Skyview Care and Rehab at Bridgeport

505 O Street, Bridgeport, NE 69336 (308) 262-0725
For profit - Individual 48 Beds Independent Data: November 2025 1 Immediate Jeopardy citation
Trust Grade
13/100
#166 of 177 in NE
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Last Inspection: March 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Skyview Care and Rehab at Bridgeport has received a Trust Grade of F, indicating a poor rating with significant concerns about the quality of care provided. Ranked #166 out of 177 facilities in Nebraska, they fall in the bottom half, and are the second-best option out of only two facilities in Morrill County. The facility's trend is worsening, with the number of issues increasing dramatically from 8 in 2024 to 22 in 2025. Staffing is rated average with a 3/5 star rating, but the turnover rate is concerning at 75%, significantly higher than the state average of 49%. While there have been no fines recorded, which is a positive sign, there have been critical findings including insufficient staff during resident transfers, which poses a serious risk of harm, and failures in monitoring and treating pressure ulcers.

Trust Score
F
13/100
In Nebraska
#166/177
Bottom 7%
Safety Record
High Risk
Review needed
Inspections
Getting Worse
8 → 22 violations
Staff Stability
⚠ Watch
75% turnover. Very high, 27 points above average. Constant new faces learning your loved one's needs.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most Nebraska facilities.
Skilled Nurses
✓ Good
Each resident gets 53 minutes of Registered Nurse (RN) attention daily — more than average for Nebraska. RNs are trained to catch health problems early.
Violations
⚠ Watch
35 deficiencies on record. Higher than average. Multiple issues found across inspections.
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 8 issues
2025: 22 issues

The Good

  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below Nebraska average (2.9)

Significant quality concerns identified by CMS

Staff Turnover: 75%

29pts above Nebraska avg (46%)

Frequent staff changes - ask about care continuity

Staff turnover is very high (75%)

27 points above Nebraska average of 48%

The Ugly 35 deficiencies on record

1 life-threatening 1 actual harm
Aug 2025 1 deficiency
CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

Licensure Reference Number 175 NAC 12-006.18(B)Licensure Reference Number 175 NAC 12-006.18(D) Based on observation, interview, and record review, the facility failed to: a) implement contact precauti...

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Licensure Reference Number 175 NAC 12-006.18(B)Licensure Reference Number 175 NAC 12-006.18(D) Based on observation, interview, and record review, the facility failed to: a) implement contact precautions as ordered by the physician, b) implement Enhanced Barrier Precautions (EBP) and adhere to infection control standards during wound care, c) and adhere to infection control standards during medication administration for 3 residents (Residents 3, 12 and 18.) These lapses created a risk of cross-contamination and potential transmission of infection to all residents residing within the facility. The facility identified a census of 28.Findings are: A. A record review of the Center for Disease Control's (CDC) article Carbapenem-resistant Pseudomonas Aeruginosa: A Serious Public Health Threat revealed pseudomonas aeruginosa bacteria are a common cause of infection in the healthcare setting. They can cause pneumonia, bloodstream infections, urinary tract infections (UTI), and surgical site infections, and they are particularly dangerous for patients with chronic lung disease. The bacteria is transmitted from person to person, via the hands of healthcare personnel or contaminated medical equipment and devices. Prevention strategies were as follows:- Perform hand hygiene. Staff should clean hands immediately before touching the resident.- Wear gown and gloves when caring for patient with pseudomonas aeruginosa. Pseudomonas aeruginosa can contaminate hands and clothes when caring for a resident, putting residents who are cared for afterward at risk for acquiring the infection. - Clean and Disinfect the patient environment and medical equipment. Staff should follow the facility's cleaning and disinfection protocol, ensure high-touch surfaces are cleaned frequently, dedicate non-critical medical equipment (stethoscopes, blood pressure cuffs) to the resident whenever possible and always clean and disinfect between residents. - Prevent transmission from sinks, toilets and other waster water plumbing. Pseudomonas aeruginosa can contaminate wastewater plumbing (sink drains, toilets). Water splashed from these sources have been associated with outbreaks of the organism. To prevent this, clean and disinfect countertops, handles, faucets, and sinks daily; keep patient care items at least three feet away from sinks and toilets; and do not discard patient waste in sinks. A record review of an admission Record revealed the facility re-admitted Resident 12 on 7/21/2025. Resident 12 was re-admitted with the primary diagnosis of pneumonia. A record review of Resident 12's visit with the Nurse Practitioner from 7/28/2025 revealed Resident 12 had symptoms of a suspected urinary tract infection (UTI) and reddened skin. Resident 12 was diagnosed with a UTI with pseudomonas aeruginosa and cellulitis (a bacterial skin infection.) The NP ordered Resident 12 to be placed in contact isolation precautions as the infection can spread through direct contact with contaminated surfaces or hands. An observation on 8/3/2025 at 8:02 revealed Nurse Aide (NA) - E answered Resident 12's call light. NA-E had entered the room partially with the sit-to-stand lift. NA-E had not donned any Personal Protective Equipment (PPE) of a gown or gloves prior to entering the room. Resident 12 stated they didn't need to go to the restroom at this time but needed a refill of water. NA-E received Resident 12's cup from them and exited the room. NA-E did not disinfect the sit-to-stand lift after entrance of the resident's room. NA-E shortly returned with more water for Resident 12 per their request. NA-E had not donned a gown or gloves prior to entering Resident 12's room. Hand hygiene of an Alcohol Based Hand Rub (ABHR) was used by NA-E only after exiting Resident 12's room for the final time. An interview on 8/6/2025 at 4:10 PM with the Chief Nursing Officer (CNO) revealed the facility does not don gown or gloves every time staff enter Resident 12's room, only when coming in contact with their urine, as the infection was found in Resident 12's urine. B) A record review of the facility's policy Enhanced Barrier Precautions (dated 8/6/2025) revealed the purpose of implementing EBP was to reduce the transmission of multidrug-resistant organisms (MDROs) n the facility. The policy defined EBP as a set of infection prevention practices requiring gown and glove use during high-contact resident care activities for resident known or suspect to be infect with a MDRO, or at increased risk. High-contact resident care activities with a high risk of transmitting pathogens include bathing/showering, dressing, changing linens, assisting with toileting, device care, wound care, and transferring/repositioning. Additionally, the policy revealed EBP would be implemented for residents with wounds and/or invasive medical devices. A record review of the facility's undated policy Pressure Ulcer Treatment revealed equipment and supplies necessary when performing pressure ulcer treatment include the fessing, tape, normal saline, and PPE of gown, gloves, mask etc. as needed. Steps of the pressure ulcer treatment procedure were as follows:1. Check the treatment administration record and obtain necessary supplies.2. Explain the procedure, provide privacy, and position the resident for the procedure.3. Assess the resident's level of pain before wound care.4. Wash hands before treatment. 5. Apply gloves.6. Remove the soiled dressing and place in an opened plastic bag. Remove soiled gloves and place in the bag. 7. Wash hands.8. Apply gloves.9. Clean area with normal saline and pat dry.10. Open package and remove dressing, maintaining sterility.11. Apply dressing/treatment according to the manufacturer's direction, the resident's care plan, and physician orders.12. Remove and discard gloves.13. Wash and dry hands thoroughly. A record review of the CDC's Wound Care Guide (dated 1/27/2023) revealed the following practices to prevent infection during wound care:- Prior to beginning wound care activities, clean supplies should be gathered then taken into the resident's room and placed on a clean surface away from potential sources of contamination. - Use an ABHR or wash with soap and water immediately before touching the resident, before moving from work on a soiled body site to a clean body site on the safe patient, after touch a resident or their immediate environment, immediately after glove removal, and after contact with blood, body fluids or contaminated surfaces. - During the procedure, separation should be maintained between clean and dirty supplies. For example, used bandages should be immediately discarded and not placed on a surface next to clean bandages.- Reusable equipment should be cleaned and disinfected after each use. - Any unused disposable supplies that entered the resident's care area should remain dedicated to that resident or be discarded. They should not be returned to the clean supply area. If supplies are dedicated to an individual resident, they should be properly labeled and stored in a manner to prevent cross-contamination or use on another resident, such as a designated cabinet in the resident's room. - Clean and disinfect any potentially contact mated surfaces after wound care activities are complete. These include any surfaces in close proximity to the resident and frequently touched surfaces in the resident's environment. A record review of Resident 18's admission Record revealed the facility re-admitted Resident 18 on 6/11/2025. Resident 18 had diagnoses of a stage 2 (characterized by the loss of the top two layers of skin, appearing as a shallow, open wound) pressure ulcer of their sacrum. A record review of Resident 18's Order Summary Report and Care Plan revealed no evidence EBP had been implemented. A continuous observation on 8/6/2025 beginning at 9:57 AM of Registered Nurse (RN) - A complete wound care treatment for Resident 18 revealed the following:- RN-A had gathered the supplies and placed on a bedside table next to the nurse's station. RN-A then pushed the bedside table down the hall without protection covering the supplies to Resident 18's room.- RN-A entered Resident 18's room and washed their hands, without donning any proper PPE. - After positioning and providing privacy, RN-A utilized ABHR. RN-A then placed a trash bag down on the resident's bed and donned gloves. RN-A then used both gloved hands to move the bedside table into a better position, contaminating their gloves.- RN-A then pushed Resident 18's incontinence brief further down with their gloved hands. RN-A then used their gloved hands to remove the old dressing. RN-A removed their gloves.- RN-A applied new gloves without the benefit of performing hand hygiene prior. Using the gauze with normal saline, RN-A cleansed the wound beginning at the area surrounding the wound working their way to the middle of the wound. The same gauze pad was utilized for the entire cleansing of the wound. - RN-A removed soiled gloves, applied ABHR, and applied new gloves. RN-A opened the Alginate with their gloved hands, cutting the packet open. RN-A opened the skin prep and dressing packages that had been exposed to potential contamination when brought down the hallway, contaminating their gloves. RN-A applied the skin prep around the edge of the wound, applied the Alginate, and then the dressing with the same gloved hands. An interview on 8/6/2025 at 10:10 AM with RN-A confirmed EBP had not been implemented for Resident 18. RN-A was unaware of the contamination during the wound care treatment procedure. C. A record review of the facility's undated policy Handwashing/Hand Hygiene revealed hand hygiene should be completed with an ABHR or soap and water in the following situations:- Before and after coming on duty- Before and after direct contact with residents- Before preparing or handling medications- Before donning gloves- After contact with objects in the immediate vicinity of the resident A continuous observation on 8/5/2025 beginning at 8:27AM of Mediation Aide (MA) - B revealed the following:- At 8:25 AM, MA-B had completed medication administration to a previous resident. At 8:27 AM, MA-B began preparing Resident 3's medication without the benefit of performing hand hygiene. MA-B did not sanitize the medication cart preparation surface prior to beginning. - MA-B used scissors to cut Resident 3's lidocaine patches in half. MA-B then utilized the scissors to cut open Resident 3's arginaid packet without sanitization of the scissors beforehand. - MA-B prepared Resident 3's medication, dispensing Resident 3's tums into a separate medication cup and the remainder into another. MA-B then sat the other medication cup on top of the medication cup with the Tums, touching the bottom of the medication cup to the Tums. - MA-B then applied gloves and proceeded to Resident 3's door, using their gloved hands to open the door. MA-B then assisted Resident 3 with applying their medicated cream to their hip as ordered with the same gloved hands.
Jun 2025 8 deficiencies 1 IJ (1 affecting multiple)
CRITICAL (K) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0725 (Tag F0725)

Someone could have died · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.04 Based on observations, record review, and interview; the facility failed to have su...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.04 Based on observations, record review, and interview; the facility failed to have sufficient staff on duty to prevent the potential for serious harm or injury while performing transfers via Hoyer or sit-to-stand mechanical lifts, this had the potential to affect 11 (Residents 1, 4, 6, 9, 10, 11, 12, 13, 14, 15, and 16) of 11 residents sampled. The facility failed to have sufficient staff on duty to ensure residents receive assistance with their Activities of Daily Living per their plan of care for 6 (Resident 1,2,3,4,12,and 19). The total survey sample was 19. The facility identified a census of 36. The facility administrator was notified on 6/7/2025 at 9:20 PM of an Immediate Jeopardy (IJ) which began on 5/5/2025. The IJ was removed on 6/7/2025, as confirmed by surveyor onsite verification. Findings Are: A record review of a facility provided document SCARAB (Skyview Care and Rehab at Bridgeport) Facility Assessment- 2025 dated 6/4/2025 revealed under the staffing plan section, Our facility houses residents in four different halls (100, 200, 300, and 400 hall). Staffing is based on resident population and the residents' needs for care and support. Our census is reviewed daily with our staff schedule in our morning meeting with management and again in the nursing department morning meeting. We adjust the staffing plan as needed when we have a change in the census or for call-offs or new admissions. We monitor staff hours and census on a daily basis. A. A record review of the facility policy Lifting Machine, Using a Mechanical with revision date of July 2017 revealed in the General Guidelines that at least two nursing assistants are needed to safely move a resident with a mechanical lift. The policy also revealed that the types of lifts that may be available in the facility are a floor-based full body sling lift, an overhead full body sling lift, and a sit to stand lift. A record review of the facility provided Resident List dated 6/7/25 revealed Residents 4, 9, 10, 14, and 16 were marked as utilizing a Hoyer lift. The list also revealed Residents 1, 6, 11, 12, 13, and 15 were marked as utilizing a Sit to Stand Lift. B. A record review of Resident 1'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 4/9/2025 revealed the resident required substantial/maximal assistance from staff for transfers. A record review of Resident 1's undated Care Plan (a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) revealed the resident required two-person assistance with the sit to stand for transfers. If Resident 1 was unable to stand, the care plan stated to use the total lift with two people. This was initiated on 3/10/2025. C. A record review of Resident 4's MDS dated [DATE] revealed the resident was dependent on staff for transfers. A record review of Resident 4's undated Care Plan revealed the resident required two-person assistance with the total lift for transfers. This was initiated on 5/1/2025. D. A record review of Resident 6's MDS dated [DATE] revealed the resident required substantial/maximal assistance with transfers. A record review of Resident 6's undated Care Plan revealed the resident required one-person assistance with the sit-to-stand lift when transferring in/out of bed and to/from the toilet. The care plan stated to use two-person assistance as needed for increased weakness or if the resident was unable to follow instructions. This was initiated on 8/7/2019 and revised on 4/21/2024. E. A record review of Resident 9's MDS dated [DATE] revealed the resident was dependent on staff for transfers. A record review of Resident 9's undated Care Plan revealed the resident required two-person assistance with the total lift for transfers. This was initiated on 4/30/2021. F. A record review of Resident 10's MDS dated [DATE] revealed the resident required substantial/maximal assistance with transfers. A record review of Resident 10's undated Care Plan revealed the resident required a 2-person pivot transfer with gait belt. The care plan also stated to use the total lift with 2 people if the resident was unable to stand, too tired or weak. This was initiated on 1/23/2025. G. A record review of Resident 11's MDS dated [DATE] revealed the resident was dependent on staff for transfers. A record review of Resident 11's undated Care Plan revealed the resident required two-person assistance with the sit-to-stand lift for transfers. This was initiated on 5/30/2025. H. A record review of Resident 12's MDS dated [DATE] revealed the resident required substantial/maximal assistance with transfers. A record review of Resident 12's undated Care Plan revealed the resident required substantial assistance by 2-person pivot transfer with a gait belt. The care plan also stated the resident would occasionally be agreeable to use a sit to stand lift. This was initiated on 10/26/2023 and revised on 1/31/2025. I. A record review of Resident 13's MDS dated [DATE] revealed the resident required substantial/maximal assistance with transfers. A record review of Resident 13's undated Care Plan revealed the resident required two-person assistance with stand/pivots with a gait belt to move between surfaces and as necessary. This was initiated on 7/15/2024. I. A record review of Resident 14's MDS dated [DATE] revealed the resident was dependent on staff for transfers. A record review of Resident 14's undated Care Plan revealed the resident required 2-person assistance with a Hoyer lift for transfers. This was initiated on 10/31/2020 and revised on 4/21/2024. J. A record review of Resident 15's MDS dated [DATE] revealed the resident was dependent on staff for transfers. A record review of Resident 15's undated Care Plan revealed the resident required 1-person assistance with transfers PRN (as needed). This was initiated on 7/2/2019 and revised on 5/5/2021. K. A record review of Resident 16's MDS dated [DATE] revealed the resident was dependent on staff for transfers. A record review of Resident 16's undated Care Plan revealed the resident required 2-person assistance for transfers with the use of the total lift. This was initiated on 1/21/2025. An interview on 6/7/25 at 6:30 PM with the Director of Nursing (DON) revealed one of the Nurse Aides (NA) working that evening was a minor and unable to utilize the mechanical lifts to transfer residents. The DON further reported the DON and this minor NA were the only staff scheduled to work the following evening from 2 pm until 10 pm. An interview on 6/7/25 at 6:50 PM with Medication Aide (MA)-H revealed MA-H had worked the past 7 days straight in an attempt to assist with the staffing shortage. MA-H stated that there were 30-some residents in the facility and normally 2-3 staff on duty would be sufficient but there were several residents that were high acuity (requiring significant staff assistance) so the current staffing levels were not enough to provide resident cares. MA-H stated that the evening prior, the staffing was the DON, the MA, and one NA. MA-H stated that there were 3 or 4 residents who required the Hoyer lift for transfers and there were several who utilized the sit-to-stand lift, but some of those residents really needed two staff present due to the residents chicken-winging (a situation where the resident's arms extend out to the side during the transfer, increasing the risk of the resident falling out of the lift sling). MA-H revealed that staff frequently transferred residents with the mechanical lifts alone because otherwise the residents would not get cares due to there not being enough staff on duty. MA-H also revealed that they had recently been told by facility management that it was now okay to use the sit-to-stand lifts alone, although this had not previously been an approved practice. An interview on 6/7/25 at 7:55 PM with Resident 4 revealed there were usually two staff to transfer the resident with the Hoyer lift, but not always. Resident 4 stated that occasionally there was only one staff present during the transfers. Resident 4 stated they felt kind of scared because everyone was leaving and that it was 24 hours a day that there had been less staff on duty than usual. An interview on 6/7/25 at 8:53 PM with MA-H confirmed that the staff had been utilizing the mechanical lifts without a second staff present while transferring the residents and that this had been occurring on a daily basis due to lack of staff on duty. MA-H stated they witnessed a staff completing a resident transfer via a mechanical lift without a second staff in the room the evening prior when MA-H entered the resident room to administer medications to the resident. An interview on 6/9/25 at 10:21 AM with Resident 12 revealed Resident 12 had resided in the facility for almost two years and utilized a sit-to-stand lift for transfers. Resident 12 stated that a lot of the time there was only one staff present in their room during the transfers because they are so short staffed here. An interview on 6/9/25 at 2:25 PM with NA-J revealed they had been working in the facility since about January of this year. NA-J confirmed that staff were supposed to have two staff present when transferring residents with the mechanical lifts. NA-J revealed that they had asked the therapy staff for assistance with transferring a resident with the sit-to-stand lift recently and the therapy staff stated that per state, you don't have to have two staff present, so NA-J did transfer the resident by themself. NA-J stated there have been many shifts with only one or two staff working on the floor and that staff rarely works just 8 hours because there is not enough staff and even after the staff gets off the floor, then they have to go back and do their charting. An interview on 6/11/25 at 9:26 AM with Resident 12 revealed that they had been getting transferred via the sit-to-stand lift with only one staff present for quite a while. Resident 12 stated, It's been so long I really couldn't tell you when it started. An interview on 6/11/25 at 10:57 AM with NA-I revealed the NA had been working in the facility for about 3 years. NA-I stated they were supposed to be on light duty but had been utilizing both the Hoyer and sit-to-stand lifts alone despite being on light duty because there was not ever enough staff on duty to use two people. NA-I stated it had been this way, due to lack of staff availability, since approximately January 2025. L. A record review of the facility policy Activities of Daily Living (ADL), Supporting with a revision date of March 2018 revealed that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. An interview on 6/7/25 at 10:14 PM with NA-L and NA-M revealed both NA's worked the night shift. NA-M stated that three nights earlier, it was after midnight before the staff finished getting the residents into bed for the night due to the lack of staff that had been available to provide cares for the residents on the evening shift. A record review of Resident 1's MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 4/15, indicating severe cognitive impairment. The MDS also revealed the resident required partial/moderate to substantial/maximal assistance from staff for their oral, toileting, and personal hygiene. The resident also required substantial/maximal assistance for their shower/bathing needs. A record review of Resident 1's undated Care Plan revealed the resident required 1-person staff assistance with their bathing/showering, dressing, personal hygiene, and toilet use. M. A record review of facility provided document for Resident 1 titled POC Response History Task: ADL- Bathing Schedule and dated 6/10/25 with a 30 day look back period revealed that staff had documented on 5/14/25, 5/17/25, 5/21/25, 5/28/25, and 5/31/25 Not applicable, and on 5/24/25 Resident Refused. There was no other documentation. A record review of the facility document for Resident 1 titled The Spa at Skyview Bathing Schedule from 5/8/25 through 6/9/25 revealed the resident was scheduled to receive showers every Tuesday, Thursday, and Saturday. The documentation revealed the resident received a shower on 5/8/25, 5/27/25 and 6/3/25. An observation on 6/7/25 beginning after 6:00 PM revealed Resident 1 sitting in the dining room in their wheelchair asking for assistance as people walk past. Resident 1 remained sitting in their wheelchair and slowly wheeled self from inside the dining room out into the hallway outside the dining room. Resident 1 intermittently asked this surveyor to help them, and stated they wanted to go to bed, surveyor informed resident several times that someone would be along to help them soon. At 7:47 PM Resident 1 was observed telling the administrator that they wanted to go to bed. The administrator told the resident that the next NA they saw, the administrator would have them help the resident. At 8:11 PM, Resident 1 again asked this surveyor to help them to their bed. Administrator heard this and told the resident they would find someone to help. At 8:28 PM, Resident 1 had been taken to their room. Observations conducted on 6/9/25 of Resident 1 revealed the following: -At 9:20 AM Resident 1 was sitting in their wheelchair at a table in the dining room. -At 9:40 AM Resident 1 continued sitting at a table in the dining room but now had food in front of them. -At 10:05 AM Resident 1 remained at the dining room table. The resident had backed their wheelchair about a foot away from the table and they were not eating or drinking. -At 10:52 AM Resident 1 was sitting in the dining room, about 2 feet away from the table. The resident had their eyes closed and their chin was resting on their chest. -At 11:05 AM Resident 1 remained in the same position in the dining room. -At 11:27 AM Resident 1 remained in the same position in the dining room. -At 11:45 AM Resident 1 remained in the same position in the dining room. -At 11:53 AM staff approached Resident 1 and asked the resident if they wanted to scoot closer to the table. Resident 1 declined so then the staff handed the resident a cup of juice, which the resident began drinking. Resident 1 remained in the same position in their wheelchair. -At 11:55 AM the Chief Nursing Officer (CNO) moved Resident 1's wheelchair so the resident was facing their table. -At 12:45 PM Resident 1 remained in the dining room. -At 12:54 PM Resident 1 remained in the dining room. An interview on 6/9/25 at 12:54 PM with the DON confirmed Resident 1 had been in the dining room since the surveyor's arrival just after 9:00 AM. The DON also asked NA-I if anyone had assisted Resident 1 to the toilet during that timeframe and the NA stated, not that I know of. N. A record review of Resident 2's MDS dated [DATE] revealed the resident had a BIMS score of 14/15 indicating they were cognitively intact. The MDS also revealed the resident required partial/moderate assistance with shower/bathing and with toileting hygiene. A record review of Resident 2's undated Care Plan revealed the resident required the assistance of 1 person with bathing showering and with toileting use. An interview on 6/7/25 at 6:50 PM with MA-H revealed that Resident 2 had reported the evening prior that they were going to wash their hair in the sink because they had not been bathed in two weeks. An interview on 6/7/25 at 7:04 PM with Resident 2 revealed the resident had not been bathed in two weeks. Resident 2 stated there was one day they did not get bathed because there was no hot water, but otherwise it had been due to there not being staff available to complete bathing. Resident 2 also revealed they needed staff assistance with wiping their bottom after they used the toilet, and they sometimes had to wait 30 minutes or more for staff to come assist with this task. An interview on 6/11/25 at 9:52 AM with Resident 2 revealed the resident had been getting bathed routinely prior to the past two weeks when they did not receive any baths. Resident 2 stated they were scheduled to receive their baths every Wednesday and Friday, which they did not like because this meant they had one day between baths and then had to go several days until the next bath. A record review of facility provided document for Resident 2 titled POC Response History Task: ADL- Bathing Schedule and dated 6/10/25 with a 30 day look back period revealed that staff had documented on 5/21/25 Shower, and on 5/22/25 and 5/25/25 Not applicable. There was no other documentation. A record review of the facility document for Resident 2 titled The Spa at Skyview Bathing Schedule from 5/5/25 through 6/9/25 revealed Resident 2 was scheduled to receive a shower every Wednesday and Friday. The documentation revealed the resident received shower on 5/28/25 and 6/8/25. O. A record review of Resident 3's MDS dated [DATE] revealed the resident had a BIMS score of 14/15 indicating the resident was cognitively intact. The MDS also revealed the resident required partial/moderate assistance from staff for wheeling 150 feet and for shower/bathing. A record review of Resident 3's undated Care Plan revealed staff were to encourage physical activity and daily ambulation, and that resident was to use assistive device if necessary. The care plan also revealed the resident had the potential for ADL self-care performance deficit r/t fatigue, impaired balance, and pain to lower back, right hip, and right knee. The resident required assistance of 1 person for bathing/showering. An interview on 6/7/25 at 7:12 PM with Resident 3 revealed that the prior week had been their third week living in the facility and that there had been several staff who had resigned since they were admitted to the facility. Resident 3 stated they felt like it's a crisis due to the facility being low on help. The resident also stated it had been about two weeks since they had been assisted with bathing, so they had just been doing sponge baths on their own in their room. Resident 3 stated that they needed assistance wheeling back to their room in their wheelchair after meals due to their arthritis. Resident 3 also stated that the evening prior, they had to wheel back to their room independently because there was no staff available, and the resident had been having pain to their right hip and leg ever since. A record review of facility provided document for Resident 3 titled POC Response History Task: ADL- Bathing Schedule and dated 6/10/25 with a 30 day look back period revealed no showers had been documented for the resident since their admission. A record review of the facility document for Resident 3 titled The Spa at Skyview Bathing Schedule from 5/5 through 6/9 revealed the resident had not been added to the bathing schedule but that the resident had received a shower on 5/17/25 (date of admission), 5/28/25, 5/31/25, and on 6/8/25. P. A record review of Resident 4's MDS dated [DATE] revealed the resident had a BIMS score of 15/15 indicating the resident was cognitively intact. The MDS also revealed the resident was dependent on staff for shower/bathing and toileting. A record review of Resident 4's undated Care Plan revealed the resident required 1-person assistance with bathing/showering and that for toileting, the resident did not have the core strength to sit up on the toilet or commode, so resident needed to be transferred to their bed for peri-cares to be performed. An interview on 6/7/25 at 7:55 PM with Resident 4 revealed that it was either last week or the week before that since their last bath but the facility staff had not shared a reason for this. A record review of facility provided document for Resident 4 titled POC Response History Task: ADL- Bathing Schedule and dated 6/10/25 with a 30 day look back period, revealed that staff had documented on 5/30/25 that the resident had refused their shower that day. There was no other documentation. A record review of the facility document for Resident 4 titled The Spa at Skyview Bathing Schedule from 5/5/25 through 6/9/25 revealed Resident 4 was scheduled to receive a shower every Monday and Friday. The documentation revealed that the resident received a shower on 5/12/25 and 6/9/25. Q. A record review of Resident 12's MDS dated [DATE] revealed the resident had a BIMS score of 15/15 indicating the resident was cognitively intact. The MDS also revealed the resident required substantial/maximal assistance with shower/bathing and was dependent on staff for toileting hygiene. A record review of Resident 12's undated Care Plan revealed the resident required substantial assistance by one staff with bathing schedule and as necessary. The Care Plan also revealed the resident required substantial assistance of two staff with the sit-to-stand for toileting. An interview on 6/9/25 at 10:21 AM with Resident 12 revealed Resident 12 had resided in the facility for almost two years and utilized a sit-to-stand lift for transfers. Resident 12 stated that the prior week they had to wait for two hours before staff was able to take them to the bathroom. Resident 12 also revealed that they were supposed to get three showers a week but that they were lucky if they even got one. The resident stated that 9 days was the longest they have had to go without a shower and that this had happened within the last two months. An interview on 6/11/25 at 9:26 AM with Resident 12 revealed that it was about a month ago when they stopped getting bathed 3 times a week like they preferred. A record review of facility provided document for Resident 12 titled POC Response History Task: ADL- Bathing Schedule and dated 6/10/25 with a 30 day look back period revealed that staff had documented on 5/16/25 and 5/23/25 Not Applicable, and on 5/21/25, 5/26/25, and 5/30/25 Shower. There was no other documentation. A record review of the facility document for Resident 12 titled The Spa at Skyview Bathing Schedule from 5/5/25 through 6/9/25 revealed Resident 12 was scheduled to receive a shower every Monday, Wednesday, and Friday. The documentation revealed that the resident received a shower on 5/5/25, 5/9/25, 5/12/25, 5/26/25, 5/28/25, 6/3/25, and 6/9/25. R. A record review of Resident 19's MDS dated [DATE] revealed the resident had a BIMS score of 10/15 indicating the resident had moderate cognitive impairment. The MDS also revealed the resident was dependent on staff for their shower/bathing. A record review of Resident 19's undated Care Plan revealed the resident required 1-person assistance with bathing/showering. An interview on 6/11/25 at 10:18 AM with Resident 19 revealed the resident was supposed to get three baths a week but lately it had been pretty hit and miss. Resident 19 stated that it varied, sometimes they would get one or more baths a week and sometimes it would stretch into two weeks. Resident 19 stated that they couldn't say when this started, it was pretty much when the staff started quitting but the resident stated they could not really say how long ago that was either. A record review of facility provided document for Resident 19 titled POC Response History Task: ADL- Bathing Schedule and dated 6/11/25 with a 30 day look back period revealed that staff had documented on 5/16/25 and 5/19/25 not applicable. Staff had also documented Shower on 5/14/25, 5/23/25, 5/24/25, 5/28/25, 5/30/25, 6/4/25, 6/6/25, and 6/9/25. A record review of the facility document for Resident 19 titled The Spa at Skyview Bathing Schedule from 5/5/25 through 6/9/25 revealed Resident 19 was scheduled to receive a shower every Monday, Wednesday, and Friday. The documentation revealed that the resident received a shower on 5/9/25, 5/14/25, 5/16/25, 5/26/25, 5/30/25, 5/31/25, 6/4/25, and 6/9/25. An interview on 6/11/25 at 11:24 AM with the DON confirmed baths should be given to the residents at least once a week unless the resident wanted them more frequently. The DON revealed that the facility did not currently have a working bathtub and that there had not been a functional bathtub since prior to their date of hire which was 1/6/25, so all of the residents have had to take showers. An interview on 6/11/25 at 11:45 AM with the CNO revealed baths are given per resident preferences, which are established upon admission but were also reestablished as part of the facility's plan of correction following their recent survey. The CNO stated they went around to all residents and asked what they preferred, and the bathing schedule was developed based on this information. S. -Abatement Statement Correction to the resident(s) affected: All residents have been assisted to bed and adequate care provided. Specify how the immediacy of the deficient practice will be corrected for the residents identified and all residents at risk for the deficient practice. Integrated Staffing Solutions (ISS) Staffing will be utilized immediately; and within 24 hours. Staffing with all available personnel will be utilized. System Changes: The facility will have all available certified and licensed staff available, including members of the interdisciplinary team available to respond to residents to ensure needs are met. In-services will be completed by DON/NHA on staffing and resident care for staff present in facility and for remaining staff before their next shift. In-services will be completed by DON/NHA that all mechanical lifts must be operated by two (2) staff members and that staff under age [AGE] cannot operate a mechanical lift independently for staff present in facility and for remaining staff before their next shift. In-services will be completed by DON/NHA that staff should notify the director of nursing (DON) or the nursing home administrator (NHA) for staff present in facility and for remaining staff before their next shift. Monitoring: NHA will monitor pending staffing daily to ensure staffing is adequate for upcoming shifts. If staffing is not adequate, staff will be notified and asked to cover shifts. At the time of the survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level.
SERIOUS (H) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected multiple residents

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1) Licensure Reference Number 175 NAC 12-006.09(H)(iii)(2) Based on record review and interviews, the facility failed to ensure 1 (Resident 4) did...

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Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1) Licensure Reference Number 175 NAC 12-006.09(H)(iii)(2) Based on record review and interviews, the facility failed to ensure 1 (Resident 4) did not develop pressure ulcers (also known as bed sores, areas of damaged skin caused by staying in one position for too long, commonly formed under boney prominence's) that were unavoidable and failed to provide monitoring, treatment and care as ordered to promote healing for 3 (Residents 4, 6, and 18) of 3 sampled residents' pressure ulcers. The facility identified a census of 36. Findings are: A record review of an undated facility policy Pressure Ulcer Risk Assessment, revealed if pressure ulcers are not treated immediately upon discovery, they can quickly get larger and become very painful and infected for the resident. Pressure ulcers are a serious condition for the resident and once developed, can be extremely difficulty to heal. Resident's skin should be routinely assessed and the condition of the resident's skin documented per the following: -A pressure ulcer risk assessment will be completed upon admission, quarterly, annually, and with any significant changes. -Because a resident at-risk can develop a pressure ulcer within 2-6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. -Nurses will conduct skin assessments at least weekly to identify changes and for any presence of developing pressure ulcers. -Documentation of the skin assessment should be recorded in the resident's medical record and include date and time and size and location of any red or tender areas. A record review of an undated facility policy Pressure Ulcer Treatment revealed pressure ulcer treatment should focus on assessing the resident and the pressure ulcer(s), managing tissue loads, pressure ulcer care, managing infection, education and quality improvement. The policy also revealed documentation should include the following in the resident's medical record after pressure ulcer care: assessment of the wound (color, size, pain, drainage) and resident refusal of treatment. If a resident refuses care, an evaluation of the basis for refusal and the identification and evaluation of potential alternatives is indicated. A. A record review of an admission Record revealed the facility re-admitted Resident 4 to the facility on 4/23/2025. Resident 4 had diagnoses of Multiple Sclerosis (MS, a disease where the body's immune system mistakenly attacks the protective covering of nerve fibers in the brain and spinal cord that can cause muscles weakness, trouble walking, numbness, and difficulty with controlling bowel and bladder), chronic obstructive pulmonary disease (COPD, a condition caused by damage to the airways or other parts of the lung), nicotine dependence, generalized muscle weakness, and legal blindness. A record review of Resident 4's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) with an Assessment Reference Date (ARD) 4/30/2025 revealed Resident 4 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15/15, which indicated Resident 4 was cognitively intact. In Section E regarding behavior, the MDS reflected that Resident 4 had not displayed any rejection of care. Additionally, the MDS revealed Resident 4 had no upper or lower extremity impairment and required maximal assistance for bed mobility and total dependence for toileting, bathing, and transfers. Resident 4 was frequently incontinent of urine and always incontinent of bowel. Furthermore, the MDS revealed Resident 4 was at-risk for developing pressure ulcer but had 0 pressure ulcers, wounds or other skin problems at the time of assessment. Resident 4 did have a pressure reducing device for their chair and orders for application or ointment/medications. A record review of Resident 4's Care Plan with a date of 5/1/2025 revealed Resident 4 required assistance with toileting. Resident 4 had no core strength to sit on the toilet or bedside commode so required to be transferred into their bed for incontinence care. Additional review of Resident 4's Care Plan revealed no focus care area regarding skin integrity or addressing Resident 4's risk for pressure ulcers with preventative interventions. A record review of Resident 4's Progress Notes from 4/23/2025 at 8:49 PM revealed Resident 4 had a 4-centimeter (cm) x 6 cm area of redness on the left groin and mild, generalized redness across their back. There was no evidence if the redness was blanchable (When a skin area blanches, it means the redness or color disappears when you press on it, leaving the skin appearing lighter. If an area of skin doesn't blanch when pressed, it could indicate a more serious condition like a pressure ulcer, non-blanching rash, or other skin damage.) A record review of Resident 4's Weekly Skin Assessment - V 2 with a date of 4/23/2025 revealed Resident 4 had redness on their left groin, diffuse redness across their back with skin intact and had no open areas. A record review of Resident 4's Weekly Skin Assessment - V 2 with a date of 4/30/2025 revealed Resident 4's skin was pink, dry, and intact without skin issues present. A record review of Resident 4's Weekly Skin Assessment - V 2 with a date of 5/6/2025 revealed Resident 4's skin was warm, dry, and intact, with no skin issues present. A record review of Resident 4's Weekly Skin Assessment - V 2 with a date of 5/13/2025 revealed Resident 4's was warm, dry, and intact with a 1 cm open area on their coccyx. There was no evidence the provider had been notified or interventions placed to prevent worsening of the area. A record review of Resident 4's Nursing Home Visit Note with Medical Provider (MP)-B from 5/15/2025 revealed Resident 4 had a sacral wound. Facility staff had reported to MP-B the sacral wound was present upon admission,however, MP-B noted the sacral wound was listed as resolved on the documentation from the discharging rehabilitation facility. MP-B placed orders to continue wound care, ensure Resident 4 had appropriate padding in their chair, frequently reposition as Resident 4 allowed, and update MP-B on wound progress every week. A record review of Resident 4's Progress Notes from 5/13/2025-5/27/2025 revealed no evidence of monitoring of Resident 4's pressure ulcer on their coccyx. The Progress Notes did reveal the following: -A note on 5/19/2025 at 3:16 AM revealed the dressing was clean, dry, and intact and staff were assisting Resident 4 with repositioning every 2 hours. -A note on 5/20/2025 at 5:36 AM revealed Resident 4 was being assisted with repositioning every 2-3 hours due to their pressure ulcer on their buttock. The dressing remained clean, dry, and intact. A record review of Resident 4's Weekly Skin Assessments V 2 revealed no evidence a weekly skin assessment had been completed for the week of 5/20/2025 or monitoring of Resident 4's pressure ulcer had been completed. A record review of Resident 4's Weekly Skin Assessment - V 2 with a date of 5/27/2025 revealed Resident 4's pressure ulcer on their sacrum was staged as a Stage 2 (partial-thickness skin loss involving the dermis, or middle layer of skin) with measurements of 1.0 cm x 1.0 cm. Another pressure ulcer was identified on Resident 4's left gluteal fold with measurements of 2.0 cm x 1.8 cm. And two areas of Moisture Associated Skin Damage (MASD) were also identified on both sides of Resident 4's buttocks. There was no evidence MP-B had been notified of the new pressure ulcer area or what interventions had been implemented to prevent worsening of the area. A record review of Resident 4's Progress Notes from 6/1/2025-6/4/2025 revealed the following: -On 6/1/2025 at 5:29 AM, Resident 4's dressing to their buttocks was changed with treatment and cleansing to the wound. There were no signs of infection. -On 6/1/2025 at 10:20 AM revealed Resident 4 had a pressure area that was blanchable that measured 3.5 cm x 4 cm on their right ischial tuberosity area of where the weight of the body rests when sitting, also known as the sit bone.) MP-B was notified via fax. -A late entry for 6/2/2025 at 11:04 AM was placed and revealed Resident 4 had two open wounds. The first wound on Resident 4's sacrum measured 2 cm x 0.5 cm x 1 cm and was staged as a Stage 3 (full-thickness skin loss where fat may be visible) Pressure Ulcer. The second wound on Resident 4's left gluteal area measured 6 cm x 4 cm x 1 cm and was also staged as a Stage 3 Pressure Ulcer. A call had been placed to MP-B's office to confirm the fax from 6/1/2025 had been received. -On 6/4/2025, a verbal reply confirming the fax sent was received by MP-B and approval for a wound clinic evaluation was obtained. A record review of Resident 4's TAR for June 2025 revealed the following: -An order to complete a skin assessment and document findings in a 'Weekly Skin Assessment - V 2 every Tuesday for skin integrity with a start date of 6/11/2024 had not been completed on 6/3/2025. -An order for Resident 4's wound dressing change once a day to cover with calmoseptine and ensure the area is not coming in contact with urine with a start date of 5/9/2025 had not completed on 6/2/2025 or 6/3/2025. A record review of an Evaluation of Clinically Unavoidable Pressure Injury with a faxed to the provider date of 6/5/2025, revealed interventions for Resident 4 prior to the development or worsening of a pressure injury included repositioning and pressure redistribution of chair cushion. Additionally, it revealed Resident 4 had clinical conditions or diagnoses that were primary risk factor for the development or worsening of pressure injuries of immobility, refusal of treatments, incontinence of bowel and/or bladder, COPD, Multiple Sclerosis, edema, history of pressure ulcers, and quadriplegia/hemiplegia/hemiparesis. The form was signed by MP-B on 6/5/2025. A follow-up interview on 6/9/2025 at 12:28 PM with the Chief Nursing Officer of the Hospital (CNOH) where Resident 4 received care revealed the CNOH had spoken with MP-B and MP-B had been informed by facility staff that Resident 4 had returned to the facility with the sacral wound, which would have made it unavoidable. MP-B was not aware Resident 4's sacral wound was not present upon re-admission to the facility and then developed within the facility. An interview on 6/4/2025 at 10:55 AM with Registered Nurse (RN) - C confirmed Resident 4 had no pressure ulcer present upon admission, but due to lack of staffing they are unable to keep up with the care and Resident 4 now has two Stage 3 Pressure Ulcers as a result. An interview on 6/4/2025 at 2:30 PM with the Director of Nursing (DON) confirmed Resident 4 had two pressure ulcer, both currently Stage 3, one on their sacrum/coccyx and one on their left gluteal fold/ischial tuberosity and that the facility's documentation confirmed Resident 4's pressure ulcers were not present upon re-admission to the facility, but had developed while in the facility and that the areas had not improved but were worsening. Additionally, the DON confirmed the facility had no evidence Resident 4's sacral wound condition/progress was monitored between 5/14/2025-5/26/2025 (13 days) or that Resident 4's wound dressing was completed on 5/28/2025, 6/2/2025, or 6/3/2025 as ordered at the time of the interview. An interview on 6/4/2025 at 2:33 PM with the facility's Chief Nursing Officer (CNO) revealed the following: -The CNO revealed the facility's process for monitoring wounds is to complete a weekly skin assessment and to notify the provider of any new wounds to obtain a new order. The provider can be notified through fax when initially discovered and staff should follow up by 8:00 AM the following day if no response. If there continues to be no response after 72 hours, management should be notified. At the time of the interview, the CNO confirmed the facility had no evidence MP-B had responded to the facility's fax from 6/1/2025 or follow up had been attempted between 6/2/2025 and 6/4/2025. At this time, the CNO asked the DON to contact the responsible nurse to log on to the electronic health record system remotely and chart a late entry. -At the time of the interview, the facility also had no evidence MP-B had been updated weekly of Resident 4's pressure ulcer progress as ordered on 5/15/2025. -The CNO confirmed Resident 4's Care Plan had no focus area regarding Resident 4 being at-risk for Pressure Ulcer or interventions to prevent pressure ulcers from developing had been developed or implemented and should have been at the time of the Care Plan development. - The CNO also confirmed Resident 4's Care Plan had not been revised or updated a focus area and interventions after Resident 4's development of Pressure Ulcers and should have been. -Initial interventions that had been put in place prior to the development of Resident 4's pressure ulcers were to place a different cushion in Resident 4's tilt and space wheelchair and heel protectors on their heels when in bed. -The facility's interventions for Resident 4's sacral pressure ulcer included to reposition Resident 4 when in bed and encourage position change when in their wheelchair, as well as a wheelchair cushion. B. A record review of an admission Record indicated the facility admitted Resident 18 on 5/21/2025 with diagnoses of generalized muscle weakness and a pressure ulcer on their sacrum, without a specified stage. A record review of Resident 18's admission MDS with an ARD of 5/28/2025 revealed Resident 18 had a BIMS score of 11/15, which indicated Resident 18 had moderate cognitive impairment. Additionally, it revealed Resident 18 utilized a walker and had no extremity impairment. Resident 18 required partial assistance with bathing and supervision for toileting, bed mobility, and transfers. Under Section H regarding bowel and bladder, the MDS revealed Resident 18 was frequently incontinent of urine and was always continent of bowel. Under Section M regarding skin conditions, the MDS revealed Resident 18 was at-risk for developing pressure ulcers and had one Stage 3 pressure ulcer present. Interventions were a pressure reducing device for chair, repositioning, nutrition and/or hydration intervention, pressure ulcer care, and applications of ointments/medications to affected area. A record review of Resident 18's Care Plan revealed a focus care area regarding pressure injuries with a last reviewed date of 5/23/2025. The area revealed Resident 18 was admitted with a Stage 3 pressure ulcer to their sacrum with the following interventions: -Administer treatments as ordered and monitor for effectiveness. -Assess, record, monitor wound healing with cares weekly. Measure length, width, depth where possible. Assess and document the status of the wound perimeter, wound bed, and healing progress. Report to the physician. -Monitor, document, and report as needed any changes in skin status of appearance, color, wound healing, signs of infection, wound size, and stage. -Weekly treatment documentation to include measurements of each area of skin breakdown's width, length, depth, and type of tissue and drainage. -Follow facility policies/protocols for the prevention/treatment of skin breakdown. A record review of Resident 18's Order Summary Report with an active orders date of 6/10/2025 revealed the following orders: -Complete a skin assessment and document findings in a 'Weekly Skin Assessment - V 2 every Thursday on day shift with a start date of 5/22/2025. -Cleanse sacral pressure ulcer with wound cleaner, apply A&D ointment, and cover with a foam dressing daily for wound care of the sacral pressure ulcer with a start date of 5/22/2025. A record review of Resident 18's Medication Administration Record/Treatment Administration Record (MAR/TAR) from May 2025 revealed Resident 18's order for wound care of the sacral pressure ulcer was not documented as completed on 5/28/2025. A record review of Resident 18's MAR/TAR for June 2025 revealed Resident 18's order for wound care of the sacral pressure ulcer was not documented as completed on 6/2/2025 or 6/3/2025. A record review of Resident 18's Weekly Skin Assessment - V2 from 5/22/2025 - 6/5/2025 revealed the following: -On 5/22/2025, Resident 18's skin was documented as dry and intact except for buttocks. Buttocks have several wounds on gluteal folds and sacrum. There was no evidence measurements of Resident 18's sacral wound had been assessed or the root cause of the wound on Resident 18's gluteal folds had been identified, or interventions had been implemented for these. -There was no evidence an assessment had been completed for 5/29/2025 as ordered. -On 6/5/2025, Resident 18's skin was documented as continuing to have a sacral wound. There was no evidence of monitoring of qualities, measurements, or progress. Additionally, there was no evidence the gluteal fold had resolved or were present. An interview on 6/10/2025 at 2:30 PM with the DON confirmed Resident 18 had a stage 3 pressure ulcer on their sacrum upon admission. The DON also confirmed the facility had no evidence of monitoring the wound's progress, measurements had been obtained, or wound care had been completed on 5/28/2025, 6/2/2025, or 6/3/2025. C. A record review of an admission Record revealed the facility admitted Resident 6 on 1/20/2017. Resident 6 had diagnoses of COPD, generalized muscle weakness,, dementia (a usually progressive condition marked by the development of multiple cognitive deficits such as memory impairment, aphasia, and the inability to plan and initiate complex behavior), and Chronic Inflammatory Demyelinating Polyneuritis (CIPD, a rare autoimmune disorder where the body's immune system attacks the myelin sheath, the protective covering of the nerves, primarily in the peripheral nervous system which can lead to progressive weakness and sensory changes in the arms and legs). A record review of Resident 6's quarterly MDS with an ARD of 5/25/2025 revealed Resident 6 had a BIMS score of 10/15, which indicated Resident 6 had moderate cognitive impairment. Additionally, the MDS revealed Resident 6 had unilateral impairment in their upper and lower extremities and utilized a wheelchair. Resident 6 was dependent on staff for toileting, bathing, and dressing. Resident 6 required substantial assistance with bed mobility and transfers. Under Section H regarding Bowel and Bladder, the MDS revealed Resident 6 had an indwelling catheter and was always incontinent of bowel. Under Section M regarding Skin Conditions, the MDS revealed Resident 6 currently had one Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) Pressure Ulcer. Interventions included a pressure reducing device for their chair and bed, repositioning, nutrition and hydration intervention, pressure ulcer care, and application of ointments/medications. A record review of Resident 6's Care Plan revealed a focus area regarding skin integrity, with a last revised date of 4/14/2025, revealed Resident 6 was at-risk for skin integrity compromise due to impaired mobility, incontinence, and occasionally moist skin folds related to obesity. Additionally, it revealed Resident 6 had a Stage 4 Pressure Ulcer to their sacrum with a wound vac (a medical device used to promote wound healing by applying controlled negative pressure to the wound bed) in place. Interventions related to the pressure ulcer included the following: -Assist in staying clean and dry by providing incontinence care as needed. -Follow facility policies/protocols for the prevention/treatment of skin breakdown. -Observe, document, and report as needed to the provider any changes in skin status of appearance, color, wound healing, signs of infection, wound size, and stage. -Weekly skin assessments, notify the provider and initiate intervention for areas of concerns. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, and type of tissue and drainage. -Low air pressure mattress on the bed. -Treatment per wound care orders from wound care provider at the hospital. -Reposition while in bed at lest every 2 hours as tolerated. -Heel protectors to both feet while resting in bed as tolerated. A record review of Resident 6's Order Summary Report with an active orders date of 6/9/2025 revealed the following orders: -Complete a skin assessment and document findings in a 'Weekly Skin Assessment - V 2' every Thursday on day shift for skin integrity with a start date of 6/13/2024. -Ensure wound vac is functioning at 125 millimeters of mercury (mmHG) every shift for wound care with a start date of 6/5/2025. -Give Arginaid (a supplement designed to support the unique nutritional needs of people with chronic wounds) twice a day for wound healing of the sacral wound with a start date of 2/1/2025. -Low flow air mattress to bed to assist with wound healing of the sacral wound with an order date of 1/31/2025. -Change wound vac dressing every 72 hours and as needed. Cleanse wound with normal saline, prep area around wound with skin prep and drape, pack wound depth with black foam and bridge to lateral trunk, not on a boney prominence, cushion tubing with foam, and anchor in place with drape for Stage 4 sacral pressure ulcer with a start date of 6/5/2025. -Zinc Sulfate 220 milligrams (mg) two times a day for wound healing with a start date of 6/6/2025. A record review of Resident 6's Medication Administration Record/Treatment Administration Record (MAR/TAR) for April 2025 revealed Resident 6's order for Arginiad twice a day for wound healing was documented as not given with a reason of Held/Other/See Progress Note on the following dates: -4/27/2025 PM, -4/28/2025 PM, -4/29/2025 AM, -4/29/2025 PM, - 4/30/2025 AM, -4/30/2025 PM. A record review of Resident 6's Progress Notes for 4/27/2025-4/30/2025 revealed Arginaid order was held or not given due to not being available. A record review of Resident 6's Medication Administration Record/Treatment Administration Record (MAR/TAR) for May 2025 revealed Resident 6's order for Arginiad twice a day for wound healing was documented as not given with a reason of Held/Other/See Progress Note on -5/27/2025 PM, - 5/29/2025 AM, -5/29/2025 PM, -5/30/2025 PM. A record review of Resident 6's Progress Notes for 5/27/2025-5/30/2025 revealed Arginaid order was held or not given due to not being available. A record review of Resident 6's Medication Administration Record/Treatment Administration Record (MAR/TAR) for June 2025 revealed Resident 6's order for Arginiad twice a day for wound healing was documented as not given with a reason of Drug Refused on 6/1/2025 AM, and Held/Other/See Progress Note on the following dates: -6/1/2025 PM, -6/2/2025 PM, -6/3/2025 AM, -6/3/2025 PM, -6/4/2025 AM, -6/4/2025 PM, -6/5/2025 AM, -6/5/2025 PM, -6/6/2025 AM, -6/6/2025 PM, -6/7/2025 AM, -6/7/2025 PM, -6/8/2025 AM, -6/8/2025 PM, -6/9/2025 AM. A record review of Resident 6's Progress Notes for 6/1/2025-6/9/2025 revealed Arginaid order was held or not given due to not being available. The physician was notified of the unavailability of the Arginaid and a new order was provided on 6/6/2025. A record review of Resident 6's Wound Care Visit Notes revealed the following: -On 5/16/2025, the note revealed Resident 6's wound vac was not running when the resident arrived at their appointment. Additionally, Resident 6 was noted to have a red area by the wound opening and was incontinent of bowel on the area around the wound. -On 5/22/2025, the note revealed Resident 6's sacral wound measured 1.6 cm x 1 cm x 2 cm with undermining (a situation where the tissue beneath the skin edges of a wound has broken down, creating a pocket or space) of 1.1 cm with orders to continue with current orders. -On 5/29/2025, the note revealed Resident 6's sacral wound measured 1.3 cm x 1 cm x 1 cm with undermining of 2.1 cm. A wound culture was obtained due to Resident 6 having feces in their wound and odor. Additionally, the note stated to continue with current plan and orders. An interview on 6/9/2025 at 10:50 AM with the DON confirmed the facility did not have Arginaid available on 4/27/2025-4/30/2025 but was ordered on 4/29/2025. Additionally, the DON confirmed the facility has not had Arginaid since 5/27/2025 due to being backordered until 6/16/2025. The provider had not been notified as of the time of the interview and should have been first contacted on 5/28/2025 when first backordered. A follow up interview on 6/9/2025 at 11:20 AM with the DON revealed the order for Arginaid had been placed on hold and would be having a pharmacy delivering the Arginaid this evening.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(H)(iii)(3) Based on observations, interviews, and record review; the facility faile...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(H)(iii)(3) Based on observations, interviews, and record review; the facility failed to implement interventions of repositioning and failed to re-evaluate and revise ineffective interventions for 1 (Resident 9) of 1 sampled resident with Moisture Associated Skin Damage (MASD, a condition that occurs when skin is repeatedly exposed to various sources of bodily secretions or effluents, often leading to irritant contact dermatitis with inflammation, with or without denudation of affected skin). The facility identified a census of 28. Findings are:A record review of the facility policy provided when the policy related to skin assessments was requested, Prevention of Pressure Injuries with a revision date of April 2020, revealed in the Mobility/Repositioning section the staff were to reposition all resident with or at risk of pressure injuries on an individualized scheduled, as determined by the interdisciplinary team. The policy also revealed in the Monitoring section, the facility was to Review the interventions and strategies for effectiveness on an ongoing basis. A record review of Resident 9's admission Record revealed the resident was admitted to the facility on [DATE]. A record review of Resident 9's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 5/20/25 revealed the resident had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 5/15 which indicated the resident had severe cognitive impairment. The MDS also revealed that Resident 9 had no behaviors of rejection of care during the lookback period, required substantial assistance from staff for rolling left and right, and was always incontinent of bowel and bladder. The resident was identified to be at risk for pressure ulcers and had moisture associated skin damage. A record review of a Braden Scale assessment for Resident 9 dated 8/9/25 revealed a score of 10 which indicated the resident was at high risk for skin breakdown. A record review of Resident 9's undated Care Plan revealed the resident had limited physical mobility, required the assistance of 2 staff for their toileting, and preferred to be changed in bed; often refusing to allow staff to check and change their brief more than once per shift when they were up in their wheelchair. The staff were to continue to encourage the resident to allow frequent brief changes. The care plan also revealed the resident had reoccurring MASD to their coccyx/buttocks and had preventative treatment in place. There was a revision dated 6/4/2025 that revealed the resident had MASD to their coccyx (an area situated at the base of the spine, below the sacrum and above the anus) with a treatment of skin prep/Calmoseptine daily/PRN (as needed). There was also an intervention stating to assist the resident with turning/repositioning while in bed/recliner. A record review of Resident 9's Physician's Orders revealed an order to cleanse their coccyx with wound cleanser or normal saline, apply skin prep (a product that forms a film to protect the skin) to the peri-wound edges, then apply Calmoseptine (an over the counter multi-purpose ointment that acts as a moisture barrier and helps protect and heal skin irritations) to the wound and surrounding tissue every shift and PRN for MASD. This order had a start date of 6/4/2025. A record review of Resident 9's Electronic Medical Records (EMR) revealed they had a physician visit on 6/18/25 with no mention of their MASD. A record review of Resident 9's EMR revealed they had a provider visit on 8/1/25 with no mention of their MASD. A record review of Resident 9's Progress Notes from 6/11/25 through 8/18/25 revealed the following notes related to their MASD:-On 7/9/2025 there was documentation the resident had MASD to their buttocks area and it was healing. -On 7/18/2025 there was documentation the resident had MASD to their buttocks area and it was healing.-On 8/8/2025 there was documentation the resident had MASD with treatment in place. -On 8/13/2025 there was documentation the resident had MASD with treatment in place. A record review of the Weekly Skin Assessments for Resident 9 revealed:-On 6/15/25 there was documentation of, Resident skin warm pink dry and intact except for MASD area at coccyx and surrounding areas. Treatment done per current MD order. Mucous membranes remain pink, moist and intact. Skin turgor good without any tenting noted.-On 6/22/25 there was documentation of, Skin warm pink moist and intact except for shearing and MASD to buttocks. Skin turgor is good without any tenting noted to hands. Mucous membranes remain pink moist and intact.-On 6/29/25 there was documentation of, Resident skin warm pink dry and intact except for MASD and shearing at coccyx and surrounding areas. Treatment done per current MD order. Mucous membranes remain pink, moist and intact. Skin turgor good without any tenting noted.-On 7/6/25 there was documentation of, Skin warm pink dry and intact except for MASD areas to buttocks which are healing well and almost closed again. Calmoseptine applied per current MD order. Mucous membranes continue to pink moist and intact.-On 7/13/25 there was documentation of, Resident skin warm pink dry and intact except for MASD and shearing at coccyx and surrounding areas. Treatment done per current MD order. Mucous membranes remain pink, moist and intact. Skin turgor good without any tenting noted.-On 7/20/25 there was documentation of, Skin warm pink dry and intact except for MASD to buttocks bilateral. Areas cleansed and Calmoseptine applied to buttocks. Skin turgor good with no tenting noted. Mucous membranes remain pink moist and intact.-On 7/27/25 there was documentation of, Resident skin warm pink dry and intact except for MASD and shearing at coccyx and surrounding areas. Treatment done per current MD order. Mucous membranes remain pink, moist and intact. Skin turgor good without any tenting noted.-On 8/3/25 there was documentation of, Skin warm pale moist and intact except for MASD areas to buttocks with some shearing present. Calmoseptine applied per current order. Resident wedged on one side to prevent further damage while in bed. Skin turgor is good without any tenting noted. Mucous membranes continue to be pink moist and intact.-On 8/9/25 there was documentation of, Skin warm pale moist and intact except for MASD areas to buttocks with some shearing present. Calmoseptine applied per current order. Skin turgor is good without any tenting noted. Mucous membranes continue to be pink moist and intact.-On 8/14/25 there was documentation of, Skin warm pink dry and intact. Skin turgor good without any tenting noted to hands. Mucous membranes remain pink moist and intact. An observation on 8/14/25 at 9:22 AM revealed Resident 9 laying on their back in their bed. An observation on 8/14/25 at 10:04 AM revealed Resident 9 remained in the same position as prior observation. An observation on 8/14/25 at 11:13 AM revealed Resident 9's position remained unchanged. An observation on 8/14/25 at 11:15 AM revealed Nurse Aide (NA)-F wheeling a Hoyer lift into Resident 9's room, then a wheelchair, and then a second staff member entered the room with them and closed the door. An observation on 8/14/25 at 12:20 PM revealed Resident 9 was seated in the dining room in their wheelchair. An observation on 8/14/25 at 12:50 PM revealed Resident 9 sitting upright in a wheelchair in their room watching TV. At 1:06 PM, Resident 9 remained sitting upright in their wheelchair watching tv in their room. An observation on 8/14/25 at 1:41 PM revealed Resident 9 remained in the same position as prior observation. An observation on 8/14/25 at 2:11 PM revealed Resident 9's position remained unchanged. An observation on 8/14/25 at 2:30 PM revealed Resident 9's position remained unchanged. An observation on 8/14/25 at 2:53 PM revealed Resident 9 remained in their wheelchair. NA-F entered the resident's room, then pushed the resident in their wheelchair down the hallway to a room with a weight scale in it. At 2:55 PM, the aide pushed Resident 9 back to their room. An interview on 8/14/25 at 3:23 PM with NA-F confirmed that Resident 9 had been up in their wheelchair since shortly after 11:00 AM that day. NA-F stated, with Resident 9, it is hit or miss on whether they will want to get up, so when the resident does get up the staff tries to keep the resident up so they will eat a full meal. An observation on 8/18/25 at 8:10 AM revealed Resident 9 lying on their back in their bed with the head of the bed (HOB) slightly elevated. An observation on 8/18/25 at 9:54 AM revealed Resident 9 positioned with a wedge pillow under their left upper body with the HOB slightly elevated. An interview on 8/18/25 at 10:10 AM with Licensed Practical Nurse (LPN)-C revealed Resident 9's treatment was to be completed by the nurses, and it had been done prior to 8:00 AM that day. LPN-C revealed Resident 9 has had a bowel movement almost every time their brief gets changed, and the nurse aides clean the resident up and then the nurse goes in and cleanses the areas with normal saline and applies Calmoseptine to the wound areas and over the resident's full bottom. An observation on 8/18/25 at 11:28 AM revealed NA-F entering Resident 9's room with a Hoyer lift and the resident's wheelchair and notified the resident NA-F would assist them out of bed as soon as NA-G came in. NA-F prepared the room for privacy and got out all necessary supplies to change the resident's brief and clothing while conversing with the resident. NA-G then entered the room, and both aides applied their gloves and began changing the resident's incontinence brief. After Resident 9's buttocks had been cleansed with peri-wipes, the resident was observed to have a light pink discoloration with some areas of white maceration (the softening and breakdown of skin caused by prolonged exposure to moisture. It occurs when the skin becomes over-hydrated, leading to a whitish, wrinkled appearance and a weakened barrier) to the entirety of their buttocks, extending onto their posterior upper thighs. Just proximal to their buttocks crease, there was an approximately 1-inch x 0.25-inch open area with a dark red wound bed. There was also a second, smaller area to the resident's upper right buttock was also dark red in appearance. Once the NA's had finished cleansing the resident, a new brief was applied and the NA's continued with getting the resident up into their wheelchair. An interview on 8/18/25 at 11:35 AM with NA-F and NA-G confirmed Resident 9's buttock wounds looked the same as they typically do, with no recent change in appearance. An observation on 8/18/25 at 1:25 PM revealed Resident 9 sitting upright in their wheelchair in their room. An observation on 8/18/25 at 2:19 PM revealed Resident 9 sitting upright in their wheelchair at a table in the dining room participating in an activity. An observation on 8/18/25 at 3:16 PM revealed Resident 9 sitting upright in their wheelchair in their room in the same position as previous observations. An interview on 8/18/25 at 2:30 PM with the Chief Nursing Officer (CNO) confirmed that Resident 9 was seen by their provider on 8/1/25 and their MASD had not been addressed.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

Licensure Reference Number 175 NAC 12-006.10(D) Based on observations, record reviews and interview; the facility staff failed to ensure a medication error rate of less than 5%. Observations of 25 opp...

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Licensure Reference Number 175 NAC 12-006.10(D) Based on observations, record reviews and interview; the facility staff failed to ensure a medication error rate of less than 5%. Observations of 25 opportunities of medication administration revealed 5 medication errors resulting in a medication error rate of 20%. The medication errors effected 2 (Resident 4 and 17). The survey had a total sample size of 19. The facility identified a census of 36. Findings are: A record review of a facility policy Administering Medications with a last revised date of April 2019 revealed medications are to be administered in accordance with prescriber orders, including any required time frame. The individual administering the medication should check the label three times to verify the right resident, medication, dosage, time, and route prior to administering the medication. A record review of a facility policy, Adverse Consequences and Medication Errors with a last revised date of February 2023 revealed examples of medication errors include omission (when a drug is ordered but not administered), unauthorized drug (when a drug is administered without a physician's order), wrong dose, wrong route, wrong drug, wrong time, or failure to follow manufacturer's instructions and /or accepted professional standards. A. A record review of Novartis' Full Prescribing Information for ondansetron revealed under administration instruction for orally disintegrating tablets (ODT) revealed directions to immediately place the oral disintegrating tablet on top of the tongue where it will dissolve. B. A record review of an admission Record revealed the facility re-admitted Resident 4 back to the facility on 4/23/2025. Resident 4 had diagnoses of schizoaffective disorder (a mental illness that combines symptoms of schizophrenia and mood disorders like bipolar disorder or depression. It's characterized by periods of psychosis (hallucinations, delusions) and mood episodes like mania or depression), anxiety (a feeling of fear, dread, and uneasiness), Multiple Sclerosis (MS, a disease where the body's immune system mistakenly attacks the protective covering of nerve fibers in the brain and spinal cord that can cause muscles weakness, trouble walking, numbness, and difficulty with controlling bowel and bladder), chronic obstructive pulmonary disease (COPD, a condition caused by damage to the airways or other parts of the lung, and legal blindness. A record review of Resident 4's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) with an Assessment Reference Date (ARD) 4/30/2025 revealed Resident 4 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15/15, which indicated Resident 4 was cognitively intact. A record review of Resident 4's Order Entries as of 6/10/2025 revealed the following orders: -Ondansetron Oral Disintegrating Tablet (ODT) 4 milligrams (mg) with instructions to administer three times a day, with first administration time between 6 AM and 9 AM, for nausea and vomiting with a start date of 5/15/2025. -Clonazepam (a sedating medication in a class called benzodiazepines) 0.5 mg with instructions to administer three times a day, with first administration time between 6 AM and 9 AM, for schizoaffective disorder and anxiety with a start date of 5/10/2025. -Gabapentin 100 mg with instructions to administer three times a day, with first administration time between 6 AM and 9 AM, for anxiety and irritability with a start date of 4/24/2025. -Lansoprazole (a drug for heartburn) 30 mg with instructions to give one time a day, between 6 AM to 9 AM, for Gastroesophageal Reflux Disease (GERD, a digestive disorder where stomach acid frequently flows back into the esophagus, causing heartburn and potentially damaging the esophageal lining) with a start date of 5/16/2025. An observation on 6/10/2025 at 9:50 AM revealed Medication Aide (MA)-G prepare Resident 4's ondansetron, clonazepam, gabapentin, lansoprazole into one medication cup. An observation on 6/10/2025 at 10:20 AM revealed MA-G took the prepared medications to Resident 4's room. Resident 4 was sitting in their wheelchair at their bedside table resting their head down on the bedside table. A plate of food, sitting on the resident's bedside table from breakfast, had been approximately 25% consumed. MA-G spooned all medication prepared to Resident 4 at once, without separating out Resident 4's ondansetron or instructing to allow to it to dissolve in their mouth. Resident 4 began to make gagging noise. MA-G provided Resident 4 with some water to assist with swallowing the medications down. Resident 4 continued to gag and shake their head, once swallowed Resident 4 stated, Can't drink, I'm gaggy today. An interview on 6/10/2025 at 10:25 AM with MA-G confirmed Resident 4's medications of ondansetron, clonazepam, gabapentin, and lansoprazole were administered late as they were to be administered between 6 AM and 9 AM. MA-G also confirmed the concern Resident 4's second dose of clonazepam was due to be given soon and would be too close to the dose just administered to Resident 4. MA-G also revealed the were unaware Resident 4's ondansetron should be dissolved on their tongue, stating that they only work this medication cart every once in a while, so they were unfamiliar with the medications. An interview on 6/10/2025 at 11:50 AM with the Director of Nursing (DON) revealed the DON had contacted Resident 4's medical provider regarding their clonazepam having been administered late and to obtain an order to hold the next dose. The DON also confirmed Resident 4's medications of ondansetron and lansoprazole were administered late and may have provided Resident 4 relief from their nausea had they been administered timely, as well as the ondansetron have been dissolved on the resident's tongue, provided more immediate relief. C. A record review of an admission Record indicated the facility admitted Resident 17 on 2/10/2025. Resident 17 had diagnoses of dementia (a usually progressive condition marked by the development of multiple cognitive deficits such as memory impairment, aphasia, and the inability to plan and initiate complex behavior) and restlessness and agitation. A record review of Resident 17's Care Plan with a last revised date of 5/20/2025 revealed a focus area regarding psychotropic medication. This area revealed Resident 17 was ordered venlafaxine for depression with an intervention to administer psychotropic medications as ordered by the physician. A record review of Resident 17's Order Entry revealed the order for venlafaxine extended release (ER) 150 mg with instructions to administer one time a day in the morning with a start date of 5/30/2025. An observation on 6/10/2025 at 10:30 AM revealed Licensed Practical Nurse (LPN) - F prepare Resident 17's venlafaxine to administer. On 6/10/2025 at 10:36 AM, LPN-F administered Resident 17's venlafaxine. An interview on 6/10/2025 at 10:42 with LPN-F confirmed Resident 17's venlafaxine had been administered late as it is to be administered between 6 AM and 9 AM, then it turns red on the EMAR. LPN-F revealed they were behind on medication administration due to being unfamiliar with this medication cart as last time they were on this medication cart was 7 months ago. An interview on 6/10/2025 at 12:40 PM with the Chief Nursing Officer (CNO) confirmed there is a 3-hour medication window from 6 AM to 9 AM for medications ordered for the AM to be administered, after 10 AM, they are considered administered late.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

Licensure Reference Number 175 NAC 12-006.10(D) Based on record review and interview, the facility failed to ensure three doses of an intravenous (IV) antibacterial medication were not omitted for 1 (...

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Licensure Reference Number 175 NAC 12-006.10(D) Based on record review and interview, the facility failed to ensure three doses of an intravenous (IV) antibacterial medication were not omitted for 1 (Resident 7) of 1 sampled resident. The facility identified a census of 36. Findings are: A record review of a facility policy, Adverse Consequences and Medication Errors with a last revised date of February 2023 revealed examples of medication errors include omission (when a drug is ordered but not administered), unauthorized drug (when a drug is administered without a physician's order), wrong dose, wrong route, wrong drug, wrong time, or failure to follow manufacturer's instructions and /or accepted professional standards. The policy defined signification medication-related errors as the requirement for the medication to be discontinued or modified, required hospitalization, resulting in disability, requiring treatment with a prescription medication, resulting in cognitive deuteriation, life threatening, or resulting in death. A record review from AstraZeneca Pharmaceuticals (the manufacture) of meropenem: Prescribing Information with a date of 12/2026 revealed skipping doses or not completing the full course of therapy may decrease the effectiveness of immediate treatment and increase the likelihood that bacteria will develop resistance and will not be treatable by meropenem or other antibacterial drugs in the future. A record review of an admission Record indicated the facility re-admitted Resident 7 on 5/27/2025. Resident 7 had diagnoses of Urinary Tract Infection (UTI), Type 1 diabetes, right artificial hip join with surgical aftercare, retention of urine, and neuromuscular dysfunction of the bladder. A record review of Resident 7's Medication Administration Record for June 2025 revealed an order for meropenem (an antibacterial medication) for 1 gram (g) with instructions to use 1g intravenously every 8 hours at 6:00 AM, 2:00 PM, and 10:00 PM for a UTI. The order had a start date of 5/28/2025 and an end date of 6/4/2025. Additionally, the MAR revealed the resident's meropenem had not been documented as administered on 6/1/2025 at 6:00 AM or 6/4/2025 at 2:00 PM. A record review of Resident 7's Progress Notes from 5/27/2025-6/1/2025 revealed the following: -On 5/27/2025 at 7:08 PM, it was documented Resident 7 had returned to the facility via an ambulance. The facility had not received report from the discharging hospital, but a report from the Emergency Medical Services (EMS) was obtained. The writer contacted the discharging hospital and received report. Resident 7 had a urine analysis (UA) during their hospital stay that was positive for pseudomonas (a type of infection). Resident 7 was started on IV meropenem 1 gram IV every 8 hours and had received six doses while in the hospital. Resident 7 was discharged with order to continue the IV meropenem 1 g IV every eight hours through 6/4/2025. At the time of resident's arrival back to the facility, Resident 7 no longer had IV access or the meropenem available. EMS was contacted and Resident 7 was taken to the local hospital. -On 5/27/2025 at 11:08 PM, Resident 7 returned to the facility with a peripheral IV and order to place a midline or peripherally inserted central catheter (PICC line) and to continue the order for meropenem 1 g IV every 8 hours through 6/4/2025. -On 5/28/2025 at 4:58 PM, Resident 7 had a midline access placed. -On 6/1/2025 at 2:48 AM, Resident 7 was discovered to have removed their midline. -On 6/1/2025 at 5:03 AM, Resident 7's meropenem order was held with a note that Resident 7 had remove their midline and there was no IV access at the time. There was no evidence IV access was attempted to be obtained. -On 6/1/2025 at 12:42 PM, Resident 7's medical provider was notified regarding Resident 7 having removed their midline. Resident 7's medical provider provided an order to send back to the hospital for a new line, but no one was available to place the line. EMS was contacted and started a new line and administered the antibiotics. A record review of a Employee Warning Report with a date of 6/2/2025 revealed a warning was given to Licensed Practical Nurse (LPN) - F from the Director of Nursing (DON) for failure to achieve established job standards and a medication error. The report revealed on 5/30/2024 at 2:00 PM, LPN-F failed to administer the prescribed medication at the scheduled time, resulting in a missed dosage that could potentially impact the patient's health. Additionally, the LPN did not inform the DON about the inability to administer the medication, which is a critical breach of protocol. Additionally, it revealed LPN-F was required to notify a Registered Nurse (RN) immediately if LPN-F was unable to administer a medication to ensure that the patient received the required doses without further delay. A record review of a Employee Warning Report with a date of 6/5/2025 revealed a warning was given to Licensed Practical Nurse (LPN) - F from the Director of Nursing for failure to achieve established job standards and a medication error. The report revealed on 6/4/2025 at 2:00 PM, LPN-F failed to administer the prescribed medication at the scheduled time, resulting in a missed dosage that could potentially impact the patient's health. Additionally, the LPN did not inform the DON about the inability to administer the medication, which is a critical breach of protocol. Additionally, it revealed LPN-F was required to notify a Registered Nurse (RN) immediately if LPN-F was unable to administer a medication to ensure that the patient received the required doses without further delay. An interview on 6/10/2025 at 11:50 AM with the DON confirmed Resident 7 had missed a total of 3 antibiotic doses, the first dose and the two doses that were not administered by LPN-F on 5/30/2025 and 6/4/2025, which had the potential to impact Resident 7's health.
CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(H)(i)(3) Based on observations, record review, and interview; the facility failed t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(H)(i)(3) Based on observations, record review, and interview; the facility failed to ensure residents received assistance with their Activities of Daily Living per their plan of care for 6 (Residents 1, 2, 3, 4, 12, and 19) of 6 sampled residents. The facility identified a census of 36. Findings Are: A record review of the facility policy Activities of Daily Living (ADL), Supporting with a revision date of March 2018 revealed that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. An interview on 6/7/25 at 10:14 PM with Nursing Assistant ( NA)-L and NA-M revealed both NA's worked the night shift. NA-M stated that three nights earlier, it was after midnight before the staff finished getting the residents into bed for the night due to the lack of staff that had been available to provide cares for the residents on the evening shift. A. A record review of Resident 1's MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 4/15, indicating severe cognitive impairment. The MDS also revealed the resident required partial/moderate to substantial/maximal assistance from staff for their oral, toileting, and personal hygiene. The resident also required substantial/maximal assistance for their shower/bathing needs. A record review of Resident 1's undated Care Plan revealed the resident required 1-person staff assistance with their bathing/showering, dressing, personal hygiene, and toilet use. A record review of facility provided document for Resident 1 titled POC Response History Task: ADL- Bathing Schedule and dated 6/10/25 with a 30 day look back period revealed that staff had documented on 5/14/25, 5/17/25, 5/21/25, 5/28/25, and 5/31/25 Not applicable, and on 5/24/25 Resident Refused. There was no other documentation. A record review of the facility document for Resident 1 titled The Spa at Skyview Bathing Schedule from 5/8/25 through 6/9/25 revealed the resident was scheduled to receive showers every Tuesday, Thursday, and Saturday. The documentation revealed the resident received a shower on 5/8/25, 5/27/25 and 6/3/25. An observation on 6/7/25 beginning at 6:00 PM revealed Resident 1 sitting in the dining room in their wheelchair asking for assistance as people walk past. Resident 1 remained sitting in their wheelchair and slowly wheeled self from inside the dining room out into the hallway outside the dining room. Resident 1 intermittently asked to be help and stated they wanted to go to bed. At 7:47 PM Resident 1 was observed telling the administrator they wanted to go to bed. The administrator told the resident that the next Nursing Assistant (NA) they saw, the administrator would have them help the resident. At 8:11 PM, Resident 1 asked to help them to their bed. The facility Administrator heard this and told the resident they would find someone to help. At 8:28 PM, Resident 1 had been taken to their room. Observations conducted on 6/9/25 of Resident 1 revealed the following: -At 9:20 AM Resident 1 was sitting in their wheelchair at a table in the dining room. -At 9:40 AM Resident 1 continued sitting at a table in the dining room but now had food in front of them. -At 10:05 AM Resident 1 remained at the dining room table. The resident had backed their wheelchair about a foot away from the table and they were not eating or drinking. -At 10:52 AM Resident 1 was sitting in the dining room, about 2 feet away from the table. The resident had their eyes closed and their chin was resting on their chest. -At 11:05 AM Resident 1 remained in the same position in the dining room. -At 11:27 AM Resident 1 remained in the same position in the dining room. -At 11:45 AM Resident 1 remained in the same position in the dining room. -At 11:53 AM staff approached Resident 1 and asked the resident if they wanted to scoot closer to the table. Resident 1 declined so then the staff handed the resident a cup of juice, which the resident began drinking. Resident 1 remained in the same position in their wheelchair. -At 11:55 AM the Chief Nursing Officer (CNO) moved Resident 1's wheelchair so the resident was facing their table. -At 12:45 PM Resident 1 remained in the dining room. -At 12:54 PM Resident 1 remained in the dining room. An interview on 6/9/25 at 12:54 PM with the Director of Nursing (DON) confirmed Resident 1 had been in the dining room since just after 9:00 AM. The DON also asked NA-I if anyone had assisted Resident 1 to the toilet during that timeframe and the NA stated, not that I know of. B. A record review of Resident 2's MDS dated [DATE] revealed the resident had a BIMS score of 14/15 indicating they were cognitively intact. The MDS also revealed the resident required partial/moderate assistance with shower/bathing and with toileting hygiene. A record review of Resident 2's undated Care Plan revealed the resident required the assistance of 1 person with bathing showering and with toileting use. An interview on 6/7/25 at 6:50 PM with MA-H revealed that Resident 2 had reported the evening prior that they were going to wash their hair in the sink because they had not been bathed in two weeks. An interview on 6/7/25 at 7:04 PM with Resident 2 revealed the resident had not been bathed in two weeks. Resident 2 reported there was one day they did not get bathed because there was no hot water, but otherwise it had been due to there not being staff available to complete bathing. Resident 2 revealed they needed staff assistance with wiping their bottom after they used the toilet, and they sometimes had to wait 30 minutes or more for staff to come assist with this task. An interview on 6/11/25 at 9:52 AM with Resident 2 revealed the resident had been getting bathed routinely prior to the past two weeks when they did not receive any baths. Resident 2 stated they were scheduled to receive their baths every Wednesday and Friday, which they did not like because this meant they had one day between baths and then had to go several days until the next bath. A record review of facility provided document for Resident 2 titled POC Response History Task: ADL- Bathing Schedule and dated 6/10/25 with a 30 day look back period revealed that staff had documented on 5/21/25 Shower, and on 5/22/25 and 5/25/25 Not applicable. There was no other documentation. A record review of the facility document for Resident 2 titled The Spa at Skyview Bathing Schedule from 5/5/25 through 6/9/25 revealed Resident 2 was scheduled to receive a shower every Wednesday and Friday. The documentation revealed the resident received shower on 5/28/25 and 6/8/25. C. A record review of Resident 3's MDS dated [DATE] revealed the resident had a BIMS score of 14/15 indicating the resident was cognitively intact. The MDS also revealed the resident required partial/moderate assistance from staff for wheeling 150 feet and for shower/bathing. A record review of Resident 3's undated Care Plan revealed staff were to encourage physical activity and daily ambulation, and that resident was to use assistive device if necessary. The care plan also revealed the resident had the potential for ADL self-care performance deficit r/t fatigue, impaired balance, and pain to lower back, right hip, and right knee. The resident required assistance of 1 person for bathing/showering. An interview on 6/7/25 at 7:12 PM with Resident 3 revealed that the prior week had been their third week living in the facility and there had been several staff who had resigned since they were admitted to the facility. Resident 3 stated they felt like it's a crisis due to the facility being low on help. The resident also stated it had been about two weeks since they had been assisted with bathing, so they had just been doing sponge baths on their own in their room. Resident 3 stated that they needed assistance wheeling back to their room in their wheelchair after meals due to their arthritis. Resident 3 also stated that the evening prior, they had to wheel back to their room independently because there was no staff available, and the resident had been having pain to their right hip and leg ever since. A record review of facility provided document for Resident 3 titled POC Response History Task: ADL- Bathing Schedule and dated 6/10/25 with a 30 day look back period revealed no showers had been documented for the resident since their admission. A record review of the facility document for Resident 3 titled The Spa at Skyview Bathing Schedule from 5/5 through 6/9 revealed the resident had not been added to the bathing schedule but that the resident had received a shower on 5/17/25 (date of admission), 5/28/25, 5/31/25, and on 6/8/25. D. A record review of Resident 4's MDS dated [DATE] revealed the resident had a BIMS score of 15/15 indicating the resident was cognitively intact. The MDS also revealed the resident was dependent on staff for shower/bathing and toileting. A record review of Resident 4's undated Care Plan revealed the resident required 1-person assistance with bathing/showering and that for toileting, the resident did not have the core strength to sit up on the toilet or commode, so resident needed to be transferred to their bed for peri-cares to be performed. An interview on 6/7/25 at 7:55 PM with Resident 4 revealed that it last week or the week before that since their last bath but the facility staff had not shared a reason for this. A record review of facility provided document for Resident 4 titled POC Response History Task: ADL- Bathing Schedule and dated 6/10/25 with a 30 day look back period, revealed that staff had documented on 5/30/25 that the resident had refused their shower that day. There was no other documentation. A record review of the facility document for Resident 4 titled The Spa at Skyview Bathing Schedule from 5/5/25 through 6/9/25 revealed Resident 4 was scheduled to receive a shower every Monday and Friday. The documentation revealed that the resident received a shower on 5/12/25 and 6/9/25. E. A record review of Resident 12's MDS dated [DATE] revealed the resident had a BIMS score of 15/15 indicating the resident was cognitively intact. The MDS also revealed the resident required substantial/maximal assistance with shower/bathing and was dependent on staff for toileting hygiene. A record review of Resident 12's undated Care Plan revealed the resident required substantial assistance by one staff with bathing schedule and as necessary. The Care Plan also revealed the resident required substantial assistance of two staff with the sit-to-stand for toileting. An interview on 6/9/25 at 10:21 AM with Resident 12 revealed Resident 12 had resided in the facility for almost two years and utilized a sit-to-stand lift for transfers. Resident 12 stated that the prior week they had to wait for two hours before staff was able to take them to the bathroom. Resident 12 also revealed that they were supposed to get three showers a week but that they were lucky if they even got one. The resident stated that 9 days was the longest they have had to go without a shower and that this had happened within the last two months. An interview on 6/11/25 at 9:26 AM with Resident 12 revealed that it was about a month ago when they stopped getting bathed 3 times a week like they preferred. A record review of facility provided document for Resident 12 titled POC Response History Task: ADL- Bathing Schedule and dated 6/10/25 with a 30 day look back period revealed that staff had documented on 5/16/25 and 5/23/25 Not Applicable, and on 5/21/25, 5/26/25, and 5/30/25 Shower. There was no other documentation. A record review of the facility document for Resident 12 titled The Spa at Skyview Bathing Schedule from 5/5/25 through 6/9/25 revealed Resident 12 was scheduled to receive a shower every Monday, Wednesday, and Friday. The documentation revealed that the resident received a shower on 5/5/25, 5/9/25, 5/12/25, 5/26/25, 5/28/25, 6/3/25, and 6/9/25. F. A record review of Resident 19's MDS dated [DATE] revealed the resident had a BIMS score of 10/15 indicating the resident had moderate cognitive impairment. The MDS also revealed the resident was dependent on staff for their shower/bathing. A record review of Resident 19's undated Care Plan revealed the resident required 1-person assistance with bathing/showering. An interview on 6/11/25 at 10:18 AM with Resident 19 revealed the resident was supposed to get three baths a week but lately it had been pretty hit and miss. Resident 19 stated that it varied, sometimes they would get one or more baths a week and sometimes it would stretch into two weeks. Resident 19 stated that they couldn't say when this started, it was pretty much when the staff started quitting but the resident stated they could not really say how long ago that was either. A record review of facility provided document for Resident 19 titled POC Response History Task: ADL- Bathing Schedule and dated 6/11/25 with a 30 day look back period revealed that staff had documented on 5/16/25 and 5/19/25 not applicable. Staff had also documented Shower on 5/14/25, 5/23/25, 5/24/25, 5/28/25, 5/30/25, 6/4/25, 6/6/25, and 6/9/25. A record review of the facility document for Resident 19 titled The Spa at Skyview Bathing Schedule from 5/5/25 through 6/9/25 revealed Resident 19 was scheduled to receive a shower every Monday, Wednesday, and Friday. The documentation revealed that the resident received a shower on 5/9/25, 5/14/25, 5/16/25, 5/26/25, 5/30/25, 5/31/25, 6/4/25, and 6/9/25. An interview on 6/11/25 at 11:24 AM with the DON confirmed baths should be given to the residents at least once a week unless the resident wanted them more frequently. The DON revealed that the facility did not currently have a working bathtub and that there had not been a functional bathtub since prior to their date of hire which was 1/6/25, so all of the residents have had to take showers. An interview on 6/11/25 at 11:45 AM with the CNO revealed baths are given per resident preferences, which are established upon admission but were also reestablished as part of the facility's plan of correction following their recent survey. The CNO stated they went around to all residents and asked what they preferred, and the bathing schedule was developed based on this information.
CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(I) Based on record review and interview the facility failed to prevent the potentia...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(I) Based on record review and interview the facility failed to prevent the potential for serious harm or injury while performing transfers via Hoyer or sit-to-stand mechanical lifts, this had the potential to affect 11 (Residents 1, 4, 6, 9, 10, 11, 12, 13, 14, 15, and 16) of 11 residents sampled. The facility identified a census of 36. Findings Are: A record review of the facility policy Lifting Machine, Using a Mechanical with revision date of July 2017 revealed in the General Guidelines that at least two nursing assistants are needed to safely move a resident with a mechanical lift. The policy also revealed that the types of lifts that may be available in the facility are a floor-based full body sling lift, an overhead full body sling lift, and a sit to stand lift. A record review of the facility provided Resident List dated 6/7/25 revealed Residents 4, 9, 10, 14, and 16 were marked as utilizing a Hoyer lift. The list also revealed Residents 1, 6, 11, 12, 13, and 15 were marked as utilizing a Sit to Stand Lift. A. A record review of Resident 1'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 4/9/2025 revealed the resident required substantial/maximal assistance from staff for transfers. A record review of Resident 1's undated Care Plan (a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) revealed the resident required two-person assistance with the sit to stand for transfers. If Resident 1 was unable to stand, the care plan stated to use the total lift with two people. This was initiated on 3/10/2025. B. A record review of Resident 4's MDS dated [DATE] revealed the resident was dependent on staff for transfers. A record review of Resident 4's undated Care Plan revealed the resident required two-person assistance with the total lift for transfers. This was initiated on 5/1/2025. C. A record review of Resident 6's MDS dated [DATE] revealed the resident required substantial/maximal assistance with transfers. A record review of Resident 6's undated Care Plan revealed the resident required one-person assistance with the sit-to-stand lift when transferring in/out of bed and to/from the toilet. The care plan stated to use two-person assistance as needed for increased weakness or if the resident was unable to follow instructions. This was initiated on 8/7/2019 and revised on 4/21/2024. D. A record review of Resident 9's MDS dated [DATE] revealed the resident was dependent on staff for transfers. A record review of Resident 9's undated Care Plan revealed the resident required two-person assistance with the total lift for transfers. This was initiated on 4/30/2021. E. A record review of Resident 10's MDS dated [DATE] revealed the resident required substantial/maximal assistance with transfers. A record review of Resident 10's undated Care Plan revealed the resident required a 2-person pivot transfer with gait belt. The care plan also stated to use the total lift with 2 people if the resident was unable to stand, too tired or weak. This was initiated on 1/23/2025. F. A record review of Resident 11's MDS dated [DATE] revealed the resident was dependent on staff for transfers. A record review of Resident 11's undated Care Plan revealed the resident required two-person assistance with the sit-to-stand lift for transfers. This was initiated on 5/30/2025. G. A record review of Resident 12's MDS dated [DATE] revealed the resident required substantial/maximal assistance with transfers. A record review of Resident 12's undated Care Plan revealed the resident required substantial assistance by 2-person pivot transfer with a gait belt. The care plan also stated the resident would occasionally be agreeable to use a sit to stand lift. This was initiated on 10/26/2023 and revised on 1/31/2025. H. A record review of Resident 13's MDS dated [DATE] revealed the resident required substantial/maximal assistance with transfers. A record review of Resident 13's undated Care Plan revealed the resident required two-person assistance with stand/pivots with a gait belt to move between surfaces and as necessary. This was initiated on 7/15/2024. I. A record review of Resident 14's MDS dated [DATE] revealed the resident was dependent on staff for transfers. A record review of Resident 14's undated Care Plan revealed the resident required 2-person assistance with a Hoyer lift for transfers. This was initiated on 10/31/2020 and revised on 4/21/2024. J. A record review of Resident 15's MDS dated [DATE] revealed the resident was dependent on staff for transfers. A record review of Resident 15's undated Care Plan revealed the resident required 1-person assistance with transfers PRN (as needed). This was initiated on 7/2/2019 and revised on 5/5/2021. K. A record review of Resident 16's MDS dated [DATE] revealed the resident was dependent on staff for transfers. A record review of Resident 16's undated Care Plan revealed the resident required 2-person assistance for transfers with the use of the total lift. This was initiated on 1/21/2025. An interview on 6/7/25 at 6:30 PM with the Director of Nursing (DON) revealed that one of the Nurse Aides (NA) working that evening was a minor and unable to utilize the mechanical lifts to transfer residents. The DON also revealed that the DON and this minor NA were the only staff scheduled to work the following evening from 2 pm until 10 pm. An interview on 6/7/25 at 6:50 PM with Medication Aide (MA)-H revealed MA-H had worked the past 7 days straight in an attempt to assist with the staffing shortage. MA-H stated that there were 30-some residents in the facility and normally 2-3 staff on duty would be sufficient but there were several residents that were high acuity (requiring significant staff assistance) so the current staffing levels were not enough to provide resident cares. MA-H stated that the evening prior, the staffing was the DON, the MA, and one NA. MA-H stated that there were 3 or 4 residents who required the Hoyer lift for transfers and there were several who utilized the sit-to-stand lift, but some of those residents really needed two staff present due to the residents chicken-winging (a situation where the resident's arms extend out to the side during the transfer, increasing the risk of the resident falling out of the lift sling). MA-H revealed that staff frequently transferred residents with the mechanical lifts alone because otherwise the residents would not get cares due to there not being enough staff on duty. MA-H also revealed that they had recently been told by facility management that it was now okay to use the sit-to-stand lifts alone, although this had not previously been an approved practice. An interview on 6/7/25 at 7:55 PM with Resident 4 revealed there were usually two staff to transfer the resident with the Hoyer lift, but not always. Resident 4 stated that occasionally there was only one staff present during the transfers. Resident 4 stated they felt kind of scared because everyone was leaving and that it was 24 hours a day that there had been less staff on duty than usual. An interview on 6/7/25 at 8:53 PM with MA-H confirmed that the staff had been utilizing the mechanical lifts without a second staff present while transferring the residents and that this had been occurring on a daily basis due to lack of staff on duty. MA-H stated they witnessed a staff completing a resident transfer via a mechanical lift without a second staff in the room the evening prior when MA-H entered the resident room to administer medications to the resident. An interview on 6/9/25 at 10:21 AM with Resident 12 revealed Resident 12 had resided in the facility for almost two years and utilized a sit-to-stand lift for transfers. Resident 12 stated that a lot of the time there was only one staff present in their room during the transfers because they are so short staffed here. An interview on 6/9/25 at 2:25 PM with NA-J revealed they had been working in the facility since about January of this year. NA-J confirmed that staff were supposed to have two staff present when transferring residents with the mechanical lifts. NA-J revealed that they had asked the therapy staff for assistance with transferring a resident with the sit-to-stand lift recently and the therapy staff stated that per state, you don't have to have two staff present, so NA-J did transfer the resident by themself. NA-J stated there have been many shifts with only one or two staff working on the floor and that staff rarely works just 8 hours because there is not enough staff and even after the staff gets off the floor, then they have to go back and do their charting. An interview on 6/11/25 at 9:26 AM with Resident 12 revealed that they had been getting transferred via the sit-to-stand lift with only one staff present for quite a while. Resident 12 stated, It's been so long I really couldn't tell you when it started. An interview on 6/11/25 at 10:57 AM with NA-I revealed the NA had been working in the facility for about 3 years. NA-I stated they were supposed to be on light duty but had been utilizing both the Hoyer and sit-to-stand lifts alone despite being on light duty because there was not ever enough staff on duty to use two people. NA-I stated it had been this way, due to lack of staff availability, since approximately January 2025.
CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-00604(D)Nebraska Revised Statute 71-6018.02(a) Based on record reviews and interviews, the...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-00604(D)Nebraska Revised Statute 71-6018.02(a) Based on record reviews and interviews, the facility failed to maintain acceptable documentation (timecards, time sheets, payroll information) that a Registered Nurse (RN) was on duty for a minimum of 8 consecutive hours a day, 7 days a week, as required. This had the potential to affect all 28 residents by limiting access to RN-level assessment, oversight, and decision-making related to resident care.Findings are: A record review of a facility provided document SCARAB (Skyview Care and Rehab at Bridgeport) Facility Assessment- 2025 dated 6/4/2025 revealed under the staffing type section, nursing services of the Director of Nursing (DON), RN, Licensed Practical Nurse (LPN), Nurse Aides (NA), and Medication Aides (MA) were needed to provide support and care for the facility's residents. Under the staffing plan section, it was revealed that a total of 5 licensed nurses providing direct care were needed. There was no evidence regarding the need for an RN to be on duty for a minimum of 8 consecutive hours a day, 7 days a week. 1.A record review of a facility provided document, Daily Assignment Sheet (dated 6/24/2025), revealed RN-U was listed as the nurse assigned to the 6PM-6AM shift. The same document listed no other RNs, two LPNs and several NAs assigned to resident care throughout the 24-hour period. A record review of the facility provided document Timecard Detail Report for RN-U, covering the date range 6/12/2025 to 8/14/2025, revealed no evidence RN-U had been on duty on either 6/24/2025 or 6/25/2025. A record review of the facility's documentation provided as evidence of RN coverage included the Chief Nursing Officer's (CNO) Vetus Time Study (dated June 2025). For 6/24/2025, the time study listed a task titled DON Coverage - RN Coverage with a total daily hour of 18.5 hours. However, the time study did not include documentation of specific hours worked, nor did it demonstrate that the hours were consecutive. Additionally, the information documented in the time study did not algin with the facility's Daily Assignment Sheet (dated 6/24/2025). 2. A record review of the facility provided document Nursing Coverage (dated 7/8/2025) revealed the CNO had been listed as the 6AM-6PM RN on duty. The same document listed no other RN, two LPNs and several NAs assigned to resident care throughout the 24-hour period. A record review of the facility's documentation provided as evidence of RN coverage included the CNO's Vetus Time Study (dated July 2025). For 7/8/2025, the time study listed a task titled Sky DON Coverage with a total of daily hours of 10 hours. However, the time study did not include documentation of specific hours worked, nor did it demonstrate that the hours were consecutive. Additionally, the information documented in the time study did not algin with the facility's Daily Assignment Sheet (dated 7/8/2025). 3. A record review of the facility provided document Nursing Coverage (dated 7/12/2025) revealed RN-P had been listed as the Registered Nurse for 2:00-10:00 PM and then the RN for 6PM-6AM. The same document listed no additional RNs, one LPN, and several NAs assigned to resident care throughout the 24-hour period. A record review of the facility provided document Timecard Detail Report for RN-P, covering the date range 6/12/2025 to 8/14/2025, revealed RN-P had been on duty on 7/11/2025 at 10:03 PM to 7/12/2025 at 7:28 AM. There was no evidence RN-P had returned for an additional shift at 2:00 PM or later on 7/12/2025 or on 7/13/2025. A record review of the facility provided document Timecard Report, for the Nursing Home Administrator (NHA), covering dates 6/12/2025 to 8/14/2025, revealed the NHA had been on duty on 7/12/2025 from 4:10 PM to 6:00 PM and 7/13/2025 from 6:00 PM to 6:23 AM. A record review of a State of Nebraska - Department of Health and Human Services' License Details revealed the NHA had an active LPN license. Additional record review of the facility's documentation provided as evidence of all nursing staff, including agency/contract and management, who had worked from 6/12/2025-8/14/2025 including Timecard Reports, Timecard Detail Reports, and Vetus Time Studies revealed no evidence of a RN having been on duty of at least 8 consecutive hours for 7/12/2025. An interview on 8/18/2025 at 1:25 PM with the NHA revealed due to a time keeping error/glitch, the NHA's timecard had shown the NHA had worked the night shift on 7/13/2025, however, the NHA had covered the night shift for licensed nurse coverage on 7/12/2025. 4. A record review of the facility provided document Nursing Coverage (dated 7/13/2025) revealed there had been no RN listed on duty for the 24-hour period. The same document listed two LPNs and several NAs assigned to resident care throughout the 24-hour period. Additional record review of the facility's documentation provided as evidence of all nursing staff, including agency/contract and management, who had worked from 6/12/2025-8/14/2025 including Timecard Reports, Timecard Detail Reports, and Vetus Time Studies revealed no evidence of a RN having been on duty of at least 8 consecutive hours for 7/12/2025. 5. A record review of the facility provided document Nursing Coverage (dated 7/16/2025) revealed the CNO had been listed as the 6AM-6PM RN on duty. The same document listed no other RNs, two LPNs and several NAs assigned to resident care throughout the 24-hour period. A record review of the facility's documentation provided as evidence of RN coverage included the CNO's Vetus Time Study (dated July 2025). For 7/16/2025, the time study listed a task titled Sky DON Coverage with a total of daily hours of 8 hours. However, the time study did not include documentation of specific hours worked, nor did it demonstrate that the hours were consecutive. Additionally, the information documented in the time study did not algin with the facility's Daily Assignment Sheet (dated 7/16/2025). 6. A record review of the facility provided document Nursing Coverage (dated 7/17/2025) revealed the CNO had been listed as the 6AM-6PM RN on duty. The same document listed no other RNs, two LPNs and several NAs assigned to resident care throughout the 24-hour period. A record review of the facility's documentation provided as evidence of RN coverage included the CNO's Vetus Time Study (dated July 2025). For 7/17/2025, the time study listed a task titled Sky DON Coverage with a total of daily hours of 10 hours. However, the time study did not include documentation of specific hours worked, nor did it demonstrate that the hours were consecutive. Additionally, the information documented in the time study did not algin with the facility's Daily Assignment Sheet (dated 7/17/2025). 7. A record review of the facility provided document Nursing Coverage (dated 7/21/2025) revealed the CNO had been listed as the 6AM-6PM RN on duty. The same document listed no other RNs, two LPNs and several NAs assigned to resident care throughout the 24-hour period. A record review of the facility's documentation provided as evidence of RN coverage included the Chief Nursing Officer's (CNO) Vetus Time Study (dated July 2025). For 7/21/2025, the time study listed a task titled Sky DON Coverage with a total of daily hours of 10.5 hours. However, the time study did not include documentation of specific hours worked, nor did it demonstrate that the hours were consecutive. Additionally, the information documented in the time study did not align with the facility's Daily Assignment Sheet (dated 7/21/2025). 8. A record review of the facility provided document Nursing Coverage (dated 7/25/2025) revealed RN-O had been listed as the Registered Nurse for 6PM-6AM. The same document listed no additional RNs, two LPNs, and several NAs assigned to resident care throughout the 24-hour period. A record review of the facility provided document Timecard Detail Report for RN-O, covering the date range 6/12/2025 to 8/14/2025, revealed no evidence RN-O had been on duty on 7/25/2025 or 7/26/2025. A record review of the facility provided document Timecard Report, for the Nursing Home Administrator (NHA), covering dates 6/12/2025 to 8/14/2025, revealed the NHA had been on duty on 7/25/2025 from 10:13 PM to 6:06 AM on 7/13/2025. Additional record review of the facility's documentation provided as evidence of all nursing staff, including agency/contract, who had worked from 6/12/2025-8/14/2025 including Timecard Reports, Timecard Detail Reports, and Vetus Time Studies revealed no evidence of a RN having been on duty of at least 8 consecutive hours for 7/25/2025. 9. A record review of the facility provided document Nursing Coverage (dated 7/26/2025) revealed no RNs had been assigned to duty for the 24-hour period. The same document revealed two LPNs, and several NAs assigned to resident care throughout the 24-hour period. A record review of the facility's documentation provided as evidence of RN coverage included the Nurse Consultant (NC)'s Vetus Time Study (dated July 2025). For 7/26/2025, the time study listed a task titled RN Coverage with a total of daily hours of 8 hours. However, the time study did not include documentation of specific hours worked, nor did it demonstrate that the hours were consecutive. Additionally, the information documented in the time study did not algin with the facility's Daily Assignment Sheet (dated 7/26/2025). 10. A record review of the facility provided document Nursing Coverage (dated 7/27/2025) revealed no RNs had been assigned to duty for the 24-hour period. The same document revealed two LPNs, and several NAs assigned to resident care throughout the 24-hour period. A record review of the facility's documentation provided as evidence of RN coverage included the Nurse Consultant (NC)'s Vetus Time Study (dated July 2025). For 7/27/2025, the time study listed a task titled RN Coverage with a total of daily hours of 8 hours. However, the time study did not include documentation of specific hours worked, nor did it demonstrate that the hours were consecutive. Additionally, the information documented in the time study did not algin with the facility's Daily Assignment Sheet (dated 7/27/2025). 11. A record review of the facility provided document Nursing Coverage (dated 7/31/2025) revealed no RNs had been assigned to duty for the 24-hour period. The same document revealed two LPNs, and several NAs assigned to resident care throughout the 24-hour period. A record review of the facility's documentation provided as evidence of RN coverage included the NC's Vetus Time Study (dated July 2025). For 7/31/2025, the time study listed a task titled 24-hour report, dashboard review, stand up meeting, MDS (Minimum Data Sets) assessments, Medicare Meeting, MDS submission, RN Coverage (8 hours) with a total of daily hours of 8 hours. However, the time study did not include documentation of specific hours worked, nor did it demonstrate that the hours were consecutive. Additionally, the information documented in the time study did not algin with the facility's Daily Assignment Sheet (dated 7/31/2025). A record review of the facility's documentation provided as evidence of RN coverage included the CNO's Vetus Time Study (dated July 2025). For 7/31/2025, the time study listed a task titled [NAME] IDR (Informal Dispute Resolution) Hearing - Travel to Sky - DON Orientation with a total of daily hours of 10.5 hours. However, the time study did not include documentation of specific hours spent on each task area, nor did it demonstrate that the hours were consecutive. A record review of Google Map's direction from [NAME], Nebraska to Bridgeport, Nebraska estimated the fastest route to be approximately 5 hours and 25 minutes long. 11. A record review of the facility provided document Nursing Coverage (dated 8/5/2025) revealed no RNs had been assigned to duty for the 24-hour period. The same document revealed two LPNs, and several NAs assigned to resident care throughout the 24-hour period. A record review of the facility provided document Timecard Detail Report for the DON covering the date range 6/12/2025 to 8/14/2025, revealed the DON had been on-duty on 8/5/2025 from 6:56 AM to 2:30 PM, a total of 7.57 hours. A record review of the facility's documentation provided as evidence of RN coverage included the CNO's Vetus Time Study (dated August 2025). For 8/5/2025, the time study listed a task titled Skyview-DON Coverage with a total of daily hours of 10 hours. However, the time study did not include documentation of specific hours worked, nor did it demonstrate that the hours were consecutive. Additionally, the information documented in the time study did not algin with the facility's Daily Assignment Sheet (dated 8/5/2025). 12. A record review of the facility provided document Nursing Coverage (dated 8/9/2025) revealed no RNs had been assigned to duty for the 24-hour period. The same document revealed one LPN, and several NAs assigned to resident care throughout the 24-hour period. A record review of the facility provided document Timecard Detail Report for the DON covering the date range 6/12/2025 to 8/14/2025, revealed 11 clock ins/clock outs between 7/28/2025 and 8/11/2025, however, there was no evidence the DON had been on duty on 8/9/2025. On 8/14/2025, the facility was requested to provide evidence of all nursing staffing coverage - including agency, contract staff, and management personnel who provided nursing coverage - form 6/12/2025 through 8/14/2025. An interview on 8/18/2025 at 11:25 AM with the NHA revealed the CNO does not clock in or out. The NHA stated that any shift without RN coverage would have been covered by the CNO. An interview on 8/18/2025 at 4:55 PM with the CNO revealed their time study is accurate and if it did not reflect their presence in the building on a particular day, they were not present. The CNO further revealed that in their absence, the NC would have provided RN coverage. An interview on 8/18/2025 at 5:50 PM was conducted with the NHA. When asked if besides the CNO, NC, DON, or other previously identified RNs may have provided RN coverage, the NHA responded, No not that I can think of. At that point, the DON entered the room. When the NHA was questioned about nurse coverage on the night shift and RN coverage for 8/9/2025, the DON interjected that they had worked the night shift on 8/9/2025 but acknowledged their timecard had not been clocking in or out correctly. The NHA confirmed the facility had no timecard correction form on file for the DON and instructed the DON to complete one at this time. Throughout the same interview, when asked about specific dates where RN coverage could not be confirmed by the already provided documentation, the NHA stated that further searching would be needed to identify any additional evidence of RN coverage and was unable to provide names of staff who may have fulfilled this requirement during the dates in question. At the time of exit, no additional evidence of RN staffing coverage had been received by the survey team. The facility was reminded during the exit conference of how to submit any further supporting documentation related to the investigation.
Mar 2025 11 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Licensure Reference 175 NAC 12-006.02(H) Based on record reviews and interviews, the facility failed to report allegations of staff-to-resident abuse to the required State agency within 2 hours involv...

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Licensure Reference 175 NAC 12-006.02(H) Based on record reviews and interviews, the facility failed to report allegations of staff-to-resident abuse to the required State agency within 2 hours involving 1 (Resident 33) of 1 sampled resident. The facility identified a census of 36. Findings are: A record review of a facility policy, Abuse Investigation and Reporting, with a last revised date of July 2017, revealed all alleged violations involving abuse will be reported to the State agency and Adult Protective Services (APS) within two hours of the alleged violation. A record review of a facility policy, Identifying Types of Abuse, with a last revised date of September 2022, revealed mental abuse is the use of verbal or non-verbal conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend or disability. Examples of mental and verbal abuse include harassing a resident; mocking, insulting or ridiculing; yelling or hovering over a resident with the intent to intimidate; threatening the resident, such as depriving a resident of care; derogatory statements directed to the resident; and isolating a resident from social activities. Some situations of abuse do not result in an observable physical injury, or the psychosocial effects of abuse may not be immediately apparent. In addition, some residents may not be able to recall what has occurred due to cognitive impairment (e.g., stroke, coma, Alzheimer's disease and may not be able to express outward signs of harm or mental anguish. Any staff to resident mental or verbal abuse is likely to cause psychical harm which may take months or year to manifest. A record review of an admission Record revealed the facility admitted Resident 33 on 6/24/2024 with a diagnosis of Dementia with mood disturbance. Resident 33 also had diagnoses of adjustment disorder with mixed anxiety and depressed mood (a mental health condition characterized by a significant emotional response to a stressful life event that leads to a combination of anxiety and depressive symptoms.) A record review of Resident 33's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) with an Assessment Reference Date (ARD) of 1/7/2025 revealed Resident 33 had a Brief Interview for Mental Status (BIMS, a brief screening that aids in detecting cognitive impairment) score of 2/15, which indicated Resident 33 had severe cognitive impairment. The MDS also revealed Resident 33 required substantial assistance from staff for oral hygiene, toileting, bathing, dressing, transfers, and personal hygiene. Additionally, the MDS revealed Resident 33 had not exhibited any behaviors in the 7 days prior to the assessment date. A record review of Resident 33's Care Plan - Cognition with a last revised date of 1/23/2025, revealed Resident 33 had impaired cognition and impaired thought processes due to Dementia and exhibited behaviors of verbal aggression and combativeness at times. Interventions for communication implemented were to use the resident's preferred name, staff to identify their selves at each interaction, face the resident when speaking and make eye contact, and reduce distractions. It also revealed Resident 33 understood consistent, simple directive sentences and to provide Resident 33 with necessary cues, stopping cares and returning if Resident 33 became agitated. A record review of an Abuse, Neglect or Misappropriate Incident Report with a date of 3/12/2025 revealed on 3/9/2025 between the hours of 10:30 AM and 12:00 PM, Nurse Aide (NA)-N had overheard raised voices coming from Resident 33's room and had notified NA-M. NA-N and NA-M entered Resident 33's room and found NA-J had been providing personal cares and had witnessed NA-J using a raised voice and telling the resident If you could stand we wouldn't need to use the life why can't you be more cooperative, like your wife. NA-N had left the room to get Licensed Practical Nurse (LPN) - D to assess the resident and notify LPN-D of the situation. When NA-N and LPN-D re-entered the room, NA-J stated to the resident, This is why nobody wants to take care of you. This statement was witnessed by NA-N, NA-M, and LPN-D. The report also revealed event and details of an allegation of verbal abuse had been reported to the Nursing Home Administrator (NHA) on 3/9/2025 at 3:54 PM via text message. The report revealed that the State Agency/APS was notified of the incident on 3/12/2025 at 9:04 AM. A record review of text messages dated 3/9/2025, from Nurse Aide (NA)-N to the MDS Coordinator (MDSC), revealed NA-N had reported to the MDSC that NA-N had overheard NA-J yelling at Resident 33. NA-N reported NA-J was degrading Resident 33 for not being able to stand up and had made the comment see this is why nobody wants to take care of you. NA-N reported Resident 33 had been crying. MDSC responded that they would inform the Director of Nursing (DON.) An interview on 3/13/2025 at 1:50 PM with the DON confirmed the MDSC had forwarded NA-N's text messages to the DON on 3/9/2025 at 3:59 PM. The DON confirmed the allegations were concerns of verbal abuse. The DON reported they had forwarded the text messages to the NHA on 3/9/2025 at 4:01 PM and the NHA had gone into the facility to investigate and believed the situation had been resolved. An interview on 3/13/2025 at 2:10 PM with the NHA revealed immediate steps of a written warning and education to NA-J were taken to protect Resident 33, although NA-J continued to work the remainder of their shift and the following day. NHA also confirmed the required State agency was not notified of the alleged abuse until 3/12/2025 as the NHA did not read through the whole text message received and was not aware of the extent of the incident. NHA agreed it was verbal abuse and should have been reported within 2 hours to the State agency/APS.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify 1 (Resident 17) of 1 sampled resident's representative in wr...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify 1 (Resident 17) of 1 sampled resident's representative in writing, as required, of the reason for Resident 17's transfer to the hospital. The facility census was 36. Findings Are: A record review of the facility policy Transfer or Discharge, Facility-Initiated with revision date of October 2022 revealed in the Policy Statement, Facility-Initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification. A record review of Resident 17's Progress Notes dated 3/7/25 revealed the resident had a change in condition, the facility had received an order from the provider to transfer the resident to the hospital for evaluation, and the facility called the resident's Power of Attorney (POA) and notified them that Resident 17 was being transferred. The Progress Notes also revealed that Resident 17 was admitted to the hospital on [DATE] with sepsis. A record review of Resident 17's electronic medical records revealed no evidence of the resident, or their representative (POA) being notified in writing of the reason for the resident's transfer to the hospital on 3/7/25. An interview on 3/11/25 at 3:00 PM with the Director of Nursing (DON) confirmed the facility did not notify Resident 17 or their representative in writing of the reason for Resident 17's transfer to the hospital on 3/7/25.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify 1 (Resident 17) of 1 sampled resident's representative of th...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify 1 (Resident 17) of 1 sampled resident's representative of the facility's bed hold policy at the time of Resident 17's transfer to the hospital. The facility census was 36. Findings Are: A record review of the facility policy Bed-Holds and Returns with a revision date of October 2022 revealed that all residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence. Residents, regardless of payer source, are provided written notice about these policies at least twice: -notice 1: well in advance of any transfer; and -notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours). A record review of Resident 17's Progress Notes dated 3/7/25 revealed the resident had a change in condition, the facility had received an order from the provider to transfer the resident to the hospital for evaluation, and the facility called the resident's Power of Attorney (POA) and notified them that Resident 17 was being transferred. The Progress Notes also revealed that Resident 17 was admitted to the hospital on [DATE] with sepsis. A record review of Resident 17's electronic medical records revealed no evidence of the resident, or their representative (POA) being notified of the facility's bed hold policy. An interview on 3/11/25 at 3:00 PM with the Director of Nursing (DON) confirmed the facility did not notify Resident 17 or their representative about the facility's bed hold policy upon Resident 17's admission to the hospital on 3/7/2025.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

Licensure Reference 175 NAC 12-006.09(F)(i) Based on record reviews and interview, the facility failed to develop a baseline care plan (BCP, a document that serves as initial instruction and guidance ...

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Licensure Reference 175 NAC 12-006.09(F)(i) Based on record reviews and interview, the facility failed to develop a baseline care plan (BCP, a document that serves as initial instruction and guidance for the resident's care) within 48 hours as required by state regulations for 1 (Resident 139) of 7 sampled residents. The facility identified a census of 36. Findings are: A record review of an undated facility policy, Care Plans - Baseline revealed BCPs should be developed for each resident within 48 hours of admission and include initial goals, physician's orders, dietary orders, therapy services, social services and Pre-admission Screening and Resident Review (PASRR, a process which requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have Serious Mental Illness or Intellectual Disability) recommendations - if applicable. A record review of an admission Record revealed the facility admitted Resident 139 on 3/4/2025 with diagnoses of cancer of the tongue and Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that cause airflow obstruction and breathing problems.) A record review of Resident 139's Care Plan revealed one focus area of advanced directives was initiated on 3/4/2025. There was no evidence a BCP had been developed to include initial goals, physician's orders, dietary orders, therapy services, or social services. An interview on 3/12/2025 at 2:30 PM with the Director of Nursing confirmed a BCP was not developed for Resident 139 wtih all required information within 24-48 hours as required.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. A record review of Resident 27's MDS dated [DATE] revealed Resident 27 was admitted to the facility on [DATE]. The MDS also r...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. A record review of Resident 27's MDS dated [DATE] revealed Resident 27 was admitted to the facility on [DATE]. The MDS also revealed Resident 27 had a BIMS score of 3/15, which indicated the resident had severe cognitive impairment. Resident 27 was always incontinent with their bowel movements and required substantial assistance from staff with toileting hygiene. A record review of Resident 27's undated care plan revealed the resident had an alteration in gastrointestinal status related to a diagnosis of constipation and was taking a laxative daily. The care plan had an intervention in place for this problem of follow facility bowel protocol for bowel management. A record review of Resident 27's Task-Bowel Elimination documentation in their electronic medical records from 2/10/25 through 3/11/25 revealed Resident 27 had no bowel movements during the following timeframes: -From 2/13/25 through 2/17/25, which was 5 days. -From 2/19/25 through 2/22/25, which was 4 days. -From 2/27/25 through 3/2/25, which was 4 days. -From 3/8/25 through the morning of 3/11/25, which was 3.5 days. A record review of Resident 27's Order Summary Report revealed an order with a start date of 1/25/2022 that stated, If no BM for 3 days, perform bowel assessment and administer 30 milliliters of Milk of Magnesia (a laxative medication). If no BM for 4 days, perform bowel assessment and administer one Dulcolax (a laxative medication) suppository. If no BM for 5 days, perform bowel assessment and administer a Fleets enema (a laxative medication inserted into the rectum). Notify MD (physician) if no results from enema. Document assessment, intervention, and result in progress note. A record review of Resident 27's Medication Administration Record (MAR) for February 2025 revealed no evidence that the resident had been offered or received Milk of Magnesia, Dulcolax suppository, or a Fleets enema. A record review of Resident 27's MAR for March 1-11, 2025 revealed no evidence that the resident had been offered or received Milk of Magnesia, Dulcolax suppository, or a Fleets enema. A record review of Resident 27's Progress Notes documented from 2/10/25 through 3/11/25 revealed no evidence that the resident's bowel status was assessed or that any interventions had been attempted when the resident had gone 3 or more days without a bowel movement. An interview on 3/11/25 at 3:05 PM with Licensed Practical Nurse (LPN)-C revealed the facility's nurse aides document resident bowel movements each shift in the electronic medical records. The night shift nurse runs a bowel report from the electronic medical records each night which shows which residents have not had a bowel movement in 3 or more days. This report is then given to the oncoming day shift nurse, who is responsible for following up with the resident, if cognitively intact, or with the nurse aides to determine if the resident had actually gone 3 or more days without a bowel movement. After the day shift nurse has done this follow up, the nurse would do an assessment of the resident and determine whether a PRN (as needed) bowel medication was needed for the resident and then would document their findings and what was done. When asked about Resident 27 being on the bowel report, LPN-C stated they would not be surprised if (Resident 27) had been on the report in the last month. Licensure Reference 175 NAC 12-006.09(H)(iv)(5) Based on record reviews and interviews, the facility failed to follow their bowel protocol orders to prevent constipation for 2 (Residents 16 and 27) of 5 sampled residents. The facility identified a census of 36. Findings are: A. A record review of an admission Record revealed the facility admitted Resident 16 to the facility on 1/20/2017 with a diagnosis of a cerebral aneurysm (a weakened area in the wall of a blood vessel in the brain that bulges.) Resident 16 also had diagnoses of dementia and constipation. A record review of Resident 16's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) with an Assessment Reference Date (ARD) of 1/22/2025 revealed Resident 16 had a Brief Interview for Mental Status (BIMS, a brief screening that aids in detecting cognitive impairment) score of 9, which indicated Resident 16 had moderate cognitive impairment. The MDS also revealed Resident 16 required total assistance with toileting and was always incontinent of bowel. A record review of Resident 16's Care Plan revealed the following: -A focus care area for Gastrointestinal (GI)/Bowels, last revised on 4/21/2024, revealed Resident 16 had an alteration in GI status related to the diagnosis of constipation. It also revealed an intervention to observe, document, and report to the physician as needed signs and symptoms of complication related to constipation with changes to abdominal distention, small or loose stools, bowel sounds, abdominal tenderness, or fecal compaction. -A focus care area for psychotropic medication use, last revised on 2/22/2025 revealed Resident 16's goal was to be free from discomfort or adverse reactions related to antidepressant therapy. It also revealed interventions to observe and document side effects every shift and observe, document, and report to the physician as needed any adverse reactions to antidepressant therapy of constipation or fecal impaction. -A focus care area for pain/discomfort that was last revised on 4/1/2024 revealed an intervention to observe for constipation and report occurrences to the physician. A record review of Resident 16's Order Summary Report as of 3/10/2025 revealed an order that a start date of 8/12/2019 that if Resident 16 had not had a bowel movement (BM) for 3 days, the nurse should perform bowel assessment and administer 30 milliliters (mL) of Milk of Magnesia ( a medication used to treat constipation). If Resident 16 had no BM for 4 days, the nurse should administer one Dulcolax suppository ( a medication used to treat constipation). If Resident 16 had no BM for 5 days, the nurse should perform a bowel assessment and administer a fleets enema. The nurse should notify the physician if no results from enema. The nurse is to document an assessment, the intervention, and the results in a Progress Note. A record review of Resident 16's Documentation Survey Report v2 (a report that reveals past documentation of bowel elimination) for the month of December 2024 revealed Resident 16 had no bowel movements during the following time periods: -12/4/2024-12/9/2024 (6 days), -12/11/2024-12/17/2024 (7 days), -12/21/2024-12/28/2024 (8 days). A record review of Resident 16's Medication Administration Record (MAR) for the month of December 2024 revealed the order that if Resident 16 had not had a bowel movement (BM) for 3 days, the nurse should perform bowel assessment and administer 30mL of Milk of Magnesia. If Resident 16 had no BM for 4 days, the nurse should administer one Dulcolax suppository. If Resident 16 had no BM for 5 days, the nurse should perform a bowel assessment and administer a fleets enema. The nurse should notify the physician if no results from enema. The nurse is to document an assessment, the intervention, and the results in a Progress Note had been documented once as completed on 12/28/2024 with a follow-up of results of unknown. There was no evidence the order had been completed for Resident 16's constipation during 12/4/2024-12/9/2024, 12/11/2024-12/17/2024, or 12/21/2024-12/27/2024. A record review of Resident 16's Progress Notes from 12/1/2024-12/31/2024 revealed no evidence an assessment or constipation interventions had been implemented for Resident 16's constipation during 12/4/2024-12/9/2024, 12/11/2024-12/17/2024, or 12/21/2024-12/27/2024. A record review of Resident 16's Documentation Survey Report v2 for the month of January 2025 revealed Resident 16 had no bowel movements during the following time periods: -1/7/2025-1/15/2025 (9 days), -1/20/2025-1/29/2025 (10 days). A record review of Resident 16's MAR for the month of January 2025 revealed the order that if Resident 16 had not had a bowel movement (BM) for 3 days, the nurse should perform bowel assessment and administer 30mL of Milk of Magnesia. If Resident 16 had no BM for 4 days, the nurse should administer one Dulcolax suppository. If Resident 16 had no BM for 5 days, the nurse should perform a bowel assessment and administer a fleets enema. The nurse should notify the physician if no results from enema. The nurse is to document an assessment, the intervention, and the results in a Progress Note had been documented as completed on 1/11/2025 with follow-up results of ineffective. There was no evidence the order had been completed for Resident 16's constipation from 1/7/2025-1/10/2025, after no results on 1/11/2025 through 1/15/2025, or 1/20/2025-1/29/2025. A record review of Resident 16's Progress Notes from 1/1/2025-1/31/2025 revealed no evidence an assessment or constipation interventions had been implemented for Resident 16's constipation during 1/7/2025-1/15/2025 or 1/20/2025-1/29/2025. A record review of Resident 16's Documentation Survey Report v2 for the month of February 2025 revealed Resident 16 had no bowel movements during the following time periods: -2/3/2025-2/9/2025 (7 days), -2/11/2025-2/19/2025 (9 days). A record review of Resident 16's MAR for the month of February 2025 revealed the order that if Resident 16 had not had a bowel movement (BM) for 3 days, the nurse should perform bowel assessment and administer 30mL of Milk of Magnesia. If Resident 16 had no BM for 4 days, the nurse should administer one Dulcolax suppository. If Resident 16 had no BM for 5 days, the nurse should perform a bowel assessment and administer a fleets enema. The nurse should notify the physician if no results from enema. The nurse is to document an assessment, the intervention, and the results in a Progress Note had not been documented as completed any time during the month of February 2025. A record review of Resident 16's Progress Notes from 2/1/2025-2/28/2025 revealed no evidence an assessment or constipation interventions had been implemented for Resident 16's constipation during February 2025. An interview on 3/12/2025 at 3:15 PM with the Director of Nursing (DON) revealed that Resident 16's charting was accurate, the facility had no additional evidence interventions for Resident 16's constipation had been implemented, and that staff should have followed the standing order of completing assessments, implementing interventions as ordered, and documenting Progress Notes. An interview on 3/13/2025 at 11:46 AM with the Chief Nursing Officer (CNO) confirmed the facility did not have a policy and is to follow the resident's orders.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09 (H)(vi)(3) Based on interviews and record review, the facility failed to administer...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09 (H)(vi)(3) Based on interviews and record review, the facility failed to administer oxygen as ordered by the physician to 1 of 1 (Resident 19) residents. The facility identified a census of 36. Findings are: A review of Resident 19's admission Record revealed they were admitted to the facility on [DATE] with a primary diagnosis of respiratory failure. A record review of Resident 19's physician orders revealed an order dated 2/11/25 for oxygen to be administered by nasal cannula at 1 liter per minute continuously. Record review of Resident 19's care plan revealed an entry dated 2/12/25 which read, Continuous oxygen via nasal cannula at 1 liters per minuete. An observation of Resident 19 on 3/12/25 at 11:05 AM revealed the resident not wearing oxygen by nasal cannula or any other means. An interview with Resident 19 on 3/12/25 at 12:27 PM confirmed they have not been wearing oxygen in the facility continuously. An interview on 3/12/25 at 12:14 PM with the Director of Nursing (DON) confirmed there was an order to administer continuous oxygen therapy to Resident 19 since they were admitted to the facility. During the interview, DON located orders from the discharging hospital on 2/11/25 and confirmed the facility was not following the oxygen order and should have been.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference 175 NAC 12-006.09(H)(i)(3) Based on observations, interviews, and record reviews, the facility failed to pro...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference 175 NAC 12-006.09(H)(i)(3) Based on observations, interviews, and record reviews, the facility failed to provide assistance with bathing services in order to maintain good hygiene for 3 (Residents 13, 15, and 16) of 3 sampled residents. The facility identified a census of 36. Findings are: A record review of a facility policy, Activities of Daily Living, Supporting with a last revised date of March 2018 revealed appropriate care and services will be provided for residents who are unable to carry out Activities of Daily Living (ADLs), including hygiene (bathing, dressing, grooming, and oral care) independently, with consent of the resident and in accordance with the plan of care. A. A record review of an admission Record revealed the facility admitted Resident 16 to the facility on 1/20/2017 with diagnoses of a cerebral aneurysm (a weakened area in the wall of a blood vessel in the brain that bulges.) Resident 16 also had diagnoses of dementia, Chronic Obstructive Pulmonary Disease (a group of lung diseases that can cause breathing problems, shortness of breath upon exertion, and fatigue,) seizures, depression, chronic pain, muscle weakness, and fibromyalgia (a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues.) A record review of Resident 16's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) with an Assessment Reference Date (ARD) of 1/22/2025 revealed Resident 16 had a Brief Interview for Mental Status (BIMS, a brief screening that aids in detecting cognitive impairment) score of 9, which indicated Resident 16 had moderate cognitive impairment. The MDS also revealed Resident 16 had one-sided impairment on both their upper and lower side and required substantial assistance with bathing. A record review of Resident 16's annual MDS with an ARD of 11/22/2024 revealed it was very important to Resident 16 to choose between a tub bath, shower, bed bath, or sponge bath. A record review of Resident 16's Care Plan revealed a focus area for ADL Function/Mobility with a last revised date of 4/21/2024. The focus area revealed Resident 16 had an ADL self-care performance deficit due to their left sided hemiplegia (paralysis on one side of the body) and generalized muscle weakness. An intervention to provide assistance of one-person for bathing/showering had been added. An observation on 3/10/2025 at 1:13 PM revealed Resident 16 was in a hospital gown resting in bed. Resident 16's hair was disheveled and greasy in appearance. An observation on 3/11/2025 at 9:05 AM revealed Resident 16 was in a hospital gown resting in bed. Resident 16's hair continued to be disheveled and greasy in appearance. A record review of a Documentation Survey Report v2 (a generated report of past documentation including bathing) from November 2024 revealed Resident 16's last bath in November was on 11/21/2024. A record review of a Documentation Survey Report v2 from December 2024 revealed Resident 16 had been offer one bath on 12/26/2024 but was documented as refused. There was no further evidence that Resident 16 had been offered or received a bath in the month of December 2024. A record review of a Documentation Survey Report v2 from January 2025 revealed Resident 16 had received one bath on 1/9/2025 (49 days since their last documented bath received.) There was no further evidence that Resident 16 had been offered or received additional baths in the month of January 2025. A record review of The Spa at Skyview Weekly Bathing Schedule (paper documentation of baths provided) with a date of 1/13/2025-1/18/2025 revealed no evidence Resident 16 had received a bath. A record review of a Documentation Survey Report v2 from February 2025 revealed no evidence that Resident 16 had been offered or received a bath in the month of February 2025. A record review of The Spa at Skyview Weekly Bathing Schedule with a date of 2/2/2025-2/8/2025 revealed no evidence Resident 16 had been offered or received a bath. A record review of The Spa at Skyview Weekly Bathing Schedule with a date of 2/17/2025-217/2025 revealed Resident 16 had received a bath on 2/20/2025 (42 days since their last documented bath received) and on 2/22/2025. A record review of a Documentation Survey Report v2 from March 2025 revealed no evidence that Resident 16 had been offered or received a bath in the month of March 2025 as of 3/12/2025. A record review of The Spa at Skyview Weekly Bathing Schedule with a date of 3/10/2025-315/2025 revealed Resident 16 had received a bath on 3/15/2025 (21 days since their last documented bath.) A record review of Resident 16's Progress Notes from 12/1/2024-3/12/2025 revealed no evidence of Resident 16 having been offered a bath, shower, or bed/sponge bath; Resident 16 having refused bathing cares; or that Resident 16 had been provided bathing cares. An interview on 3/13/2025 at 9:30 AM with the Director of Nursing (DON) revealed that the DON was aware of a lack of baths being provided due to staffing concerns. An interview on 3/17/2025 at 2:00 PM with the DON revealed that the lack of charting for bathing Resident 16 was accurate and there was no other evidence that Resident 16 had received any additional assistance with bathing. B. A record review of Resident 15's medical record reveals they were admitted on [DATE] with diagnoses of heart disease, autistic disorder (a developmental disability that affects social communication and interaction), a colostomy (a surgical procedure where the colon is cut and diverted to the abdominal wall), and osteoarthritis of both knees (a degenerative joint disease). A record review of a facility document titled, Activities of Daily Living, Supporting, which was last revised March 2018, revealed that care and services will be provided for residents who are unable to carry out ADL's independently. A record review of Resident 15's care plan revealed this resident required one person to assist with bathing, and staff should offer a bed bath if the resident refused a shower. Record review of paper bath records provided by the facility revealed Resident 15 refused a bath on 2/20/25, received a bath on 2/22/25, and received a bath on 3/1/25. Record review of Resident 15's electronic medical record revealed the following: -From 3/1/25 to 3/17/25, no baths were documented, and not available was charted on 3/7/25. -From 2/1/25 to 2/28/25, no baths were documented, and not available was charted on 2/7/25. -From 1/16/25 to 1/31/25, no baths were documented, and not available was charted on 1/16 and 1/20. Record review of progress notes in Resident 15's electronic medical record between 2/15/25 and 3/17/25 revealed no baths charted. An interview on 3/17/25 at 1:50 PM with the DON confirmed that Resident 15 did not get baths as required. DON stated they were aware that Resident 15 had refused baths and showers but staff was supposed to offer bed baths. C. A record review of Resident 13's census data and face sheet revealed resident was admitted [DATE] with the diagnoses of: Essential(primary) hypertension , other muscle weakness, Type Two Diabetes Mellitus without complications, Tremors, Unspecified abnormalities of gait and mobility, unsteadiness on feet, morbid (severe) obesity due to excessive calories. A record review of Resident 13's quarterly MDS dated [DATE] revealed in Section C, a BIMS a score of 14, a score of 13-15 is cognitively intact. Section F: Bathing choices were very important. Section GG: toileting dependent, bathing partial or moderate assist. A record review of Resident 13's Care Plan revealed: ADL functioning/Mobility: I have an ADL self-care performance deficit r/t weakness, congestive heart failure, respiratory failure, pain, date initiated: 10/26/2023 revision on: 01/31/2025, 02/1/2025 Occupational Therapy evaluation. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care. Including appropriate support and assistance with a) Hygiene (bathing, dressing, grooming, and oral care) last revised March 2018. A record review of the facility bathing schedules revealed the week of 02/09/2025 through 02/16/2025 were missing and 02/23/2025 was missing. The bathing schedules that were available revealed that they did not match what was documented in Point of care (POC) (the electronic charting system for the staff to document). According to the bathing schedules, Resident 13 did not receive a bath from 01/18/2025 to 02/2/2025 for a total of 14 days. Resident 13 did not receive a bath from 02/20/2025 to 02/27/2025 for a total of 7 days. According to the POC, Resident 13 did not receive a bath from 03/1/2025 to 03/10/2025 for a total of 10 days. An interview on 03/10/25 at 11:53 AM with Resident 13 revealed that the resident would like to have a bath three times a week but has not had a bath in over a week and it upsets the resident. The resident goes on to say that new staff tell the residents they will be right back and sometimes you don't see them again and that the resident sometimes ends up having accidents because the staff do not come back. An interview with Resident 13 on 03/11/2025 at 11:30 AM revealed the resident stated they feel yucky. Resident also verbalized that has not had a bath in over two weeks, and that the facility does not have enough staff. An interview on 03/10/2025 at 10:30 AM with the DON revealed that the DON was unable to locate all the bathing schedules for the last few months due to the all the new staff. The DON confirmed that they were unable to verify baths given.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference 175 NAC 12-006.09 (I) Licensure Reference 175 NAC 12-006.19(A) Based on observations, interviews, and record...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference 175 NAC 12-006.09 (I) Licensure Reference 175 NAC 12-006.19(A) Based on observations, interviews, and record reviews, the facility failed to: develop and implement interventions for Resident 32's falls, failed to ensure Resident 17's carpet was free from buckling to prevent the potential for an avoidable accident. The sample size was 4. The facility identified a census of 36. Findings are: A. A record review of a facility policy, Assessing Falls and Their Causes with a last revised date of October 2010 revealed after a resident falls, appropriate interventions to prevent future falls will be recorded in the resident's medical record. A record review of an admission Record revealed the facility admitted Resident 32 on 8/4/2023 with a diagnosis of Chronic Myeloid Leukemia (a caner of the blood and bone marrow.) Resident 32 also had diagnoses of paroxysmal atrial fibrillation (a heart rhythm disorder that can cause rapid, irregular heartbeats, shortness of breath, dizziness, and fatigue), unsteadiness on feet, generalized muscle weakness, abnormalities of gait and mobility, and osteoporosis (a bone disease that weakens bones, making them more likely to break.) A record review of Resident 32's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) with an Assessment Reference Date (ARD) of 2/11/2025 revealed Resident 32 had a Brief Interview for Mental Status (BIMS, a brief screening that aids in detecting cognitive impairment) score of 15, which indicated Resident 32 was cognitively intact. The MDS also revealed Resident 32 used a walker and wheelchair for mobility and required supervision during ambulation, transfers, toileting, and dressing. Further review of the MDS revealed Resident 32 had one fall since their last assessment that resulted in a major injury. A record review of Resident 32's Care Plan revealed a focus area for falls with a last revised date of 2/12/2025. The care plan revealed Resident 32 was at risk for falls related to a recent fall with fracture and decreased/mobility and balance. An unwitnessed fall on 5/4/2024 and 5/18/2024 and a witnessed fall on 11/28/2024 in the driveway with family were noted. The following interventions were implemented: -Three interventions were initiated on 8/7/2023 to anticipate and meet Resident 32's needs, for physical therapy to evaluate and treat as ordered or as needed, and to ensure Resident 32's environment was safe with floors free of spills or clutter, a working and reachable call light, the bed in low position at night, and personal items within reach. -An intervention for Resident 32's fall on 5/4/2024 was initiated and implemented on 5/8/2024 for 1 person assist for transfers until Resident 32's medications were adjusted. -An intervention for Resident 32's fall on 5/18/2024 was initiated and implemented on 5/22/2024 for Resident 32 to order new shoes or wear non-slip socks instead of high-top shoes and to ensure that Resident 32 is wearing non-skid socks, slippers or appropriate footwear. -Two interventions were initiated on 2/12/2025 to educate the resident/family/caregivers about safety reminders and what to do if a fall occurs and follow facility fall protocol. A record review of Resident 32's Progress Notes from 5/4/2024 revealed the following: -At 2:18 PM, Resident 32 was observed lying on the floor in the hallway. Resident 32 complained of hitting their head hard and was sent to the Emergency Department for further evaluation. There was no evidence an intervention to prevent additional falls had been implemented. -At 3:00 PM, Resident 32 returned from the Emergency Department and was noted to have no fractures, but did have a hematoma to the left side of their head. There was no evidence an intervention to prevent additional falls had been implemented. A record review of Resident 32's Un-witnessed Fall Report from 5/4/2024 revealed Resident 32 was observed lying on the floor in the hallway. Resident 32 complained of hitting their head hard and was sent to the Emergency Department for further evaluation. There was no evidence an intervention to prevent additional falls had been implemented. A record review of Resident 32's Progress Notes from 11/28/2024 revealed the following: -At 2:27 PM, Resident 32's friend had come into the facility to notify staff that Resident 32 had fallen in the parking lot. Resident 32 was transported to the Emergency Department for evaluation. There was no evidence an intervention to prevent additional falls had been implemented. -On 11/28/2024 at 5:17 PM, the Emergency Department contacted the facility to update them on Resident 32's condition and had reported Resident 32 had sustained a right fibula (calf bone) fracture. There was no evidence an intervention to prevent additional falls had been implemented. A record review of Resident 32's Witnessed Fall Report from 11/18/2024 revealed Resident 32's friend had come into the facility to notify staff that Resident 32 had fallen in the parking lot. Resident 32 was transported to the Emergency Department for evaluation. An Interdisciplinary Team (IDT) Review note was implemented on 12/2/2024 with discussion of Physical Therapy and Occupation Therapy to evaluate/treat Resident 32. There was no evidence an intervention that the facility was responsible for implementing to prevent additional falls immediately following Resident 32's fall had been implemented. A record review of Resident 32's Progress Notes from 3/6/2025-3/7/2025 revealed the following: -On 3/6/2025 at 6:05 PM, Resident 32 was found to be laying on the floor complaining of severe right hip and ankle pain. Resident 32 was transported to the Emergency Department for evaluation. There was no evidence an intervention to prevent additional falls had been implemented. -On 3/7/2025 at 1:50 AM, Resident 32 returned from the Emergency Department with 8/10 right hip pain and a bruise of 5.5 x 20 cm to the back of their right upper leg. There was no evidence an intervention to prevent additional falls had been implemented. A record review of Resident 32's Un-witnessed Fall Report from 3/6/2025 revealed Resident 32 was found to be laying on the floor complaining of severe right hip and ankle pain. Resident 32 was transported to the Emergency Department for evaluation. There was no evidence an intervention to prevent additional falls had been implemented. An additional record review of Resident 32's fall care plan revealed an intervention had not been implemented for Resident 32's fall on 5/4/2024 until 5/8/2024, an intervention for Resident 32's fall on 11/18/2024 had not been implemented until 2/12/2025, and there was no evidence an intervention had been implemented for Resident 32's fall on 3/6/2025. An interview on 3/12/2025 at 2:30 PM with the Director of Nursing (DON) confirmed no interventions for Resident 32's falls on 5/4/2024 and 11/18/2024 were implemented immediately and had been implemented late. The DON also confirmed no intervention for Resident 32's fall on 3/6/2025 had been implemented. An interview on 3/10/2025 at 9:02 AM with Resident 32 revealed Resident 32 had a fall a few days ago. Resident 32 reported they had been sitting on their walker at their sewing machine and had stood up in their walker when their right foot snapped causing Resident 32 to fall to the ground. Resident 32 revealed they were unable to use the call light to call for assistance as one was on their bed and one was on their recliner, both not within reach. Resident 32 reported injury of a large hematoma (bruise) on their hip and continues to have pain in their hip affecting their ability to participate in activities due to the inability to tolerate sitting for extended periods of time. An observation on 3/10/2025 at 9:03 AM revealed Resident 32 was resting in their recliner. Resident 32's call light was not within reach as the call light was tightly wrapped around Resident 32's bed rail. An interview on 3/10/2025 at 9:33 AM with the DON confirmed Resident 32's call light was not within reach and should have been. The DON immediately moved Resident 32's call light within their reach. B. An observation on 3/11/25 at 8:43 AM in Resident 17's room (room [ROOM NUMBER]), revealed the carpet had several large buckles (ripples) in the central area of the resident's room. Resident 17 was not in the room at that time. A walker was located in the room. A record review of Resident 17's electronic medical record revealed they were admitted to the facility on [DATE] with heart disease, dementia (a progressive decline in cognitive function), megalencephalic leukoencephalopathy (a genetic disorder that affects brain development and function), and chronic obstructive pulmonary disease. A record review of Resident 17's medical records revealed the resident fell in their room on the following dates: 1/24/25 at 2:30 AM, 1/24/25 at 8:00 AM, 1/26/25 at 1:00 AM, and 2/4/25 at 12:25 AM. A record review of the fall investigations for each of the four falls revealed the following possible contributing factors for the falls: altered balance, improper footwear, walking backward, and walking without assistance. A record review of a facility policy, Assessing Falls and Their Causes, last revised October 2010 revealed all relevant environmental issues should be addressed promptly. An interview on 3/12/25 at 8:50 AM with the Maintenance Director (MTD) revealed that the carpet was damaged by a prior resident who drove their electric wheelchair in circles repeatedly. MTD confirmed the carpet needed to be replaced. They also confirmed this has been present for several months
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0729 (Tag F0729)

Could have caused harm · This affected most or all residents

Licensure Reference 175 NAC 12-006.04(A)(iii)(2)(a) Based on record reviews and interview, the facility failed to complete a nurse aide registry check prior to hire as required for 5 [Nurse Aide (NA) ...

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Licensure Reference 175 NAC 12-006.04(A)(iii)(2)(a) Based on record reviews and interview, the facility failed to complete a nurse aide registry check prior to hire as required for 5 [Nurse Aide (NA) - E, NA-O, Assistant Director of Nursing (ADON), Dietary Aide (DA) - A, and Dietary Supervisor (DS)] of 5 sampled employees. This had the potential to affect all residents who reside within the facility. The census was 36. Findings are: A record review of a facility policy, Background Screening Investigations with a last revised date of March 2019 revealed for any individual applying for a position of a NA, the state NA registry is contacted to determine if any findings of abuse, neglect, mistreatment, or theft have been entered into the applicant's file. There was no evidence of a nurse aide registry check being completed prior to hire if the employee has direct, unsupervised access to residents. A record review of a facility staff list, with a date of 3/10/2025, revealed the following: -NA-E was hired on 12/6/2024. -NA-O was hired on 10/30/2024. -The ADON was hired on 11/20/2024. -DA-A was hired on 2/20/2025. -The DS was hired on 1/8/2025. A record review of NA-E's personnel file revealed no evidence a NA registry check had been completed prior to hire. A record review of NA-O's personnel file revealed no evidence a NA registry check had been completed prior to hire. A record review of the ADON's personnel file revealed no evidence a NA registry check had been completed prior to hire. A record review of DA-A's personnel file revealed no evidence a NA registry check had been completed prior to hire. A record review of the DS's personnel file revealed no evidence a NA registry check had been completed prior to hire. An interview on 3/12/2025 at 10:00 AM with the Business Office Manager confirmed the facility does not run NA registry checks prior to hire.
CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected most or all residents

Licensure Reference 175 NAC 12-006.04(B)(ii)(1) Based on record reviews and interview, the facility failed to ensure 12 hours of ongoing training had been completed for the year for 5 [Nurse Aide (NA)...

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Licensure Reference 175 NAC 12-006.04(B)(ii)(1) Based on record reviews and interview, the facility failed to ensure 12 hours of ongoing training had been completed for the year for 5 [Nurse Aide (NA) - G, NA-H, NA- F, MA-I, and NA- K] of 5 sampled employees. This had the potential to affect all residents who reside within the facility. The facility identified a census of 36. Findings are: A record review of the facility's SCARAB Facility Assessment with a last revised date of 1/15/2024 revealed nurse aides will complete at least 12 hours of ongoing training per year, including dementia and abuse. A record review of a facility staff list, with a date of 3/10/2025, revealed the following: - NA-G was hired on 8/11/1989. - NA-H was hired on 9/1/2018. - NA-F was hired on 8/30/2023. - MA-I was hired on 1/13/2023. - NA-K was hired on 12/17/2018. A. A record review of an In-Service Quiz - Infection Control with a date of 3/8/2024 had been completed by NA-G, however, at the time exit, the facility had not provided evidence of hours completed for this training. A record review of in-services attended by NA-G from 8/11/2023-8/10/2024 revealed the following: -3/12/2024 - Survey Preparedness, Abuse, COVID Vaccine, - 1.25 hours -4/9/2024 - Survey Preparedness, Abuse, COVID, Back to Basics - 1.25 hours -5/14/2024 - Survey Preparedness, Abuse, COVID, Fire Safety - 1.25 hours -There was no evidence NA-G had completed ongoing training on dementia. -A total of 4.75 hours of ongoing training was able to be verified by the facility documentation provided. B. A record review of in-services attended by NA-H from 9/1/2023-8/31/2024 revealed the following: -4/9/2024 - Survey Preparedness, Abuse, COVID, Back to Basics - 1.25 hours -5/14/2024 - Survey Preparedness, Abuse, COVID, Fire Safety - 1.25 hours -7/10/2024 - Abuse, COVID, Attitudes, Dress Code, Dining, Respect, Resident Complaints - 1.25 hours -There was no evidence that NA-H had completed ongoing training on dementia. -A total of 4.75 hours of ongoing training was able to be verified by the facility documentation provided. C. A record review of in-service quizzes from 8/30/2023-8/29/2024 completed by NA-F revealed the following: -12/28/2023 - Communication with Alzheimer's Elders -12/28/2023 - Infection Control -At the time of exit, the facility had not provided evidence of hours completed for these trainings as requested. A record review of in-services attended by NA-K from 8/30/2023-8/29/2024 revealed the following: -3/12/2024 - Survey Preparedness, Abuse, COVID Vaccine, - 1.25 hours -4/9/2024 - Survey Preparedness, Abuse, COVID, Back to Basics - 1.25 hours -7/10/2024 - Abuse, COVID, Attitudes, Dress Code, Dining, Respect, Resident Complaints - 1.25 hours -8/14/2024 - Lock Out/Tag Out, Social Media, Abuse, Complaints, Menus, Parking - Unable to verify hours -There was no evidence that NA-K had completed ongoing training on dementia. -A total of 4.75 hours of ongoing training was able to be verified by the facility documentation provided. D. A record review of in-service quizzes from 1/13/2024-1/13/2025 completed by MA-I revealed the following: -2/4/2024 - How to Prevent Falls -2/24/2024 - Successful Dining -3/12/2024 - Infection Control -7/15/2024 - Communication with Alzheimer's Elders -8/1/2024 - An Effective Reminiscence Program -8/19/2024 - How to Prevent Falls (Duplicate course as 2/4/2024) -10/14/2024 - Resident Rights -At the time of exit, the facility had not provided evidence of hours completed for these trainings as requested. A record review of in-services attended by MA-I from 1/13/2024-1/13/2025 revealed the following: -4/9/2024 - Survey Preparedness, Abuse, COVID, Back to Basics - 1.25 hours -7/10/2024 - Abuse, COVID, Attitudes, Dress Code, Dining, Respect, Resident Complaints - 1.25 hours -10/22/2024 - Emergency Procedures - 1.25 hours -11/12/2024 - Abuse and Neglect, Resident Rights, Customer Service - 1 hour -11/14/2024 - Legionella - 0.5 hours -There was no evidence that MA - I had completed ongoing training on dementia. -A total of 6.25 hours of ongoing training was able to be verified by the facility documentation provided. E. A record review of in-service quizzes from 12/17/2023-12/16/2024 completed by NA-K revealed the following: -2/12/2024 - Falls -2/24/2024 - Communication with Alzheimer's Elders -2/24/2024 - Infection Control -3/12/2024 - Resident Right's -3/12/2024 - An Effective Reminiscence Program -8/1/2024 - Successful Dining -At the time of exit, the facility had not provided evidence of hours completed for these trainings as requested. F. A record review of in-services attended by NA-K from 12/17/2023-12/16/2024 revealed the following: -3/12/2024 - Survey Preparedness, Abuse, COVID Vaccine, - 1.25 hours -4/9/2024 - Survey Preparedness, Abuse, COVID, Back to Basics - 1.25 hours -5/14/2024 - Survey Preparedness, Abuse, COVID, Fire Safety - 1.25 hours -7/10/2024 - Abuse, COVID, Attitudes, Dress Code, Dining, Respect, Resident Complaints - 1.25 hours -8/14/2024 - Lock Out/Tag Out, Social Media, Abuse, Complaints, Menus, Parking - Unable to verify hours -9/9/2024 - Enhanced Barrier Precautions - Unable to verify hours -10/30/2024 - Dementia - 4 hours -A total of 10 hours of ongoing training was able to be verified by the facility documentation provided. An interview on 3/13/2025 at 1:45 PM with the Director of Nursing (DON) confirmed the facility documentation revealed NA-G, NA-H, NA-F, MA-I, and NA-K had not met the required 12 hours of ongoing training.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175-NAC 12-006.11(E) Based on observation, interview, and record review, the facility failed to dispo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175-NAC 12-006.11(E) Based on observation, interview, and record review, the facility failed to dispose of expired foods, clean dry storage area and freezer, failed to implement hand hygiene practices to prevent the potential for cross contamination, use hair and beard restraints, and obtain food temperatures prior to serving to prevent the potential for foodborne illness. This had the potential to affect all residents who ate from the kitchen. The facility census was 36 . Findings are: A. An observation during the initial kitchen tour on 3/10/2025 from 7:30 AM to 8:18 AM revealed the two upright freezers with dried old food particles in the bottom and dark stains with black smears on the outside of the freezers. One freezer with approximately 3 inch ice build up around inside on the sides and top, the inside of the door with yellow stains from a food spillage and dried old food particles on the bottom. The dry food storage area revealed 1 bag of spiral rotini unsealed and no date, 1 package of spaghetti noodles unsealed and no open date. 1 bag of macaroni unsealed and no open date. A cart with canned goods with old food particles on the shelves. One refrigerator with a bottle of Premium lemon juice with an expiration date of 1/18/2025, and an opened date of 3/7/2025, low moisture mozzarella cheese opened 2/21/2025 that was expired, [NAME] sour cream 1/2 empty with no open date, Cottage cheese 3/4 full with no open date, a pitcher of dark brown liquid undated and unlabeled. Under a prep table there was a canister of flour and a canister of sugar with dried chunks of multicolored old food particles on the lids and the canisters had black smudge marks on the outside and on the lids. There was a rolling cart by the dishwasher with clean plates stack on 1st and 2nd shelf and the cart had food stains and chunky old food particles on all the shelves. The ice machine with a white crusty substance inside the machine where the ice was located, and directly on top of the machine, around the lid and streaked down the front of the machine. An ice scoop was sitting directly on top of the machine without a holder or any type of barrier. There was a shelf for storing baking pans with a dried flaky brown substance and white stains on the counter above it. A staff's personal cell phone and drink were sitting on a shelf with the clean dishes. An interview on 3/10/2025 at 8:18 AM with [NAME] A confirmed the expired food items listed, foods opened with no open dates and cleanliness concerns in the kitchen as listed. Record review of facility policy titled Receiving Food and Storage last revised 11/2022 revealed under refrigerated and frozen foods, all foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). Dry Food Storage, dry foods that are stored in bins are removed from original packaging are labeled and dated (use by date). B. An observation during meal preparation on 3/10/2025 from 9:18 AM to 10:20 AM revealed [NAME] A with no beard/mustache cover on and had greater than a 1/4 inch in length mustache. [NAME] A completed hand hygiene (HH) and applied gloves, then obtained a chopping board and 2 medium onions and chopped them for cooking. [NAME] A obtained a pan, added butter, then without the benefit of HH or changing gloves, continued to chop onions and divided into 2 separate bowls without measuring. [NAME] A removed left glove, obtained the recipe book and a large can of tuna, used both hands to open the tuna, wiped hands on apron, drained the tuna and poured into a bowl with onions. [NAME] A removed the right glove, without HH, obtained lemon juice into a measuring cup and poured onto the tuna. [NAME] A then completed HH for 14 seconds and applied gloves, stirred the onions and beans, then obtained a jar of mayonnaise from the refrigerator. [NAME] A finished the tuna sandwich mixture, covered with plastic wrap and placed in the refrigerator. Cook A applied clean gloves without the benefit of HH and removed refried beans from the stove, sat them on the counter and added an undetermined amount of onions and green chilies to the beans. [NAME] A grabbed a dishrag from a pile of soiled rags and wiped the counter with gloves on. Without changing gloves, [NAME] A opened another can of green Chiles and added to the bean mixture. [NAME] A then opened a can of enchilada sauce and began to layer tortillas with the same soiled gloves on, added bean mixture and enchilada sauce and removed gloves. [NAME] A then obtained shredded cheese from the refrigerator and grabbed handfuls of cheese with bare hands to spread on top of the enchilada casserole. An observation on 3/10/2025 at 11:40 AM revealed [NAME] A had removed the casserole from the oven, when asked what the temperature had reached, [NAME] A responded I cooked it at a higher temp so I know that it is hot enough, no temp taken. [NAME] A adjusted facial glasses with gloved hands, obtained the soiled dishrag and wiped the prep counter down, with the same soiled gloves on [NAME] A cut churros and sprinkled with cinnamon. During the meal service on 3/10/2025 at 11:48 AM [NAME] A washed hands for 9 seconds and applied gloves. [NAME] A began serving the meal without obtaining any temperatures, using scoops and ladles, and touching other objects, then [NAME] A opened the refrigerator and removed a sandwich with the soiled gloves. [NAME] A removed gloves and completed HH for 10 seconds and did not apply gloves. [NAME] A continued to obtain sandwiches from the refrigerator. The Dietary Supervisor (DS) entered the kitchen, completed HH for 10 seconds and applied gloves, the DS did not have a beard cover on and had a beard and mustache. The DS began washing dishes and handing them to [NAME] A to put away. In between putting dishes away and serving [NAME] A obtained a block of cheese from the refrigerator and began peeling off slices of cheese with bare hands for the sandwiches. [NAME] A rinsed hands, without gloves, began serving foods, then applied gloves, then touched more sandwiches to serve. [NAME] A then began touching the menu slips from residents, the scoops, and wiped gloved hands on pant leg and apron, then began picking up the churros with the same soiled gloves to serve to the residents. An interview on 3/10/2025 at 2:00 PM with [NAME] A confirmed that HH was not completed or not completed for 20 seconds, that the dishrag was soiled that was used during meal service, and did not change gloves or wear gloves at appropriate times during meal service. Record review of facility policy titled Preventing Foodborne Illness-employee hygiene and sanitary practices last revised 11/2022 revealed under the Hand Washing/Hand Hygiene section, Number 6: Employees must wash their hands. D. Before coming into contact with any food surfaces. F. After handling soiled equipment or utensils. G & H. During food preparation as often as necessary to remove soiled and contamination, and to prevent cross contamination with changing tasks and/or after engaging in other activities that contaminate the hands. Gloves and direct food contact section, Number 8. Contact between food and bare hands is prohibited. Hair nets section: Number 15. Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling foods to keep hair from contacting exposed food, clean equipment, utensils and linens.
Jan 2025 2 deficiencies
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

License Reference Number 175 NAC 12-006.02 (H) Based on record review and interview, the facility failed to submit their investigation of an incident within 5 working days as required for 1 (Resident ...

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License Reference Number 175 NAC 12-006.02 (H) Based on record review and interview, the facility failed to submit their investigation of an incident within 5 working days as required for 1 (Resident 1) of 2 sampled residents. The facility identified a census of 37. Findings Are: A record review of a facility document titled Abuse, Neglect, or Misappropriation and dated 10/23/24, revealed Resident 1 had a fall with injury on 10/15/24 at 10:00 PM. The document further revealed the investigation was submitted to the State Agency on 10/23/24. An interview on 1/6/25 at 1:15 PM with the Administrator confirmed the facility did not submit their investigation of Resident 1's fall with injury that occurred on 10/15/24 to the State Agency within 5 working days as required.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Licensure Reference175 NAC 12-006.09(I) Based on record reviews and interview, the facility failed to develop new interventions for falls for 1 (Resident 2) of 3 sampled residents. The facility identi...

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Licensure Reference175 NAC 12-006.09(I) Based on record reviews and interview, the facility failed to develop new interventions for falls for 1 (Resident 2) of 3 sampled residents. The facility identified a census of 37. Findings Are: A record review of a facility policy, Falls and Fall Risk, Managing, with a last revised date of March 2018 indicated if falls recur despite initial interventions, staff will implement additional or different interventions. A record review of an admission Record indicated the facility admitted Resident 2 on 5/27/2022 with diagnoses of history of falling, dystonia (a brain condition that causes uncontrollable muscle movement,) hemiplegia (weakness on one side of the body,) muscle weakness, unsteadiness on feet, and abnormalities of gait and mobility. A record review of Resident 2's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning), with an Assessment Reference Date of 11/8/2024 indicated Resident 2 had a Brief Interview for Mental Status (BIMS, a brief screening that aids in detecting cognitive impairment) score of 15/15, indicating Resident 2 had no cognitive impairment. The MDS also indicated Resident 2 required use of a walker and wheelchair; supervision with transfers; and partial assistance with dressing. It also revealed Resident 2 was taking an antipsychotic (a class of drugs that treat symptoms of psychosis, such as hallucinations, delusions, and disorganized thinking,) diuretic (a water pill,) and opioid (narcotic pain) medications. A record review of Resident 2's undated Care Plan revealed the following related to Resident 2's falls: - Resident 2 was at risk for falls related to chronic pain, impaired mobility, and poor safety awareness. - Resident 2 had fallen on 9/5/2024, 10/2/2024, 10/7/2024, 11/1/2024, 11/26/2024, 12/2/2024, 12/24/2024, and 12/25/2024. The care plan did not reflect Resident 2's falls that occurred on 9/23/2024 or 1/3/2025. - Duplicate interventions for Resident 2's falls on 10/7/2024, 12/2/2024 of Physical Therapy (PT)/Occupational Therapy (OT) evaluations, educating Resident 2 on the hazards of walking backwards, using the grabber to reach for items, and call for assistance were placed. - No interventions were placed on the Care Plan for Resident 2's falls on 9/23/2024, 11/26/2024, 12/25/2024, or 1/3/2025. A record review of an Incident Audit report with an incident date of 9/23/2024 indicated Resident 2 had spilled something on the floor and attempted to clean it up independently when Resident 2 lost their balance and fell to the floor. Resident 2 was educated to use staff for assistance. An Occupational Therapy (OT) evaluation for strengthening was placed. A record review of an Incident Audit report with an incident date of 10/7/2024 indicated Resident 2 had a fall while trying to undress due to losing their balance. A rehabilitation form was sent to therapy to assist with dressing and balance. A record review of an Incident Audit report with an incident date of 11/26/2024 indicated Resident 2 was encouraged to call for assistance with moving item in the room. All frequently used item were within safe reach. A Physical Therapy (PT) evaluation was for safety awareness and sequencing for safe ambulation was sent. A record review of an Incident Audit report with an incident date of 12/2/2024 indicated following Resident 2's fall an order for PT/OT evaluation with focus of fall prevention and safety awareness was placed. A record review of an Un-witnessed Fall document with a date of 12/25/2024 indicated Resident 2 had self-reported a fall in their room after stepping backwards causing their heel to step on the footrest of their wheelchair. The intervention placed was to educate/discuss with Resident 2 regarding walking backwards. The note also reflected that Resident 2 was currently working with PT/OT for balance and safety. A record review of an Un-witnessed Fall document with a date of 1/3/2025 indicated Resident 2 had an unwitnessed fall on 1/2/2025. Resident 2 reported they were reaching for a tissue when the box slide from the bed and Resident 2 also slid out of bed. The intervention placed was to ensure all frequently used items are within reach, educated on call light use for assistance, and PT/OT for sequencing and safety/fall prevention. An interview on 1/6/2025 at 12:25 PM with the Registered Nurse Consultant (RNC) confirmed the following: - No interventions for Resident 2's falls on 9/23/2024, 11/26/2024, 12/25/2024, and 1/3/2025 were placed on their care plan. - The intervention for Resident 2's fall on 9/23/2024 was to use the reacher/grabber for items on the floor, which was a duplicate intervention. - The intervention for Resident 2's fall on 11/26/2024 was to ensure items were in reach, which was a duplicate intervention. - The intervention for Resident 2's falls on 10/7/2024, 12/2/2024, 12/25/2024, and 1/3/2025 were duplicate interventions for PT/OT evaluation, noting Resident 2 was currently still working with PT/OT during their fall on 12/25/2024. - The intervention for Resident 2's fall on 1/3/2025 was to ensure items were within close reach, which was a duplicate intervention.
Apr 2024 8 deficiencies
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review and interview; the facility failed to ensure to notify the physician of low blood pressures for 1 (Resident 2) of 5 residents...

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Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review and interview; the facility failed to ensure to notify the physician of low blood pressures for 1 (Resident 2) of 5 residents who was on blood pressure medication. The facility census was 41 at the time of survey. Findings are: A record review of Resident 2's undated facility admission Record revealed an admission date of 11/15/16 to the facility with a primary diagnosis of Chronic Obstructive Pulmonary Disorder (COPD). A record review of Resident 2's Annual Minimum Data Set (MDS -a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 10/10/23 revealed a Brief Interview for Mental Status (BIMS - a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 2 which indicated severe cognitive impairment. Record review of Resident 2's Comprehensive Careplan initiated on 11/21/19 revealed: -problem Cardiovascular/Circulatory: I have an altered cardiovascular status r/t hypertension -goal to be free from cardiac complications -with an intervention to monitor vital signs and to notify provider of abnormalities. Record review of Resident 2's physician orders revealed an order of: Metoprolol Tartrate Oral Tablet (Metoprolol Tartrate a medication used to treat high blood pressure) give 50 milliequivalent (mEq) by mouth two times a day for hypertension (high blood pressure). Hold for heart rate less than 60. Record review of Resident 2's blood pressures revealed: -4/22/2024 8:02 AM 91 / 59 mmHg Diastolic Low of 60 exceeded, -4/21/2024 9:27 AM 98 / 60 mmHg, -4/9/2024 11:28 AM 97 / 54 mmHg Diastolic Low of 60 exceeded, -3/29/2024 8:37 PM 115 / 41 mmHg Diastolic Low of 60 exceeded, -3/29/2024 9:54 AM 111 / 63 mmHg, -3/28/2024 4:17 PM 88 / 60 mmHg Systolic Low of 90 exceeded, -3/28/2024 10:32 AM 71 / 55 mmHg Systolic Low of 90 exceeded Diastolic Low of 60 exceeded, -3/28/2024 9:14 AM 77 / 55 mmHg Systolic Low of 90 exceeded Diastolic Low of 60 exceeded, -3/27/2024 8:18 PM 122 / 82 mmHg, -3/21/2024 1:09 PM 91 / 67 mmHg, -2/29/2024 8:01 AM 116 / 58 mmHg Diastolic Low of 60 exceeded. Record review of Resident 2's Medication Administration Record dated April, 2022 revealed Blood pressure and pulse was not monitored daily with metoprolol. Interview on 04/23/24 at 9:45 AM with Registered Nurse (RN)-A confirmed that metoprolol should not have been given if blood pressure was 71/55 and 77/55. The blood pressure was not rechecked and should have been and the MD should have been notified and was not. Record review Medication Regimen Review (MRR) from pharmacy consult with no recommendations each month from 6/2023 through 4/2024. Review of the facility's undated policy titled Medication Regimen Review (MRR) revealed the MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities that could potentially have adverse consequences.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Licensure Reference Number 175 NAC 12-006.09B Based on record review and interview, the facility failed to ensure completion of the admission Minimum Data Set (MDS - a comprehensive assessment of each...

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Licensure Reference Number 175 NAC 12-006.09B Based on record review and interview, the facility failed to ensure completion of the admission Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) within the required time for 1 (Resident 95) resident. This affected 1 of 6 residents reviewed for MDS accuracy. The facility census at the time of the survey was 41. Findings are: A record review of Resident 95's undated facility admission Record revealed an admission date of 3/26/24 to the facility with a primary diagnosis of unspecified dementia. A record review of Resident 95's admission MDS revealed an admission date of 3/26/24 and an Assessment Reference Date (ARD) of 4/5/24. A record review of Resident 95's admission MDS revealed an ARD (marks the end of a 7 day period during which a resident is observed and assessed) of 4/5/24. A record review of Resident 95's admission MDS revealed a completion date of 4/23/24. Record review of the Resident Assessment Instrument manual (RAI- instruction manual to ensure that the MDS is completed correclty) revealed that the admission assessment must be completed with 14 days of the resident's admission to the facility. Interview on 04/23/24 at 5:06 PM with Regional MDS Nurse Coordinator confirmed Resident 95's admission MDS was not completed. The ARD was 4/5/24 Interview on 04/23/24 at 05:30 PM with MDS coordinator confirmed the RAI manual guidelines is used to complete the MDS. Interview on 04/24/24 09:34 AM with the Regional MDS nurse coordinator confirmed that (gender) is in the building 2 days per week and in that time is responsible for MDS, Infection Prevention and Control and wound care. The rest of the time the works is done remotely.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

Licensure Reference Number 175 NAC 12-006.09C1a Based on record review and interview; the facility failed to ensure that the written summary of the baseline care plan (written plan required to be deve...

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Licensure Reference Number 175 NAC 12-006.09C1a Based on record review and interview; the facility failed to ensure that the written summary of the baseline care plan (written plan required to be developed within 48 hours of admission detailing the instructions needed to provide initial effective and person centered care of the resident that meet professional standards of quality care) for 1 (Resident 94) of 6 sampled residents. The facility census at the time of survey was 41. Findings are: Record review of Resident 94's undated Comprehensive Care Plan (CCP- written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) revealed an admission date to the facility on 4/15/24 with a primary diagnosis of Osteomyelitis. Record review of Resident 94's Electronic Medical Records revealed no baseline careplan. Interview on 04/23/24 at 5:51 PM with the MDS coordinator confirmed there was not a baseline careplan completed for Resident 94 and there should have been, it was also confirmed that the resident was not offered a copy of the baseline careplan. Review of the facility's policy dated March 2022 titled Care plans - Baseline, revealed: - Baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission. - The resident and/or representative are to be provided a written copy of the baseline careplan. - Provision of the summary to the resident and/or resident representative is documented in the medical record.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Licensure Reference 175 NAC 12-006.09D7b Based on interviews and record reviews; the facility failed to identify causative factors and implement new interventions to prevent falls for 1 (Resident 13) ...

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Licensure Reference 175 NAC 12-006.09D7b Based on interviews and record reviews; the facility failed to identify causative factors and implement new interventions to prevent falls for 1 (Resident 13) of 2 sampled residents. The facility identified a census of 41. Findings are: A record review of an admission Record indicated the facility admitted Resident 13 on 5/26/2015 with diagnoses of muscle weakness, edema, Obstructive Sleep Apnea, hypertension, and Major Depressive Disorder. A record review of a significant change Minimum Data Set with a date of 5/15/2023 revealed Resident 13 had a Brief Interview for Mental Status score of 12/15, which indicated Resident 13 had moderate cognitive impairment. Resident 13 also required moderate assistance with bathing, supervision with oral hygiene, and was dependent from toileting and dressing. A. A record review of Resident 13's Care Plan with a date initiated of 9/18/2019 revealed Resident 13 was at risk for falls. Interventions were as follows: - Anticipate and meet my needs (initiated on 9/18/2019) - Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance (initiated on 9/18/2019) - Bed alarm to be used while in recliner (initiated on 7/18/2023) - Encourage me to be aware of my surroundings when I choose to transfer/toilet without staff assist (initiated on 4/13/2020) - Encourage me to call for staff assist with transfers/toileting/mobility if I am feeling short of breath or weakness during the day (initiated on 4/13/2020) - Encourage resident to report symptoms of hypoglycemia; cool clammy skin, confusion, tremors, sweat weakness (initiated on 4/27/2023) - Moved closer to the nurses' station (initiated on 9/5/2023) A record review of the facility's fall record revealed Resident 13 had falls on the following dates: 5/4/2023, 6/3/2023, 6/20/2023, 6/29/2023, 7/16/2023, 7/18/2023, 8/14/2023, 8/21/2023, 8/28/2023, and 9/26/2023. A record review of the Resident 13's care plan revealed no new interventions placed after falls for the following dates: 5/4/2023, 6/3/2023, 6/20/2023, 6/29/2023, 7/16/2023, 8/14/2023, 8/21/2023, and 9/26/2023. An interview on 4/22/2024 at 3:16 PM with Registered Nurse (RN) - C confirmed new interventions were not implemented after each of Resident 13's falls. An interview on 4/24/2024 at 8:52 AM with the Director of Nursing revealed it is the responsibility of the charge nurse to place an intervention immediately after the fall. A record review of the facility policy Falls - Clinical Protocol with a last revised date of March 2018 revealed staff and physician will identify pertinent intervention to try to prevent subsequent falls. If underlying causes cannot be readily identified, staff will try various relevant interventions. B. A record review of an Incident Report with a date of 5/4/2023 revealed no causative factor was identified from the fall. A record review of an Incident Report with a date of 7/16/2023 revealed no causative factor was identified from the fall. A record review of an Incident Report with a date of 8/28/2023 revealed no causative factor was identified from the fall. A record review of an Incident Report with a date 9/26/2023 revealed no causative factor was identified from the fall. An interview on 4/24/2024 at 9:01 AM with RN-B confirmed no causative factors were identified for the falls. A record review of the facility policy Falls - Clinical Protocol with a last revised date of March 2018 revealed staff will begin to try to identify possible causes within 24 hours of the fall.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Licensure Reference 175 NAC 12-006.17 Based on observations and record review, the facility failed to implement infection control practices during medication administration for 3 (Resident 16, Residen...

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Licensure Reference 175 NAC 12-006.17 Based on observations and record review, the facility failed to implement infection control practices during medication administration for 3 (Resident 16, Resident 31, and Resident 95) of 9 sampled residents. The facility identified a census of 41. An observation on 4/22/2024 at 12:02 PM revealed Registered Nurse (RN) -C had prepared a insulin syringe with 6 units of insulin. RN-C then applied gloves. RN-C then touched the inner rim of the trash to throw away an empty box of gloves and did not change gloves after touching the inner rim of the trash can. RN-C then injected the insulin into Resident 16. An observation on 4/22/2024 at 12:12 PM revealed RN-C had dialed a insulin pen with 10 units of insulin. RN-C then applied gloves. RN-C had knocked and attempted to enter the room by turning the doorknob with the gloved hand. RN-C was asked to wait one minute by nursing. While waiting, RN-C touched RN-C's hair. The nursing staff then stated they were ready. RN-C had again opened the door with RN-C's gloved hand. RN-C then injected Resident 31's insulin into the Resident 31's arm. An observation on 4/22/2024 at 12:26 PM revealed Medication Aide (MA) - D had attempted to administer Resident 95 medication. Resident 95 spit the medication out onto the table. MA-D scooped medication back into the medication cup, crushed the medication, then administered again to Resident 95. An interview on 4/24/2024 at 9:34 AM with the Director of Nursing confirmed these practices were deficient in infection control prevention. A record review of facility policy Handwashing/Hand hygiene with a last revised date of August 2019 revealed integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associate infection and should be used before aseptic procedures. A record review of the Center for Disease Control's Infection Prevention During Blood Glucose Monitoring and Insulin Administration revealed a procedure to change gloves when gloves have been contaminated before touching clean surfaces.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

Licensure Reference Number 175 NAC 12-006.10D Based on observations, interviews, and record reviews; the facility failed to maintain a medication error rate less than 5%, which affected 3 (Resident 8,...

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Licensure Reference Number 175 NAC 12-006.10D Based on observations, interviews, and record reviews; the facility failed to maintain a medication error rate less than 5%, which affected 3 (Resident 8, Resident 16, and Resident 34) of 9 sampled residents. The medication error rate was 11.11%. The facility census was 41. A record review of facility policy Administering Medications with a last revised date of April 2019 revealed the following: - Medications are administered within one hour of their prescribed time. - Verify the right resident, right medication, right dosage, right time and right route. - The charge nurse must accompany new nursing personnel on their medication rounds for minimum of 3 days to ensure established procedures are followed and proper resident identification methods are learned. A. An observation on 4/22/2024 at 12:17 PM revealed Medication Aide (MA)-D had administered Resident 8's Sinemet at this time. A record review of Resident 8's Medication Administration Record revealed the medication was scheduled for 1100. B. An observation on 4/22/2024 at 12:35 PM revealed MA-D had not administered Resident 16's Albuterol. An observation on 4/22/2024 at 12:47 PM revealed MA-D was not able to administer Resident 16's albuterol as MA-D was not knowledgeable of how to setup the nebulizer machine. MA-D had asked Registered Nurse (RN)-C for assistance for setup. MA-D did not chart as given after the assistance. A record review of Resident 16's Medication Administration Record revealed no documentation as administered for the albuterol AM or Mid-Day. A record review of Resident 16's Medication Administration Record revealed the medication was scheduled for AM and Mid-Day. An interview on 4/22/2024 at 12:35 PM with MA-D revealed I'm running super behind, guess I missed it [AM dose.] C. An observation on 4/22/2024 at 12:38 PM revealed MA-D had not administered Resident 34's budesonide. An interview on 4/22/2024 at 12:38 PM with MA-D revealed it was not given as it had to be reordered, stating it had no date we had to toss it. An interview on 4/22/2024 at 12:58 PM with MA-D revealed this was MA-D's second day of administering medications without assistance. MA-D revealed MA-D had received a couple days of training, but I felt like it was enough but I guess not. An interview on 4/22/2024 at 1:01 PM with RN-C confirmed MA-D needed additional training before administering additional medications. An interview on 4/22/2024 at 1:24 PM with the Director of Nursing (DON) revealed 2-3 days of training is done and a competency is completed. The DON follows up with them after training to see how comfortable they are. The DON was aware medications were behind, but not aware of the errors or RN-C feeling additional training was needed.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected most or all residents

Licensure Reference 175 NAC 12-006.11D Based on observations, interviews, and record reviews, the facility failed to prepare foods following the recipe to ensure nutritive value. This had the potentia...

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Licensure Reference 175 NAC 12-006.11D Based on observations, interviews, and record reviews, the facility failed to prepare foods following the recipe to ensure nutritive value. This had the potential to affect all 41 facility residents that ate food prepared in the kitchen. The facility identified a census of 41. Findings are: A continuous observation of meal preparation of French Onion Pork Chop on 4/23/2024 from 7:09 AM to 8:00 AM revealed the following: - The Dietary Supervisor (DS) had measured three boneless pork chops. The first porkchop was six ounces, the second was three ounces, the third was three ounces. - The DS did not measure the remaining prepared porkchops - The DS had grabbed four fresh onions from the pantry. Once the DM had began to cut the onions, threw away two of the onions, which were bad. - The DS had placed a bag of French onion soup mix on top of porkchops - No stock chicken and soup base had been used An interview on 4/23/2024 at 7:15 AM with the DS revealed the porkchops were to be about four ounces. An interview on 4/23/2024 at 7:52 AM with the DS revealed the onions were bad and the facility did not have any onions or red wine vinegar so substituted it for the French onion soup mix. A record review of the facilities' Patient Menu Substitution Log revealed on 4/23/2024 onion soup was substituted for onions due to not enough onion and vinegar. A record review of French Onion Pork Chop recipe revealed the ingredients of pork chops 5 ounces bone in, 3 quarts of fresh onion, 3 cups of red wine vinegar, and 3 quarts of stock chicken and soup base.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference 12-006.11E Based on observations, interviews, and record review, the facility failed to ensure foods were la...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference 12-006.11E Based on observations, interviews, and record review, the facility failed to ensure foods were labeled, dated, and served within best by dates, and prepare food under sanitary conditions, the facility failed to ensure potentially hazardous foods of meat and dairy products were held at 135 degrees or higher on the steam table. This had the potential to affect all 41 residents that ate food prepared in the kitchen. The facility identified a census of 41 residents. Findings are: A. An initial kitchen observation on 4/18/2024 at 7:02 AM revealed the following in the kitchen: - Several saran wrapped pieces of cornbread, without preparation or use by dates on the kitchen counter - A bin of sugar with a label including a prepared date of 2-1-24 but no use by date - A bin of flour with a label including a prepared date of 2-1-24 but no use by date An initial kitchen observation on 4/18/2024 at 7:02 AM revealed the following in the refrigerator in the kitchen: - An opened Sysco chicken base without an opened date - An opened Sysco beef base without an opened date - An opened container of Kosher Dill pickles without an opened date - A half stick of used margarine without an opened date - A pureed salad in a bowl without a preparation date - Several single serving strawberry yogurts without preparation dates - A half of tomato in a plastic bag without a preparation date An initial kitchen observation on 4/18/2024 at 7:02 AM revealed the following in the pantry: - An opened with minimal remaining of Captain Crunch cereal with no open date - Two opened boxes with ¼ remaining of Honey Nut Cheerios with no open date - An opened box with ½ remaining of Vanilla Wafers with no open date An initial kitchen observation on 4/18/2024 at 7:02 AM revealed the following in the freezer on the left in the pantry: - A bag of peaches with a preparation date of 2/16 without a use by date - A bag of pasta sauce with a preparation date of 3/23 without a use by date - A bag of beef tips with a preparation date of 4/12 without a use by date - A bag of nacho cheese with a preparation date of 4/12 without a use by date An initial kitchen observation on 4/18/2024 at 7:02 AM revealed an opened bag of half used blueberries with no open or use by date in the freezer on the right in the pantry. An interview and walk through on 4/23/2024 at 7:25 AM with the Dietary Supervisor (DS) confirmed the foods should be labeled with the date the food was opened and a date the food should be used by. A follow-up kitchen observation on 4/23/2024 at 7:16 AM revealed a loaf of Choice Round Top Wheat Sliced Bread was being used to serve breakfast by Cook-B. The loaf of bread had a best by date of 4/15/2024. Another loaf of Brest Choice Round Top Wheat Slice bread was ¼ used and was also being used to serve breakfast with. This loaf had a best by date of 4/22/2024. Another loave of [NAME] Texas Toast had a best by date of 4/22/2024. An interview on 4/23/2024 at 7:17 AM with the Dietary Supervisor (DS) confirmed the breads were past the best by date and were disposed of and replaced with bread within the best by dates. The DS stated the breads had just been purchased yesterday and the DS would need to be more watchful at ensuring the best by dates were current when purchasing. A record review of a facility policy Food Receiving and Storage last revised in October 2017, revealed dry foods that are stored in bins will be removed from original packaging, labeled, and dated use by date. A record review of Nebraska Food Code 2017, Section 3-501.17, revealed food held more than 24 hours must indicated the date or day by which the food shall be consumed or discarded. B. An observation on 4/23/2024 at 7:21 AM revealed the DS had weighed three raw porkchops then applied new gloves without performing hand hygiene prior to the application of the gloves. The DS then began to gather seasonings from the above shelf with the same gloves. An observation on 4/23/2024 at 7:33 AM revealed the DS had placed a baking sheet in the dishwasher. The DS then completed hand hygiene for 12 seconds before applying gloves to return to preparing porkchops for lunch. An observation on 4/23/2024 at 7:45 AM revealed the DS had placed remaining raw porkchops on a baking sheet then completed hand hygiene for 10 seconds. The DS then flipped the cooking porkchops on the stovetop. An observation on 4/23/2024 at 7:52 AM revealed the DS had returned to the kitchen and did not perform hand hygiene upon return to the kitchen. An interview on 4/23/2024 at 12:07 AM with the DS revealed the DS was knowledgeable regarding the need to perform hand hygiene for at least 20 seconds upon changing gloves and returning to the kitchen. An observation on 4/23/2024 at 12:03 AM revealed Cook-B had gloves on then touched the refrigerator handles, then had touched a sandwich and chips and placed on a plate. An observation on 4/23/2024 at 12:18 PM revealed Cook-B had gloves on and had applied oven mitts over gloves to remove a tray from the steam table. Cook-B had removed the oven mitts then prepared another plate of chips with the same pair of gloves. An observation on 4/23/2024 PM revealed Cook-B had wiped down gloves, then opened the refrigerator with same pair of gloves. Cook-B then touched the inner rim of a plate while plating the meal onto the plate. A continuous observation on 4/23/2024 from 12:07 to 12:51 PM revealed Cook-B had used the same pair of gloves throughout the entire time of serving meals to residents. An interview on 4/23/2024 at 12:31 PM revealed Cook-B was aware of the need to wash hands when preparing food and when switching gloves. Cook-B stated Cook-B did not need to change out gloves as Cook-B had a sanitizer towel to wipe down my gloves. A record review of the facility policy Handwashing/Hand Hygiene with a last revised date of August 2019 revealed the policy only required employees to wash hands for 15 seconds. A record review of The Nebraska Food Code 2017 Section 2-301.12 revealed food employees must perform hand hygiene of hands and arms for at least 20 seconds. A record review of The Nebraska Food Code 2017 Section 3-304.15 revealed single-use gloves shall be used for only one task and then discarded when damaged, soiled, or when interruptions occur in the operation. C. An observation on 4/23/2024 at 11:51 AM revealed the following initial temperatures for the steam table: - Pureed Pork Chop: 122.1 F - Potatoes with butter: 125.6 F An observation on 4/23/2024 at 12:41 PM revealed the following ending temperatures for the steam table: - Pureed Pork Chop: 130 F - Potatoes with butter: 119 F An interview on 4/23/2024 at 11:52 AM with Cook-B revealed Cook-B had believed all food temperatures must be kept above 165 F degrees on the steam table. A record review of the facility policy Food and Nutrition Services with a last revised date of April 2019, revealed Potential Hazardous Foods, including meat and dairy products, must be maintained at a temperature below 41 F or above 135 F.
Feb 2023 5 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05 Based on record review and interview, the facility failed to ensure 1 (Resident #41...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05 Based on record review and interview, the facility failed to ensure 1 (Resident #41) Advanced Directive choice was documented and communicated correctly to the interdisciplinary team and to the staff responsible for the residents care. Facility census was 41. Findings are: Record review of Resident #41's Do Not resuscitate Request/Order form revealed Resident 41 did not want a DO NOT RESUSCITATE order. The document was signed by the Power of Attorney for the resident on [DATE]. A review of the admission Record for Resident #41 revealed the following Advanced Directive instruction DNR (do not resuscitate): NO intubation, may use ambu bag. Artificial nutrition 3 months only. A review of the E Mar (electronic medical record) for Resident #41 revealed a code status for the residents as DNR: No intubation, may use ambu-bag. Artificial nutrition 3 months only. A review of the Order Summary Report for Resident #41 revealed an order for DNR: No intubation, may use ambu bag. Artificial nutrition 3 months only. A review of the Care Plan for Resident #41 revealed Advanced Directives: I wish to be a full code, dated [DATE]. It also revealed Actions/Tasks related to the Advanced Directive as In the event that I am found without a pulse or not breathing CPR (cardiopulmonary resuscitation) will be initiated, dated [DATE]. On [DATE] an interview with the Director of Nursing revealed the resuscitation order for Resident #41 was not documented correctly in the residents medical records. An interview with the Administrator revealed the resuscitation order for Resident #41 was not accurate and was not documented correctly in the residents records.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on observation, record review and interview; the facility staff failed to perform peri care as required. This had the potential to effect 1 reside...

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LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on observation, record review and interview; the facility staff failed to perform peri care as required. This had the potential to effect 1 resident (Resident 24). The facility identified a census of 41 residents at the time of the survey. Findings are: Review of Resident 24's Care Plan (specifies an individual's health care and support needs and how the support will be given) with a date of 1/24/2023 revealed Resident 26 was incontinent of urine, occasionally incontinent of bowel, wore a brief, and had impaired mobility. Review of Resident 24's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 1/24/2023 under Bowel & Bladder Assessment-V2, revealed the facility staff were to check and change the resident. Observation of personal care for Resident 24 on 2/21/203 at 11:33 AM, revealed Resident 24 lying in bed. Nursing Assistant ( NA)-1 and NA-2 entered the resident's room and had explained what they were going to be doing. NA-1 and NA-2 had donned gloves. Both NA-s had explained Resident 24's legs were contacted. Resident 24's brief was unfastened, and NA-1 had begun to perform peri care. NA-1 had taken a Prevail adult washcloth and wiped the top of Resident 24's penis,then used a clean Prevail cloth to wipe down each side of the resident's groin. NA-1 had not wiped under Resident 24's penis, had not cleaned the head of the resident's penis, and had not cleansed the resident's scrotum. NA-1 and NA-2 had rolled Resident 24 onto the resident's right side and removed the old brief and had placed a new brief under the resident. NA-1 was on the left side of Resident 24 and had not cleansed the resident's buttocks nor did NA-2. The clean brief was secured onto the Resident 24. Interview with NA-1 on 12/21/2023 at 11:44 AM confirmed they had not fully cleaned Resident 24's penis, did not clean the resident's scrotum, and had not cleaned the resident's buttocks prior to placing a clean brief Resident 24.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

Licensure Reference Number 175 NAC 12-006.18B Based on observation and interview, the facility failed to ensure a resident's bathroom sink was in working order for 1 (Resident 17). The facility reveal...

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Licensure Reference Number 175 NAC 12-006.18B Based on observation and interview, the facility failed to ensure a resident's bathroom sink was in working order for 1 (Resident 17). The facility revealed a census of 41 residents at the time of survey. Findings are: Observation in Resident 24's bathroom on 2/15/2023 at 10:00 AM revealed a trash can sitting directly underneath of the partially filled with water. Further observations revealed a section of pipe was missing from under the sink with the opening from the wall stuffed with a cloth like material. Observation in Resident 24's bathroom on 2/21/2023 at 9:15 AM revealed a trash can was sitting under the sink and had water in it. A section of pipe was missing from underneath of the sink. There was portion of pipe that protruded from the wall underneath the bathroom sink stuffed with cloth like material that appeared to be a rag. On 2-21-2023 at 5:40 PM an interview was conducted with the Administrator in Resident 24's bathroom. During the interview the Administrator confirmed Resident 24's skin skin was not in working condition.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Licensure Reference Number 175 NAC 12-006.11E Based on observations and interview, the facility staff failed to 1) ensure outdated foods were not available for use; 2) failed to complete hand hygiene ...

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Licensure Reference Number 175 NAC 12-006.11E Based on observations and interview, the facility staff failed to 1) ensure outdated foods were not available for use; 2) failed to complete hand hygiene as required; 3) failed to ensure kitchen equipment was clean and in working order; 4) failed to ensure refrigerator temperature audits, food temperature logs, and kitchen cleaning logs were completed; 5) failed to complete an ice machine cleaning log; and 6) failed to ensure the kitchen was clean. This had the potential to affect all the residents who resided in the facility. The facility identified a census of 41 residents at the time of the survey. Findings are: Initial tour observation of the kitchen on 2/14/2023 at 11:45 AM revealed the kitchen floor was dirty with debris and there was build up of white and brown substances underneath the counter with the dirty/rinsing sink, under the dishwasher, under the counter of the clean side counter of the dishwasher, under refrigerator 1, and under and behind the ice machine. There was a large amount of water on the kitchen floor that ran from the dirty side of the rinsing sink, all along the floor to the clean side of the dishwasher counter, to the end of the wall where the handwashing sink was, and up the side of the wall towards the back kitchen door. There was a cloth like material that appeared to be a towel and it had a light brown and black color on it. The cloth like material was wrapped around the handwashing sink pipe. The hand washing station was right next to the clean side of the dishwasher counter. The walls on the right side that surrounded the dishwasher and attached counters were dirty from the floor up with buildup and debris. There was water running under and to the left side of the ice machine. There was a rectangle baking pan underneath of the ice machine that had water in it. The ice machine was filled with water and there was some ice floating. There was build up of dust and debris on the pipes underneath the sink, on the water heater to the dishwasher, on the back of the stove (there was a metal shelving unit and carts with clean dishes sitting up against the back of the stove), and in the opening on the right side of the stove where one knob was. There was a black substance covering a large portion of the hood vent above the stove. The dry food storage room had an unopened package of tortillas with an expiration date of 11/28/2022, there were eight unopened packages of flour tortillas with an expiration date of 2/5/2023, and there were three opened packages of flour tortillas with an expiration date of 2/5/2023. There was an unopened box of Quaker Grits that had an expiration date of 10/24/2022. Observation in the kitchen on 2/14/2023 at 12:07 PM revealed Cook-2 had entered the kitchen, retrieved a hair net from a box that was on the top shelf of a metal rack (against the stove) next to clean dished and washed their hands for 10 seconds. Observation in kitchen's the dry food storage room on 2/15/2023 at 1:40 PM, revealed the twelve expired packages of tortillas were sitting on the shelf. The box of expired grits had been opened and were in a Ziplock bag with an opened date of 2/15/2023. Interview in the dry food storage area with the Administrator on 2/15/2023 AT 1:57 PM had confirmed there were twelve packages of expired flour tortillas, and an expired box of Quaker Grits had an open date of 12/15/2023 written on the Ziplock bag. Interview with Cook-2 in the dry food storage room on 12/15/2023 at 1:57 PM had confirmed they had opened the expired box of grits and had served them for breakfast. Observation of lunch meal food preparation on 2/21/2023 at 11:46 AM revealed Cook-1 had washed their hands for 12 seconds. Review of the kitchen's Fridge 1's Food procurement-store/prepare/serve-Sanitary Refrigerator Temperature and Sanitation Audit for the months of January 2022 and February 2023 (up to the 14th) had missing documentation from the evening shift on the following days: 1/5/2023, 1/6/2023, 1/18/2023, 1/19/2023, 2/8/2023, and 2/10/2023. Fridge 2's Food procurement store/prepare/serve-Sanitary Refrigerator Temperature and Sanitation Audit for the month of February 2023 (up to the 14th) had missing documentation on the following days: 2/8/2023 and 2/10/2023. Interview with the Administrator in the kitchen on 2/21/2023 at 10:14 AM confirmed the findings from 2/14/2023 at 11:45 AM and 2/21/2023 at 9:54 AM. The Administrator further confirmed that the right side of the oven was not in working order and the black colored build up/residue in the hood vent above the stove. The Administrator further reported nit knowing how long the clean prep sink had been out of order. Interview with the Registered Dietician on 2/21/2023 at 10:14 AM, confirmed the findings from 2/14/2023 at 11:45 AM and 2/21/2023 at 9:54 AM. The Registered Dietician revealed there had been issues with the dishwashing machine and had an ECO lab representative look at it on 2/3/2023, but the issue was not resolved. Interview with the Administrator on 2/21/2023 at 6:48 PM revealed the facility did not have documentation of the ice machine being clean until 2/17/2023 (Ice Machine Cleaning sheet) and that was the only day documented on the cleaning sheet.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0923 (Tag F0923)

Could have caused harm · This affected most or all residents

Licensure Reference Number 175 NAC 12-007-04.D Based on observation and interviews the facility failed to ensure bathroom ventilation systems were functioning, preventing lingering odors from permeati...

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Licensure Reference Number 175 NAC 12-007-04.D Based on observation and interviews the facility failed to ensure bathroom ventilation systems were functioning, preventing lingering odors from permeating for 15 residents (Residents #1, 7, 10, 4, 18, 16, 25, 17, 11, 22, 33, 31, 19, 24, and 41.) The facility census was 41 residents. Findings are: Observations on 2/15/2023 revealed the following: - 10:00 AM through 10:30 AM the bathroom ventilation system was non-functional and was not venting bathroom air in the rooms occupied by Residents #1, 7, 10, 4, 18, 16, 25, 17, 11, 22, 33, 31, 19, 24, and 41. -12:00 PM through 12:30 PM the bathroom ventilation system was non-functional and was not venting bathroom air in the rooms occupied by Residents #1, 7, 10, 4, 18, 16, 25, 17, 11, 22, 33, 31, 19, 24, and 41. Observations with the facility Administrator and Maintenance on 2/21/2023 revealed the bathroom ventilation system was non-functional and was not venting bathroom air in the rooms occupied by Residents #1, 7, 10, 4, 18, 16, 25, 17, 11, 22, 33, 31, 19, 24, and 41.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "What changes have you made since the serious inspection findings?"
  • "Why is there high staff turnover? How do you retain staff?"
  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • No fines on record. Clean compliance history, better than most Nebraska facilities.
Concerns
  • • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s), Payment denial on record. Review inspection reports carefully.
  • • 35 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
  • • Grade F (13/100). Below average facility with significant concerns.
  • • 75% turnover. Very high, 27 points above average. Constant new faces learning your loved one's needs.
Bottom line: Trust Score of 13/100 indicates significant concerns. Thoroughly evaluate alternatives.

About This Facility

What is Skyview Care And Rehab At Bridgeport's CMS Rating?

CMS assigns Skyview Care and Rehab at Bridgeport an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Nebraska, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Skyview Care And Rehab At Bridgeport Staffed?

CMS rates Skyview Care and Rehab at Bridgeport's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 75%, which is 29 percentage points above the Nebraska average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 60%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Skyview Care And Rehab At Bridgeport?

State health inspectors documented 35 deficiencies at Skyview Care and Rehab at Bridgeport during 2023 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 33 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Skyview Care And Rehab At Bridgeport?

Skyview Care and Rehab at Bridgeport is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 48 certified beds and approximately 34 residents (about 71% occupancy), it is a smaller facility located in Bridgeport, Nebraska.

How Does Skyview Care And Rehab At Bridgeport Compare to Other Nebraska Nursing Homes?

Compared to the 100 nursing homes in Nebraska, Skyview Care and Rehab at Bridgeport's overall rating (1 stars) is below the state average of 2.9, staff turnover (75%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Skyview Care And Rehab At Bridgeport?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the facility's high staff turnover rate.

Is Skyview Care And Rehab At Bridgeport Safe?

Based on CMS inspection data, Skyview Care and Rehab at Bridgeport has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Nebraska. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Skyview Care And Rehab At Bridgeport Stick Around?

Staff turnover at Skyview Care and Rehab at Bridgeport is high. At 75%, the facility is 29 percentage points above the Nebraska average of 46%. Registered Nurse turnover is particularly concerning at 60%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Skyview Care And Rehab At Bridgeport Ever Fined?

Skyview Care and Rehab at Bridgeport has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Skyview Care And Rehab At Bridgeport on Any Federal Watch List?

Skyview Care and Rehab at Bridgeport is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Skyview Care and Rehab at Bridgeport

505 O Street, Bridgeport, NE 69336 | (308) 262-0725

F
Trust Grade (13/100)
1.0
CMS Rating
35
Deficiencies

Strengths

  • Licensed facility

Concerns

  • 1 Immediate Jeopardy citation
  • 1-star rating
  • 35 deficiencies

Ask about: Inspection Response, Staff Retention, Rn Coverage

nursinghomedata.org | Data: CMS November 2025