Adept Nursing & Rehab Of Grand Island
Inspection history, citations, penalties and survey trends for this long-term care facility in Grand Island, Nebraska.
- Location
- 800 Stoeger Drive, Grand Island, Nebraska 68803
- CMS Provider Number
- 285221
- Inspections on file
- 18
- Latest survey
- May 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Adept Nursing & Rehab Of Grand Island during CMS and state inspections, most recent first.
The facility did not complete required Nurse Aide Registry Checks prior to hiring four staff members, including a nurse aide, medication aide, LPN, and hospitality aide. These staff began working and providing care to residents before the checks were performed or documented, contrary to facility policy and state requirements.
The facility did not update its Facility Assessment to include ventilation services, despite a resident using a Trilogy Non-invasive ventilator continuously. The assessment was last revised without accounting for ventilator-dependent residents, and an LPN reported not receiving direct training on the device. The Regional Nurse Consultant confirmed the omission.
A staff member began work without a completed pre-employment health screening, and multiple staff failed to follow Enhanced Barrier Precautions by not wearing required PPE during high-contact care for two residents with wounds. Additionally, an ADT did not perform proper hand hygiene during wound care for a resident on EBP.
Staff were not trained on the Trilogy Non-invasive ventilator, despite a resident having physician orders for its use. The facility's assessment did not include ventilation services, and an LPN confirmed no training was provided on ventilator or dialysis care. The Regional Nurse Consultant also confirmed that required training had not been completed.
The facility did not post required daily nurse staffing information in any accessible location, as confirmed by multiple observations and interviews with facility leadership. Despite having designated frames for postings at nurse's stations, these remained empty throughout the survey, and the required information was not made available to residents, staff, or visitors.
Surveyors found that two residents received medications from stock bottles that were not labeled with the date opened, contrary to facility policy. Additionally, the medication storage room was observed to be unsanitary, with soiled floors, sink, and counters where medications were stored. Both the ADON and RNC confirmed these deficiencies.
Two nurse aides did not complete the required 12 hours of annual continuing education, with one aide completing no hours and another only 8 hours during their respective annual training periods. The facility's records and administrator confirmed the deficiency, as the required training was not provided within the specified timeframes.
Three residents, including individuals with schizophrenia, dementia, and other serious conditions, were administered psychotropic medications without documented informed consent. Facility records lacked evidence that residents or their representatives were informed of the benefits, risks, and alternatives to these medications, and staff confirmed that required consent documentation was missing or incomplete.
A resident with multiple diagnoses and intact cognition expressed a wish not to have CPR performed, which was also indicated by their responsible party. However, the electronic medical record, including order entry, profile header, and care plan, continued to list the resident as a full code. The DON confirmed that the resident's wishes were not accurately reflected in the documentation.
Two residents were administered psychotropic medications for unapproved indications: one received Quetiapine for anxiety and another received Mirtazapine for insomnia, despite neither condition being an FDA-approved use for these drugs or properly documented in the medical record. The DON confirmed the lack of appropriate indications for both cases.
A resident with a left leg amputation, chronic pain, and diabetes was inaccurately coded on the MDS regarding mobility device use and pain medication. The MDS documented walker use, but both the resident and staff confirmed wheelchair use. Additionally, the MDS failed to reflect that the resident received scheduled opioid pain medication, despite physician orders and medication records showing regular administration.
A resident with schizophrenia, anxiety, and major depression was admitted without a completed PASRR Level 1 screening, as required by facility policy and state Medicaid rules. The DON confirmed that the necessary pre-admission screening was not performed.
Three residents with significant medical conditions experienced prolonged periods without bowel movements, and facility staff failed to provide or document required bowel care interventions or assessments as ordered. Despite care plans and physician orders for as-needed laxatives and monitoring, there was no evidence of interventions or documentation in the medical records, as confirmed by nursing leadership.
A resident with multiple medical conditions experienced a progressive decline in hand function and upper extremity strength, impacting their ability to feed themselves and reposition in bed. Despite observable changes and increased dependence on staff, the care plan lacked interventions for impaired range of motion, and required therapy assessments were not completed. Staff and therapy leadership were unaware of the resident's decline, resulting in a failure to maintain the resident's ROM and functional abilities.
The facility did not ensure that two residents received their required initial post-admission visits from a physician within the mandated timeframe. In one case, a PA conducted the initial visit instead of a physician, and in another, the physician visit occurred after the required 30-day period.
A resident with chronic pain and diabetes, who required assistance with oral hygiene, reported having multiple broken teeth and had not seen a dentist since admission. The resident was not asked about dental needs, and observation confirmed dental issues. The care plan identified oral health risks, but no dental services were provided or arranged, as confirmed by the Regional Nurse Consultant.
A resident with a renal diet and strict religious restrictions against pork was repeatedly served meals containing pork products and other non-compliant items, despite clear documentation of their dietary needs. The dietary staff did not follow the specified restrictions, resulting in the resident being unable to eat the provided food.
A resident with severe cognitive impairment and multiple comorbidities was found to have a healing arm fracture of unknown origin. Facility staff did not report the injury or submit an investigation to the state agency or adult protective services within required time frames, despite policy requiring prompt notification for such incidents.
A resident at risk for pressure ulcers did not receive adequate care, as the facility failed to conduct weekly skin assessments, delayed dietary interventions, and did not ensure the use of heel boots. The resident's skin conditions worsened due to these deficiencies, as confirmed by staff observations and interviews.
The facility failed to ensure proper use of PPE, hand sanitization, and infection control practices, including incomplete pre-employment health screenings and improper urinary catheter care, increasing the risk of cross-contamination and infection among residents.
The facility failed to maintain three rooms and two halls in good repair, compromising residents' right to a safe, clean, and homelike environment. Observations included holes in ceilings, warped paint, yellow-brown stains, and gray-black fuzzy material. The Facility Administrator and Regional Director of Operations confirmed the damage was due to a water leak from holes in the roof, which had been repaired, but the interior damage remained unaddressed.
The facility failed to include necessary interventions for urinary elimination in a resident's care plan and did not document a discharge plan for another resident who expressed a desire to leave. These deficiencies were confirmed through observations, record reviews, and staff interviews.
The facility failed to conduct and document care plan meetings for several residents, including those with significant medical conditions, over extended periods. This deficiency was confirmed through record reviews and interviews with residents and their representatives, revealing a systemic failure to comply with care planning requirements.
The facility failed to ensure residents were free from significant medication errors, specifically in the administration and storage of insulin pens. An RN incorrectly primed an insulin pen, and several insulin pens were improperly labeled and stored, as confirmed by the DON.
The facility failed to ensure routine bowel movements for a resident with multiple diagnoses, including schizophrenia and chronic kidney disease. Despite the facility's constipation prevention protocol, the resident did not receive necessary interventions or assessments for extended periods. Staff interviews confirmed the lack of orders for an as-needed laxative and the absence of documented assessments or interventions.
The facility staff failed to manage complaints of pain for a resident admitted with multiple fractures and other medical conditions. Despite the resident's severe pain, no pain medication was administered until the following day. The facility did not follow protocols for timely medication delivery or utilize non-pharmacological pain interventions as documented in the care plan.
Failure to Complete Pre-Employment Nurse Aide Registry Checks
Penalty
Summary
The facility failed to ensure that Nurse Aide Registry Checks were completed prior to hire for four out of five sampled staff members, as required by facility policy and state regulations. Specifically, the employee files for a nurse aide, a medication aide, an LPN, and a hospitality aide either contained registry checks completed months after their hire dates or lacked documentation of the checks entirely. In each case, the staff members had already begun working and had completed initial orientation training before the registry checks were performed or documented. Interviews with the Facility Administrator confirmed that the expectation was for these checks to be completed before employment began, and acknowledged that this requirement was not met for the identified staff. Observations showed these staff members actively providing care or assistance to residents during the survey period. For example, the nurse aide was observed exiting a resident's room, the medication aide was assisting a resident at the medication cart, and the hospitality aide was helping residents access the courtyard. The lack of timely registry checks meant that the facility could not verify whether these staff had any findings of abuse, neglect, or misappropriation of property prior to their employment, contrary to the facility's written policies and procedures.
Facility Assessment Lacked Ventilator Services for Resident Needs
Penalty
Summary
The facility failed to review and revise its Facility Assessment to ensure it included all necessary resources to meet the needs of its residents, specifically omitting ventilation services. The Facility Assessment, last revised and reviewed in April 2025, did not account for residents requiring ventilator support. Record review showed that one resident had a physician's order for a Trilogy Non-invasive ventilator to be used at bedtime or while napping, but the resident reported using the ventilator continuously, only removing it for cleaning or hose changes. Additionally, an LPN stated they had not received direct training from the facility on the use of the Trilogy Non-invasive ventilator. The Regional Nurse Consultant confirmed that the Facility Assessment should have been updated to include ventilator services.
Deficiencies in Infection Control: Pre-Employment Screening, Enhanced Barrier Precautions, and Hand Hygiene
Penalty
Summary
The facility failed to ensure completion of pre-employment health history screening for one of five sampled staff members. Specifically, the employee file for a hospitality aide did not contain a fully completed Health Questionnaire, as required by facility policy. The section for test information, including vital signs and provider follow-up, was left blank, and the employee did not sign or date the form. Despite this, the Director of Nursing signed off on the document as complete, and the aide began working and providing direct assistance to residents. Additionally, the facility did not follow its Enhanced Barrier Precautions (EBP) policy for residents with chronic wounds. During high-contact care activities, such as transferring a resident with a wound using a full body lift, two nurse aides failed to wear the required personal protective equipment (PPE), including gloves and gowns, despite signage and their own acknowledgment of the policy. Another instance involved the Assistant Director of Nursing in Training providing personal hygiene care to a resident on EBP without wearing a gown, contrary to facility policy and their own admission of the requirement. The facility also failed to ensure proper hand hygiene during wound care for a resident on EBP. The Assistant Director of Nursing in Training applied two different substances to the resident's wound area without changing gloves or performing hand hygiene between applications, as required by the facility's hand hygiene policy. This lapse was confirmed by both the staff member involved and the Assistant Director of Nursing.
Lack of Staff Training on Trilogy Non-Invasive Ventilator
Penalty
Summary
The facility failed to provide training to staff on the use of the Trilogy Non-invasive ventilator, as required by licensure regulations. Record review showed that the facility's assessment did not include ventilation services, despite having a resident with physician orders for the use of a Trilogy Non-invasive ventilator at bedtime or while napping. Interviews with a resident revealed that the ventilator was being used continuously, except during cleaning or hose changes. Additionally, an LPN reported not receiving any training on the Trilogy Non-invasive ventilator or on recognizing dialysis-related signs and symptoms. The Regional Nurse Consultant confirmed that training on ventilator and dialysis services had not been completed for staff review.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted as required by its own policy and federal regulations. The policy specified that nurse staffing information, including facility name, current date, resident census, and the total number and actual hours worked by RNs, LPNs, and nurse aides per shift, must be posted daily in a prominent and accessible location for residents, staff, and visitors. Multiple observations conducted over several days revealed that the daily nurse staffing posting was not present anywhere in the facility, including at entry doors, nurse's stations, administrative offices, dining room, and other common areas. Interviews with facility leadership, including the Facility Administrator and Regional Director of Operations, confirmed that the daily nurse staffing information was not posted as required. Although there were designated frames for the postings at nurse's stations, these remained empty throughout the survey period. The failure to post the required information had the potential to affect all 58 residents residing in the facility, as the information was not made available at any time during the recertification survey.
Failure to Properly Label and Sanitarily Store Medications
Penalty
Summary
Surveyors observed that stock medication bottles used for two residents were not labeled with the date they were opened, as required by facility policy and professional standards. During medication administration, a medication aide prepared and administered medications from bottles that lacked an opening date, and both the aide and the Assistant Director of Nursing confirmed that the bottles should have been dated but were not. The facility's policy specifies that stock medications must include the original manufacturer's or pharmacy-applied label and the expiration date, but this was not followed in these instances. Additionally, the medication storage room was found to be unsanitary during inspection. Observations included dried black splatters and debris on the floor, a sink with a thick layer of brown and black sticky substance with black fuzzy particles, and counters with dried liquid splatters in the area where medications were stored. Both the Assistant Director of Nursing and the Regional Nurse Consultant confirmed that the medication storage room was not clean or sanitary, despite facility policy requiring daily cleaning to ensure proper sanitation.
Failure to Ensure Nurse Aides Complete Required Annual Continuing Education
Penalty
Summary
The facility failed to ensure that nurse aides completed the required minimum of 12 hours of continuing education annually, as mandated by facility policy and state regulations. Specifically, one nurse aide (NA-G), who worked per diem throughout the year, did not complete any hours of continuing education during their annual training period based on their hire date. Facility records confirmed multiple work shifts for this aide during the relevant period, but no training hours were documented. The Facility Administrator acknowledged that the facility is responsible for ensuring all nurse aides, regardless of their work schedule, meet the annual training requirement and confirmed the deficiency for NA-G. Additionally, another nurse aide (NA-H) completed only 8 hours of continuing education during their annual training period, falling short of the 12-hour requirement. Although the Facility Administrator attempted to locate additional in-service documentation, the only additional trainings found were outside the required annual period. The deficiency was confirmed by the Facility Administrator, who acknowledged that the required training hours were not met for NA-H within the specified timeframe.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document informed consent for the use of psychotropic medications prior to administration for three residents. For one resident with schizophrenia, anxiety, and major depression, record reviews showed that antipsychotic medications were started upon admission, but there was no psychotropic medication informed consent form present in the medical record at the time of survey. When a consent form was later provided, it was incomplete, missing key information such as the resident's current medications and physician details. Further investigation revealed inconsistencies in the documentation, including a consent form with signatures that did not match the original, and no evidence that the resident's guardian had been properly informed or contacted regarding the consent. Another resident with hemiplegia, diabetes, dementia, and a history of stroke was found to be receiving antidepressant and antipsychotic medications on a routine basis. The medical record lacked documentation that the resident or their responsible party had been informed of the benefits, risks, and alternatives to these medications. Interviews with facility staff confirmed that such documentation was expected but not present in the resident's health record. A third resident with hydrocephalus, diabetes, and dementia, who was cognitively intact, was also receiving routine antidepressant medications. Similar to the other cases, there was no documentation in the medical record indicating that informed consent had been obtained or that the resident or their representative had been informed about the medications. Staff interviews confirmed the absence of required documentation for informed consent prior to the administration of psychotropic medications.
Failure to Accurately Document Resident Code Status in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's wishes regarding code status were accurately documented and reflected in the electronic medical health record. Specifically, a review of the resident's records showed that although the resident and their responsible party had indicated a desire not to have CPR performed, the electronic medical record, including the order entry, profile header, and care plan, continued to list the resident as a full code with instructions to begin CPR in the event of an arrest. The facility's policy required that code status be communicated and documented in designated sections of the medical record, but this was not followed in this case. The resident involved was admitted with diagnoses including metabolic encephalopathy, obesity, and schizoaffective disorder, and was assessed as cognitively intact with a BIMS score of 14. During an interview, the resident clearly stated they did not wish to have CPR performed. Despite this, the documentation in the electronic medical record did not reflect the resident's wishes, as confirmed by the DON, who acknowledged the discrepancy between the resident's expressed wishes and the information recorded in the system.
Psychotropic Medications Used Without Approved Indications
Penalty
Summary
The facility failed to ensure that psychotropic medications were prescribed and administered only for approved indications in accordance with facility policy and regulatory requirements. For one resident with hemiplegia, type 2 diabetes, dementia, and a history of stroke, Quetiapine, an antipsychotic medication, was ordered and administered for anxiety, which is not an FDA-approved indication for this drug. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment, and the medication was given routinely as per the physician's order. The Director of Nursing (DON) confirmed that anxiety was not an approved indication for Quetiapine. In another case, a resident with hydrocephalus, type 2 diabetes, and dementia was prescribed Mirtazapine, an antidepressant, for insomnia. The MDS showed the resident was cognitively intact and received the medication routinely. However, the resident did not have a diagnosis of insomnia documented in their medical record, and the DON confirmed that insomnia was not an approved indication for Mirtazapine. These findings demonstrate that the facility did not ensure psychotropic medications were used only for specific, diagnosed, and documented conditions as required.
Inaccurate MDS Coding for Mobility and Pain Management
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one resident, resulting in multiple discrepancies between the resident's actual condition and the documented assessment. The resident, who was admitted with diagnoses including an absence of the left leg below the knee, chronic pain, and type 2 diabetes mellitus, was incorrectly coded in several MDS sections. Specifically, the MDS indicated that the resident used a walker for mobility, while interviews with the resident and staff confirmed that the resident used a wheelchair and rarely got out of bed. The Regional Nurse Consultant also confirmed that the MDS coding did not accurately reflect the resident's use of a wheelchair. Further review revealed that the MDS was incorrectly coded regarding the resident's pain management and medication use. Although the resident had a physician's order for scheduled Hydrocodone-Acetaminophen and received this opioid medication routinely during the look-back periods, the MDS was coded to indicate that the resident did not receive scheduled pain medication and was not taking an opioid. These inaccuracies were confirmed through interviews and review of the resident's medication administration records and physician orders.
Failure to Complete PASRR Level 1 Screening Prior to Admission
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) Level 1 screening prior to admitting a resident with diagnoses of schizophrenia, anxiety, and major depression. According to the facility's policy, all applicants must be screened for serious mental disorders or intellectual disabilities before admission, in accordance with state Medicaid rules. Record review showed that the resident was admitted without a completed PASRR Level 1 evaluation in the medical record. The Director of Nursing confirmed during an interview that the screening was not completed as required prior to the resident's admission.
Failure to Provide and Document Bowel Care Interventions
Penalty
Summary
The facility failed to provide appropriate bowel care services for three residents, as evidenced by a lack of interventions and documentation when residents did not have bowel movements for several days. For one resident with hemiplegia, diabetes, dementia, and a history of stroke, there was no documented bowel movement for seven consecutive days, and no interventions or assessments were recorded in the medical record during this period. The Medication Administration Record also showed no administration of as-needed cathartic medication, and the Assistant Director of Nursing (ADON) confirmed the absence of both interventions and documentation. Another resident, diagnosed with hydrocephalus, diabetes, and dementia, experienced multiple periods without documented bowel movements, including three days in April and four days in May. During these times, there was no evidence in the progress notes or MAR of any interventions or assessments to address the lack of bowel movements. The ADON confirmed that the medical record lacked documentation of both interventions to promote bowel movements and bowel assessments for this resident as well. A third resident, admitted with diabetes, a foot ulcer, and on palliative care, reported not having a bowel movement in two weeks and was aware of their own elimination patterns. The review of the resident's records showed the last documented bowel movement was over two weeks prior, and although there were physician orders for as-needed laxatives, there was no documentation of these being administered. The care plan included monitoring and recording bowel movements daily and following physician orders for laxatives if no bowel movement occurred for three or more days, but there was no evidence these interventions were implemented. Interviews with facility staff confirmed the absence of required documentation and interventions for all three residents.
Failure to Maintain Resident's Range of Motion and Functional Abilities
Penalty
Summary
The facility failed to ensure that a resident maintained their range of motion (ROM) to promote their highest practicable level of independence. The resident, admitted with diagnoses including absence of left leg below the knee, chronic pain, and type 2 diabetes mellitus, was cognitively intact and required staff assistance for bed mobility and transfers. The resident was noted to have impaired ROM in one upper extremity and both lower extremities, but their care plan did not include any focus area or interventions related to impaired ROM. The resident reported progressive loss of hand function, specifically curling of fingers and inability to straighten them, which affected their ability to feed themselves and reposition in bed—tasks they previously could perform. Observations confirmed the resident's difficulty in grasping utensils and repositioning independently, requiring increased staff assistance. Staff interviews corroborated the resident's decline in upper extremity function and increased dependence. The Director of Rehab acknowledged that a therapy screen or evaluation was not completed as required, and was unaware of the resident's decline in hand function and upper extremity strength. This lack of assessment and intervention contributed to the resident's continued decline in ROM and functional abilities.
Failure to Ensure Timely Initial Physician Visits for New Admissions
Penalty
Summary
The facility failed to ensure that the required initial post-admission physician visit was completed for two residents. For one resident, the initial visit after admission was conducted by a Physician Assistant (PA) rather than a physician, as confirmed by both documentation and interviews with facility staff. Facility policy and regulatory requirements specify that the initial comprehensive visit in a skilled nursing facility must be performed by a physician, not by a non-physician practitioner. The progress note for this resident documented the visit by the PA as the initial skilled nursing facility care visit, which was not in compliance with the stated requirements. For another resident, there was no evidence that a physician completed the required initial visit within 30 days of admission. The first documented physician visit for this resident occurred beyond the 30-day window, and this was confirmed by the Regional Nurse Consultant. Both cases demonstrate a failure to meet the regulatory requirement for timely and appropriate physician visits following admission.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to promptly provide or obtain dental services for a resident who had been admitted with multiple medical conditions, including chronic pain and type 2 diabetes mellitus. The resident reported having multiple broken teeth and stated they had not seen a dentist since admission. The resident also indicated they had not been asked about their dental needs or desires to see a dentist. During an observation, holes were noted in two of the resident's lower left back teeth. The resident expressed discomfort when chewing tough or hard foods and voiced a desire to see a dentist. A review of the resident's records showed that the care plan identified a risk for oral or dental health problems and included interventions for daily oral hygiene. The resident was assessed as cognitively intact and required assistance with eating and oral hygiene. Despite these documented risks and needs, there was no evidence that dental services had been provided or arranged since the resident's admission. The Regional Nurse Consultant confirmed that the resident had not been seen by a dentist during their stay.
Failure to Provide Diet Consistent with Resident's Medical and Religious Needs
Penalty
Summary
A deficiency occurred when a resident with a renal diet and strict religious dietary restrictions against pork or pork by-products was not provided meals in accordance with these requirements. Despite clear documentation on the resident's meal ticket and care plan specifying a renal diet, no added salt, no pork or pork by-products, and fluid restrictions, the resident was served a hot dog containing both beef and pork, as well as other menu items not aligned with their dietary needs. The Certified Dietary Manager (CDM) confirmed that dietary staff were not following the listed dietary restrictions, and the product label for the hot dogs revealed they contained a beef and pork blend, contrary to the resident's requirements. The resident expressed dissatisfaction and an inability to eat the provided food due to these issues. Further observations showed the resident was again served breakfast items that did not comply with their dietary restrictions, including a banana and orange juice, despite the meal ticket specifying no citrus or banana. The resident left some items uneaten, stating they could not consume them. Interviews with the resident's Power of Attorney confirmed the importance of adhering to the dietary restrictions for religious reasons, and the CDM acknowledged that appropriate meal options were not provided. The resident's medical history included nontraumatic intracerebral hemorrhage, dysphasia, malnutrition, and dependence on renal dialysis, making adherence to dietary requirements critical.
Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report and submit an investigation for an injury of unknown origin to the State Agency and adult protective services within the required time frames for one resident. According to the facility's policy, all alleged violations, including injuries of unknown origin, must be reported to the administrator, state agency, and adult protective services immediately, but not later than two hours if the event involves abuse or results in serious bodily injury, or within 24 hours if it does not. A resident with severe cognitive impairment, hemiplegia, diabetes, dementia, and a history of stroke was found to have a healing humerus fracture of unknown origin after returning from a primary health care provider visit. The resident's care plan documented multiple prior falls without injury, and the medical record did not identify a probable or possible source for the fracture. Interviews with facility staff confirmed that the provider notified the facility of the fracture, and an internal investigation suggested the injury may have occurred prior to admission, based on information from the resident's responsible party. However, the Assistant Director of Nursing and the Regional Director of Operations both confirmed that the state agency and adult protective services were not notified, and no written report or investigation was submitted to the state agency as required by facility policy and regulatory requirements.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care and services to prevent and treat pressure-related skin conditions for a resident. The resident, who was admitted with multiple diagnoses including spinal stenosis, spinal cord injury, diabetes, peripheral vascular disease, and dementia, was at risk for pressure ulcers. Despite being cognitively intact, the resident had functional limitations and was dependent on staff for mobility and toileting. The care plan identified the resident's risk for pressure ulcers and existing wounds, but lacked interventions for dietary changes and consistent use of heel boots. Observations and record reviews revealed that the facility did not adhere to its own policies for skin assessments and pressure injury prevention. The resident's skin assessments were not conducted weekly as required, and the resident was observed without the necessary heel boots, which were supposed to be worn at all times. Additionally, the resident's head of the bed was elevated beyond the recommended angle, contributing to pressure on the heels. The facility also failed to implement dietary recommendations from the registered dietitian in a timely manner, delaying the administration of ProStat, a dietary supplement for wound healing. Interviews with staff confirmed these deficiencies. The LPN acknowledged the absence of heel boots on the resident, and the DON confirmed the delay in starting the recommended dietary supplement. The DON also acknowledged the lack of documented weekly skin assessments, which coincided with the worsening of the resident's skin conditions. These failures in care and documentation contributed to the progression of the resident's pressure-related skin conditions.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure that staff followed requirements for wearing and discarding of Personal Protective Equipment (PPE) in resident rooms for residents with Covid-19 infection and for residents requiring Enhanced Barrier Precautions. Observations revealed that staff did not consistently wear the required PPE, such as gowns, gloves, and face shields, when entering the rooms of residents with confirmed Covid-19. Additionally, staff did not perform proper hand sanitization between resident rooms during laundry delivery, increasing the potential for cross-contamination. Interviews with staff confirmed that they were aware of the PPE requirements but did not always adhere to them. The facility also failed to ensure that pre-employment health history screenings were completed and reviewed for five sampled staff members. The health questionnaires in the employee health files were either incomplete or lacked documentation of review by the Director of Nursing (DON). This oversight had the potential to expose residents to transmissible diseases from staff members. Furthermore, the facility did not maintain proper infection control practices during urinary catheter care for a resident. Observations showed that the urinary collection bag was allowed to rest on the floor, and the measuring container was not rinsed after use. Additionally, staff did not follow proper handwashing procedures before and after handling the urinary catheter equipment. These lapses in infection control practices increased the risk of cross-contamination and infection among residents.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility staff failed to ensure that three of twenty-seven rooms and two of three halls were maintained in good repair, compromising the residents' right to a safe, clean, comfortable, and homelike environment. During an environmental tour, it was observed that room [ROOM NUMBER] had a square hole in the ceiling exposing underlayment, warped and rippling paint, yellow-brown staining, gray-black fuzzy material along the wall to ceiling trim, and cracked ceiling material. Additionally, the curtain in the room had gray-black fuzzy material, and there was a large hole in the roof soffit outside the room. Room [ROOM NUMBER] had peeling and warped paint, yellow-brown staining on the ceiling, loose and missing trim, and was cluttered with wheelchairs in disrepair and opened and closed boxes. The hallway ceiling connecting B Wing to C Wing had yellow-brown stains, loose edging, and peeling wallpaper exposing dry wall beneath. Residents residing in these rooms and adjacent areas were directly affected by these conditions. In an interview, the Facility Administrator (FA) acknowledged the presence of water damage due to holes in the roof, which had been repaired, but was unsure when the damage had occurred. The Regional Director of Operations (RDO) confirmed the roof repair and stated that the water damage had occurred in November 2023. Despite the roof being fixed, the interior damage had not been adequately addressed, leading to the observed deficiencies in the rooms and hallway. The facility census at the time was 37 residents.
Deficiencies in Care Plan and Discharge Planning
Penalty
Summary
The facility failed to ensure the comprehensive care plan for Resident 39 included necessary interventions for urinary elimination. Despite Resident 39 having a Foley catheter, the care plan did not document the indwelling urinary catheter or provide any interventions for staff to care for it. Observations revealed that the urinary collection bag was improperly placed, and the catheter tubing contained dark yellow urine. Interviews with staff confirmed that the care plan should have included the indwelling urinary catheter and related interventions, but it did not. This oversight was confirmed by the Regional Nurse Consultant (RNC) during an interview. Additionally, the facility did not include a discharge plan for Resident 1, who expressed a desire to leave the facility. Despite Resident 1 being cognitively intact and independent in various activities of daily living, the care plan did not reflect the resident's expressed discharge goal. The resident had contacted an Assisted Living facility, but the facility allegedly intervened, leading to the Assisted Living facility not accepting the resident. The Director of Nursing (DON) confirmed that there was no documentation in Resident 1's medical record or care plan reflecting the resident's discharge goal or any interventions to assist in meeting this goal. The facility's failure to include necessary interventions for urinary elimination in Resident 39's care plan and the lack of a discharge plan for Resident 1 were identified as deficiencies. These issues were confirmed through observations, record reviews, and interviews with staff, including the DON and RNC. The facility's policies on comprehensive care plans and discharge planning were not followed, leading to these deficiencies being noted by the surveyors.
Failure to Conduct and Document Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan meetings were conducted to allow residents and their representatives to participate in the development and revision of the residents' plans of care. This deficiency was identified for 5 out of 12 sampled residents, including those with significant medical conditions such as stroke, hemiplegia, dementia, major depression, and muscle weakness. The facility's policy mandates that care plan meetings should be held quarterly and that residents or their representatives should be involved in these meetings. However, the facility did not adhere to this policy, as evidenced by the lack of documentation of care plan meetings for the affected residents over extended periods, ranging from 4.5 months to over 9 months. Interviews with residents and their representatives confirmed that they had not been invited to or informed about care plan meetings for significant durations, further corroborating the lack of compliance with the facility's policy and regulatory requirements. For Resident 11, who was admitted with diagnoses including stroke and dementia, there was no documentation of any care plan meetings from 8/1/23 to 5/14/24, despite a scheduled meeting on 8/17/23. Similarly, Resident 18, diagnosed with major depression and sleep apnea, had no documented care plan meetings from 8/1/23 to 5/14/24, and the resident confirmed not being invited to a meeting in over six months. Resident 14, admitted with muscle weakness and altered mental status, also had no documented care plan meetings from 12/31/23 to 5/14/24, and the resident's spouse confirmed the lack of meetings since admission. Resident 1, with diagnoses including personality disorder and bipolar disorder, had no documented care plan meetings from 8/11/23 to 5/14/24, and the resident could not recall the last meeting attended. Lastly, Resident 25, diagnosed with depressive and anxiety disorders, had no documented care plan meetings from 9/21/23 to 5/14/24, and the resident could not remember the last time they were invited to a meeting. The Facility Administrator confirmed the absence of documentation for care plan meetings for all these residents, indicating a systemic failure to comply with care planning requirements.
Significant Medication Errors in Insulin Administration and Storage
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration and storage of insulin pens. During an observation of medication administration, a Registered Nurse (RN-C) was seen administering insulin to a resident without correctly priming the insulin pen as per the facility's policy and manufacturer instructions. The RN-C added 2 units of insulin to the prescribed dose for priming, which was incorrect. The Director of Nursing (DON) confirmed that RN-C did not prime the insulin pen correctly and had not received recent competency training on insulin administration. Additionally, several insulin pens for multiple residents were found to be improperly labeled and stored. Insulin pens for residents were missing critical information such as the open date, resident's name, prescribing physician's name, medication name, prescribed dose, strength, quantity, expiration date, and appropriate instructions and precautions. Some pens were stored in the medication cart instead of being refrigerated as required by both facility policy and manufacturer recommendations. The DON confirmed these deficiencies in labeling and storage. The residents involved in these deficiencies included those who required insulin for blood sugar regulation. The improper administration and storage of insulin could potentially lead to significant medication errors, impacting the residents' health. The facility's failure to adhere to its policies and manufacturer guidelines for insulin pen use and storage was evident in the observations and interviews conducted during the survey.
Failure to Ensure Routine Bowel Movements for Resident
Penalty
Summary
The facility failed to ensure routine bowel movements for a resident diagnosed with schizophrenia, a compression fracture of the vertebra, chronic kidney disease, and type two diabetes. The resident, who was cognitively severely impaired with a BIMS score of 3, did not have a documented bowel movement from 04/20/2024 to 04/24/2024 and 04/29/2024 to 05/05/2024. Despite the facility's constipation prevention protocol, which required offering an as-needed laxative on the third day without a bowel movement and a suppository on the fourth day, there were no orders for an as-needed laxative for the resident. Additionally, there was no documentation of any intervention or assessment of the resident's abdomen, bowel sounds, pain, or appetite during these periods of constipation. Interviews with the facility staff, including a registered nurse, a medication aide, the infection prevention nurse, and the director of nursing, confirmed that the resident did not receive the necessary interventions or assessments as per the facility's protocol. The staff reported that they relied on a list provided by the DON or IP nurse to identify residents needing bowel movement interventions, but the resident in question did not receive any such interventions. The DON confirmed the lack of orders for an as-needed laxative and the absence of any documented assessments or interventions for the resident's constipation during the specified periods.
Failure to Manage Pain for Resident
Penalty
Summary
The facility staff failed to manage complaints of pain for Resident 192, who was admitted with multiple fractures and other medical conditions. Upon admission, Resident 192 reported excruciating pain, which was rated as a 10 on a scale of 0-10. Despite the resident's severe pain, no pain medication was administered until the following day. The resident's baseline care plan indicated a pain management regimen, but the facility did not provide the necessary medications promptly, nor did they utilize non-pharmacological pain interventions as documented in the care plan. Interviews with staff revealed that the facility had protocols for ensuring timely medication delivery, including using a backup pharmacy and an emergency drug box containing pain management medications. However, these protocols were not followed in Resident 192's case. The resident did not receive any doses of prescribed pain medications on the day of admission, and the first doses were only administered in the early hours of the following day, despite the resident's reported pain levels of 9 and 8. The facility's pain management policy requires a systematic approach to recognizing, assessing, treating, and monitoring pain. This includes evaluating the resident for pain upon admission and managing pain consistent with the care plan and professional standards. The facility failed to adhere to this policy, as evidenced by the lack of timely pain medication administration and the absence of documented non-pharmacological pain management interventions for Resident 192. The Director of Nursing confirmed that medications to control pain should be provided to those who are prescribed and in need, which did not occur in this instance.
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Surveyors found that the facility did not maintain a medication error rate below 5%, identifying multiple late and improperly timed medication administrations and a missing medication. A medication aide gave a cholesterol medication and wound-healing supplements significantly later than their scheduled times, and another aide administered acetaminophen well outside the ordered time window and could not obtain a prescribed dose of Ingrezza because it had not arrived from the pharmacy. An LPN administered fast-acting Humalog insulin before a meal when no food was available and was unaware of the required timing of insulin in relation to meals, while the facility’s insulin policy lacked guidance on meal-related timing despite manufacturer instructions specifying administration within 15 minutes before or immediately after eating.
A resident with severe cognitive impairment, a history of CVA, and total dependence for ADLs developed a new right ankle wound and a new DTI to the left heel. Facility policy and licensure rules require immediate notification of the resident representative and physician for significant changes in condition, but review of progress notes showed no documentation that the representative was informed. An LPN confirmed the representative was not updated about the new wounds, despite the requirement to do so.
A family member filed a written grievance about a staff member’s attitude toward a resident and the family member, but the facility did not complete the grievance documentation or ensure timely communication of the specific resolution. The grievance form lacked documented resolution and administrator review, the ADM was initially unaware of the grievance, and the SW delayed completing the form while awaiting permanent interventions from nursing leadership. Although staff reported discussing a general resolution with the resident and family, the family member later stated they had not been informed of the actual grievance resolution, and the grievance form was not fully completed until well beyond the facility’s stated 10–14 day timeframe for resolving grievances.
The facility failed to report an allegation of physical abuse to law enforcement as required by its abuse reporting policy. A cognitively intact resident with dementia, anxiety, bipolar disorder, and major depressive disorder reported refusing a shower when a NA placed a lift sling under them, after which the situation escalated and both the resident and the NA exchanged punches. Skin assessments documented multiple new bruises on both of the resident’s arms and hands that were not present the prior day. Although facility policy required timely notification of law enforcement for such allegations, documentation in the abuse report form and EHR showed no law enforcement notification, and facility leadership confirmed that the incident and bruising were not reported to police.
A resident receiving hospice services with a condition expected to limit life expectancy had a DNR order requested by their representative and entered into the medical orders, but the comprehensive care plan (CCP) was not updated to reflect this change in code status. Facility policy required the CCP to be reviewed and revised by the interdisciplinary team following MDS assessments, yet the CCP continued to show an earlier full code status instead of the current DNR. The SSS acknowledged that the code status should have been updated when the change was made.
A resident with ESRD on dialysis, Type 2 DM, A-fib, COPD, and CHF, and requiring total assistance with ADLs, had physician orders for sacral and coccyx skin care, including cleansing, application of preventative ointment up to four times daily and PRN, and use of a sacral mepilex dressing. The order appeared on the Order Listing Report but was absent from the Nurse Administration Record, so staff were not cued to provide the treatment. During observed incontinence care, the resident’s sacral area was pink and no mepilex dressing was in place. An LPN confirmed the treatment was ordered but not provided and attributed the omission to a possible electronic medical record glitch.
Two residents at risk for or with existing pressure ulcers did not receive appropriate, individualized pressure ulcer prevention and treatment. One resident with hemiplegia, severe cognitive impairment, total ADL dependence, and incontinence developed multiple heel and ankle wounds after initial blanchable redness was noted; ordered Prevalon boots were repeatedly unavailable, the order to use them at all times was not promptly updated in the NAR, a turning schedule was not entered into the EHR, tissue analytics were missed on a scheduled date, and a nutrition consult and initiation of ordered supplements for wound healing were significantly delayed. Another resident with a stage 2 pressure ulcer was repeatedly observed on a DermaFloat LAL mattress left on the firmest setting, and the DON confirmed staff had not followed the manufacturer’s instructions to adjust and verify the mattress setting to prevent bottoming out.
A resident with ESRD on dialysis, along with multiple comorbidities including CHF, COPD, A-fib, and Type 2 DM, had physician orders and a care plan for a therapeutic renal diet, a 1200 ml/day fluid restriction divided across meals and med passes, and no water pitcher in the room, consistent with facility policy for dialysis residents. Observations showed a full water pitcher at the bedside and meal trays providing more than the ordered 240 ml of fluid per meal, while documentation also reflected conflicting fluid restriction amounts. Staff confirmed the resident had been offered more fluid than ordered and that a water pitcher had been present. In addition, on a dialysis day, multiple scheduled 9 a.m. medications were not administered because the resident was away at dialysis and the facility had not coordinated medication timing around dialysis services, contrary to its own policy.
The facility failed to respond to resident call lights within its stated goal of 7 minutes, with documented response times exceeding 30 minutes for multiple residents. A cognitively intact resident reported being left on the toilet for extended periods, and call system data showed call lights active for well over an hour on several occasions. Another resident with moderately impaired cognition had call lights unanswered for more than an hour, including after returning from dialysis. A third cognitively intact resident reported waiting up to two hours, with records confirming multiple call light activations lasting over an hour. The DON acknowledged that call light times over 30 minutes were not timely.
A resident with ESRD on thrice-weekly dialysis, along with DM2, A-fib, COPD, and CHF and moderate cognitive impairment, did not receive scheduled morning medications, including metoprolol and linagliptin, while away at dialysis. The MAR documented that the 9 AM metoprolol dose was not given because the resident was away from the facility without medications, and a progress note confirmed that morning medications were not administered due to the dialysis appointment. The DON later confirmed these omissions and identified them as medication errors.
Failure to Maintain Acceptable Medication Error Rate and Proper Medication Timing
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 5 errors out of 39 opportunities, resulting in a 12.82% error rate. The facility’s policy allowed medications to be given within one hour before or after the scheduled time, but staff did not adhere to this window. One medication aide administered pravastatin 10 mg to a resident at 8:52 PM when it was scheduled for 7:00 PM, and confirmed it was given late. The same aide also administered LiquaCel 30 cc and Juven 1 packet to another resident at 9:20 PM, despite orders for these supplements to be given twice daily with morning and evening medications at 8:00 AM and 7:00 PM, and confirmed these were also late. Additional errors involved improper timing and availability of medications. An LPN administered 4 units of Humalog, a fast-acting mealtime insulin ordered to be given before meals, to a resident at 7:37 AM when the resident had no food present and did not receive a meal tray until 8:18 AM; the LPN stated they did not know how quickly food should be provided after fast-acting insulin. The facility’s insulin policy lacked guidance on timing relative to meals, while the manufacturer’s prescribing information specified administration within 15 minutes before or immediately after a meal. Another medication aide administered acetaminophen 500 mg (two tablets) at 7:30 AM instead of the scheduled 6:00 AM dose and was unable to locate the resident’s ordered Ingrezza 80 mg capsule, confirming the medication had not arrived from the pharmacy and required reordering. The DON confirmed that the acetaminophen should have been given at 6:00 AM.
Failure to Notify Resident Representative of New Wounds
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition, specifically the development of new wounds. The facility’s policy titled "Change in Condition" dated 05-21-2023 states that changes in a resident’s condition or treatment are to be immediately shared with the resident and/or resident representative and reported to the attending physician or delegate. The policy requires notification of the resident, resident representative, and physician for events such as accidents resulting in injury with potential need for physician intervention, significant changes in physical, mental, or psychosocial status, and the need to significantly alter treatment. Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) also requires immediate notification of the resident, the resident’s doctor, and a family member of situations that affect the resident. Record review showed that one resident, admitted on a specified date, had a history of cerebrovascular accident (stroke) affecting the right side, severe cognitive impairment with a BIMS score of 5, total dependence for toileting, hygiene, dressing, bed mobility, transfers, and bathing, frequent urinary incontinence, and constant bowel incontinence, and did not have a pressure ulcer at the time of the MDS dated 01-26-2026. A Tissue Analytics Document dated 03-03-2026 revealed the resident had developed a new wound on the right ankle and a new deep tissue injury to the left heel. Progress notes contained no indication that the resident’s representative was informed of these new wounds. In an interview, an LPN confirmed that the resident’s representative was not updated about the new wounds and acknowledged that they should have been.
Failure to Timely Complete and Communicate Grievance Resolution
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to resolve and communicate the resolution of a grievance submitted on behalf of a resident. The facility’s written policy required Social Services and department managers to investigate written grievances, submit a written report of findings to the administrator, and ensure the resident or complainant was informed of the investigation findings and corrective actions in a timely manner, with documentation on the grievance form. A family member filed a written grievance concerning a staff member’s attitude toward the resident and the family member. The initial grievance form obtained from the social worker showed the grievance was received, but the sections for resolution and administrator review were incomplete, and the administrator reported being unaware of the grievance until it was brought to attention by surveyors. Interviews revealed that the social worker left the grievance form incomplete because they were waiting for permanent interventions from nursing leadership and did not document the final, grievance-specific resolution until much later. The social services supervisor stated the grievance was being processed, and the assistant DON reported speaking with the staff member involved, who denied the allegation, and removing that staff member from the resident’s care. Although facility staff reported that grievance resolution had been provided to the resident and family through a one-to-one discussion, the resident’s family member later stated they had not been notified of the grievance resolution. The administrator indicated that a reasonable timeframe for grievance resolution, including completion and review of the form, was 10–14 days, but the grievance form was not fully completed until nearly two months after the grievance was filed, and the permanent, grievance-specific resolution was not communicated to the family at the time the grievance was initially addressed.
Failure to Report Alleged Physical Abuse and Resulting Bruising to Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of physical abuse to law enforcement within the required timeframe. Facility policy, revised 08/08/2024, required the administrator or designee to notify multiple entities, including law enforcement, no later than two hours after an allegation involving serious bodily injury or within 24 hours if there was no serious bodily injury. The policy also specified notification of the state licensing authority, Ombudsman, resident representative, APS, the resident’s attending physician, and the facility medical director. Despite this written requirement, documentation showed that law enforcement was not notified following an allegation of physical abuse involving a resident. The resident involved had been admitted in 2019 and had diagnoses including moderate vascular dementia with agitation, generalized anxiety disorder, bipolar disorder, and major depressive disorder. A recent MDS showed a BIMS score of 15, indicating the resident was cognitively intact, and noted episodes of care rejection but no documented physical behavioral symptoms toward others. On the date of the incident, a NA entered the resident’s room, placed a lift sling under the resident, and informed the resident they would be taking a shower; the resident reported refusing the bath and stated that the situation escalated into both the resident and the NA exchanging punches. Subsequent skin assessments documented multiple bruises on both upper extremities that were not present the day before. A Potential Resident Abuse Report Form and the EHR contained no evidence that law enforcement was notified, and both the Administrator and Social Services Supervisor confirmed in interviews that the allegation of physical abuse and associated bruising were not reported to law enforcement, contrary to facility policy and reporting requirements.
Failure to Update Comprehensive Care Plan to Reflect Current DNR Status
Penalty
Summary
The facility failed to update a resident’s comprehensive care plan (CCP) to reflect the current resuscitation status after a change in code status was ordered. Facility policy on Comprehensive Care Plans, last reviewed/revised on 09/02/2025, required the CCP to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Record review showed that the resident was admitted on 09/23/2024, had a condition or chronic disease that may result in a life expectancy of less than six months, and was receiving hospice services. A Do-Not-Resuscitate (DNR) order dated 04/03/2026 documented that the resident’s representative requested DNR status, and an order listing report showed a DNR order dated 04/22/2026. However, the resident’s CCP printed on 04/28/2026 at 9:18 AM still reflected a “full code, do not resuscitate” status dated 10/02/2024, indicating the CCP had not been updated to match the current DNR order. In an interview, the Social Services Supervisor confirmed that the code status should have been updated at the time of the code status change.
Failure to Implement Physician-Ordered Sacral Skin Treatment
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered skin integrity interventions for a resident with multiple comorbidities. The resident’s MDS dated 03-24-2026 documented End Stage Renal Disease with dialysis dependence, Type 2 Diabetes Mellitus, A-Fib, COPD, and Chronic Heart Failure, as well as moderate cognitive impairment with a BIMS score of 12. The resident required setup and cleanup assistance with eating and total assistance with hygiene, toileting, bathing, dressing, bed mobility, and transfers, and was receiving dialysis services. The physician’s order, as shown on the Order Listing Report printed 04-28-2026, directed staff to cleanse the buttocks and coccyx with foam soap and water, pat dry, apply preventative ointment up to four times daily and as needed for soiling, and secure the area with a sacral mepilex dressing. Despite this order, the Nurse Administration Record for April 2026 contained no entry for the ordered wound care to the buttocks and coccyx, meaning the treatment was not listed to cue staff for administration. During an observation of incontinence care on 04-30-2026 at 10:40 AM, the resident’s sacral area showed pink skin discoloration and there was no mepilex dressing present on the sacral or coccyx area, indicating the ordered treatment had not been provided. In an interview later that day at 2:30 PM, an LPN confirmed that the resident was supposed to receive wound care to the sacral and coccyx area, acknowledged that the treatment had not been provided, and stated there must have been a glitch in the electronic medical record program because the order did not appear on the NAR.
Failure to Implement and Adjust Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
The deficiency involves the facility’s failure to develop, implement, and reevaluate effective interventions to prevent pressure ulcer development and to promote wound healing for two residents at risk or with existing pressure injuries. Facility policy required Braden Scale risk assessments on admission, weekly for four weeks, then quarterly or with significant change, and mandated a systematic approach including prompt assessment and treatment, monitoring, and modification of interventions as needed. The policy also required that interventions be adjusted when risk changed, when new or recurrent pressure injuries developed, when there was lack of healing progression, or when residents were non-compliant. The Braden Scale reference used by the facility defined scores of 10–12 as high risk and 13–14 as moderate risk for pressure ulcer development. One resident with a history of stroke, right-sided hemiplegia, severe cognitive impairment, total dependence for ADLs, and bowel and bladder incontinence was identified as at moderate to high risk for pressure ulcer development on admission, with a baseline care plan including a pressure-relieving wheelchair cushion and a comprehensive care plan identifying high risk for skin breakdown. The care plan listed general interventions such as Braden evaluations, observation and documentation of skin condition, use of a special mattress, skin hygiene, and nutritional and lab monitoring. A skin check initially showed no pressure ulcers, but a subsequent skin check documented blanchable redness to the right heel. An order was in place for Prevalon boots to be worn in bed, but progress notes over several consecutive days documented that the boots were not available, and heels were instead floated on a pillow. A pressure ulcer on the right heel was then identified, and later tissue analytics showed the wound had significantly enlarged, with additional findings of a new dark area consistent with a deep tissue injury on the right heel, a new wound on the right ankle possibly related to pressure or boot straps, and a deep tissue injury on the left heel. Practitioner instructions were to protect the heels at all times, including when out of bed and to avoid resting the feet on foot pedals, but the medication/nurse administration record was not updated to reflect the “at all times” order until many days after it was given. For this same resident, the facility did not promptly obtain a nutritional evaluation for wound healing, as the dietician’s assessment and recommendation for a nutritional supplement occurred several weeks after the first pressure ulcer was identified, and the ordered supplement was not started until several days after the recommendation. Tissue analytics documentation was also not completed on one of the scheduled dates, and interviews with nursing staff confirmed that a turning/repositioning schedule was not entered into the electronic health record to cue staff, despite the resident’s high risk and existing wounds. Staff interviews further confirmed that the resident was non-compliant with Prevalon boots and that the interdisciplinary team had not re-evaluated pressure-relief interventions for the feet during this period. Another resident, cognitively intact but totally dependent for bed mobility, transfers, and personal care, and always incontinent of bowel and bladder, was assessed as at risk for pressure ulcers and already had a stage 2 pressure ulcer. This resident was observed on multiple occasions lying in bed on a Joerns DermaFloat low air loss mattress that was consistently set at the firmest setting. The manufacturer’s instructions for this mattress required individualized adjustment of the comfort setting using a hand-check method to prevent bottoming out and directed that the proper setting be documented and re-evaluated as the resident’s condition warranted. The DON confirmed that the facility had not followed the mattress manual for setup for this resident and could not confirm that the mattress was at the correct setting to prevent bottoming out as described in the manual.
Failure to Adhere to Dialysis Resident Fluid Restriction and Medication Scheduling
Penalty
Summary
Surveyors identified that the facility failed to follow its own policy for dialysis residents and to adhere to physician-ordered fluid restrictions and medication timing for one dialysis-dependent resident. The facility’s policy required that dialysis residents receive fluids only as ordered by the physician, that nursing and dietary staff organize the division and distribution of fluids, that no water pitcher be present when restricted, and that medications be administered before departure and after return from dialysis so as not to interfere with treatment. The resident had end stage renal disease on dialysis, Type 2 diabetes mellitus, atrial fibrillation, COPD, and chronic heart failure, with a care plan and orders specifying a therapeutic diet, low potassium, no added salt, double protein, and a 1200 ml/day fluid restriction divided as 240 ml at each meal and 120 ml with each med pass, and no water pitcher in the room. Despite these orders and care plan interventions, observations showed a 600 ml water pitcher in the room filled to the 500 ml mark, and lunch trays that included a 240 ml milk carton plus additional juice and ice, exceeding the ordered 240 ml fluid allotment at meals. Record review further showed conflicting fluid restriction documentation, with an After Visit Summary listing a 1500 ml fluid restriction while the facility’s orders and care plan reflected a 1200 ml restriction, and staff interviews confirmed that the resident had been offered more than the ordered 240 ml of fluid with meals and that a water pitcher had been present contrary to the care plan. Additionally, the facility failed to coordinate medication administration around dialysis treatments. The Medication Administration Record documented that multiple scheduled 9 a.m. medications, including atorvastatin, fluticasone nasal spray, linagliptin, sennosides-docusate, metoprolol tartrate, mucinex ER, carboxymethylcellulose eye drops, and ipratropium-albuterol inhalation solution, were not given on a dialysis day because the resident was away from the facility without medications. The DON confirmed that these medications were omitted due to the resident being at dialysis and acknowledged not knowing that medication administration should be scheduled around dialysis services, contrary to the facility’s dialysis care policy.
Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely response to resident call lights, with multiple documented instances of response times far exceeding 30 minutes. One cognitively intact resident (BIMS score 13) reported being left on the toilet for a very long time in mid-January and again on a later date in April, though for a somewhat shorter period. Alarm Average Response Time Reports (AARTR) showed that this resident’s call light remained on for 167 minutes and 51 seconds on one January date, and for 46 minutes and 32 seconds and 73 minutes and 34 seconds during two separate call light activations in April. Another resident with moderately impaired cognition (BIMS score 12) had a family member report that the resident had to wait an hour to be laid down after dialysis. AARTR data for this resident showed call light durations of 61 minutes and 38 seconds and 76 minutes and 33 seconds on separate occasions in April. A third cognitively intact resident (BIMS score 15) reported having waited as long as two hours for a call light to be answered, and AARTR records documented call light durations of 65 minutes and 18 seconds and 63 minutes on two separate occasions. The DON stated that the facility’s goal for call light response was 7 minutes and confirmed that call light times over 30 minutes were not timely.
Failure to Administer Ordered Medications During Dialysis Absence
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when required medications were not administered as ordered while the resident was away from the facility for dialysis. The resident had multiple serious diagnoses, including end stage renal disease requiring dialysis, type 2 diabetes mellitus, atrial fibrillation, COPD, and chronic heart failure, and was assessed with moderate cognitive impairment. The resident required extensive assistance with most activities of daily living and was receiving dialysis services three times weekly. The comprehensive care plan documented scheduled dialysis on Monday, Wednesday, and Friday. On a documented dialysis day, the resident did not receive the scheduled 9 AM dose of metoprolol tartrate 25 mg because the resident was away from the facility without medications. The medication administration record showed a code indicating the medication was not given due to the resident being away, and a progress note stated that morning medications were not administered because the resident was at dialysis that morning. Later, the physician ordered metoprolol to be given after the resident’s heart rate was found to be 116. In an interview, the DON confirmed that the resident did not receive metoprolol and linagliptin on that date and acknowledged that the omission constituted a medication error.
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