Colonial Manor Of Randolph
Inspection history, citations, penalties and survey trends for this long-term care facility in Randolph, Nebraska.
- Location
- 811 South Main Street, Randolph, Nebraska 68771
- CMS Provider Number
- 285183
- Inspections on file
- 23
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Colonial Manor Of Randolph during CMS and state inspections, most recent first.
A resident with diabetes and multiple chronic conditions had a standing sliding scale Humulin insulin order requiring specific doses for blood glucose levels over 400. Facility policy required medications to be administered per PCP orders. On several occasions, the resident’s blood glucose readings were significantly elevated, yet the medical record contained no evidence that insulin was administered or what dose, if any, was given. The DON and an RN consultant confirmed there was no documentation that the ordered sliding scale insulin was provided at those times.
The facility did not ensure that the Dietary Manager held the required certification or that a full-time dietician was employed. The Operations Manager, lacking necessary training, served as both interim DM and cook, and menu substitutions were made due to improper food ordering. Dietary staff did not receive adequate training or demonstrate competency, affecting all residents receiving meals from the kitchen.
The facility did not serve meals according to the planned and approved menus, instead substituting available food items due to insufficient ordering by an untrained interim Dietary Manager. The interim manager did not consult with the Registered Dietician regarding these changes, resulting in all residents receiving meals that differed from the posted menu.
The facility did not consistently obtain or document food temperatures for meals, as required by policy, with multiple instances where hot foods were reheated and served to residents without temperature checks. Dietary staff confirmed the omission of temperature monitoring and documentation, which affected all residents receiving food from the kitchen.
Multiple residents with significant care needs experienced prolonged delays in call light responses, with documented wait times frequently exceeding the facility's 10-minute standard. Residents dependent on staff for mobility, toileting, and hygiene reported waiting up to an hour for assistance, particularly during evening shifts. Interviews and records confirmed that insufficient staffing contributed to these delays, and grievances regarding the issue were not investigated or resolved.
A resident reported feeling threatened by an OM, who stated the resident would be discharged to a homeless shelter if an outstanding bill was not resolved. The resident informed the SSD, who acknowledged the concern as verbal abuse but failed to report the allegation to the State Agency or notify facility leadership, as required by policy.
A resident reported feeling threatened by an Operations Manager who stated that unresolved billing issues could result in discharge to a homeless shelter. The Social Service Director did not notify the Administrator or initiate an investigation, and the incident was not reported to the State Agency as required by policy.
The facility failed to label and date food items stored in a resident refrigerator, as observed during a kitchen tour. Items such as a juice-like drink, tomatoes, a sandwich, and a container with mixed food were found without proper labeling. The Operations Manager confirmed that these items should have been labeled and dated, posing a potential risk to the 38 residents consuming food from the facility kitchen.
A facility failed to provide a resident and/or their representative with the required bed hold information when the resident was transferred to the hospital. The facility's policy mandates that written information regarding the bed hold provision be given at admission and before hospital transfers, or within 24 hours in emergencies. A review of the resident's records showed no evidence of such notification, which was confirmed by the facility's administrator.
The facility failed to revise care plans for two residents who expressed suicidal ideation. One resident, with complex medical conditions, expressed self-harm thoughts, but their care plan lacked interventions for these concerns. Another resident, with depression and other diagnoses, also expressed self-harm thoughts, but their care plan did not document these or include necessary interventions. The DON confirmed the omissions in both cases.
A resident with severe cognitive impairment and a history of stroke and hemiplegia was found to have a large bruise on the left hand, which was not documented or monitored by the facility staff. Despite being reported by a nurse aide, the bruise was not included in the Weekly Skin Evaluations, and no causal factors were evaluated. The facility's care plan interventions for skin monitoring were not followed, indicating a lapse in procedure adherence.
A facility failed to document a stop date for a PRN order of Lorazepam for a resident with severe cognitive impairment and multiple diagnoses, including anxiety and seizures. The facility's policy requires PRN psychotropic medications to have a stop date or documented duration, which was not adhered to, as confirmed by the DON and ADON.
A facility failed to maintain a medication error rate below 5%, with errors affecting two residents. An LPN did not expel air from an insulin pen before administering the dose to a resident, and an RN administered Pantoprazole to another resident only 9 minutes before a meal, contrary to the physician's order.
The facility failed to adhere to infection control protocols, with staff not wearing PPE correctly, improper storage of a resident's oxygen equipment, and inadequate hand hygiene practices. An RN was observed with a mask below their nose, and a CNA did not change gloves or wash hands during care. Additionally, a resident's urinal was stored next to food, violating infection control practices.
Failure to Administer Ordered Sliding Scale Insulin
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to administer insulin as ordered by the primary care practitioner for a resident with multiple chronic conditions. Facility policy required that medications and treatments be administered only upon written orders from authorized prescribers and that all medications, treatments, and procedures be administered per physician order. The resident’s Minimum Data Set dated 2/19/26 showed the resident was cognitively intact, required substantial assistance with several activities of daily living, and received insulin injections and a diuretic daily during the assessment period. The resident had diagnoses including chronic kidney disease, heart failure, hypertension, diabetes, Parkinson’s disease, depression, and anxiety. A physician order dated 9/17/25 directed sliding scale Humulin insulin dosing based on blood glucose levels, with 12 units to be given for blood sugars greater than 400. Record review showed multiple instances where the resident’s blood glucose readings were significantly elevated without documented administration of insulin as ordered. On 10/5/25 at 5:00 PM, the resident’s blood sugar was 561, with no evidence in the medical record that any insulin was administered or what dose, if any, was given. On 10/6/25 at 11:00 AM, the resident’s blood sugar was 461, with no documentation that the ordered 12 units of insulin were given. On 10/10/25 at 7:00 AM and again at 11:00 AM, the resident’s blood sugar was 499 on both occasions, with no evidence that insulin was administered or what dose was provided. In an interview, the DON and the RN consultant confirmed there was no evidence that the resident received the ordered sliding scale insulin at these times.
Failure to Employ Qualified Dietary Staff and Maintain Menu Standards
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, as required by regulation. Specifically, the Dietary Manager (DM) position was vacant after the previous DM left, and the Operations Manager (OM), who lacked the required certification and training, was serving as the interim DM. The OM also worked as a cook without having received any training for the DM or cook roles and had not consulted with the Registered Dietician regarding menu changes. Additionally, the facility did not employ a full-time dietician, and dietary staff had not received adequate training or demonstrated competency to serve as cooks. Record review and staff interviews revealed that the OM was responsible for ordering food and, due to insufficient ordering, the facility was unable to follow the preapproved/planned menus. Instead, available food from the freezers and storeroom was used as substitutes. The dietary schedule showed the OM frequently filled in as a cook due to staffing shortages, and the Interdisciplinary Team (IDT) assisted with dietary aide duties, receiving only limited training related to dishwasher safety and temperature logs. These deficiencies had the potential to affect all residents who consumed food prepared in the facility.
Failure to Follow Planned Menus Due to Untrained Interim Dietary Management
Penalty
Summary
The facility failed to follow its planned and preapproved menus for all residents who consumed food from the facility kitchen. On the specified date, the noon meal served to residents did not match the posted menu; instead of the listed breaded chicken patty on a bun, mini baker potatoes, cream gravy, country trio vegetables, bread with margarine, and flamingo cake, residents received Salisbury steak, au gratin potatoes, country trio vegetables, white gravy, and a cookie. This deviation occurred because the Operations Manager, who was acting as the interim Dietary Manager after the previous manager left, did not order enough food for the planned menus and substituted available items from the facility's storeroom and freezers. The interim Dietary Manager had no training for the role and did not consult with the Registered Dietician regarding these menu changes.
Failure to Ensure Hot Foods Served at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that hot foods were served at a palatable temperature for residents, as required by policy and regulatory standards. Review of the facility's food temperature logs over several weeks revealed numerous instances where food temperatures were not obtained or recorded for breakfast, noon, and evening meals. The facility's policy required that food temperatures be taken and documented for all items prepared in the dietary department, with hot foods maintained at 135°F or higher and reheated foods reaching 165°F. However, logs showed repeated omissions in temperature documentation across multiple days and meals. Direct observations during a noon meal service showed dietary staff removing pre-cooked hot dogs and soup from the refrigerator, reheating them in the microwave, and serving them to residents without checking or recording the food temperatures. During an interview, dietary staff confirmed that temperatures were not obtained or documented for these items and acknowledged that this was a recurring issue, partly due to staffing concerns. This failure had the potential to affect all residents who consumed food from the kitchen.
Delayed Call Light Responses Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide timely responses to resident call lights, as evidenced by multiple documented instances where residents waited significantly longer than the facility's expected response time of 10 minutes. The facility's Resident Call Light Policy requires staff to respond to call lights as timely as possible and to ensure all residents have access to a functional and responsive call light system. However, review of call light response logs revealed numerous occasions where call lights were left unanswered for periods ranging from over 10 minutes to more than an hour. One resident, who was cognitively intact and dependent on staff for all activities of daily living due to conditions such as quadriplegia and pressure ulcers, experienced repeated delays in call light responses, with several instances exceeding 30 minutes and some over an hour. Another resident with heart failure and dependent on staff for bathing and toileting reported waiting up to 30 minutes for assistance, particularly during evening shifts. A third resident with spina bifida and paraplegia, who required assistance with personal hygiene and dressing, also reported frequent long waits for call light responses, including a documented grievance where the call light was not answered for 56 minutes. This resident indicated that the issue persisted, especially during certain shifts, and that submitting a grievance did not result in any noticeable changes. Interviews with the affected residents confirmed their experiences of delayed responses, with particular concern for insufficient staffing during evening shifts. The administrator acknowledged that the facility's expectation was for call lights to be answered within 10 minutes and confirmed that the documented response times did not meet this standard. There was also a lack of evidence that grievances related to call light response times were investigated or addressed.
Failure to Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of potential staff-to-resident abuse to the State Agency as required by policy and regulation. A resident reported feeling threatened by the Operations Manager (OM), who stated that if the resident did not resolve an outstanding bill, the facility would issue a 30-day notice and, if no alternate placement was found, the OM would take the resident to a homeless shelter with their medications. The resident communicated these concerns to the Social Service Director (SSD), expressing that they felt threatened and did not want to be placed at a homeless shelter. Despite the resident's report and the SSD's acknowledgment that the resident was verbally abused, the SSD did not report the allegation to the State Agency or notify anyone else at the facility. A review of facility investigations over the relevant period showed no evidence that this allegation of verbal abuse was reported as required. The OM confirmed the statements made to the resident regarding discharge and potential placement at a homeless shelter.
Failure to Investigate and Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to investigate and report an allegation of potential staff-to-resident verbal abuse as required by policy and state regulations. A resident reported to the Social Service Director (SSD) that they felt threatened by the Operations Manager (OM), who stated that if the resident did not resolve an outstanding bill, the facility would issue a 30-day notice and, if no alternate placement was found, the OM would take the resident to a homeless shelter with their medications. The SSD acknowledged feeling that the resident was verbally abused but did not notify the facility Administrator or initiate an investigation into the allegation. A review of facility records showed no evidence that the allegation was reported to the State Agency or that an investigation was conducted. Interviews confirmed that the OM made the statements to the resident and that the Administrator was unaware of the allegation, resulting in no investigation or report being submitted as required. The facility's policy mandates immediate reporting and investigation of such allegations, but these steps were not followed in this case.
Failure to Label and Date Food Items in Resident Refrigerator
Penalty
Summary
The facility failed to adhere to food safety standards as outlined in the Nebraska Food Code, which is based on the United States Food and Drug Administration Food Code. During an observation conducted on September 30, 2024, it was noted that several food items in the resident refrigerator were not labeled or dated. These items included a juice-like drink in a 24-ounce clear plastic container, two containers with tomatoes, a sandwich in plastic wrap, and a container with peppers, onions, chicken legs, and squash. The lack of labeling and dating of these items is a violation of the food safety standards, specifically the requirement that refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than twenty-four hours must be clearly marked to indicate the date of preparation. The facility's Operations Manager confirmed during an interview on October 2, 2024, that items stored in the kitchen refrigerators should indeed be labeled and dated. This oversight in food storage practices had the potential to affect all residents consuming food from the facility kitchen, given the facility's census of 38 residents. The failure to properly label and date food items could lead to foodborne illnesses, posing a significant risk to resident health and safety.
Failure to Provide Bed Hold Information
Penalty
Summary
The facility failed to provide the required bed hold information to a resident and/or their representative when the resident was transferred to the hospital. According to the facility's Bed Hold policy, revised in December 2023, written information regarding the right to exercise the bed hold provision of 15 days should be provided at admission and again before transferring to a hospital or going on therapeutic leave. In cases of emergency transfer, this information should be given within 24 hours. The information should include the duration of the state bed-hold, the reserve bed payment policy, the facility's policy on bed-hold periods, and the conditions for the resident's return to the facility. A review of the nursing progress notes for a resident revealed that on September 10, 2024, the resident reported difficulty breathing and requested to be evaluated in the emergency room. The resident was admitted to the hospital and later discharged back to the facility on September 12, 2024. However, there was no evidence in the medical record that the resident or their representative was notified of the facility's bed hold policy during this period. The facility's administrator confirmed the lack of documented evidence of providing the required bed hold information during an interview conducted on October 2, 2024.
Failure to Revise Care Plans for Suicidal Ideation
Penalty
Summary
The facility failed to ensure that the care plans for two residents were appropriately revised to address significant mental health concerns. Resident 30, who had intact cognitive functioning and complex medical conditions including hemiplegia, diabetes, hypertension, and vascular disease, expressed suicidal ideation. Despite these expressions, the resident's care plan, last revised on 7/14/24, did not include interventions for the resident's comments of self-harm. The facility's Director of Nursing (DON) confirmed that the care plan did not address the resident's suicidal ideation or the safety interventions that were implemented, such as 15-to-30-minute checks and the use of plastic silverware. Similarly, Resident 35, who was cognitively intact and had diagnoses of depression, spine narrowing, heart disease, and stroke, also expressed thoughts of self-harm. The resident's care plan, last revised on 9/3/24, did not document these thoughts or include interventions to address them. Although a physician fax indicated interventions such as increased staff interaction and encouraging outdoor activities, these were not incorporated into the care plan. The DON confirmed that the care plan did not address the resident's thoughts of self-harm and that the interventions from the fax were not implemented.
Failure to Monitor and Report Bruising on Resident
Penalty
Summary
The facility staff failed to identify and monitor a bruise on Resident 17, who was admitted with diagnoses of stroke, hemiplegia, and anemia, and had severe cognitive impairment. The resident required substantial to maximal assistance with daily activities and was at risk for skin impairment. Despite these risks, the facility's care plan interventions, which included monitoring and reporting changes in skin status, were not followed. Observations revealed a large bruise on the resident's left hand, which was not documented in the Weekly Skin Evaluations, indicating a lapse in monitoring and reporting. Nurse Aide (NA)-B reported the bruise to the Charge Nurse a week prior, but there was no evidence of follow-up or evaluation of causal factors. The Treatment Administration Records, Nursing Progress Notes, and Weekly Skin Evaluations did not reflect the presence of the bruise, nor was there any monitoring to ensure healing. Registered Nurse (RN)-I confirmed that staff were responsible for weekly skin evaluations to identify and monitor new skin issues, but was unaware of the bruise on Resident 17's hand, highlighting a breakdown in communication and procedure adherence.
Failure to Document Stop Date for PRN Antianxiety Medication
Penalty
Summary
The facility failed to ensure that a resident's antianxiety medication, Lorazepam, had a documented stop date or duration for use, which is a requirement for PRN orders of psychotropic medications. The facility's policy mandates that PRN orders for psychotropic medications should be limited to 14 days unless the provider documents the rationale and duration for extending the order. However, the review of the Medication Administration Records for August and September 2024 revealed that the Lorazepam order, initiated on August 14, 2024, lacked a stop date or specified duration. The resident involved had severe cognitive impairment and was diagnosed with cancer, seizures, anxiety, depression, and a psychotic disorder. The resident was also receiving hospice services and required assistance with daily activities. Despite these conditions, the facility did not adhere to its policy regarding the administration of psychotropic medications, as confirmed by interviews with the Director of Nursing and the Assistant Director of Nursing. They acknowledged that the PRN order for Lorazepam should have included a stop date, which was not documented in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by observations and interviews. During the survey, 31 medications were observed, resulting in 2 errors, which affected 2 out of 3 residents, leading to an error rate of 6.45%. The facility's policy on administering medications, reviewed in May 2021, requires medications to be administered according to orders and within one hour of the prescribed time. Additionally, the policy mandates that the individual administering the medication must verify the right resident, medication, dosage, time, and route by checking the label three times before administration. The first error involved Resident 25, who had a physician's order for Insulin Glargine 15 units subcutaneously twice a day. The LPN administering the insulin failed to expel 2 units of potential air bubbles from the insulin pen before selecting the ordered dose, as per the manufacturer's instructions. The second error involved Resident 21, who had a physician's order for Pantoprazole 20 milligrams to be administered daily, 30 to 60 minutes before a meal. The RN administered the medication only 9 minutes before the resident was served breakfast, contrary to the physician's order. Both errors were confirmed through interviews with the respective nursing staff.
Infection Control Deficiencies in PPE Use, Equipment Storage, and Hand Hygiene
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, as evidenced by multiple observations of staff not wearing personal protective equipment (PPE) correctly. Specifically, a registered nurse (RN) was repeatedly seen with their mask below their nose and eye protection improperly positioned while interacting with residents and visitors. This was confirmed by interviews with the Infection Preventionist and the Director of Nursing (DON), who acknowledged the improper use of PPE. Additionally, the facility did not follow its policy for the proper storage of respiratory equipment. Observations revealed that Resident 34's oxygen tubing and nasal cannula were left on the floor or improperly stored without a bag, contrary to the facility's policy. Interviews with staff and the resident confirmed that the tubing was not stored in a bag as required, which was also acknowledged by the DON. The facility also failed to maintain proper hand hygiene practices. During care for Resident 23, a certified nursing assistant (CNA) did not change gloves or perform hand hygiene at the required intervals, despite handling soiled items and performing personal care tasks. Furthermore, Resident 30's urinal was repeatedly observed on the overbed table next to food and snacks, which was not in line with the facility's infection control practices, as confirmed by an RN.
Latest citations in Nebraska
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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