meals and in resident care areas to prevent the potential spread of COVID-19, failed to perform hand hygiene (cleaning) between residents to prevent cross-contamination (spread of bacteria from one surface to another), failed to ensure oxygen nasal cannula (a tube inserted in the resident's nose to deliver oxygen) was off the floor, failed to sanitize (clean) and store nebulizer administration set (a device used to deliver liquid medication to the lungs) per facility policy, failed to sanitize COVID-19 testing surfaces to prevent the spread of COVID-19 between tests, failed to ensure infection control practices were followed during…

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

Licensure Reference Number 175 NAC 12-006.05(21) Based on observation and interview, the facility failed to provide a homelike environment for all 10 residents in the dining room by leaving plates with food, cups with fluid, and silverware on the plastic serving trays in front of the residents. This affected Residents 80, 82, 26, 67, 2, 33, 18, 24, 88, and 64. The total facility census was 96. Findings are: An observation on 02/09/2023 at 12:00 PM revealed 10 residents in the second-floor dining room received lunch trays and the plates that contained food, cups that contained fluids, and silverware were located on the plastic trays and left in front of Resident 80, 82, 26, 67, 2, 33, 18, 24, 88, and 64. An observation on 02/13/2023 at 07:42 AM revealed 8 residents in the second-floor dining room received lunch trays and the plates that contained food, cups that contained fluids, and silverware were located on the plastic trays and left in front of Resident 80, 82, 26, 2, 33, 18, 88, and 64. In an interview on 02/13/2023 at 10:42 AM, the Director of Nursing (DON) confirmed that the…

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

Based on record review and interview; the facility staff failed to identify and communicate Advance Directive to nursing staff for 1 (Resident 77) of 1 sample resident. The facility census was 96. Findings are: Review of Resident 77's Face sheet dated 3-29-22 revealed there were not any Advanced Directives selected for this resident in this chart. Interview 2-9-22 at 2:14 PM with the Social Service Director revealed Resident 77 did not have an advanced directive. Interview with the Administrator on 2-13-23 at 3:00 PM confirmed that the facility did not have a copy of Resident 77's Advanced Directives.

175 NAC 12-006.09b1(2) Based on record review and interviews, the facility failed to ensure the completion of a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) for 1 Resident (16) after the resident had a significant change in condition. The facility's census was 96. Findings are: A review of Resident 16's Electronic Health Record revealed that the resident had the 3rd, 4th, and 5th toes of their right foot amputated on 12/7/22. A review of the resident's Quarterly MDS Section G Functional Status dated 10/21/22 revealed that the resident was marked as requiring limited (non-weight bearing) assistance with bed mobility, and supervision (non-touching assistance) with walking in their room and the corridors, transferring between surfaces, toilet use, and maintaining personal hygiene. A review of Resident 16's Quarterly MDS Section K Swallowing/Nutritional Status dated 10/21/22 revealed that the resident was marked No for question K0300 Loss of 5% or more in the last month or loss of 10% or more…

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 12-006.09D6(7) Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 249) of 3 sampled resident's oxygen tank was full and working to provide the resident's oxygen as ordered. The total facility census was 96. Findings are: An observation on 02/08/2023 at 10:41 AM revealed Resident 249 was lying in bed with the oxygen nasal cannula (a tube inserted in a resident's nose to deliver oxygen) in the nose, but the gauge on the oxygen tank revealed the tank was empty. In an interview on 02/08/2023 at 10:41 AM, Resident 249 confirmed that the resident could not feel oxygen flowing from the nasal cannula. An observation on 02/08/2023 at 11:09 AM revealed Nursing Assistant (NA)-A entered Resident 249's room to assist the resident, exited the room, and returned to the Nurse's Station. An observation on 02/08/2023 at 11:16 AM revealed Resident 249's oxygen tank was empty per the gauge on the oxygen tank. In an observation with the Assistant Director of Nursing (ADON) on 02/08/2023 at 11:43 AM, the ADON confirmed that 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 Based on record review and interview; the facility staff failed to follow pre-dialysis instructions identified on a Dialysis Communication Sheet and failed to provide post-dialysis monitoring in accordance with physicians orders for 1(Resident 68) of 1 sampled resident. Findings are: A record review of the facility's undated Dialysis Communication Sheet contained the following instructions: -An assessment should be performed prior to the resident leaving for dialysis. This should include any concerns with the Resident, the vital signs (temperature, pulse rate, respirations and blood pressure) taken prior to leaving, any concerns with fluid intake, any antibiotics started, any medication or dietary changes and any episodes of falling or changes in condition noted. -The nurse performing this assessment should sign their name and time the sheet when the resident leaves the facility. -This should be put in the Red Dialysis binder with the resident name and given to the resident to take with them to dialysis. Record review of Resident 68's Red…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.12E1 Licensure Reference Number 175 NAC 12-006.12E8 Based on observation, interview, and record review, the facility failed to ensure 2 (Residents 58 and 248) of 3 sampled resident's medications were secured and not stored in the resident's rooms and failed to ensure an unidentified medication in room [ROOM NUMBER] was stored safely. The total facility census was 96. Findings are: A. Record review of the facility's Self Administering (taking medication without supervision of a staff member) of Medications Policy dated 02/13/2023 revealed that if a resident chose to self-administer medications, an assessment of the residents physical and mental ability should have been performed, and the medications should have been in a locked box. An observation on 02/08/2023 at 2:42 PM revealed Resident 248 had 1 Ventolin Inhaler (an inhalation (breath in) medication used to open a person's airways when) on the overbed table by the bed and there was a pink wash basin on the dresser 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.