The Banyan at Montclair

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure all food stored in the facility's kitchen was labeled, sealed, and/or dated, ensure food was discarded that was past it's use-by date, and failed to ensure all kitchen equipment was clean and sanitized. This had the potential to affect all residents that consume food from the kitchen.A record review of the facility's Food Safety Requirements with a date reviewed/revised of 5/2025 revealed facility staff shall inspect all food, product, and beverages for proper storage to include labeling, dating, and monitoring food so it is used by its use by date. All equipment used shall be cleaned and sanitized. A.An observation on 12/10/2025 at 7:12 AM - 8:04 AM The True 2 door reach-in fridge contained a bag of a green leafy substance that was not labeled or dated. The true 2 door reach-in fridge by the double ovens had contained a plastic bag of brown patties that was not labeled and dated and 1 gallon container of Mayonnaise that had been opened with no open date. The walk-in refrigerator…

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

Licensure Reference Number 175 NAC 12.006.02(H) Based on observation, interview, and record review, the facility failed to ensure Adult Protective Services (APS) was notified within 2 hours of an allegation (a statement, made without giving proof, that someone has done something wrong) of potential abuse for 1 (Resident 51) of 3 sampled residents. The total facility census was 113. Findings are:A record review of the facility's Abuse, Neglect, and Exploitation policy with a Date Reviewed/Revised of 8/4/25 revealed an alleged violation is: A situation or occurrence that is observed or reported by staff, resident, relative, visitor, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Reporting of all alleged violations to the Administrator, state agency, adult protective services would be done immediately, but no later than 2 hours after the allegation was made if the allegation…

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

Licensure Reference Number 12-006.09(H)(vi)(3)g Based on observation, interview and record review the facility failed to ensure oxygen and BiPap orders were obtained and followed for 1 (Resident 73) of 4 residents sampled. The facility census was 113. The findings are:Record review of the facility policy titled Noninvasive Ventilation (CPAP, BiPAP, AVAPS, Trilogy) dated 05-20-2025 revealed it is the policy of this facility to provide noninvasive ventilation as per physician's orders and current standards of practice. BiPAP or bi-level positive airway pressure, is a respiratory therapy intervention that delivers an inhale pressure and an exhale pressure to provide a patent airway. It requires a machine that generates the separate pressures through a tube into a mask that fits over the nose or mouth. A personal BiPAP device may be brought into the facility for the resident's use. If brought in, the nurse/respiratory therapist will verify the settings on the machine prior to use. Record review of Resident 73'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.

Based on record review and interview, the facility failed to evaluate and identify situational triggers for post -traumatic stress disorder [PTSD, a psychological reaction occurring after experiencing a highly stressing event (such as wartime combat, physical violence, or a natural disaster) that is usually characterized by depression, anxiety, flashbacks, recurrent nightmares, and avoidance of reminders of the event] for 1 (Resident 12) of 2 residents reviewed. The facility census was 113. Findings are:Record review of a facility policy entitled Trauma Informed Care dated 3/25/25 revealed the following information: It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and / or re-traumatization. Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life…

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 hold blood pressure medications according to prescribed blood pressure parameters for 2 (residents 1 and 3) of 5 sampled residents. The facility census was 113. Findings are: A. A record review of the facilities Medication Administration policy with a revision date of 10/15/25 revealed the following: Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. A record review of the facilities Unnecessary Drugs-Without Adequate Indication for Use policy with a revision date of 11/4/24 revealed the following: Information gathered during the initial and ongoing evaluations will be incorporated into the resident's comprehensive care plan that reflects person-centered medication related goals and parameters for monitoring the residents condition, including the likely medication effects and potentials for adverse consequences. A record review of Resident 3's quarterly…

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, record review, and interview, the facility failed to ensure a medication error rate of less than 5%. Observation of 25 medications revealed 4 errors with a resulting error rate of 16%. The medication errors are related to 1 (Resident 100) of 4 sampled residents. The facility census was 113.Findings are:A record review of the facilities Medication Administration policy with a revision date of 10/15/25 revealed the following: Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. Ensure that the six rights of medication administration are followed:a. Right residentb. Right drugc. Right dosaged. Right routee. Right timef. Right documentation A record review of the facilities Medication Errors policy with a revision date of 8/16/25 revealed the following: The facility must ensure that it is free of medication error rates of 5% or greater as well as significant medication error events. A record review…

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 006.11 Based on observation, interview and record review, the facility failed to ensure to physician's ordered diet was followed for 1 [Resident 122] of 1 sampled resident with orders for a renal diet. The facility had a total census of 113. Findings are:A review of Resident 122's admission Record revealed Resident 1 was admitted to the facility on [DATE] with a diagnosis of dependence on renal dialysis and end stage renal disease [a stage of impairment that appears irreversible and permanent]. A review of Resident 122's order summary revealed an order dated 12/3/25 of a renal diet with regular texture and thin liquid consistency. A review of Resident 122's care plan revealed an intervention of providing and serving diet as ordered. Observations on 12/11/25 at 12:22 PM revealed Resident 122 with lunch tray. Resident 122's lunch included chicken, cornbread, macaroni and cheese, Brussel sprouts, and pumpkin pie. A review of facility menu for 12/11/25 and Resident 122's 12/11/25 tray…

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)Licensure Reference Number 175 NAC 12.006.19(A)(i) Based on observation, interview, and record review, the facility failed to ensure staff transported clean linen in a manner to prevent potential cross contamination, ensure clean sheets were utilized for Resident 70, and failed to ensure Resident 1's nebulizer (neb)(a machine used to deliver aerosolized medications to the lungs) administration kit was cleaned after each use. The facility census was 113. Findings are: A. An observation on 12/15/2025 at 7:29 AM revealed Medication Aide-A exited the laundry room and walked down the 100 hallway to Resident 11's room with unbagged, clean, bedding draped over MA-A's left arm and against MA-A's hand and clothing. An observation on 12/15/2025 at 2:55 PM revealed NA-B exited the dining room and walked to the South side of building into the resident care areas with unbagged, clean, linens being carried between NA-B's left arm and chest against NA-B's clothing. In an interview…

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

Licensure Reference Number 175 NAC 12-006.19 Based on observations and interviews, the facility failed to maintain the carpets in clean condition to prevent urine odors in 13 resident rooms (Rooms 103, 105, 106, 109, 203, 205, 207, 208, 311, 317, 407, 409) of 45 occupied resident rooms on the north side of the building and the carpets throughout the 100, 200, 300 and 400 hallways of the north side of the facility. This had the potential to affect 17 residents that resided in those rooms. The facility had a total of 81 occupied resident rooms in the facility. The facility census was 110. Findings are: Observation during the environmental tour 6/25/25 between 8:00 AM and 9:50 AM, with the facility Maintenance Director [MD], Housekeeping Director [HD] and Administrator [ADM], revealed the following environmental concerns in resident use areas in the facility: - Carpets were stained in spots on the north side of the building on the 100, 200, 300 and 400 hallways. - A piece of carpet was pulled up and folded over itself beside the vending machine in the 400 hallway. - Carpets were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY D. Record review of Resident 16's admission Record revealed that Resident 16 was admitted to the facility on [DATE] with diagnoses that included secondary Parkinsonism, and Alzheimer's Disease early onset. Record review of Resident 16's Clinical Census revealed that Resident 16 was discharged to the hospital on [DATE]. Record review of Resident 16's quarterly MDS dated [DATE] revealed that Resident 16 had a BIMS score of 15. The MDS manual identified that a score of 13-15 indicated the resident was cognitively intact. The MDS identified that Resident 16 had verbal behaviors exhibited toward others and rejection of care 1-3 days per week. The MDS identified that Resident 16 used a wheelchair for ambulation and required supervision with activities of daily living. Record review of a Health Status Note for Resident 16, dated 12/10/24, revealed the following information: - Note Text: Resident called 911 and stated [gender] couldn't breathe. However, resident was non-compliant with nursing staff, refused to be…

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

Licensure Reference Number 175 NAC 12-006.11E Nebraska Food Code 2017 4-904.11(A) Based on observation, record review and interviews; the facility failed to handle dishware in a manner to prevent the potential for food borne illness while serving foods in the facility dining room. This had the potential to affect 7 (Residents 3, 44, 53, 72, 99, 105, and 250) residents that received foods during the meal service and failed to ensure a refrigerators were maintained below 41 degrees in 1 (Resident 75) of 15 resident refrigerators. The facility census was 110. Findings are: A. Record review of an undated facility Policy entitled Proper Handling of Tableware revealed the following information: Handling of clean tableware: - Do not touch eating surfaces of forks, spoons, knives, rims of glasses, or the inside of bowls and plates. - Glasses, cups and bowls should be handled by the base or out edge only. Observation during dining services on 06/23/25 between 12:00 PM and 12:28 PM revealed Dietary Aide (DA) A served a drink to Resident 72. Observation revealed that DA-A handled the glass 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.

D. An observation on 6/23/2025 at 10:48 AM revealed a nebulizer machine (a machine that changes liquid medicine into fine droplets inhaled through a mouthpiece or a mask) and tubing and a room telephone placed directly on the carpeted floor beside the bed of Resident 64. An observation on 6/24/2025 at 5:00 PM revealed a nebulizer machine and tubing and room telephone on the floor beside the bed of Resident 64. An observation on 6/24/2025 at 7:10 AM revealed a nebulizer machine and tubing and room telephone on the floor beside the bed of Resident 64. An interview on 6/23/2025 at 10:50 AM with Resident 64 confirmed the nebulizer machine and tubing and the room telephone are always kept on the floor of the resident's room. An interview on 6/24/25 at 5:10 PM with Licensed Practical Nurse (LPN) O confirmed having the nebulizer machine, tubing and telephone on the floor is an infection control risk. An interview on 6/24/25 at 5:15 PM with Medication Aide (MA) P confirmed the placement of the nebulizer machine, tubing and telephone on the floor is an infection control risk. An interview on…

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

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on record review and interview; the facility failed to notify the provider of unavailable medication for 1 (Resident 57) of 7 sampled residents. The facility staff identified a census of 110. The findings are: Record review of an undated facility policy entitled Unavailable Medications revealed: 4. Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable: a. Determine reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provide to obtain the medication. b. Notify physician of inability to obtain medication upon notification or awareness that medication is not available. Obtain alternative treatment orders and/or specific orders for monitoring resident while medication is on hold. Record review of Resident 57's admission Record printed 6/25/25 identified Resident 57 as having diagnoses of bipolar disorder (a condition characterized by dramatic shifts in mood,…

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 reviews and interviews, the facility failed to resolve an ongoing grievance (a complaint or protest) and provide a written decision regarding grievance to the resident's representative. This had the potential to affect 1 (Resident 40) out of 1 resident sampled. The facility census was 110. Findings are: A record review of Resident 40's 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 05/22/2025 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 10. According to the MDS Manual a score of 8-12 indicates a person has moderately impaired cognition Section I of the MDS revealed the Resident was diagnosed with non-Alzheimer's dementia. Record review of the grievance form dated 03/16/2025 by the Director of Rehab (DOR) G on behalf of Resident's 40's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.05(H) Based on interview and record review the facility failed to protect 1(Resident 3) of 2 resident's sampled from physical abuse. The facility census was 110. Findings are: A. Record review of Resident 3's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 05-09-2025 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. -had a cerebral infarction also known as a stroke with paralysis on one side of the body. -required limited assistance with bathing, transferring into or out of the tub or shower, and ambulation. Record Review of Resident 3's Comprehensive Care Plan (CCP) dated 06-03-2025 revealed Resident 3 had been involved in a resident-to-resident altercation in June of 2025. An interview conducted with Resident 3 on 06-26-2025 at 9:53 AM revealed on 06-02-2025…

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

Licensure Reference Number 175 NAC 12-006.02(H) Based on record reviews and interviews, the facility failed to notify the required State Agency of a significant injury within the required time frame for 1 (Resident 70) of 1 sampled. The facility staff identified a census of 110. Findings are: A record review of Resident 70's admission Record revealed the facility admitted the Resident on 04/15/2024. Further review of Resident 70's admission Record revealed diagnoses of history of falling, schizoaffective disorder, bipolar type, violent behavior, traumatic subdural hemorrhage without loss of consciousness, and other chronic pain. A record review of Resident 70's 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 04/04/2025 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 5. The MDS manual states a score of 0-7 indicated the Resident had severe impairment. A record review of…

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

Licensure Reference Number 175 NAC 12-006.09(D) Based on record review and interview, the facility failed to complete the Quarterly Minimum Data Set (MDS, a federally mandated assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) within the required time frames for 1 (Resident 72) of 29 sampled residents. The facility staff identified a census of 110. The findings are: Record review of the Centers for Medicare and (&) Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) Manual Version 1.18.11 dated 10/2023 revealed a quarterly MDS must be completed and signed not later than 14 days from the assessment reference date. Record review of Resident 72's quarterly MDS with a reference date of 6/10/25 revealed that as of 6/26/25 at 10:36 AM, the MDS had not been signed as completed, which is two days after the reference date. During an interview on 6/26/25 at 10:36 AM, the MDS Coordinator (MDSC-I) stated MDSC-I had begun the role in April and due to still learning, Regional MDS support was to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(B) Based on record reviews and interview, the facility failed to ensure the 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 04/25/25 reflected only medications received for 1 (Resident 49) of 6 sampled residents. The facility staff identified a census of 110. The findings are: Record review of the Centers for Medicare and (&) Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.8.11 dated 10/2023, Section N - Medications revealed: The intent of the items in this section is to record the number of days, during the last 7 days (or since admission/entry or reentry if less than 7 days) that any type of injection, insulin and/or select medications were received by the resident. N0415 Steps for Assessment instructed to review the resident's medical record for documentation that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(F) Based on record review and interview, the facility staff failed to ensure a Baseline Care Plan was completed for 1( Resident 255) of 1 residents within 48 hours of admission. The facility had a census of 110. Findings are: Record review of a Order summary Report sheet printed on 6-24-2025 revealed the facility staff admitted Resident 255 on 06-18-2025. A record review of the Resident 255's discharge orders from the hospital dated [DATE] revealed the following information: Renal Diet (a meal plan designed to support kidney health by carefully managing the intake of sodium, potassium, phosphorus, and protein along with fluid). 1500 milliliters (ml - a unit of measurement) a day fluid restriction. Dialysis (a mechanical treatment that performs the function of healthy kidneys to remove waste and excess fluid from the blood). Monday/Wednesday/Friday at 6:00 AM. Resident had a hemodialysis catheter (a soft flexible tube used to access a patient's blood for hemodialysis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on record reviews and interviews, the facility failed to revise the comprehensive care plan for 1 (Resident 70) of 1 sampled. The facility census was 110. The findings are: A record review of Resident 70's admission Record revealed the facility admitted the Resident on 04/15/2024. Further review of Resident 70's admission Record identified diagnoses of history of falling, schizoaffective disorder, bipolar type, violent behavior and other chronic pain. A record review of Resident 70's 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 04/047/2025 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 5. The MDS manual states a score of 0-7 is considered a score of 0-7 indicated the Resident had severe impairment. A record review of progress notes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09 (H) Based on record review and interview the facility failed to establish a restorative nursing program with frequency of modalities for 3 (Resident 3, 37 and 72) of 5 residents sampled. The facility census was 110. Findings are: A. Record review of Resident 3's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 05-09-2025 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. -had a cerebral infarction also known as a stroke with paralysis on one side of the body. -required limited assistance with bathing, transferring into or out of the tub or shower, and ambulation. -was receiving restorative range of motion, and ambulation. Record review of Resident 3's Comprehensive Care Plan (CCP) dated 07-16-2024 revealed the following: -Focus Resident 3 was working with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview and record review the facility failed to assess the ability to smoke safely, which resulted in physical injury for 1 (Resident 50) of 1 smoking residents sampled and failed to implement a fall mat for 1 (Resident 99) of 2 residents sampled. The facility census was 110. The findings are: A. Record review of Resident 50's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 12-23-2024 revealed the facility staff assessed the following about the resident: -had admitted to the facility on [DATE]. -Brief Interview of Mental Status (BIMS) was scored at a 5. According the MDS Manual a score of 0-7 indicates a person has severe cognitive impairment. -had a previous cerebrovascular accident (stroke) with hemiplegia (paralysis to one side of the body) and aphasia (a brain disorder that affects how you speak and understand language). -had limited range of motion to the right arm and leg. - was non…

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)(2) Based on observation, interview, and record review; the facility staff failed to evaluate and implement a toileting program for 1 (Resident 72) of 1 sampled resident. The facility staff identified a census of 110. The findings are: Record review of a facility policy entitled Incontinence dated 8/2024 revealed: -Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. - 4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. Record review of Resident 72's admission Record (AR) printed on 06/25/25 revealed the facility admitted the resident on 11/07/23. Further review of the AR identified that Resident 72 had diagnoses of type 2 diabetes mellitus, chronic constipation, benign prostatic hyperplasia (a condition where the prostate gland enlarges, potentially causing urinary problems), polyuria (increased urine production), and bilateral osteoarthritis of…

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

Licensure Reference Number 175 NAC 12-006.09(I) Based on observations, record reviews, and interviews; the facility failed to assess for bed assist bar (a bar affixed to the bed used to assist the resident in bed mobility and positioning) use for 1 (Resident 49) of 1 sampled resident. The facility staff identified a census of 110. The findings are: Record review of Resident 49's admission Record printed 06/25/25 revealed the facility admitted the resident on 06/25/23 and identified Resident 49 had diagnoses that included stroke, dementia, epilepsy, weakness, other abnormalities of gait and mobility, and reduced mobility. Record review of Resident 49's 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) revealed Resident 49 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 11. According to the MDS manual, a score of 11 indicated the resident had a moderate cognitive impairment. 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.

Licensure Reference Number 175 NAC 12-006.10(D) Based on observation, record review, and interview; the facility staff failed to ensure a medication error rate of less than 5 percent (%). Observation of 35 medications revealed 3 errors with a resulting error rate of 8.57%. The medication errors are related to 1 (Resident 91) of 6 sampled residents. The facility staff identified a census of 110. The findings are: Record review of Resident 91's Medication Administration Record (MAR) dated 06/2025 revealed Resident 91's practitioner had ordered medications that included: -potassium 20 milliequivalents (mEq) to be given in the morning; -divalproex tablet delayed release 500 mg to be given twice a day; and -artificial tears one drop in both eyes to be given twice a day. Observation on 06/25/25 at 7:57 AM revealed Medication Aide (MA-S) prepared Resident 91's medications for administration. The potassium and divalproex medication cards from which medications are dispensed and compared to the MAR read Do Not Crush. MA-S crushed all the resident's medications prior to mixing with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1) and 12-006.09(H)(iii)(2) Based on observation, interview and record review the facility failed to evaluate, monitor, implement interventions for pressure ulcer prevention and promote healing for 4 (Resident 1,2,3 and 4) of 5 residents sampled. The facility census was 108. The findings are: Record review of the facility's policy titled Wound Treatment Management dated 04-01-2024 indicated the policy was to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. The policy explanation and compliance guidelines revealed the following: -Wound treatments will be provided in accordance with physician's orders, including cleansing method, type of dressing, and frequency of dressing change. -In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. -The effectiveness of treatments…

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 12-006.01 (C) Licensure Reference Number 175 NAC 12-006.02(A)(G) Based on observations, record review, and interviews; the facility administration staff failed to ensure effective management of facility resources to maintain the highest practical well being 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 result. The facility staff identified a census was 119. Findings are: Review of the facility survey history revealed the facility received a citation at F584 for failing to ensure temperatures on the 200 hallway were maintained on 12-05-2024. F 584, The facility failed to maintain temperatures in resident rooms and common area. The facility failure resulted in an Immediate Jeopardy (IJ) situation. According to the Center for Medicare and Medicaid Services (CMS) A IJ is a situation in which the nursing home's non-compliance with one or more requirements has caused, or is likely to cause, serious injury, harm, impairment,…

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 12-006.19 and 175 NAC 12-007.04(C) Based on observations, interviews, and record reviews, the facility failed to ensure temperatures were maintained on the 200 hallway which has the potential to affect 16 residents residing on the 100 hallway, the handrails on the 300/400 unit were in good repair which has the potential to affect 37 residents residing in the 300 and 400 hallway, the door to the smoking room was in good repair which has the potential to affect 16 residents who smoke at the facility, and a guard was in place on the baseboard heater in room [ROOM NUMBER] which has the potential to affect 2 resident residing in room [ROOM NUMBER]. The facility had a total census 117 residents. Findings are: A. Observations on 12/2/24 at 3:24 PM revealed a temperature of 69 F [Fahrenheit] on the thermometer located in the 200 hallway. Observations on 12/3/24 between 11:40 AM and 3:46 PM revealed the following temperatures on the thermometer located in the 200 hallway: -12/3/24 11:40 AM 63…

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 ensure an order for daily weights was followed for 1 (Resident 34), failed to ensure a providers' order was clarified for 1 (Resident 12) and failed to ensure an order to discontinue medication was transcribed for 1 (Resident 7). The total sample size was 24. The facility had a census of 117. Findings are: A. A record review of Resident 24's Minimum Data Set (MDS - a standardized assessment tool used to evaluate the health of residents in nursing homes that are certified by Medicare or Medicaid) dated 9/2/24 revealed Resident 34 had a Brief Interview for Mental Status (BIMS - a screening tool used to assess a person's cognitive functioning) of 15, indicating the resident was cognitively intact. A record review of Resident 34's Electronic Health Record (EHR) revealed Resident 34 has the following diagnoses: -Acute on chronic diastolic (congestive) heart failure (a condition in which the heart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.18 Based on observation, record review and interview, the facility failed to ensure a nurse performed hand hygiene, changed gloves, and wore a gown when providing care to 1 resident (Resident 115) of 1 resident who was on Enhanced Barrier Precautions (EBP - a set of infection control practices that use gowns and gloves during high-contact care activities to reduce the spread of multidrug-resistant organisms (MDROs). The total sample was 24. The facility census was 117. Findings are: A. A record review of Resident 115's Minimum Data Set, dated [DATE] (MDS - a standardized assessment tool used to evaluate the health of residents in nursing homes that are certified by Medicare or Medicaid) dated 9/2/24 revealed Resident 115 had a Brief Interview for Mental Status (BIMS - a screening tool used to assess a person's cognitive functioning) of 4, indicating the resident had severe cognitive impairment. A record review of Resident 115's Electronic Health Record (EHR) 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 175 NAC 12-006.17(A)(v) Based on record reviews and interviews, the facility failed to maintain a complete and accurate medical record for 1(Resident 1) of 5 sampled residents. The facility census was 118. Findings are: A record review of Resident 1's admission Record printed 11/13/2024 revealed the resident was over [AGE] years of age, was admitted to the facility on [DATE] and had diagnoses including chronic kidney disease, diabetes, heart failure, and pressure injuries to their left heel and sacral area (the area at the base of the spine between the hips). The resident was discharged to an acute care hospital on [DATE]. A review of a communication app used by the facility to communicate with the Primary Care Provider (PCP) revealed the following information: On 10/11/2024 at 5:48 PM, from the facility iPad, an image of a handwritten note from the resident's cardiologist. On 10/21/2024 at 4:18 PM, from the PCP, a response to notification that the nurse had been unable to obtain…

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)(1) and 175 NAC 12-006.18(B) Based on record reviews, observations, and interviews, the facility failed to ensure that Resident 2's indwelling urinary catheter was cleaned in a manner to prevent potential urinary tract infection and failed to ensure that Enhanced Barrier Precautions were maintained for in order to prevent the potential for cross-contamination for 2 (Residents 2 and 5) of 4 sampled residents. The facility census was 118. Findings are: A. A record review of the facility's undated Suprapubic Catheterization (SP catheter-a tube that goes into the bladder through the lower abdomen to drain urine) policy marked Copyright 2023 at the bottom revealed that the stoma (the opening the catheter goes into the bladder through) should be cleaned outward from the stoma in a circular motion. B. A record review of the facility's undated Enhanced Barrier Precautions policy marked Copyright 2024 at the bottom revealed that Enhanced Barrier Precautions (EBP) was an infection control intervention that employed the use of a gown 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 175 NAC 12-006.05(S) Based on interview and record review, the facility failed to ensure that 1 (Resident 5) of 3 sampled residents was able to have a visitor of their choice. The facility had a census of 123. Finding are: A record review of Resident 5's Clinical Resident Profile revealed Resident 5 had been admitted to the facility on [DATE] and the residents' family member was listed as their responsible party and their Power of Attorney for health care and financial. A record review of Resident 5's Minimum Data Set (MDS - a standardized assessment tool used to evaluate the health status of nursing home residents) revealed Resident 5 had a Brief Interview for Mental Status (BIMS - a cognitive screening tool used to assess a persons' cognitive functioning) of 3 indicating the resident severely cognitively impaired. A record review of an e-mail, dated 9/5/2024 from the facility Administrator (Admin) to the Ombudsman (a person who investigates, reports on and helps settle complaints) 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 175 NAC 12-006.05(S) Based on interview and record review, the facility failed to resolve grievances in a timely manner for 1 resident (Resident 5) of 3 residents sampled. The facility had a census of 123. Findings are: A record review of Resident 5's Clinical Resident Profile revealed Resident 5 had been admitted to the facility on [DATE] and the residents' family member was listed as their responsible party and their Power of Attorney for health care and financial. A record review of Resident 5's Minimum Data Set (MDS - a standardized assessment tool used to evaluate the health status of nursing home residents) revealed Resident 5 had a Brief Interview for Mental Status (BIMS - a cognitive screening tool used to assess a persons' cognitive functioning) of 3 indicating the resident severely cognitively impaired. A record review of the Social Services progress notes revealed the following note dated 9/3/2024. Care conference held with the resident (Resident 5). Social Services in…

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

Licensure Reference Number 175 NAC 12.006.11(E) Based on observation, interviews and record review, the facility kitchen staff failed to ensure food was thawed in a manor to prevent the potential for food borne illness, failed to ensure that foods were labeled and dated and failed to discard food that was out of date This has the potential to effect all residents who ate food from the kitchen. The facility claimed a census of 123 residents. Findings are: An observation of the kitchen on 8/22/24 at 7:30 AM revealed the following: - The refrigerator contained 35 small containers of an unlabeled, undated food on a tray. -A second tray contained 46 containers of a jello-like substance which was not labeled and was dated 8/15/2024 and 3 containers of a jello-like substance which was not labeled and was dated 8/3/2024. -A third tray contained 11 portions of an unlabeled food dated 8/11. -A 4th tray contained 40 containers of an unlabeled food, 37 of which were dated 8/21/24 and 3 which were dated 8/13/24. An observation on 8/22/2024 at 8:35 AM of a kitchen sink revealed it contained 8…

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(G) Based on observation and interviews, the facility failed to ensure sufficient staff were available to answered calls for assistance in a timely manner for 6 (Residents 4,11,12,13,14 and 15) of 37 residents observed on the 500-600 hall. The facility census was 123. Findings are: An observation of call lights being on and the call light notification system on 8/26-2024 from 10:40 AM to 10:45 AM revealed the following information: -The call light for room [ROOM NUMBER] had been on for 27:44 minutes. -The call light for room [ROOM NUMBER] had been on for 32.27 minutes. -The call light for room [ROOM NUMBER] had been on for 39:00 minutes. -The call light for room [ROOM NUMBER] had been on for 17:09 minutes. -The call light for room [ROOM NUMBER] had been on for 13:37 minutes. -The call light for room [ROOM NUMBER] had been on for 16:01 minutes. An interview on 8/26/2024 at 11:00 AM was conducted with Registered Nurse-E (RN). During the interview RN -E reported 5-10…

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.(D)(iii) Licensure Reference Number 175 NAC 12-006.12.(D)(vi) Based on observation, interview and record review the facility staff failed to ensure that an insulin injector pen was labeled correctly for 1 resident (Resident 6), failed to ensure that an expired insulin injector pen for 1 resident (Resident 5) was discarded and failed to ensure that an insulin injector pen was identified and dated before it was placed in the medication cart. The facility staff identified there were 26 residents in the facility who receive insulin via insulin injector pens. The facility staff identified a census of 131. Findings are: An observation of the labels of the opened insulin injector pens for 26 residents were examined on [DATE] from 9:45AM to 10:05 AM A. An observation on [DATE] at 9:45 AM of a medication cart revealed 1 opened Victoza insulin pen was labeled with Resident 6's name. Further review revealed the Victoza insulin pen did not have an opened-on date or an expiration…

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 Based on record review and interview, the facility failed to ensure 1 [Resident 2] of 5 sampled residents was free from a significant medication error. The facility had a total census of 130 residents. Findings are: A review of Resident 2's admission record revealed an admission date of 3/22/21 with a diagnosis of Type 2 Diabetes Mellitus [a condition that involves the way the body regulates and uses sugar as a fuel]. A review of Resident 2's hospital discharge orders dated 5/14/24 revealed a new order for Lispro insulin [fast acting insulin] sliding scale to be given with meals and night based on the following blood sugars: -151-200 give 2 units -201-250 give 4 units -251-300 give 6 units -351-400 give 8 units -More than 400 call MD [Medical Doctor] -Stop Lyumjev KwikPen U-100 insulin 100 unit/ml -Change insulin glargine U-300 300 unit/ml [Toujeo; a long-acting insulin] to 12 units subcutaneously nightly A review of APRN A [Advance Practice Registered Nurse] orders for Resident 2 dated 5/14/24 revealed the following order: Resume previous…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09 Based on record review and interview, the facility failed to monitor 2 (Resident 1 and 3) of 3 residents post procedural appointments. The facility identified a census of 132. Findings are: A. Record review of Resident 1's Census revealed an admission date of 10/13/24. Record review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment completed to do care-planning) dated 4/15/24, revealed the resident's Brief Interview of Mental Status (BIMS, is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) had a score of 8, which indicated the resident was severely cognitively impaired. Record review of Resident 1's undated Diagnosis sheet revealed the following diagnoses: Alzheimer's Disease, inguinal hernia, chronic atrial fibrillation, pain, Vitamin D deficiency, benign prostatic hyperplasia, hypertension, inflammatory disorder of the scrotum, muscle wasting, insomnia, and chronic…

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 12-006.04B2 Based on record review and interview, the facility failed to complete competencies for 7 (staff members C, T, U, V, W, X and Y) of 34 Licensed Practical Nurse [LPN] employees files, 2 (staff members Z, and AA) of 36 Registered Nurse [RN] employee files and 6 (staff members J, K, L, BB, CC and DD) of 122 Nurse Aide [NA] employee files. The files reviewed included both facility and agency staff. This had the potential to affect 126 residents that resided in the facility. The facility census was 126. Findings are: A. Record review of the Facility Assessment Tool dated 12/20/23 revealed the following information related to competencies: Staff are provided ongoing education utilizing online education, staff in services, conferences and competency/skills fair. Consider the following competencies (this is not an inclusive list): - Activities of daily living: Bathing (tub, shower, sitz), bed making (occupied and unoccupied), bedpan, dressing, feeding, nail and hair care, Perineal care ( female and male), mouth care (brushing teeth or dentures),…

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 12-006.09D1c Based on record review, interview, and observation, the facility failed to provide bathing per resident preference for 2 (Resident 78 and 384) of 13 sampled residents. The facility identified a census of 126. Findings are: A. Record review of the facility policy Resident Showers and the policy is undated. The policy states: It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per the current standards of practice. Policy explanation and Compliance Guidelines: 1) Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. B. Record review of Resident 78's Quarterly Minimum Data Set (MDS, a federally mandates assessment tool used for care planning) dated 1/5/24 revealed Resident 78's Brief Interview of Mental Status (BIMS) was a 5. According to the MDS [NAME] a score of 0 to 7 indicates a person has 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number: 175 NAC 12-006.17B Based on observations, record review and interview; the facility staff failed to implement infection control precaution to prevent the spread of infectious disease for 1 (Resident 100) and failed to utilized handwashing and gloving techniques during the provision of care and treatments for 3 (Resident 120, 41 and 80). The total sample size was 12. The facility staff identified a census of 126. Findings are: A. Review of Resident 100's electronic medical record revealed Resident 100 was admitted on [DATE]. Diagnoses list in electronic medical records identified a diagnosis of Extended Spectrum Beta Lactamase Resistance [an enzyme found in some strains of bacteria that is antibiotic resistant] during stay dated 3/11/24. A review of Resident 100's Urinalysis result dated 12/27/23 showed moderate Leukocyte Esterase [white blood cells] with specimen forwarded for culture and sensitivity. A review of Resident 100's Urine Culture Result dated 12/29/23 revealed microbiology…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review and interview, the facility failed to ensure the responsible party was notified of a change of condition for 1 [Resident 32] of 4 sampled residents. The facility had a total census of 126. Findings are: A review of Resident 32's electronic medical record revealed Resident 32 was admitted to the facility on [DATE] with a diagnosis of unspecified dementia. A review of Resident 32's Progress Note dated 3/13/24 at 6:03 PM revealed Resident 32 was being sent to emergency room for evaluation and treatment of left sided weakness, facial drooping, and slurred speech since 3/8/24. Resident 32's Progress Note indicated Resident 32's physician was informed and a verbal order was received to send to emergency room via 911. A review of Resident 32's Progress Note dated 3/13/24 at 6:16 PM revealed Resident 32's family was notified of Resident 32's condition and transfer to the hospital. A review of Neurology Consult Note dated 3/14/24 identified a…

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

Licensure Reference Number 175 NAC 12.006.02(8) Based on observation, record review, and interview; the facility failed to report an allegation of staff to resident abuse within the required timeframe to the Department of Health and Human Services [DHHS] for 1( Residents 233) of 4 facility self report investigations reviewed. The facility census was 126. Findings are: Record review of an undated facility policy entitled Abuse , Neglect, Exploitation revealed the following information: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, Adult Protective Services and to all other required agencies within specified timeframe's: - a. Immediately, but not later then 2 hours after the allegation is made, if the events that cause the allegation of abuse or result in serious bodily injury or: - b. Not later then 24 hours if the events that cause the allegation do not involve abuse and do not involve serious bodily injury. B. The Administrator will follow up with government agencies, during business hours, to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09 Based on record review and interview, the facility failed to ensure monitoring was completed for change of resident condition for 1 [Resident 32] of 4 sampled residents. The facility has a total census of 126 residents. Findings are: A review of Resident 32's electronic medical record revealed Resident 32 was admitted to the facility on [DATE] with a diagnosis of unspecified Dementia. A review of Resident 32's Progress Note dated 3/13/24 at 6:03 PM revealed Resident 32 was being sent to emergency room for evaluation and treatment of left sided weakness, facial drooping, and slurred speech since 3/8/24. Resident 32's Progress Note dated 3/13/24 indicated Resident 32's physician was informed and verbal order was received to send to emergency room via 911. A review of Neurology Consult Note dated 3/14/24 identified a diagnosis of subacute CVA [Cerebral vascular accident]. In an interview on 3/18/24 at 12:14 PM, LPN [Licensed Practical Nurse] A reported that Medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 12-006.10D Based on observation, interview, and record review the facility failed to ensure residents were free of significant medication errors for 1 (Resident 137) of 8 sampled residents. The facility census was 126. Findings are: Record review of Resident 137's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated -3-11-2024 revealed Resident 137 admitted to the facility on [DATE] with diagnoses of Seizure Disorder-Epilepsy, Anemia, Arthritis, Cerebrovascular Accident, Depression, and Asthma. The MDS also revealed Resident 137 had a Brief Interview of Mental Status score (BIMS, an assessment that aids in detecting cognitive impairment. A score of 0-7 equals severe impairment, 8-12 indicates moderate impairment and 13-15 indicates cognitively intact) of 15 indicating Resident 137 was cognitively intact. An interview with Resident 137 on 03-18-2024 at 2:17 PM revealed Resident 137 was concerned that (gender) was not getting all the medications…

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 Based on record review and interview, the facility staff failed to ensure 5 Nursing Assistants (NA) (NA-G, NA-H, NA-I, NA-J and NA-K) of 33 Nursing Assistants sampled received and completed 12 hours of continuing education. The facility staff identified a census of 135. Findings are: A record review of the employee files of 5 nursing assistants (NA) revealed there was no evidence of the employees receiving and completing the required 12 hours of continuing education. Record review of NA-G's employee record revealed a hire date of: 10/31/2022. Record review of NA-H's employee record revealed a hire date of 8/22/2022. Record review of NA-I's employee record revealed a hire date of 10/17/2022. Record review of NA-J's employee record revealed a hire date of 10/10/2022. Record review of NA-K's employee record revealed a hire date of 2/14/2022. Interview on 03/04/2024 at 9:00 AM with the Facility Administrator confirmed [gender] was unable to find education for NA-G, NA-H, NA-I, NA-J, and NA-K. The Administrator was unable to confirm if the 5…

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.