Adept Nursing & Rehab of Sutherland

Licensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview, the facility failed to assess and evaluate underlying causes of behavior to prevent the unnecessary use of a psychotropic (medications that affect the mind, emotions, or behavior, often used to treat mental health disorders) medication for 1 (Resident 3) of 1 sampled resident. The facility identified a census of 45. Findings are: A record review of an undated facility policy Use of Psychotropic Medications revealed the following: -Psychotropic medication should only be used to treat the resident's medical symptoms -Underlying medical conditions should be identified and ruled out prior to initiating a psychotropic medication -Non-pharmacological interventions must be attempted to minimize the need for psychotropic medications. A record review of a facility policy, Pain Management with a date of 4/1/2024, revealed staff will observe nonverbal indicators of pain which may indicate the presence of pain, such as increased or recurring restlessness, facial expressions, behaviors (such as resisting care,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.11(E) Based on observations, interview, and record review, the facility failed to store, label, cover, and use or discard food and drink items to prevent the potential for foodborne illness. This had the potential to affect all 39 residents that resided at the facility and consumed foods from the kitchen. Findings are: A record review of 2017 Nebraska Food Code, under section 3-501.17 revealed food held for more than 24 hours should be clearly marked to indicate the date by which food should be consumed or discarded. An observation on 12/16/24 at 10:57 AM during the initial kitchen tour revealed the following refrigerated items: -2 unlabeled, undated bulk bags of salad mix of lettuce, purple cabbage, carrots, and one of the bags contained lettuce which had turned brown. -One 1-gallon ziploc bag with lettuce, unlabeled. -1 unlabeled gallon-sized bag of bulk shredded carrots, mushy with liquid in bag. -1 opened 1-gallon size bottle of [NAME] Lynch salad dressing, labeled…

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 review and interview, the Minimum Data Set (MDS, a federally mandated assessment used for Care Planning purpose) was not coded correctly for pressure ulcer of 1 (Resident 34) out of 10 sampled residents' pressure sores. The facility census was 39. Findings are: A record review of the admission Record with the printed date of December 18th, 2024 revealed that Resident 24 was admitted to the facility on [DATE] with the diagnoses of: Type 2 Diabetes Mellitus with Hyperglycemia (a condition where someone with type 2 diabetes has elevated blood sugar levels, also known as high blood sugar or hyperglycemia), Pressure Ulcer to Left Heel, unstageable (Unstageable pressure ulcers are a type of bed sore that occurs when prolonged pressure on an area of the skin cuts off blood flow and oxygen to the tissue). A record review of Resident 24's Care Plan dated 12/12/24 revealed a focus, goal and intervention for Pressure Ulcers. A record review of Resident 24'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.

Licensure Reference 175 NAC 12-006.09(F)(i) Based on record reviews and interview, the facility failed to develop baseline care plans (a document that outlines a resident's healthcare needs and safety concerns when they are first admitted to a nursing home) within 48 hours of admission as required for 2 (Residents 9 and 96) of 2 sampled residents. The facility identified a census of 39. Findings are: A record review of an undated facility policy, Baseline Care Plan revealed baseline care plans will be developed within 48 hours of a resident's admission. A. A record review of an admission Record revealed the facility admitted Resident 9 on 6/14/2024 with diagnoses of: depression, repeated falls, difficulty swallowing, and Chronic Obstructive Pulmonary Disease (a common lung disease that causes breathing problems and restricted airflow). A record review of Resident 9's AS - Baseline Careplan - V 1 revealed a signed date of 6/17/2024, which was more than 48 hours after Resident 9's admission. B. A record review of an admission Record revealed the facility admitted Resident 96 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 175 NAC 12-006.09(E)(iii) Based on record reviews and interview, the facility failed to develop a comprehensive care plan (CCP, a document that outlines a resident's needs and the services that are to be provided to meet these needs) regarding activities of daily living (ADLs) for 1 (Resident 97) of 12 sampled residents. The facility identified a census of 39. Findings are: A record review of a facility policy, Comprehensive Care Plans with a date of 4/1/2024 indicated the CCP would, at a minimum, include the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psycho-social well-being and resident specific interventions that reflect the resident's needs and preferences. A record review of an admission Record revealed the facility admitted Resident 97 on 11/13/2024 with diagnoses of Chronic Respiratory Failure (a long-term condition that prevents the body from exchanging oxygen and carbon dioxide properly,) Chronic Obstructive Pulmonary Disease (a common lung disease that causes breathing problems 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.

Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on observation, record review, and interview, the facility failed to identify and update the comprehensive care plan with interventions after a fall for one (Resident 39) of one sampled resident. The facility identified a census of 39. Findings Are: A record review on 12/16/24 of Resident 39's Minimum Data Set (MDS, a federally mandated process that helps to standardize assessments, improve the accuracy of care, and facilitate care management) dated 11/18/24 reveals in Section GG: Resident 39 was independent with eating. They required set up assistance with oral hygiene. They were total dependence with transfers and toileting. They required moderate assistance with upper body dressing and maximum assistance with lower body dressing. A record review on 12/16/24 of Resident 39's diagnosis revealed diagnoses of: -Amyotrophic lateral Sclerosis (a terminal, progressive, and fatal neurological disorder that affects the nerve cells in the brain and spinal cord) -Unspecified Osteoarthritis (a condition that causes the breakdown 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 175 NAC 12-00609(H)(iv)(5) Based on record reviews and interviews, the facility failed to provide interventions for constipation for 1 (Resident 15) of 1 sampled resident. The facility identified a census of 39. Findings are: A record review of an admission Record indicated the facility admitted Resident 15 on 8/3/2023 with diagnoses of dementia and constipation. A record review of Resident 15's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) with a date of 10/15/2024 indicated Resident 15 had severe cognitive impairment, required moderate assistance with toileting and was occasionally incontinent of bowel. A record review of Resident 15's undated Care Plan revealed a focus area of risk for constipation due to medication side effects. Interventions implemented on 12/29/2023 included to administer medication as ordered, monitor to response to medication, dietary consult as needed, record bowel movement pattern each day, and report irregularities of bowel patterns to the physician. 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 175 NAC 12-006.09(H)(vi)(3)(g) Based on observations, interviews, and record reviews; the facility failed to administer oxygen following the prescriber's orders for 1 (Resident 9) of 4 sampled residents. The facility identified a census of 39. Findings are: A record review of a facility policy, Oxygen Concentrator, with a last reviewed/revised date of 12/3/2024, under the use of the concentrator indicated the nurse shall verify physician's orders for the rate of flow. A record review of an admission Record revealed the facility admitted Resident 9 on 6/14/2024 with diagnoses of Chronic Obstructive Pulmonary Disease (COPD, a common lung disease that causes breathing problems and restricted airflow.) A record review of Resident 9's undated Care Plan revealed a focus area for impaired respiratory status with risks for shortness of breath, respiratory distress, increased anxiety, and hypoxia (low oxygen levels.) The area included an intervention, initiated on 12/16/2024, to provide oxygen therapy as ordered by the physician. A record review of Resident 9's Order…

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 12-006.10D Based on observations, record review and interviews; the facility failed to ensure a medication error rate of less than 5%. Observations of 26 medications opportunities revealed 4 errors resulting in a medication error rate 16%. The errors affected 1 (Residents 2) of 3 sampled residents. The facility census was 39. Findings: A record review of the undated Medication Administration policy revealed the following: -Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. -Administer medication as ordered in accordance with manufacturer specifications. A record review of the Medication list for Resident 2 revealed: -A start date of 5/24/24 for Advair Diskus 100/50 MCG/dose 1 puff inhale orally two times a day for Asthma. Rinse mouth after use. -A start date of 5/24/24 for Azelastine HCL Solution (treats allergy symptoms like a stuffy or runny nose, sneezing, and itching) 137 micrograms (MCG)/Spray 1 spray in both nostrils two times a day. -A start date of 5/25/24 Blood glucose( amount of sugar 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 12-006.18(D) Based on observations, interviews, and record review, the facility failed to perform hand hygiene and change gloves while performing catheter care for one (Resident 39) of one sampled resident. The facility identified a census of 39. Findings Are: A record review of a policy titled Enhanced Barrier Precautions dated 3/20/24 stated on page 1, number 3b: PPE (personal protection equipment) for enhanced barrier precautions is only necessary when performing high-contact care activities. Page 2 number 4 stated high-contact care activities include: d) providing hygiene, f) changing briefs, g) device care including urinary catheters. An observation on 12/18/24 at 7:19 PM of Nurse Aide (NA)-C and NA-D performing foley catheter care on Resident 39. An Enhanced Barrier Precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or…

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 interviews and record reviews, the facility failed to implement safety checks, education, or hazard assessments to ensure resident saftey for use of a bath chair, this affected 1 (Resident 4) of 1 resident sampled. Facility identified a census of 47. Findings are: An interview on 09/26/2024 at 1:31 PM with Bath Aide (BA)-D revealed that all residents are brought down to the bath house in their wheelchair or walked down to the bath house for their bathing needs. BA-D continued to reveal however there was once exception and that was Resident 4, who prefers being transported on a shower chair from their room to the bath house and back. An interview on 09/26/2024 at 2:19 PM with BA-C revealed, BA-C provides Resident 4 a shower during evening shifts. BA-C states that Resident 4's preference is to take a shower in the evening and that Resident 4 will be provided a shower in the shower chair provided from the facility and transported back and forth from their room to the bath house. BA-C explains that they are…

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 observation, interview, and record review, the facility failed to provide assistance with grooming to 3 (Residents 1, 12, and 15) of 3 sampled residents. The facility census was 48. A. A record review of Resident 1's admission Record revealed the resident was admitted to the facility on [DATE]. A record review of Resident 1's Minimum Data Set (MDS), a federally mandated assessment tool utilized to develop resident care plans, dated 1/23/24 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 4/15, which indicated the resident had moderate cognitive impairment. Section GG revealed the resident required partial or moderate assistance for toileting, personal hygiene, and transfers. The resident required substantial or maximum assistance with upper body dressing and was dependent on staff assistance for lower body dressing. A record review of Resident 1's undated Care Plan revealed the resident required extensive, one-person physical…

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 12-006.09B Based on record review and interview, the facility failed to code dialysis on the Minimum Data Set (MDS a federally mandated assessment tool utilized to develop resident care plans) assessment for 1 (Resident 1) of 1 sampled resident. The facility census was 48. The Findings Are: A record review of facility policy MDS 3.0 Completion dated 8/1/2023, revealed Policy Explanation and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State. A record review of Resident 1's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease and Dependence on Renal Dialysis. A record review of Resident 1's End of PPS Part A Stay MDS dated [DATE], Section O revealed dialysis was not indicated as a special treatment that resident had received. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09C1c Based on record review and interview, the facility failed to revise a Care Plan for a provider order 1 (Resident 1) of 1 sampled resident. The facility census was 48. The Findings Are: A record review of Resident 1's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease (ESRD) and Dependence on Renal Dialysis. A record review conducted on 2/14/24 of Resident 1's undated Care Plan revealed The resident needs hemodialysis related to (r/t) ESRD. Presence of right subclavian catheter (removed on 12/20/2023). Stitches in place: Daily Dressing Change. A record review conducted on 2/14/2024 of Resident 1's current Physician's Orders revealed the resident did not have an order for a daily dressing change related to stitches being in place post-removal of a right subclavian catheter. A record review of Resident 1's January 2024 Medication Administration Record revealed the order Clean area to right clavicle…

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 observation, record review, and interview the facility failed to remove a dressing per the physician's order and failed to document in the Treatment Administration Record that the AV fistula dressing was being removed and the site was being monitored as required. This affected 1 (Resident 1) of 1 sampled resident. The facility census was 48. The Findings Are: A. A record review of Resident 1's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease and Dependence on Renal Dialysis. A record review of Resident 1's progress note dated 1/15/2024 at 9:08 AM by the Director of Nursing (DON) revealed the DON, Administrator, resident's child, and a social worker from the dialysis center had a meeting to discuss how the resident was tolerating dialysis and concerns from the dialysis center. The social worker voiced a concern that the dressing on the resident's arteriovenous (AV) fistula site was not always being removed between dialysis 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 12-006.17 Based on observations, interviews, and record reviews; the facility staff failed to perform wound care to prevent the potential for cross-contamination and infection. This failure had the potential to affect 2 (Resident 2 and 9) of 2 sampled residents. The facility census was 48. Findings are: A. A record review of Resident 2's admission Record revealed the resident had an Original admission date of 4/20/2021. Resident 2 had a diagnosis of a pressure ulcer of the sacral region, stage III. A record review of Resident 2's Minimum Data Set (MDS-a comprehensive assessment tool used to develop a resident's Care Plan) with a date of 12/23/2023 under Section-M- Skin Conditions revealed the resident was at risk for developing pressure ulcers/injuries and had a pressure ulcer/injury, a scar over a boney prominence. Resident 2 had one stage 2 pressure ulcer. A record review of Resident 2's Treatment Administration Record (TAR) from 2/1/2024 to 2/29/2024 revealed an order with a start date of 2/9/2024 to cleanse the left sacrum wound with normal…

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

LICENSURE REFERENCE NUMBER 175 NAC12-006.04D2 Based on interview and record review, the facility failed to have a qualified Dietary Manager. This had the potential to affect all of the residents who consumed food from the kitchen. The facility staff identified a census of 42. An interview with the Food Service Supervisor (FSS) on 11/14/23 from 11:00 AM to 11:12 AM revealed that the FSS was enrolled in dietary manager classes and will graduate in the Spring of 2024 and was currently not certified as a dietary manager. The interview also revealed the FSS splits their time with this facility and a second facility. The FSS verbalized there is a Consultant Registered Dietician who comes to the facility monthly. Record review of a list of key personnel received from the facility for this location revealed that the FSS was listed as the Food Service Supervisor, and there was no Certified Dietary Manager on the list.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.11E Based on observations, interviews, and record review, the facility failed to maintain cleanliness of equipment, floors, walls, stove, oven and storage areas, failed to ensure puree foods were temped prior to serving, failed to perform hand hygiene and gloving during meal prep and service, failed to prepare food in a sanitary condition to prevent cross contamination and food borne illness. This had the potential to affect all residents that ate foods prepared in the facility kitchen. The facility census was 42. The findings are: A. An initial kitchen tour observation on 11/13/23 from 9:50 AM to 10:47 AM revealed the following concerns: - The floor around the dishwasher and below the juice machine had debris such as old food particles and a buildup of dirt and grime. - The shelf below the kitchen work shelf and the shelf above the stove had a buildup of debris such as old food particles and dust. - There were lids and cups directly on the kitchen floor, including a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number NAC 175 12-006.17 AND 12-006.17D The facility staff failed to perform hand hygiene and gloving during personal hygiene cares and failed to complete personal hygiene cares in a manner to prevent the potential for cross contamination for 2 (Residents 13 and 19) of 2 sampled residents and failed to perform hand hygiene correctly after leaving a Enhanced Barrier Precaution room. The facility identified a census of 42. Findings are: A. Record review of Resident 13's Minimum Data Set (MDS) (a federally mandated comprehensive assessment tool used for resident care planning) dated 9/22/2023 revealed under Section C that the resident's Brief Interview for Mental Status (BIMS) (an assessment that determines a resident's cognitive status) a score of 7. This indicated the resident was moderately to severely impaired cognitively. Section G revealed the resident needed full assistance with personal hygiene, toileting and transfers. Record review of Resident 13's active diagnosis list last revised…

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 ensure their Infection Control Nurse completed specialized training in infection prevention and control prior to assuming the role of the Infection Preventionist. This had the potential to affect all residents residing in the facility. The facility census was 42. The Findings Are: An interview on 11/15/23 at 11:10 AM with Licensed Practical Nurse (LPN)-C confirmed LPN-C was the facility's Infection Control Nurse. LPN-C revealed they have not completed all of the CDC Nursing Home Infection Preventionist Training Course but has Modules 1-12A done. An interview on 11/15/23 at 6:50 AM with the facility Administrator revealed LPN-C was currently enrolled in the CDC Nursing Home Infection Preventionist Training Course. A record review of the CDC Nursing Home Infection Preventionist Training Course for LPN-C verified the completion of only Modules 1 through 12A. A record review of the facility's Infection Preventionist Job Description, undated, revealed a Required Qualification of Completed specialized training in infection…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.05 (21) Based on observations, interview, and record review, the facility failed to maintain 1 (Resident 3) of 3 sampled resident's dignity as evidenced by placing Resident 3 to face the wall during dining and in their room. The facility census was 42. The findings are: A record review of Resident 3's Face Sheet dated 11/16/2023 revealed Resident 3 was admitted to the facility on [DATE] with a primary diagnosis of Other Encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition). A record review of Resident 3's Minimum Data Set (MDS) dated [DATE], Section C revealed a Brief Interview for Mental Status (BIMS) was not completed as the resident is rarely/never understood. Section G revealed the resident required extensive assistance with bed mobility and eating, and total assistance with transferring and toileting. An observation on 11/13/23 at 1:01 PM revealed Resident 3 was brought to the dining room in their wheelchair and was…

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

Licensure Reference Number NAC 17512-006.09D4 Based on observations, interviews, and record reviews, the facility failed to implement interventions to maintain range of motion for 1 (Resident 13) of 2 sampled residents. The facility staff identified a census of 42. Findings are: Record review of Resident 13's Minimum Data Set (MDS) (a federally mandated comprehensive assessment tool used for resident care planning) dated 9/22/2023 revealed a Brief Interview for Mental Status (BIMS) (an assessment used to determine a resident's cognitive condition) score of 7. A score of 7 indicated severely to moderately impaired cognition. Section G indicated the resident needed full assistance with personal hygiene, toileting and transfers. Record review of Resident 13's active diagnosis list revealed diagnoses as follows: peripheral vascular disease, unspecified, contracture, left and right hand, and chronic pain. Record review of Resident 13's Care Plan with a revision date of 6/28/2022 revealed a problem for the resident being at risk for decline in functional status related to limited…

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 12-006.09D Based on observations, interviews, and record reviews, the facility failed to implement interventions for pain management, failed to evaluate the effectiveness and failed to re-evaluate interventions to manage 1 (Resident 13) of 2 sampled resident's pain. The facility identified a census of 42. Findings are: Record review of Resident 13's Minimum Data Set (MDS) (a federally mandated comprehensive assessment tool used for care planning) dated 9/22/23 revealed in Section C, a Brief Interview of Mental Status (BIMS) (an assessment that determines a resident's cognitive function) score of 7, which indicated the resident is severely to moderately cognitively impaired. Section G revealed the resident was full assistance with personal cares, toileting, and transfers. The MDS in Section J revealed Resident 13 was in frequent pain and recieved scheduled pain medications. Record review of Resident 13's active diagnoses listed included: Chronic pain and contractures to left and right hands. An interview with Resident 13 on 11/14/23 at 7:59 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 175NAC 12-006.09D1 Based on observation, record review, and interview the facility failed to follow resident preferences for bathing for 2 residents (Residents 1 and 2) of 3 residents reviewed. The facility census was 39. Findings are: A. Record review of the undated facility Administrative Admissions Packet revealed the section titled Resident Rights. The section revealed that the resident has a right to a dignified existence. The section revealed the resident has the right to choose health care consistent with his or her plan of care. The resident has a right to reasonable accommodation of individual needs and preferences. Record review of the Facility Assessment Tool dated 8/9/23 revealed the paragraph in Part 1 titled Other. The paragraph revealed that Resident Preferences and staffing: during the admission process the resident/family are asked about their normal daily schedule and what they were used to at home. The facility staffs to accommodate residents who prefer 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.

Licensure Reference Number 175NAC 12-006.09D1b Based on observation, record review, and interview the facility failed to follow the plan of care for resident transfers (movement from one surface to another such as from the bed to a chair) to prevent the potential for decline in physical ability for 1 resident (Resident 1) of 3 residents reviewed; and the facility failed to provide physical therapy as ordered for 1 resident (Resident 1) of 3 residents reviewed to improve the resident's physical abilities. The facility census was 39. Findings are: A. Record review of the undated facility Administrative Admissions Packet revealed the section titled Resident Rights. The section revealed that the resident has a right to be fully informed in advance about care, treatment, and any changes in that care or treatment which may affect the resident's well-being. The resident has the right to choose health care consistent with his or her plan of care. The resident has a right to reasonable accommodation of individual needs and preferences. Record review of the Facility Assessment Tool dated…

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