Licensure Reference Number 175 NAC 12-006.09(H) Based on interview and record review the facility failed to perform neurological checks after a fall for 2 (Resident 1 and 3) of 4 residents sampled. The facility census was 59. The findings are: A. Record review of Resident 1's Electronic Health Record (EHR) revealed Resident 1 had an unwitnessed fall on 02-01-2025. Record review of Resident 1's Neuro Vital Sign Sheet Report (NVSSR) dated 02-01-2025 revealed at the top of the sheet instructions that after the completion of the initial neurological evaluation with vital signs, continue with evaluations every 30 minutes for 4 sets, then every 8 hours for the next 3 days. Furthermore, the NVSSR only had vital signs logged on the form. An interview with Registered Nurse (RN) H on 02-24-2025 at 7:50 AM revealed when performing neurological checks, the first check is completed when the fall occurred and then every 30 minutes for 4 sets, then every 8 hours for 3 days. Additionally, the vital signs are charted on the NVSSR and the remainder of the assessment is to be charted into the EHR. Record review of Resident 1's assessments titled Neuro (Neurological) Check revealed 2 entries dated 02-01-2025 and one dated 02-02-2025. B. Record review of Resident 3's EHR revealed Resident 3 had an unwitnessed fall on 01-31-2025. Record review of Resident 3's NVSSR dated 01-31-2025 revealed only vital signs were logged on the form. Record review of Resident 3's assessments titled Neuro Check revealed only 2 entries dated 01-31-2025. Record review of the facility's policy Neurological Evaluation-Rehab/Skilled revealed the following: -the purpose of the policy is to establish a baseline neurological status upon which subsequent evaluations may be compared and changes in neurological status may be determined. Use the neurological evaluation following a witnessed fall when a resident has hit the head, following an unwitnessed fall, and following a resident event that results in a known or suspected head injury. An interview with the Director of Nursing (DON) on 02-24-2025 at 7:52 AM confirmed the Neuro Check entries in the EHR should match the vital signs on the NVSSR and confirmed that the Neuro Check evaluation was not completed at the appropriate intervals for Resident 1 and 3.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 12-006.09 (I)(i)(3). Based on observation, interview and record review the facility failed to implement fall interventions for 2 (Resident 3 and 4) of 4 residents sampled. The facility census was 59. The findings are: A. Record review of Resident 3's Minimum Data Set (MDS; a federally mandated assessment tool used for care planning) dated 12-18-2024 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS), a brief screen that aids in detecting cognitive impairment, was scored as a 4. According to the MDS Manual a score of 0-7 indicates severe cognitive impairment. -required moderate assistance with toileting, bathing and lower body dressing -required supervision assistance with transfers. Record review of Resident 3's care plan printed on 02-20-2025 revealed Resident 3 had a fall on 12-25-2024 and the intervention put into place to prevent further falls was to have the call light secured to the bed with Velcro. An observation on 02-20-2025 at 10:55 AM revealed Resident 3 was lying in bed on the left side and the call light cord that is not secured to the bed with Velcro. An observation on 02-20-2025 at 12:45 PM revealed Resident 3 was lying in bed and the call light was not secured to the bed with Velcro. An interview with Registered Nurse (RN) D on 02-20-2025 at 12:50 PM confirmed the call light was not in secured. B. Record review of Resident 4's MDS dated [DATE] revealed the facility staff assessed the following about the resident: -BIMS was scored as a 9. According to the MDS Manual a score of 8-12 indicates moderate cognitive impairment. -required maximum assist with bathing -required moderate assist with personal hygiene and bed mobility. -required supervision with transfers. Record review of Resident 4's care plan printed on 02-20-2025 revealed Resident 4 had a fall on 12-25-2024 and the intervention put into place to prevent further falls was to have the call light secured to the bed with Velcro for ease of access. An observation on 02-20-2025 at 10:50 AM revealed Resident 4 was asleep in the recliner. The call light is not secured to the bed with Velcro. It is lying on the bed. An observation on 02-20-2025 at 1:30 PM revealed Resident 4 was sitting in his recliner and the call light is laying on the bed not secured with Velcro. An interview on 02-20-2025 at 1:35 PM with Nurse Aid E revealed Resident 4 was to have the call light secured with Velcro and confirmed it wasn't. Record review of the Facility Policy Falls Resource Packet dated 05/07/2025 revealed Fall reduction efforts include: -Communicating with the resident, family and visitors: -to identify fall risk factors and implement interventions to reduce falls. -communicating residents' fall risk and reduction efforts to employees: Through shift report, employee meetings and in-services and care conferences.

Licensure Reference Number 12-006.12(D)(i) Based on observation, interview and record review the facility failed to ensure the treatment carts on the 200 and 500 halls were secure while left unattended. The facility census was 59. An observation on 02-20-2025 at 1:20 PM revealed an unlocked treatment cart on the 200 Hall. An interview on 02-20-2025 at 1:25 PM with Registered Nurse (RN) D revealed insulin (a medication used to treat Diabetes) was stored in the treatment cart and confirmed the treatment cart was unlocked and should have been when left unattended. An observation on 02-20-2025 at 1:34 PM revealed an unlocked treatment cart on the 500 Hall. An interview on 02-20-2025 at 1:40 PM with RN F revealed insulin was stored in the treatment cart and confirmed the treatment cart was unlocked and should have been when left unattended. Record review of the facility policy titled Medications: Acquisition Receiving Dispensing and Storage dated 03-29-2024 revealed under section 5 the following: Medications will be stored in a locked medication cart, drawer or cupboard. Only the person passing medications and the director of nursing services and/or designee will be permitted to have access to the keys to the medication storage areas.

Licensure Reference Number 175 NAC 12-006.09(G)(ii) Based on record review and interview; the facility staff failed to provide a Transfer Discharge notification for 1 (Resident 18) of 1 resident. The facility had a census of 62. Findings are: A record review of Resident 18's progress notes revealed the resident had been sent to hospital on 7/5/2024 following a fall. Record review of Resident 18's medical record that included progress notes, faxes, demographic sheets and practitioner ordered revealed the was no evidence the facility staff had provided a Transfer Discharge notice to the resident or their responsible part. An interview on 11/20/2024 at 2:11 PM with the Facility Administrator confirmed a transfer discharge notification was not completed for Resident 18 Record review of the facility Discharge and Transfer Policy reviewed/revised 01/03/24 revealed the following information: -Policy -Before a location transfers or discharges a resident, the location must: 1. Notify the resident and the residents' representative of the transfer or discharge and the reason for the move in writing and in a language and manner they understand. The Notification of Transfer or Discharge or other state required form, will serve as the written notice to be given to the resident or the residents representative. Note: When a resident is temporarily transferred on an emergency basis to an acute care center this type of transfer is considered to be a facility-initiated transfer and a notice of transfer must be provided to the resident and resident representative as soon as practicable before the transfer. -Transfer to Hospital 3. The social-worker or designated individual will: b. Complete the Notification of Transfer or Discharge. (NOTE) The charge nurse is responsible for completion of notification procedures if the transfer occurs at a time social services is not at the location.

Licensure Reference Number 175 NAC 12-006.10 Based on record review and interview; facility staff failed to ensure 1 (Resident 18) of 5 residents was free of duplicate medication orders (orders for two or more identical medications or same therapeutic class). The facility had a census of 62. Findings are: A record review of Resident 18's Minimum Data Set (MDS -a federally mandated process for assessing the health needs and functional capabilities of residents in nursing homes) revealed Resident 18 had a Brief Interview for Mental Status (BIMS - a mandatory tool used to identify the cognitive function of a resident in a nursing home) of 12, which indicated Resident 18 is moderately cognitively impaired. A record review of Resident 18's electronic health record (EHR) revealed the following diagnoses: Adult failure to thrive, Bipolar disorder, Anxiety disorder, History of falling, Chronic Kidney Disease, stage 3, legal blindness. A record review of Resident 18's EHR revealed the following medication orders: -Acetaminophen Extra Strength Tablet 500 MG. Give 500 milligrams (mg) by mouth every 6 hours as needed for Pain Acetaminophen not to exceed 3,000 mg per day with a order start date of 7/9/2024. -Acetaminophen Extra Strength Tablet 500 MG. Give 500 mg by mouth four times a day for Pain Acetaminophen not to exceed 3,000 mg per day with a order start date of 8/31/2023. -Acetaminophen Tablet 325 MG Give 650 mg by mouth every 4 hours as needed for Pain. Acetaminophen not to exceed 3,000 mg per day with a order start date of 7/6/2024. An interview on 11/21/2024 at 10:42 AM with the Director of Nursing (DON) confirmed Resident 18 had three separate orders for Acetaminophen. The DON confirmed those medications would be considered duplicate therapy.

Licensure Reference Number 175 NAC 1-009.04(i) Based on record review, observation, and interview, the facility staff failed to maintain water temperatures in resident handwashing sinks to prevent the potential for hot water burns. This effected 6 of 62 residents (Resident 2, 13, 33, 36, 41 and 42). The facility identified a census of 62. Findings are: Observations on 11/18/2024 at 9:38 AM-10:30 AM revealed the following water temperature in residents hand washing sink: -Resident 36's water temperature was 128 degrees Fahrenheit. -Resident 41,42,13, and 33's water temperature was 122.3 degrees Fahrenheit. Observation with the Maintenance Director ( MD), Administrator, and Maintenance Technician Assistant (MTA)-C on 11/18/2024 between 12:52-1:26 PM revealed the following water temperatures in resident hand washing sinks: -Resident 36's water temperature was 130.1 degrees Fahrenheit. -Resident 41's water temperature was 130.0 degrees Fahrenheit. -Resident 13 and 33's water temperature was 129.0 degrees Fahrenheit. -Resident 2's water temperature was 130.7 degrees Fahrenheit. Interview with the MD, Administrator and MNT-C on 11/18/2024 at 1:30 PM revealed the MNT-C had been using an inferred thermometer for resident room water temperatures. MD reported to MNT-C the thermometer being used was incorrect. The MD and ADM confirmed the water temperatures in the resident rooms are above the temperatures of 110-115 degrees Fahrenheit. Record review of the Facility policy titled Plumbing Systems, Resource Packet dated 1/17/2024, identifies Boilers water Heaters and Thermostatic mixing valves (TMVs)-R/S. LTC Senior Living. Hot Water Systems- R/S. LTC, Senior Living. Legionnaires Disease and Water Management Program- R/S. LTC Water temperatures- R/S. LTC, Senior Living, Outpatient Therapy Good Samaritan Society locations monitor water temperatures in the water systems to maintain max hot water temperatures within a range that provides both comfort and safety. Water temperatures must be compliant with all existing federal, state, and local statues. Procedure: Monitoring Water Temperatures (Rehab/Skilled locations) 1.) It is recommended that one room close to the hot water source and one room further away from the hot water source be monitored per week per wing. The room selection should vary from week to week. 2.) The time of day that the temperatures are taken should also vary to ensure that they the desired temperature range is achieved under various hot water demand conditions. 3.) Use the appropriate thermometer that is periodically calibrated (when calibrated these thermometers are typically accurate to 1 to 2 degrees Fahrenheit). 4. Let the hot water run from the faucet for two to three minutes. 5. Insert the stem into the stream of hot or cold running water so that the sensor is fully immersed for approximately 15 seconds to achieve the accurate temperature. The recommended hot water (HW) temperature range for domestic water is 110 degrees to 115 degrees Fahrenheit.

Licensure Reference Number 175 NAC 12-006.10D Based on observations, interviews and record review; the facility failed to ensure that insulin was administered within recommended time frames for 1 of 1 residents (Resident 46). The facility census was 48. Findings are:A record review of Resident 46's Minimum Data Set (MDS, a federally mandated assessment tools used for care planning) dated 6/30/2023 revealed Resident 46 had a score of 15 on the Brief Interview for Mental Status (BIMS).This indicated Resident 46 had intact cognition. A record review of Resident 46's MDS revealed Resident 46 had a diagnosis of Diabetes Mellitus (a disease in which the body doesn't produce insulin to control the amount of glucose or sugar in the blood). An interview on 9/21/2023 at 7:41 AM was conducted with Resident 46. During the interview Resident 46 reported getting insulin (an animal derived or synthetic form of insulin used to treat diabetes) hours after eating. A record review of a physicians' order dated 7/4/2023 contained the following instructions: Insulin Aspart 100 unit/3 ml Pen 2-10 units SQ AC/HS (before meals/at bedtime) per sliding scale and hyperglycemia if BS (blood sugar) is: -150-200, give 2 units, -201-250, give 4 units, -251-300, give 6 units, -301-350, give 8 units, -350-400, give 10 units, -401-450, give 12 units, -if over 450 please call hospice. A record review of Resident 46's Electronic Health Record revealed the resident received blood glucose testing (a test that measures the level of sugar in your blood) at 8:00AM, 12:00PM, 5:00 PM and 9:00 PM. A record review revealed Resident 46 received insulin based on the numbers obtained from the blood glucose monitoring. An interview on 9/26/2023 at 1:16 PM with the Interim Director of Nursing (IDON) confirmed blood glucose checks were performed on Resident 46. The IDON confirmed Resident 46's Medication Administration Record (MAR) indicated Resident 46 received insulin based on the blood glucose monitoring performed. A record review of a Physicians' Order dated 9/25/2023 at 2:47 PM and marked as noted by the IDON contained the following information: Order Clarification. Accuchecks(A method of measuring glucose levels in blood) AC/HS. (AC=before meals, HS=Bedtime). An interview with the DON on 9/25/2023 at 3:00PM confirmed the accu check order was not received until 9/25/2023. A record review of Resident 46's Medication Administration Record (MAR) revealed the following: -Resident 46's blood glucose level was checked on 8/3/23 at 9:00PM and (gender) received 6 units of insulin at 2:17AM on 8/4/2023. Six hours and 17 minutes after the blood glucose level was checked. -Resident 46's blood glucose level was checked on 8/21/23 at 9:00PM and (gender) received 6 units of insulin at 3:04AM on 8/22/23. Six hours and 4 minutes after the blood glucose level was checked. -Resident 46's blood glucose level was checked on 8/24/23 at 9:00PM and (gender) received 8 units of insulin at 1:46AM on 8/25/23. Four hours and 46 minutes after the blood glucose level was checked. -Resident 46's blood glucose level was checked at 9:00PM on 8/31/23 and (gender) received 10 units of insulin on 9/01/23 at 2:16AM. Five hours and 16 minutes after the blood glucose level was checked. -Resident 46's blood glucose level checked at 9:00PM on 9/8/2023 and (gender) received 8 units of insulin at 12:36AM on 9/9/2023. Three hours and 36 minutes after the blood glucose level was checked. -Resident 46's blood glucose was checked on 9/18/2023 at 9:00PM and (gender) received 8 units of insulin at 12:29AM on 9/19/2023. Three hours and 29 minutes after the blood glucose level was checked. An interview on 9/26/2023 at 1:13 PM with the IDON confirmed the MAR indicated Resident 46 received insulin after the scheduled time of 9:00PM for the following dates: 8/3/2023, 8/21/2023, 8/24/2023, 8/31/2023, 9/8/2023 and 9/18/2023. The IDON confirmed it is not the expectation of the facility to give insulin late and it is not the standard of practice of the facility to give medication late.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10A1 Based on observations, record review and interview; the facility staff failed to evaluate 2 (Resident 10 and 11) of 2 residents for the ability to self medicate and to ensure security of medications. The facility staff identified a census of 46. Findings are: A. Observation on 6-06-2023 at 9:15 AM revealed Registered Nurse (RN) B prepared medications to administer to Resident 10 including Ipratropium-Albuterol ( medication use to assist with ease of breathing) via a nebulizer. Further observations revealed RN B placed the Ipratropium-Albuterol medication into the container of the nebulizer and left Resident 10's room. Observation of the medication administration on 6-06-2023 at 9:15 AM revealed that RN B set the following medications on Resident 10's night stand and the medications weren't secured: -Saline nasal mist. -Lotrimin powder. -Artificial tears. -Artificial salvia. -Ear wax remover. Record review of a Resident Self-Administration of Medication (RSAM) sheet dated 3-17-2020 revealed Resident 10 had not requested to self administer medications. Further review of the RSAM dated 3-17-2020 revealed the facility staff had identified Resident 10 was able to safely administer some medications, however, there was no indication of what the medications were that Resident 10 could safely self administer. On 6-06-2023 at 9:25 AM an interview was conducted with RN B. During the interview RN B confirmed unsecured medications were on Resident 10's night stand and further reported not being aware if Resident 10 had been evaluated for the ability to self medicate. B. Observation on 6-06-2023 at 9:32 AM revealed Licensed Practical Nurse (LPN) D prepared Resident 11's medications for administration. Further observation on 6-06-2023 at 9:32 AM revealed LPN D took the medications into Resident 11's room, set them on Resident 11's tray table and left the room without observing Resident 11 taking the medications. Record review of Resident 11's medical record revealed there was no information the facility staff had evaluated Resident 11 to be able to safely self administer medications. On 6-06-2023 at 12:21 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON reported the facility staff had not completed an evaluation of Resident 11's ability to safely self administer medication. Record review of the facility policy and procedure for Resident Self-Administration of Medications dated 10-21-2022 revealed the following information: -Purpose: -To determine if the resident can safely self-administer medications. -To identify which medications may be safely self-administered. -Procedure: -1. Complete the Resident self-Administration of Medications to determine if the resident can safely administer medications and create a plan to assist the resident to be successful in this process. The interdisciplinary team must make a determination weather each resident who express a desire to self-administer medications can do this safely. -3. The Interdisciplinary team will determine where medications will be stored.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-00605(8) Based on observations, record review and interview; the facility staff failed to evaluate the use of a seatbelt as a restraint for 1 (Resident 7) of 1 sampled resident. The facility staff identified a census of 46. Findings are: Record review of Resident 7's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning dated 5-30-2023 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIM) was an 11. According to the MDS [NAME], a BIMS of 8 to 12 indicates moderately impaired cognition. -Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. -No restraints were in place. Record review of Resident 7's Comprehensive Care Plan (CCP) revised on 3-09-2023 revealed Resident 7 was at risk for falls and had a history of falls. The goal identified for Resident 7 was to be free from falls. Interventions identified on Resident 7's CCP to meet this goal included using a seat belt while in a wheelchair. Further review of Resident 7's CCP revised on 3-09-2023 revealed Resident 7 was able to buckle and unbuckle the seat belt independently. Review of Resident 7's medical record that included progress notes and practitioner orders revealed there was no evidence the facility had evaluated the seatbelt as a restraint or how the seatbelt was being used to treat a medical condition. Observation on 6-05-2023 at 2:15 PM revealed Resident 7 was seated in a wheelchair with a connected seatbelt in Resident 7's room. During the observation on 6-05-2023 at 2:15 PM, Resident 7 was asked if Resident 7 was able to remove the seat belt. Further observations at this time revealed Resident 7 was not able to remove the seat belt. Observation on 6-06-2023 at 8:00 AM with Nursing Assistant (NA) C revealed Resident 7 was seated in a wheelchair in Resident 7's room. Resident 7 was observed to have a seatbelt connected. During the observation Resident 7 was requested to remove the seatbelt. Resident 7 attempted to remove the seatbelt and was not able to. Resident 7 reported during the observation on 6-06-2023 at 8:00 AM having requested to be shown how to remove the seatbelt. On 6-06-2023 at 8:00 AM an interview was conducted with NA C. During the interview NA C confirmed Resident 7 was not able to remove the seat belt when requested. On 6-06-2023 at 12:33 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON reported there was no evaluation of the seatbelt as a potential restraint. Record review of the facility policy and procedure for Restraints dated 10-21-2022 revealed the following information: -Policy: -Residents are free from any physical or chemical restraints imposed for purpose of discipline or convenience and not required to treat the residents medical symptoms. -Definition: -Physical restraints: -a. Physical restraints may include, but not limited to: hand mitts, soft ties,vest, and lap cushions. Also included as restraints are location practices that meet the definition of a restraint such as, using devices in conjunction with a chair such as trays, tables and belts that prevent a resident from rising.

Licensure Reference: 175 NAC 12-006.09 Based on record review and interview, the facility failed to ensure neurological assessments [an assessment of neurological functions, motor and sensory response, and level of consciousness] were accurate and complete after a fall in accordance with facility policy for 1 [Residents 4] of 4 sampled residents. The facility had a total census of 46 residents. Findings are: A. A review of the facility policy titled Neurological Evaluation-Rehab/Skilled dated 2/10/23 revealed the following: Use: -Following a witnessed fall when a resident has hit his/her head -Following an unwitnessed fall -Following a resident event that results in a known or suspected head injury (e.g., hemorrhagic stroke) Policy/Procedure: -After the completion of initial neurological evaluation with vital signs, continue with evaluations every 30 minutes x 4, then every eight hours x 3 days or as directed by the provider. -Subsequent neurological evaluations should be compared to baseline and previous neurological evaluations. All items on the Neuro Check UDA should be completed with each evaluation. -Notify physician of any neurological evaluation findings which are a change from the baseline or previous evaluations. Document all physician notifications on PN-Communication/visit with Physician. B. A review of an Incident Report for Resident 4 dated 5/2/23 at 11:19 PM revealed Resident 4 slid out of bed on to the floor with Resident 4's knees up. Fall was not witnessed. No injuries were identified. Record review of Neuro Check forms documented in the electronic medical record completed on Resident 4 after the fall on 5/2/23 at 11:19 PM revealed neurological assessments were completed on the following dates and times: -5/2/23 at 11:19 PM -5/2/23 at 12:15 AM -5/3/23 at 2:29 AM -5/3/23 at 5:17 AM -5/3/23 at 2:58 PM Record review of Resident 4's Neuro Check forms dated 5/2/23 at 12:15 AM, 5/3/23 at 2:29 AM, and 5/3/23 at 25:17 AM revealed the temperature, pulse, blood pressure, and oxygen saturation level was dated 5/2/23 at 11:19-11:20 PM. The respiration rate was dated 5/2/23 at 5:18 PM and the pain level was dated 5/3/23 at 12:07 AM. A review of Resident 4's Progress Notes revealed Resident 4 was transferred to the hospital at 1 PM on 5/3/23. In an interview on 6/6/23 at 1:36 PM, the Director of Nursing confirmed that all vitals should be taken with each neuro check.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and interview; the facility staff failed to implement additional interventions to prevent being found on the floor for 2 (Resident 6 and 7) of 4 sampled residents. The facility staff identified a census of 46. Findings are: A. Record review of Resident 6's Comprehensive Care Plan (CCP) revised on 4-10-2023 revealed Resident 6 was at risk for falls. The goal identified on Resident 6's CCP was to be free of falls. Interventions identified on Resident 6's CCP included having the bed in the lowest position, provide a reacher and non-skid tape next to Resident 6's bed. Record review of Resident 6's Progress Notes (PN) dated 5-20-2023 revealed Resident 6 was found sitting on the floor. Review of Resident 6's medical record that included Resident 6's CCP revealed there was not a new intervention implemented to prevent Resident 6 from being found on the floor. On 6-06-2023 at 2:09 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON reported there were no new interventions implemented related to Resident 6 being found on the floor on 5-20-2023. B. Record review of Resident 7's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning dated 5-30-2023 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIM) was an 11. According to the MDS [NAME], a BIMS of 8 to 12 indicated moderately impaired cognition. -Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Record review of Resident 7's Comprehensive Care Plan (CCP) revised on 3-09-2023 revealed Resident 7 was at risk for falls and had a history of falls. The goal identified for Resident 7 was to be free from falls. Interventions identified on Resident 7's CCP to meet this goal included placing non-skid strip on the floor in front of a recliner, a reacher and ant-roll back device on the wheelchair. Record review of a Incident Audit Report (IAR) dated 5-02-2023 revealed Resident 7 was found on the floor. Further review of the IAR dated 5-02-2023 revealed there was no implementation of an additional intervention to prevent Resident 7 from being found on the floor. On 6-06-2023 at 2:09 PM an interview was conducted with the DON. During the interview the DON reported there were no new interventions implemented to prevent further incidents of Resident 7 being found on the floor.

Licensure Reference: 12-006.04A3b Based on record review and interview, the facility failed to ensure 1 [Agency Direct Care Staff Member E] of 1 sampled agency staff member had completed a training and competency evaluation program as required for placement on the state nurse aide registry. The facility had a total census of 46 residents. Findings are: A review of Nebraska Public Health Licensure Unit Certification of Licensure dated 6/8/23 revealed Agency Direct Care Staff Member E had a pending status as a nurse aide. The Certification of Licensure did not identify Direct Care Staff Member E had passed the clinical evaluation. A review of an undated response from Direct Care Staff Member E's agency confirmed that Direct Care Staff Member E had a Medication Aide license which qualified Direct Care Staff Member E to work the shifts. In an interview on 6/6/23 at 1:49 PM, the Director of Nursing confirmed Direct Care Staff Member E had provided care to Resident 2 on 5/23/23. A review of an undated document revealed Direct Care Staff Member E had worked a shift starting 6/4/23 at 5:50 PM and ending at 6:15 AM on 6/5/23. In an interview on 6/6/23 at 3:56 PM, the Administrator reported the facility has a contract with the agency to provide nurse aides that are active on the nurse registry.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, record review and interview; the facility staff failed to ensure a medication error rate of less than 5%. Observations of 33 medications administered revealed there were 2 errors resulting in an error rate of 6.06%. The errors affected 2 (Resident 9 and 10) of 4 residents reviewed for medication administration. The facility staff identified a census of 46. Findings are: A. Record review of an Order Summary Report (OSR) sheet dated 6-6-2023 revealed Resident 9's practitioner ordered medications that included Levemir insulin, 22 units to be given in the AM. Observations on 6-6-2023 at 8:45 AM revealed Registered Nurse (RN) A prepared Resident 9's medications for administration. Further observation on 6-62023 at 8:45 AM revealed RN A prepared 21 units of Levemir insulin and reported that was the correct amount to be given and RN A was prepared to give the Levemir insulin to the resident. On 6-6-2023 at 8:45 AM an interview was conducted with RN A. During the interview RN A confirmed the does of 21 units Levemir insulin was not the correct dose and would be an error. B. Record review of a OSR sheet dated 6-6-2023 revealed Resident 10's practitioner ordered medications that included Artificial Tears eye drops to be given 2 times a day. Observation on 6-6-2023 at 9:15 AM revealed RN B started preparing Resident 10's medications for administration. During the observations the artificial tears were not available to be given. On 6-6-2023 at 9:25 AM an interview was conducted with RN B. During the interview RN B reported the artificial tears were not available to be given and further reported placing a re-order for the medication.

B. Review of Resident 24's medical record revealed Resident 24 was transferred to the hospital on 8/5/2022 for uncontrolled respiratory failure. Review of Resident 24's medical record revealed a bed hold signed for the hospitalization on 8/5/2022, however not letter was sent to Resident 24 or Resident 24's representative with the reason for the transfer. Interview on 08/16/22 at 8:06 AM with the administrator revealed no letter was sent to Resident 24 or Resident 24's representative regarding transfers. Review of Resident 24's medical record revealed hospitalizations on the following dates: 2/15/22, 5/1/22, 8/1/22, 8/5/22 Interview on 08/16/22 at 10:05 AM with the administrator revealed the facility does not send letters when transferring residents to the hospital. Based on record review and interview, the facility failed to provide a written notice of the reason for transfer for 2 (Residents 38 and 24) of 2 residents reviewed. The facility census was 48. Findings are: A. Record review of Resident 38's Census Record revealed that Resident 38 had been sent to the hospital on 3/29/22, 6/13/22, 6/18/22 and 8/5/22. Record review of Resident 38's Electronic Medical Record revealed no written notice of the reason for the transfers had been provided to the patient or the representative at the time of those transfers. Interview on 08/16/22 at 10:52 AM with the facility Administrator confirmed that no written notice of the reason for the transfers had been provided to the resident or the representative at the time of those transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D6 Based on observation, record review and interview; the facility failed to have physician orders for Oxygen therapy and failed to maintain the CPAP (a device used to deliver positive air pressure to a residents airway to prevent closure during sleep) in a working manner for 1 (Resident 42) of 1 sampled resident. The facility staff identified a census of 48. The findings are: Interview conducted with Resident 42 on 08/10/22 at 11:04 AM revealed the CPAP leaks water all over and Resident 42 hasn't worn the CPAP for two or three weeks or more. Resident 42 stated that (gender) has been using the Oxygen concentrator and the nasal cannula at night since the CPAP leaks. Observation on 08/10/22 at 11:15 AM of ResMed air curve 10 CPAP machine on the night stand revealed the CPAP tubing and mask lying on top of table. Observation of Oxygen Concentrator with nasal cannula and tubing rolled up and laid on top of the Oxygen Concentrator. Review of Resident 42's medical record revealed an admission date of 07/27/2020. Review of the MDS (Minimun Data Set; a federally mandated comprehensive assessment tool used for care planning) dated 07/01/2022 revealed a Brief Interview for Mental Status score of 15. According to the MDS [NAME] a score of 13-15 indicates a resident is cognitively intact. Record review of Resident 42's medical record revealed progress notes dated 7/28/2022 21:45 CPAP on at HS off in the AM setting on home settings 2L Oxygen (O2) two times a day resident states CPAP is broken/leaking. Resident 42 is wearing O2 at night. Review of Progress note dated 7/29/2022 00:17 revealed CPAP on at HS off in the AM setting on home settings 2L Oxygen two times a day. Resident 42 stated to nurse the CPAP is not working right and leaking water. Review of the current physician orders revealed CPAP on at HS off AM setting on home settings 2L Oxygen two times a day for Obstructive Sleep Apnea (a common sleep related breathing disorder). Review of the current physician orders revealed no order for the use of Oxygen via Nasal Cannula. Review of the MAR/TAR (Medication Administration Record/Treatment Administration Record) for July/August 2022 revealed July documentation of on and off everyday except Thursday July 28 charted as see nurses notes and as did not occur and July 29 as did not occur. On August 1 charted as did not ocurred and the rest of the days in August documented as on and off. Review of the current comprehensive care plan revealed the CPAP or Oxygen usage had not been addressed. Review of the policy for oxygen administration dated 06/29/22 revealed oxygen administration is carried out only with a medical provider order. A licensed nurse trained in the use of oxygen is responsible for the proper administration of oxygen to the resident. Interview with the DON (Director of Nursing) and the ADON (Assistant Director of Nursing) on 08/11/22 at 12:39 PM confirmed there were no orders for Oxygen via nasal cannula on the physician orders. Further interview revealed the DON and ADON were unaware that the CPAP was not working.

D. An observation on 08/10/2022 at 09:03 AM of medication administration by LPN-A (Licensed Practical Nurse) to Resident 6 revealed the following medications were administered: -Baclofen 10mg - Give 10 mg orally four times a day. -Culturelle - Give 1 capsule by mouth every 12 hours. -Glipizide 5mg - Give 5mg orally three times a day for Diabetes. -Methenamine 1 GM - Give 500 mg by mouth every 12 hours. -Lamotrigine 25mg - Give 2 tablet orally two times a day -Amlodipine 10mg - Give 10 mg by mouth one time a day -Aspirin 81mg - Give 81 mg by mouth one time a day -Atenolol 50mg - Give 50 mg orally one time a day. -Loratadine 10mg - Give 10 mg by mouth one time a day -Fluticasone - 1 spray in both nostrils in the morning -Metformin 500mg x 2 -Give 1000 mg by mouth two times a day -Oxybutynin 5mg - Give 1 tablet by mouth three times a day -Preser-vision x 2 - Give 2 tablet by mouth in the morning. -Tylenol 325mg x 2 - Give 650 mg orally every 4 hours as needed for Pain LPN-A did not wash or sanitize their hands prior to giving oral medications. LPN-A did not wash or use hand sanitizer prior to or after the administration of nasal spray. LPN-A did not wash hands or use hand sanitizer before entering resident room, before donning gloves or after doffing gloves or after leaving resident room. LPN-A did not wash or sanitize their hands prior to starting a medication pass on another resident. E. An observation on 08/10/2022 at 09:33AM of medication administration by LPN-A to Resident 31 revealed the following medications were administered: -Advair inhaler. 1 puff inhale orally two times a day. -Diltiazem 240mg -Give 240 mg by mouth one time a day. -Loratadine 10mg - Give 10 mg by mouth one time a day -Tylenol 325mg x 2 Give 650 mg by mouth every 4 hours as needed for pain/fever -Miralax x 17gm - Give 17 mg by mouth one time a day. -Risperdal liquid 0.25ml - Give 0.25 mg by mouth one time a day. LPN-A did not hand sanitize or wash hands prior to or after administering medications. An interview with LPN -A on 08/10/2022 at 09:40 AM confirmed that hand sanitizer was not kept on the cart but was available in the hallways in wall dispensers. F. An observation on 08/10/2022 at 12:10 PM of medication administration to Resident 35 By RN-B (Registered Nurse) revealed the following medications were administered: -Amlodipine 10mg - Give 10mg by mouth once a day. -Eliquis 5mg - 5mg two times daily -Artificial Tears - 1 drop in both eyes as needed every 6 hours. -Fluoxetine 1.25ml - Give 1.25ml by mouth once a day. -Fluticasone nasal spray - 1 spray in each nostril in the morning. -Hydrochlorothiazide 25mg - 25mg once a day. -Primidone 125mg - Give 125mg once a day. -Cetirizine 10mg - Give 5mg once a day by mouth -Metoprolol 50mg - 1 tab daily -Finasteride 10mg. - Give 5mg by mouth once a day. RN-B did not sanitize or wash their hand prior to or after giving medications. RN-B did not wash or sanitize their hands prior to donning or doffing gloves. A record review of the facility's policy on Medication Administration dated 07/01/2022 revealed that handwashing is the first action to take prior to beginning medication pass and following the administration of medication for each resident. An interview with the facility Administrator on 08/16/2022 at 09:45AM confirmed the expectation is hand hygiene is to be performed prior to administration of medication, doning and doffing of gloves, before entering a resident room and when departing a resident room. B. An observation on 8/10/22 at 11:26 AM revealed Medication Aide (MA) C leaving the clean linen closet with clean sheets draped over both shoulders and a bundle of clean linens held against (gender) body. An interview on 8/16/22 at 10:03 AM with MA C revealed that linens should be carried away from the body. An interview on 8/16/22 at 11:17 AM with the Director of Nursing (DON) confirmed that clean linens should be transported to the resident's rooms in a bag and not held against the staff member's body. C. An observation on 8/10/22 at 10:23 AM revealed Nurse Aide (NA) D walking in hallway with (gender) mask worn below the nose. An observation on 8/10/22 at 12:11 PM revealed NA D in the dining room standing next to a table with (gender) mask worn below the nose. Seated at the table were Residents 1, 6, 9, and 14, who all had their masks down to eat. NA D was within 6 feet of all of the residents. An observation on 8/11/22 at 3:16 PM revealed NA E pushing a resident in the hallway with (gender) mask below the nose. An observation on 8/11/22 at 3:29 PM revealed NA D in a resident's room with (gender) mask worn bellow the nose. An interview on 8/15/22 at with NA F revealed that a mask should be worn to cover both the nose and mouth. An interview on 8/16/22 at 11:17 AM with the DON confirmed that the expectation for masks was that they be worn up over the nose and mouth. LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 Based on observation, record review and interview; the facility staff failed to maintain Oxygen tubing and a CPAP (Continuous Positive Airway Pressure) a device used to deliver positive air pressure to a residents airway to prevent closure during sleep) mask to prevent cross contamination for 1 (Resident 42) of 1 sampled resident, failed to perform hand hygiene prior to medication administration for Resident 6, 30 and 31, failed to wear facial masks near Resident 9, 14, 1 and 6 and handle clean linen in a manner to prevent the potential for cross contamination. The facility staff identified a census of 48. The findings are: A. Observation on 08/10/22 at 03:30 PM of the oxygen tubing rolled up and on top of the concentrator without being covered. The CPAP mask was uncovered on top of overbed table. Observation on 08/11/22 at 07:30 AM of the oxygen tubing rolled up and on top of the concentrator without being covered. The CPAP mask was uncovered on top of overbed table. Review of the current physician orders revealed an order dated 08/11/22 for CPAP on at hour of sleep and off in the AM setting on home settings 2Liters Oxygen two times a day for Obstructive Sleep Apnea ( a common sleep related breathing disorder). Record review of the medical record revealed no indication of documentation that the oxygen tubing was changed or the CPAP had been changed/cleaned. Review of the Policy for Oxygen administration dated 06/29/22 revealed when oxygen is not in use, store cannula in zip lock bag secured to the oxygen concentrator. Interview conducted with the Director of Nursing (DON) on 08/11/22 at 12:39 PM revealed that Oxygen tubing is changed weekly on Saturdays and confirmed there was no documentation of Oxygen tubing being changed on this resident due to no order for Oxygen. Oxygen tubing and CPAP equipment should be in a bag when not in use.