Adept Nursing & Rehab of South Sioux City

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.11(E) Based on observations and interviews, the facility failed to a) ensure food products were disposed of prior to expiration dates, b) failed to implement and maintain the cleaning of food preparation equipment and surfaces to prevent the potential for food borne illness. This had the potential to affect 48 of 49 residents who eat from the kitchen. The facility census was 49. Finding are: During the initial kitchen tour on 06/24/24 from 9:05AM to 9:30 AM revealed the following: The walk-in refrigerator: -Gallon of 2% milk found in the walk-in refrigerator was open and only had ½ contents left was undated. In the walk-freezer: -Walk-in freezer had visible frost/ice buildup on the outside of the freezer door on the lower portion near the floor. The ice build-up covered the full length of the freezer door and approximately 8 inches high. -Unlabeled, undated bag of what appeared to be frozen egg patties or waffles observed inside walk-in freezer. In the reach-in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.19 Based on observations and interviews: the facility staff failed to maintain hallyway carpets in the center hallway, south hallway and the common area between 400 north and south hallways with the potential to effect 35 residents, failed to ensure2 (room [ROOM NUMBER], 402 and 405) ventilation covers were clean and failed to ensure a privacy curtain was in 1 residents room, room [ROOM NUMBER]. The facility staff identified a census of 49. Findings are: Observations on 6/24.2024 between 8:40 AM and 9:30 AM of the environmental tore revealed the following: - A shared toilet between rooms [ROOM NUMBERS] that lacked doors on both sides of the toilet. -Lingering strong urine smell in room [ROOM NUMBER]. -Bathroom ventilation's covers in rooms 310, 402, 405 covered with a gray fuzzy substance, resembling dust. -Stains (irregular shaped discolored blotches significantly darker than the surrounding carpet) down the Center, and South Hallways, and in the common area between 400…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.18 Based on observation, interview and record review: the facility staff failed to ensure hand hygiene was performed after glove changes during peri care, catheter care, and wound care and failed to prevent potential cross contamination during these cares by placing the washcloths in the sink basins and on the bed covers without a barrier for 2 of 2 residents surveyed (Residents 1 and 21). The facility claimed a census of 49. Findings are: A. Record Review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 05-25-2024 revealed Resident 1 admitted to the facility on [DATE] with the diagnosis of Heart Failure, Diabetes Mellitus Type 2, Schizophrenia, and Morbid Obesity. The MDS indicated Resident 1 had an indwelling catheter and required maximal assistance from staff to roll in bed, perform upper body dressing and personal hygiene and was dependent on staff to perform transfers, bathing, lower body dressing, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide a written notice of transfer for 1 (Resident 252) and/or their representative upon transfer to the hospital and failed to notify a representative of the Office of the State Long-Term Care Ombudsman for 2 of 2 (Resident 1 and 252) residents sampled for hospitalizations. The facility census was 49. Findings are: A. Review of a Electronic Health Record (EHR,, is a digital version of a patient's paper chart)) for Resident 252 revealed Resident 252 had a fall on 05/25/24 and was transferred by ambulance to the hospital at 11:45 PM and returned to the facility on [DATE] at 2:31 AM. No bed hold notice was given to the resident or responsible party at time of transfer. On 05/26/24 at 12:30 PM Resident 252 was transferred by ambulance to the hospital. No bed hold notice was given to the resident or responsible party at time of transfer. An interview with the Social Services Director (SSD) on 06/26/24 at 10:50 AM confirmed that the facility did not give…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide a written notice of a bed hold for 2 (Resident 252 and 1) of 2 sampled residents. The facility census was 49. Findings are: A. A review of medical record for Resident 252 revealed Resident 252 had a fall on 05/25/24 and was transferred by ambulance to the hospital at 11:45 PM and returned to the facility on [DATE] at 02:31 AM. No bed hold notice was given to the resident or responsible party at time of transfer. On 05/26/24 at 12:30 PM Resident 252 was transferred by ambulance to the hospital. No bed hold notice was given to the resident or responsible party at time of transfer. Facility's Bed Hold Notice Upon Transfer Policy dated 8/1/23 revealed the following: At time of emergency transfer the resident and/or resident representative will be informed of bed hold option. The details of the bed hold will be provided in writing to the resident and/or resident representative soon as possible. An interview with Social Services Director (SSD) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a Preadmission Screening Resident Review (PASARR, a federally mandated screening process to ensure Nursing Home residents with mental illness and/or developmental disabilities receive the care and services they need in the most appropriate setting) was accurately completed for 1 (Resident 34) of 2 sampled residents. The facility sample was 49. Finding are: Record review of Resident 34's admission Minimum Date Set ( MDS, a federally mandatory assessment tool used for care planning) dated 07/14/2023 was admitted to the facility on [DATE] with the diagnoses of Unspecified Dementia, Generalized Anxiety Disorder, Major Depressive Disorder, and Delusional Disorder. Record review of PASARR Level 1 screening form dated 07-12-2023 revealed Resident 34 was assessed as having no diagnosis or suspicion of Serious Mental Illness (SMI) or Intellectual Disability or Related Condition (ID/RC). Interview with the Social Services Director on 06/26/24 at 10:00 AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.09(H)(iii)(3) Based on observation, interview and record review;the facility staff failed to conduct skin evaluations and failed to provide wound treatments in the order time frames for 1( Resident 21) of 1 Residents. The facility census was 49. Findings are: A. Record review of Resident 21's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 05-21-2024 revealed Resident 21 admitted to the facility on [DATE] with diagnosis of morbid obesity, alcoholic cirrhosis of the liver, left above the knee amputation and was a carrier of Methicillin Resistant Staph Aureas (MRSA, is a staph bacteria that does not get better with the type of antibiotics that usually cure staph infections). The MDS also revealed Resident 21 had a Brief Interview of Mental Status (BIMS, an assessment that aids in detecting cognitive impairment. A score of 0-7 equals severe impairment, 8-12 indicates moderate impairment and 13-15 indicates cognitively intact) score…

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

Licensure Reference Number NAC 175 12-06.09(H)(iii)(2) Based on observation, interview and record review, the facility failed to implement a ordered treatment for 1 (Resident 37) of 3 sampled residents for wound care. The facility identified a census of 49. Findings are: Record review of Resident 37's (Treatment Administered Record) TAR for June 2024 revealed a treatment order for Resident 37's left heel ,was Skin Prep daily with an order date of 6/5/2024. An observation on 6/26/24 at 6:56 AM revealed (Registered Nurse) RN-A came into Resident 37's room to complete the residents wound care. RN-A had poured Betadine in a medication cup outside of the room and brought this medication cup into the room and reported the Betadine was for Resident 37's left heel ulcer. Further observation revealed RN-A using a cotton ball applied the Betidine to Resident 37's left heel. On 06/26/24 at 10:56 AM a interview was conducted with the (Director of Nursing) DON. During the interview the DON reported the treatment should have been performed as ordered. The DON confirmed the treatment order 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(l) Based on observation, interview and record review the facility failed to implement interventions to prevent reoccurring falls for 1 of 4 residents (Resident 40). The facility census was 49. Findings are: Record Review of Resident 40's most recent Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 05-14-2024 revealed Resident 40 had a Brief Interview of Mental Status (BIMS, an assessment that aids in detecting cognitive impairment. A score of 0-7 equals severe impairment, 8-12 indicates moderate impairment and 13-15 indicates cognitively intact) score of 7 indicating severe impairment. The MDS also revealed Resident 40 had the diagnosis' of End Stage Renal Disease, Heart Failure, Diabetes Mellitus and Depression. According to the MDS Resident 40 needed partial assistance from staff for bed mobility, transfers, oral hygiene and upper body dressing and maximal assistance from staff for lower body dressing, bathing and personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.09(J) Based on observation, interview and record review, the facility failed to follow physicians' orders for the administration of tube feeding for 1 (Resident 42) of 1. The facility identified a census of 49. Findings are: Record review of Resident 42's Minimum Data Set (MDS - a federally mandated assessment tool for Medicare and Medicaid residents) dated 2/22/2024 revealed Resident 42 had a Brief Interview for Mental Status (BIMS) score of a 8. According to the MDS [NAME] a score of 8 to 12 indicates a persons cognition is moderately impaired. Record review of Resident 42's MDS dated [DATE] revealed Resident 42 was receiving tube feeding. Record review of a practitioners order dated 6-21-2024 revealed Resident 42's practitioner order Novasource renal ( a feeding formula) to be given at 65 milliliters (ml) per hour for 12 hours. An observation on 06/26/2024 at 7:1 5 AM of Resident 42 revealed Resident 42's tube feeding was being administered via gravity (a method 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 Based on interview and record review, the facility failed to ensure targeted behaviors were identified, and that behavior monitoring for psychotropic medication was initiated for one resident (Resident 4) of 2 residents surveyed. The facility had a census of 49. Findings are: Record review of Resident 4's Minimum Data Sets (MDS - a federally mandated assessment tool for residents on Medicare and/or Medicaid) dated 5/28/2024 revealed Resident 4 had a Brief Interview of Mental Status (BIMS - a federally mandated tool to assess residents' cognitive function) of 15, indicating Resident 4 was cognitively intact. According to Resident 4's MDS dated [DATE] Resident 4 had the following diagnoses: Non-infective gastroenteritis and colitis, Type 2 Diabetes, Bipolar disorder, Malignant primary neoplasm, insomnia, Obesity, Muscle wasting and atrophy, anemia, Hypertension, cognitive communication deficit, repeated falls. Record review of a Order Summary Report (OSR) dated 6/25/2024 for Resident 4 revealed the practitioner…

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 12-006.09D3(2) Licensure Reference Number 175 NAC 12-006.09D1c Based on observations, interviews and record review the facility failed to provide toileting for 1 (Resident 4) and failed to answer call lights for 4 (Resident 1,7,11, and 12) of 5 total sampled residents. The facility census was 53. Findings; A. Record Review of Resident 4's Minimum Data Set (MDS, a federally mandated assessment tool use for care planning) dated 11/21/2023 revealed under section GG, Resident 4 was dependent on staff to perform toileting, bathing, grooming and wheelchair mobility. Under section H of the MDS, Resident 4 was identified as totally incontinent of bowel and bladder. Record Review of Resident 4's Care Plan revealed Resident 4 needed extensive to total assistance from staff with activities of daily living due to dementia. Resident 4 is incontinent of bowel and bladder and wears adult briefs. Staff are to assist Resident 4 by checking and changing the adult briefs every 2-3 hours.…

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 interview and record review, the facility failed to notify 1 (Resident 1) of 1 sampled residents the provider and the resident's representative of a medication that was unavailable. The facility census was 49. Findings are: A record review of the facility's undated Notification of Changes policy revealed the facility must inform or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances (situations) that required notification included a significant change in the resident's physical, mental, or psychosocial condition. A. A record review of Resident 1's Clinical Census dated 10/31/2023 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 1's Medical Diagnosis dated 10/31/2023 revealed the resident had diagnoses of: Acute and Chronic Respiratory Failure with Hypoxia (sudden and long-term respiratory failure with low oxygen), Epilepsy (a neurological…

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 interview and record review, the facility failed to report an alleged incident of abuse for 1 (Resident 3) of 3 sampled residents to Adult Protective Services (APS) and to The State of Nebraska Department of Health and Human Services (DHHS). The total facility census was 49. Findings are: A record review of the Abuse, Neglect, and Exploitation (taking advantage of a resident) Prohibition (forbidding) and Prevention Program Policy dated 09/01/2018 revealed all covered individuals, including mandated reporters, employees and long-term care communities have an obligation to report all allegations of abuse, neglect, or exploitation to the appropriate state agencies immediately, but no later than 24 hours after the allegation or occurrence. A report of the investigation was to be provided to the state agency within 5 working days of the incident. A record review of Resident 3's Progress Notes revealed on 10/18/2023 at 2:54 AM another resident was found standing over Resident 3 and attempted to undress them. Resident 3 attempted 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 12-006.05(9) Based on record review and interview; the facility failed to protect Residents 35 and 95's right to be free from resident-to-resident physical abuse and to protect Resident 7's right to be free from neglect related to a fall with injury. The sample size was 4 and the facility census was 42. Findings are: A. Review of the facility policy Abuse, Neglect and Exploitation Prohibition and Prevention Program with a revision date of 9/1/18 revealed the policy was a mechanism for the prompt identification, investigation and reporting of any allegation or complaint of abuse, neglect or exploitation. The policy indicated allegations of potential abuse were to be immediately reported to a supervisor, the facility Administrator or designee and in accordance with the state and federal laws. If there was reasonable suspicion of a crime or if serious bodily injury occurred then the report was to be made immediately but no later than 2 hours. Allegations were to promptly 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview; the facility failed to complete investigations of potential resident-to-resident abuse for Residents 95 and 35 and a fall with injury for Resident 7 and to assure completed investigations were sent to the State Agency within 5 working days. In addition, the facility failed to submit the results of an investigation of potential staff-to-resident abuse involving Resident 6 within the required time frame. The sample size was 4 and the facility census was 42. Findings are: A. Review of the facility policy Abuse, Neglect and Exploitation Prohibition and Prevention Program with a revision date of 9/1/18 revealed the policy was a mechanism for the prompt identification, investigation and reporting of any allegation or complaint of abuse, neglect or exploitation. The policy indicated allegations of potential abuse were to be immediately reported to a supervisor, the facility Administrator or designee and in accordance with the state…

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 Based on interview and record review; the facility failed to have staff who were trained and certified in Cardiopulmonary Resuscitation (CPR-emergency procedures performed if a person stops breathing or their heart stops) for transportation of residents identified as having a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures would be provided to keep them alive) status. This had the potential to affect all 13 (Residents 195, 16, 145, 38, 37, 45, 96, 25, 26, 32, 2, 1 and 97) residents identified as having as a full code. The facility census was 42. Findings are: Review of the facility list of residents with a full code status revealed the following residents were designated as a full code; Residents 195, 16, 145, 38, 37, 45, 96, 25, 26, 32, 2, 1 and 97. During an interview on [DATE] at 12:39 PM, the Consultant Director of Nursing (DON) confirmed the following: -any residents who had an appointment 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 C. Review of the facility policy titled Obtaining a Fingerstick Glucose, with a revision date of 10/2011 revealed staff should do the following: -review the resident's care plan and provide for any special needs, -assemble equipment and supplies, -use individual devices for individual residents, -place the equipment on the bedside stand or overbed table, -ensure blood glucose meters are cleaned and disinfected between resident uses, and, -clean and disinfect reusable equipment according to the manufacturer's instructions and current infection control standards of practice. On 5/11/23 at 8:50 AM observation of RN-T knocked and entered Resident 97's room. Resident 97 was in isolation. RN-T performed hand hygiene, obtained supplies from the mediation cart which included the resident's glucometer supply container and the resident's scheduled insulin. RN-T stopped outside of the resident's room, performed hand hygiene and applied a mask. RN-T knocked and entered the resident room and placed the resident's glucometer…

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 12-006.051 Based on record review and interview the facility failed to provide the required Advanced Beneficiary Notice (ABN) to Resident 22 prior to discharge from Medicare services. The sample size was 3 and the facility census was 42. Findings are: Review of Resident 22's Skilled Nursing Facility Protection Notification Review revealed the resident's Skilled Services Episode began on 11/14/22 and the Last Covered Medicare Day was 12/14/22. The Notice of Medicare Non-Coverage was provided to the resident on 12/12/22, however the facility did not provide the resident/resident representative with the required information related to the reasons and costs of the non-covered Medicare benefits. During an interview on 5/10/23 at 2:00 PM the facility Consulting Administrator confirmed the facility had not completed the required ABN's for Resident 22.

Licensure Reference Number 175 NAC 12-006.09D5b Based on observation, record review and interview the facility failed to provide an individualized activity program to meet the needs of Resident 13. The sample size was 14 and the facility census was 42. Findings are: Review of the facility policy Azria Activity Programs dated June 2018 revealed the activity program was provided to support the well-being of residents and to encourage both independence and community interaction. The Activities were offered based on resident-centered assessments and designed to encourage maximum individual participation and geared to the individual resident's needs. Review of Resident 13's Minimum Data Set (MDS-federally mandated assessment used to develop resident Care Plans) dated 2/15/23 revealed the resident was severely impaired cognitively, and displayed inattention and disorganized thinking. Resident 13 had dementia and depression and received extensive assistance with bed mobility, transfers, toileting and dressing. Review of Resident 13's Care Plan with a revision date of 5/8/23 revealed the…

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

Licensure Reference Number 175 NAC 12-006.09Da Based on record review and interview the facility failed to identify a potential safety risk related to the use of an electric lift chair resulting in a fall with injury for Resident 7. The sample size was 5 and the facility census was 42. Findings are: A. Review of the facility policy Azria Falls dated 3/2018 revealed the following; -the facility identified individuals with a history of falls and risk factors for falling, -residents with repetitive falls often had identifiable underlying cause/s, -staff evaluated and documented falls that occurred while the individual was in the facility; for example, when and where they happen, and any observations of the event, -identified falls as witnessed or unwitnessed, -identified possible fall causes within 24 hours, -collected and evaluated information until a cause was determined, or it was determined a cause could not be found, -identified pertinent interventions to prevent subsequent falls and to address potentially significant consequences, -monitored and documented the individual'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 12-006.09D8b Based on observation, record review, and interview; the facility failed to implement recommendations for ongoing weight loss for Resident 97. The sample size was 5 and the facility census was 42. Findings are: Review of the facility policy Weight Assessment and Intervention, last revised 9/2008 revealed the following: -the multidisciplinary team would strive to prevent, monitor, and intervene for undesirable weight loss, -nursing staff would measure resident weights on admission, the next day and weekly for 2 weeks, if no weight concerns, weight would be measured monthly thereafter, -weights were to be recorded for each resident, -any weight change of 5 pounds or more or 3 pounds or more if the resident was under 100 pounds would be retaken, if verified, nursing would notify the dietary manager or dietician, -the dietician would review records and follow trends, negative trends would be evaluated by the interdisciplinary team (IDT), -significant unplanned and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on interview and record review, the facility failed to address Resident 16's behavioral needs. The sample size was 18 and the facility census was 24. Findings are: Review of Resident 35's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/22/23 revealed the resident was admitted [DATE] with diagnoses of non-Alzheimer's dementia, anxiety, depression and mood disturbance. The assessment indicated the resident's cognition was moderately impaired. The assessment revealed no evidence of behaviors, and the resident mood interview was conducted with no mood indicators identified. Review of Resident 35's Nursing Progress Notes revealed the following: -8/30/22 at 5:10 PM resident self-propelled wheelchair to the dining room, next to another resident who was also propelling a wheelchair. Resident 35 asked the other resident if they wanted a kiss. Resident 35 was redirected this was inappropriate; and -8/31/22 at 5:13…

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.