Omaha Nursing and Rehabilitation Center

Licensure Reference Number 175 NAC 12-006.09(H)(iv)(1). Based on observation, interview and record review, the facility failed to perform catheter care in a manner to prevent cross contamination for Resident 9; and the facility failed to assess an indwelling catheter for continued use for Resident 7. The facility census was 64. The findings are: A.Record review of Resident 9's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 06-16-2025 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored at 12. According to the MDS Manual a score of 8-12 indicates a person has moderate cognitive impairment. -required total assistance with hygiene, dressing, toileting, bathing, bed mobility and transfers. -had a urinary catheter. Record review of the Resident 9's Order Summary Report (OSR) printed on 07-30-2025 revealed an order dated 06-12-2025 for indwelling catheter care every shift. Observation on 07-30-2025 at 9:40 AM of Nursing Assistant (NA) J providing catheter care to Resident 9…

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

Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g)Based on observation, interview, and record review, the facility failed to obtain and implement physician's orders for the use of a continuous positive airway pressure (CPAP) non-invasive ventilator for 1 (Resident 65) of 1 sampled resident. The facility staff identified a census of 64.The findings are:Record review of Resident 65's admission Record printed 7/29/2025 revealed the facility admitted the resident on 5/29/2025. Further review of the admission record identified Resident 65 had diagnoses which included atrial fibrillation (a-fib, very rapid uncoordinated contractions of the atria of the heart resulting in a lack of synchronism between heartbeat and pulse beat), anxiety an abnormal and overwhelming sense of apprehension and fear often marked by physical signs, by doubt concerning the reality and nature of the threat, and by self-doubt about one's capacity to cope with it), heart failure, chronic obstructive pulmonary disease (COPD, pulmonary disease that is characterized by chronic typically irreversible airway…

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 The facility failed to notify the practitioner of irregularities identified in the admission medication regimen review for 1 (Resident 47) of 1 resident's sampled. The facility census was 64. The findings are:Record review of Resident 47's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 07-12-2025 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].- had a subarachnoid hemorrhage (bleeding that occurs in the space between the brain and the surrounding membrane).-Brief Interview of Mental Status was scored at a 12. According to the MDS Manual a score of 8-12 indicates moderate cognitive impairment.-required total assistance with toileting-required moderate assistance with bed mobility, toilet transfers and lower body dressing.-required supervision with upper body dressing, and hygiene- was taking high risk medications including antipsychotics, antianxiety, antidepressants,…

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 12-005 (G) The facility failed to ensure residents were free of unnecessary medications for 1 (Resident 47) of 5 residents sampled. The facility census was 64. The findings are:Record review of Resident 47's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 07-12-2025 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].- had a subarachnoid hemorrhage (bleeding that occurs in the space between the brain and the surrounding membrane).-Brief Interview of Mental Status was scored at a 12. According to the MDS Manual a score of 8-12 indicates moderate cognitive impairment.-required total assistance with toileting-required moderate assistance with bed mobility, toilet transfers and lower body dressing.-required supervision with upper body dressing, and hygiene- was taking high risk medications including antipsychotics, antianxiety, antidepressants, anticoagulants, diuretics, and opioids.…

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 12-006.17Based on record review and interview, the facility failed to maintain an accurate medical record for 1 (Resident 32) of 1 sampled resident. The facility staff identified a census of 64.The findings are:Record review of Resident 32's Clinical Census printed 7/27/2025 identified the facility admitted the resident on 4/21/2025.Record review of Resident 32's Medical Diagnoses printed 7/27/2025included cirrhosis of the liver (widespread disruption of normal liver structure by fibrosis and the formation of regenerative nodules that is caused by any of various chronic progressive conditions affecting the liver [such as long-term alcohol abuse or hepatitis]), muscle weakness, generalized edema, and type 2 diabetes mellitus (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production).Record review of Resident 32's admission Minimum Data…

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 12-006.18B Based on observation, interview and record review, the facility staff failed to use Personal Protective Equipment (PPE (gowns, gloves, masks and face shields)), during cares for 2 (Resident 10 and Resident 16) of 2 sampled residents, which were both identified to require Enhanced Barrier Precautions (EBP (A form of infection control to minimize transmission of infectious disease). Findings are: A.An observation on 07/29/2025 at 10:25 AM revealed a sign on Resident 10's door that indicated the resident was in EBP and the required PPE that should be worn by staff. An observation on 07/29/2025 at 10:25 AM revealed Certified Nursing Assistant-A (CNA) and CNA- B entered Resident 10's room and donned (put gloves on) gloves without performing any hand hygiene. During this observation, CNA-B turned the resident and preformed standard perineal care. CNA-B doffed (removed gloves) gloves, and applied Alcohol Based Hand Rub (ABHR) before donning a new pair of gloves to complete the Perineal care. CNA-B then doffed the gloves and donned a new pair 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.

Nebraska Licensure Reference Number 175 NAC 12-006.09(H)Based on interview and record review, the facility failed to manage pain for 1 (Resident 5) of 4 sampled residents. The facility staff identified a census of 65.The findings are:Record review of Resident 5's admission Record revealed the facility admitted the resident on 08/27/19 and identified Resident 5 had diagnoses which included pneumonia, chronic inflammatory demyelinating polyneuritis (an autoimmune disorder that attacks the nerve cell coverings), carpal tunnel of unspecified upper limb, neuropathy (nerve pain), chronic pain, and osteoarthritis.Record review of Resident 5's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 05/01/25 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14. According to the MDS manual, a BIMS score of 14 indicated that the resident had intact cognition. Further review of the…

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

Nebraska Licensure Reference 175 NAC 12-006.12Based on interview and record review, the facility failed to ensure medications were available for 1 (Resident 5) of 4 residents sampled. The facility staff identified a census of 65.The findings are: Record review of Resident 5's admission Record revealed the facility admitted the resident on 08/27/19 and identified Resident 5 had diagnoses which included pneumonia, chronic inflammatory demyelinating polyneuritis (an autoimmune disorder that attacks the nerve cell coverings), carpal tunnel of unspecified upper limb, neuropathy (nerve pain), chronic pain, and osteoarthritis.Record review of Resident 5's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 05/01/25 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14. According to the MDS manual, a BIMS score of 14 indicated that the resident had intact cognition. Further…

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 Licensure Reference 175 NAC 12-006.09(H)Based on record review and interviews, the facility failed to evaluate the potential for allergy to medication for 2 (Resident 4 & 5) of 4 residents sampled. The facility staff identified a census of 65.The findings are:A. Record review of Resident 5's admission Record revealed the facility admitted the resident on 08/27/19 and identified Resident 5 had diagnoses which included respiratory failure with hypoxia (low oxygen), chronic obstructive pulmonary disease (COPD, pulmonary disease that is characterized by chronic typically irreversible airway obstruction resulting in a slowed rate of exhalation), pneumonia, and chronic inflammatory demyelinating polyneuritis (an autoimmune disorder that attacks the nerve cell coverings).Record review of Resident 5's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) revealed a Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a signed Advance Directive Code Status Form was completed to confirm resident's directives for Cardiopulmonary Resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) for 1 [Resident 1] of 6 sampled residents. The facility had a total census of 63 residents. Findings are: A record review of Resident 1's admission Record revealed Resident 1 was admitted to the facility on [DATE]. Resident 1's admission Record identified the following diagnoses: Type 2 Diabetes Mellitus, congestive heart failure [weakened heart muscle that cannot pump blood effectively], and chronic obstructive pulmonary disease [lung disease causing restricted airflow and breathing problems]. A record review of Resident 1's quarterly 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 [DATE] revealed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1) Based on observations, record review, and interview; the facility staff failed to implement interventions to prevent the development of pressure ulcers for 1 (Resident 2 and 4) of 3 sampled residents. The facility staff identified a census of 63. Findings are: A. Record review of Resident 2's Order Summary Report (OSR) printed on 10-30-2024 revealed Resident 2 admitted to the facility on [DATE] with a diagnoses of: Hyperlipidemia (fat particles in the blood system) Hypokalemia (low potassium level) Muscle weakness, Dysphagia (difficulty swallowing), Disorder of Plasma-protein Metabolism, Unspecified Protein Calorie Malnutrition. Further review of OSR printed on 10-30-24 revealed Resident 2's practitioner ordered Resident 2 to have a Prevalon boot (device used to help with preventing pressure ulcers to heels) to the left foot while in bed. Record review of Resident 2's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(l) Based on record review and interview; the facility staff failed to implement additional interventions to prevent falls for 1 (Resident 4) of 4 sampled residents. The facility staff identified a census of 63. Findings are: Record review of Resident 4's Order Summary Report (OSR) printed on 10-30-2024 revealed Resident 4 re-admitted to the facility on [DATE] with the diagnoses of Schizoaffective disorder, Depression, Obesity, and need for assistance with personal Cares. Record review of Resident 4's Minimum Data Set (MDS, a standardized assessment tool used to evaluate the health status of residents in long-term care (LTC) nursing facilities) dated 10-02-2024 revealed Resident 4 had a Brief Interview for Mental Status (BIMS, a score from the BIMS assessment that indicates a person's cognitive function) of a 15. According to the MDS [NAME] a BIMS of 13 to 15 indicates a person is cognitively intact. Further review of Resident 4's MDS dated [DATE] revealed Resident 4…

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, record review and interview; the facility staff failed to follow practitioners orders for wound care for 1 (Resident 3) of 3 sampled residents. The facility staff identified a census of 60. Findings are: Record review of an Order Summary Report (OSR) sheet printed on 10-01-2024 revealed Resident 3 was admitted to the facility on [DATE] with the diagnoses of Hypertension, Severe Sepsis with Septic Shock ( infection with severe complication) and Diabetes. Further review of the OSR sheet printed on 10-01-2024 revealed Resident 3's practitioner order a treatment to Resident 3's left foot second toe as follows: -Lt (left) 2nd toe: clean with mild soap and water, pat dry, apply betadine ( a antiseptic used for skin disinfection) and allow to dry. Cover with a non-adherent dressing and secure it with Kerlex and tape. Record review of a Office Visit Form (OVF) dated 9-26-2024 revealed Resident 3 had gone to their practitioner due to a toe nail…

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 12-006.18B3 Licensure Reference Number 175 NAC 12-006.18A(1) Based on observation and interview, the facility failed to maintain walls, floors, resident equipment, fixtures, air conditioning and ventilation covers in a clean, safe and functional manner in 9 rooms (Rooms 231, 232, 234, 235, 236, 237, 238, 239, 240), which had the potential to affect 14 of 14 residents that utilized those rooms. The total number of occupied resident rooms on the second-floor north hallway, rooms 231 thru 240, was 9. The facility census was 58. Findings are: Observations on 06/10/24 from 7:54 AM through 9:00 AM revealed the following: -Multiple dark brown smeared substance, resembling bowel movement, noted on toilet riser and toilet seat in room [ROOM NUMBER]. -Floor radiator cover was open and exposed in room [ROOM NUMBER]. The opening was approximately 8 inches by 2 inches exposing air conditioner conduit. -One missing drawer in a 6-drawer built in dresser near the sink in room [ROOM NUMBER].…

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 12.006.09D1b Based on record review and interview; the facility staff failed to to maintain functional ambulation for 1 (Resident 19), failed to follow up a audiology appointment for 1 (Resident 1) of a total sample of 4. The facility staff identified a census of 59. Findings are: A. Record Review of Resident 19's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 02-02-2024 revealed 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 15 indicating cognitively intact. The MDS also indicated Resident 19 had diagnosis of High Blood Pressure, Peripheral Vascular Disease with toe amputation, End Stage Renal Disease currently on dialysis, Diabetes Mellitus Type 2 and Heart Failure. The MDS also indicated Resident 19's vision was severely impaired and Resident 19 needed…

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 12-006.090 Based on observation, record review and interviews, the facility failed to ensure a resident received a complete dose of seizure medication as ordered for 1 (Resident 34) of 5 residents observed during medication administration. The facility census was 58. Findings are: Record review of Resident 34's Comprehensive Care Plan (CCP, a document that details goals, action steps and appropriate timelines to address a resident's medical, behavioral health and social services needs)) initiated on 12/10/2021 revealed Resident 34 admitted to the facility on [DATE] with the following diagnoses: Cerebral Infarction (stroke- occurs as a result of disrupted blood flow to the brain), Hydrocephalus (is a buildup of fluid in ventricles of the brain), Alcohol dependence ( a chronic disease in which a person craves drinks that contain alcohol and is unable to control drinking), Traumatic Subarachnoid hemorrhage (pathologic presence of blood with the subarachnoid spaces in the brain,…

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 12.006.17B Based on observation, interview, and record review, the facility failed to follow the Enhanced Barrier Precautions (EBP) while preforming cares for Resident's 34,53 and 215 and failed to ensure an oxygen nasal cannula did not come in contact with the floor for Resident 3. The total sample size was 11 resident reviewed for infection control practices. The facility census was 58. Findings are: A. Record review of the facility (Enhanced Barrier Protection policy) EBP dated 2/2024 revealed catheter care is considered a high-contact resident care activity. According to the facility EHB policy dated 2/2024, catheter care/ toileting/ brief changes require a gown and gloves for barriers. B. An observation on 6/12/24 at 8:35 AM revealed (Nursing Assistant) NA-D and NA-E completed handwashing and set up of supplies upon entering the room. It is noted that Resident 215 had a (Enhanced Barrier Protection) EBP sign on the door. Further observation revealed NA-D and NA_E completed…

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 12.006.09 Based on observations, interviews and record review, the facility failed to implement interventions for pain management for 2 residents (Resident #4 and Resident #8) of 8 residents sampled. The facility census was 55. Findings are: A. Record review of a undated demographic sheet revealed Resident #4 was admitted to the facility on [DATE] for Multiple Sclerosis. Resident #4's other diagnoses included: generalized anxiety disorder, depressive disorder, chronic pain and Temporomandibular Joint Disorder (TMJ). Review of Resident #4's Minimum Data Set (MDS, a comprehensive assessment used for care planning) dated 11/11/22 identified a Brief Interview for Mental Status (BIMS) of 11. According to the MDS [NAME] a score of 8 to 12 indicated a person has moderately impaired cognition. Record review of Resident #4's Care Plan revealed the resident has chronic pain related to Multiple Sclerosis and Temporomandibular joint disorder (TMJ). Resident 4 had the following interventions: -…

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 12-006.17D Based on observation, record review and interview, the facility staff failed to utilize handwashing and gloving techniques to prevent the potential for cross contamination for Resident #5 and while handling linen for Resident #6. The sample size was 8 and the facility identified a census of 55. Findings are: A. Observation on 10/26/23 at 4:23 AM revealed Nursing Assistant (NA)-B entered Resident #5's room, placed gloves on and did not complete hand hygiene. NA-B then assisted Resident 5 to the wheelchair and then to the bathroom. Resident 5 was observed to be incontinent of urine. NA-B changed gloves after the soiled brief was removed and did not performing hand hygiene. NA-B then cleaned up a liquid substance from the floor and then grabbed a clean brief with the contaminated gloves. NA-B then disposed of the gloves and placed another pair on without performing hand hygiene. NA-B assisted Resident 5 with placement of the new brief. NA-B collected trash and continued to the hallway with contaminated gloves on. A interview on 10/26/23 at…

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

LICENSURE REFERENCE NUMBER 175 NAC12-006.04D2 Based on record review and interview; the facility failed to ensure there was a qualified Dietary Manager (DM). This had the potential to affect 59 of 62 residents in the building. The facility staff identified a census of 62. Findings are: Record review of the facility's Job description states The individual must be a Certified Dietary Manager, Certified Food Service Manager or has a similar national certification from a national certifying body for food service management and safety. On 5/2/23 at 11:50 AM an interview was conducted with the Administrator (ADM). During the interview the ADM revealed the Dietary Manager had not started the classes for certification or completed a program for Dietary Management.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.05(15) Based on observation, record review and interview; the facility failed to ensure full visual privacy in 11 (resident rooms 103, 104, 105, 206, 207, 209, 224, 228, 229, 237, 238) of 20 dual occupancy rooms as evidenced by no privacy curtains present that would surround the bed near the doorway to ensure visual privacy from the doorway or the resident's roommate. The facility census was 62. Findings are: Record review of a facility Policy and Procedure entitled Dignity and Respect and dated April 2021 revealed the following: 1. Residents shall be appropriately dressed in clean clothes arranged comfortably on their persons. 2. Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the resident from people that passed by the room. Observation on 04/30/23 at 6:51 AM revealed that upon opening the door to the room, staff were in the room providing care to Resident 11 and exposed skin was…

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

Licensure Reference Number 175 NAC 12.006-15 Based on observation and interview, the facility failed to ensure that resident rooms were home like with personal items in use in 5 (resident rooms 129, 130, 132, 136, 140) of 17 occupied resident rooms on the 1st floor of the facility. The facility census was 62. Findings are: Observation on 05/02/23 between 2:30 PM to 02:44 PM with the facility Administrator revealed that resident rooms 129, 130, 132, 136, and 140 were not home like and did not contain personal items or pictures to make the rooms feel home like and to provide visual stimulation to the residents that resided in those rooms. Interview on 05/02/23 at 02:50 PM with the Administrator confirmed that resident rooms 129, 130, 132, 136, and 140 did not appear home like and did not have any personal items or pictures present. Interview on 05/02/23 at 03:04 PM with the facility Social Services Worker confirmed that resident rooms 129, 130, 132, 136, and 140 were not home like and confirmed that the facility had not attempted to provide a home like environment by getting pictures…

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 12-006.09B2 Based on record review and interview, the facility failed to ensure that residents' Minimum Data Set (MDS, a required comprehensive assessment of the resident used to create an individualized comprehensive care plan) assessments were completed within the required 14 days after the Assessment Reference Date (ARD, the last day of the observation period that the assessment covered for that resident) for 5 (Residents 26, 24, 43, 40 and 1) of 5 residents reviewed. The facility census was 62. Findings are: A. Record review of Resident 26's Quarterly MDS revealed that the ARD was identified as 3/16/23. The MDS was completed on 4/18/23 and should have been completed on 3/30/23. The MDS was completed a total of 19 days late. B. Record review of Resident 24's Quarterly MDS revealed that the ARD was identified as 3/16/23. The MDS was completed on 4/19/23 and should have been completed on 3/30/23. The MDS was completed 20 days late. C. Record review of Resident 43's Quarterly MDS revealed that the ARD was identified as 3/22/23. The MDS was…

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

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on observations, record review, and interviews; the facility administration staff failed to ensure effective management of facility resources to maintain the highest practical wellbeing of residents and the facility environment as evidenced by failure to implement an effective plan of action to maintain correction for previously cited areas of deficient practice and failure to ensure the facility identified and developed plans of action to identify multiple issues of deficient practice. The facility staff identified a census was 62. Findings are: Review of the facility during the current survey revealed the following deficiencies: -F550. The facility failed to ensure resident dignity was maintained for 2 of 3 residents. -F583. The facility failed to ensure full privacy in 11 of 20 dual occupancy rooms. -F584. The facility failed to ensure that rooms appeared homelike in 5 of 17 rooms. -F609. The facility failed to report an elopement for 1 resident in the required time frame. -F623. The facility failed to ensure the resident and/or…

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

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and staff interviews; the facility Quality Assessment Performance Improvement Plan (QAPIP) failed to identify ongoing issues relevant to F550, F580, F609, F657, F676, F689, F712, F730, F755, F758, F761, F812, F835 and F867 and implement plans of action to identify and correct the deficient practice. The QAPI failed to ensure repeated deficiencies at F692 and F697 were corrected and the correction maintained. This deficient practice had the potential to affect all residents who reside in the facility. The facility staff identified a census of 92. Findings are: Record review of a undated facility Quality Assurance and Performance Improvement (QAPI) program revealed the following information: -Goal: -1. Implement a QAPI program that involves all staff and focuses on benchmarks to ensure quality of care and quality of life. -3. Continued improvement of management of risk including but not limited to preventative interventions to reduce adverse outcomes. On 5-02-2023 at 2:00 PM an interview with Nursing Assistant (NA) K…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.05(21) Based on observation, record review and interview; the facility failed to ensure that resident's dignity was maintained for 2 (Resident 40 and 24) of 3 residents reviewed as evidenced by exposure of an incontinence brief and tube feeding bottles in visual sight in a common area of the facility for Resident 40 and the use of a sign on Resident 24's door that described personal hygiene care needs. The sign was in sight of visitors and other residents that passed by the room. The facility census was 62. Findings are: A. Record review of Resident 40's quarterly Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) dated 3/23/23 identified that Resident 40 was admitted to the facility on [DATE] with diagnoses that included Cerebral Vascular Accident (CVA, stroke), Aphasia (the inability to speak or comprehend) and Traumatic Brain Injury. The MDS identified that Resident 40 was severely cognitively impaired, required extensive to total…

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

LICENSURE REFERENCE NUMBER 175 NAC 12.006-02(8) Based on record review and interview; the facility failed to report an elopement for 1 (Resident 50) of 1 sampled resident to the required state agency within the required time frame of 2 hours. The facility staff identified a census of 62. The findings are: Record review of Resident 50's Incident of Elopement dated 3/27/23 revealed the following: On 3/27/23 at 9:20 AM the facility door alarm sounded. Staff initiated response and went to exit doors. The administrator exited the building and noted Resident 50 outside in the parking lot stepping off the driveway. Resident was redirected and escorted back into the building. Record review of the facility report dated 3/30/23 revealed the required state agency was notified on 3/28/23 at 9:09 AM. Record review of the facility Elopement Policy and Procedure revised on 2/2022 revealed the following: -In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will: ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including…

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(5) Based on record review and interview, the facility failed to ensure the resident and /or the resident's representative were notified in writing of the reason for transfer to the hospital for 1 (Resident 66) of 1 resident reviewed for hospitalization. The facility census was 63. Findings are: Record review of Resident 66's Clinical Progress Notes dated 2/3/23 revealed that Resident 66 was sent to the hospital directly from an offsite Urology appointment. Record review of Resident 66's Electronic Medical Record revealed no documentation related to a written notice of the reason for transfer to the hospital provided to the resident and / or resident's representative for the hospitalization on 2/3/23. An interview on 5/2/23 at 1:00 PM with the facility Social Services Worker confirmed that no written notice of transfer to the hospital on 2/3/23 had been provided to Resident 66 or the resident's representative.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a new PASARR (Pre-admission Screening and Resident Review, a screening to determine the presence of a mental illness or intellectual disability) review had been completed after a diagnosis of a mental disorder was identified for 1 (Resident 19) out of 1 reviewed for PASARR. The facility census was 62. Findings are: Record review of Resident 19's Face Sheet identified that Resident 19 was admitted [DATE] with diagnoses that included Anxiety Disorder, identified on 3/30/22, and Unspecified Dementia with other Behavioral Disturbance identified on 10/1/22. Review of Resident 19's admission Level 1 PASARR completed on 4/13/15 revealed that there was no evidence to suggest mental illness and no further screening was required unless the individual was suspected or found to have a mental illness condition. Record review of Resident 19's Annual Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) dated 5/6/22, section…

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.

LICENSE REFERENCE NUMBER 175 NAC 12.006.09D2 Based on observation, record review and interview; the facility failed to ensure geri sleeves (a protective covering for arms) were in place as ordered for 1 (Resident 43) of 2 sampled residents. The facility staff identified a census of 62. The findings are: Record review of Resident 43's current physician orders revealed an order dated 4/27/23 for geri sleeves to elbows every shift. Record review ofa progress note for Resident 43 dated 4/9/23 revealed the resident should wear sleeves at all times in room and out of room per Hospice nurse three times a day. Observation on 04/30/23 at 11:30 AM revealed Resident 43 did not have geri sleeves on (gender) arms. Observation on 05/01/23 at 7:52 AM revealed Resident 43 did not have geri sleeves on (gender) arms. Observationn on 5/2/23 at 8:49 AM revealed Resident 43 was up in wheelchair and did not have geri sleeves on bilateral arms. Bruising noted to left arm. An interview with the DNS (Director of Nursing Services) on 5/2/23 at 9:35 AM confirmed the order for geri sleeves from Hospice. 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 12-006.17B Based on observation, record review and interview; the facility staff failed to apply personal protective equipment and perform hand hygiene and glove changes in a manner to prevent cross contamination for 1 (Resident 64) of 11 residents observed for personal care and wound cares. The facility census was 62. Findings are: Record review of an undated facility Policy and Procedure entitled Hand Hygiene identified the following policies: 3. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents. e. Before and after handling an invasive device (tube feeding would fall under this). g. Before handling clean or soiled dressing, gauze pads etc. h. Before moving from contaminated body site to a clean body site during resident care. i. After contact with residents' intact skin. Record review of Resident 64's admission Minimum Data Set (MDS, a comprehensive assessment used to develop 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.