Accura Healthcare Of O'neill
Inspection history, citations, penalties and survey trends for this long-term care facility in O' Neill, Nebraska.
- Location
- 1102 North Harrison Street, O' Neill, Nebraska 68763
- CMS Provider Number
- 285108
- Inspections on file
- 25
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Accura Healthcare Of O'neill during CMS and state inspections, most recent first.
Facility staff failed to timely report an elopement to the State Agency as required by policy and state regulations. A resident with severe cognitive impairment, who required total assistance with toileting and extensive assistance with dressing and hygiene but could ambulate independently, opened a back door, exited into the parking lot, and triggered a door alarm. A NA first checked the front door, then the back door, and upon opening it observed the resident walking in the back parking lot and redirected the resident inside. Review of facility reporting records showed the incident was not reported within required timeframes, and the DON confirmed the elopement had not been reported as it should have been.
The facility did not follow its own Antibiotic Stewardship Program protocols, failing to track, document, or review antibiotic use and related laboratory data. The Infection Preventionist confirmed that there was no identification or analysis of organisms to determine if antibiotic prescribing met established criteria, potentially affecting all residents.
Several residents did not receive timely lab work, prescribed medications, or required treatments due to delays, lack of documentation, and failure to follow physician orders. There were also failures to monitor fluid restrictions, administer eye drops and compression garments, and complete weekly wound assessments, with staff and the DON confirming these deficiencies.
Staff did not consistently follow individualized care plans and facility policies for safe transfers and fall prevention. For example, a resident with hemiplegia was not always assisted by two staff during mechanical lift transfers, and several residents at high risk for falls did not have required interventions such as alarms, stop signs, or body pillows in place. Additionally, new interventions were not developed after repeated falls, and some residents were not laid down after meals as care planned. These actions and inactions resulted in an unsafe environment and failure to prevent accidents.
The facility did not ensure that GDRs for psychotropic medications were addressed in a timely manner or that clinical rationales for not attempting GDRs were documented. For three residents with histories of mental illness or depression, the consultant pharmacist made repeated recommendations for GDRs, but prescribers either declined without providing clinical justification or did not address the recommendations, and the required documentation was missing.
Multi-dose insulin pens for several residents with diabetes were not dated when first opened, as required by facility policy and professional standards. During a medication cart observation, it was found that insulin pens lacked opening dates, and both an LPN and the DON confirmed that insulin should be dated to prevent use beyond 28 days. This deficiency affected multiple residents receiving scheduled and sliding scale insulin.
Surveyors observed staff failing to perform proper hand hygiene, use required PPE during high-contact care for residents on Enhanced Barrier Precautions, and clean shared equipment such as mechanical lifts between uses. These deficiencies were noted during care for residents with incontinence, MDRO history, wounds, and indwelling devices, with staff often not following facility policies for infection prevention.
A resident with an indwelling catheter and multiple medical conditions was repeatedly observed with their catheter drainage bag uncovered and visible from the hallway, contrary to facility policy requiring privacy bags. The DON confirmed that dignity bags should have been used for all residents with catheters, but this was not done in this case.
The facility did not notify practitioners when two residents experienced missed medications, non-compliance with fluid restrictions, and absence of prescribed compression garments. One resident did not receive an anticoagulant for several days without physician notification, while another exceeded fluid limits, missed steroid eye drops, and went without compression garments for an extended period, with delayed and incomplete communication to the physician.
The facility did not document clinical rationales for not attempting gradual dose reductions of psychotropic medications for a resident with serious mental illness, and also failed to limit and properly renew PRN antipsychotic medication orders for another resident with severe cognitive impairment, as required by policy and regulation.
A resident admitted with a stage II sacral pressure ulcer did not receive any wound care or treatment orders during their stay, despite clear documentation of the ulcer and its required care. The resident, who had multiple health issues, left the facility after reporting the lack of wound care. The DON confirmed that no treatment orders were obtained and no policy for pressure ulcer management was in place.
The facility failed to develop and implement a water management program, including a risk assessment and control measures/testing protocols, to address potential hazards. The administrator confirmed the absence of these measures, affecting all 34 residents.
The facility failed to maintain a system to identify repeat resident grievances and ensure sustainable resolutions. Recurring concerns such as cold food, untimely call light responses, and missing laundry were documented, but no evidence of corrective actions or sustained resolutions was found. Interviews confirmed that the facility had not come up with solutions or followed up with residents to ensure acceptable resolutions.
The facility failed to ensure proper accounting and documentation for medications awaiting destruction for eight residents. An observation revealed a locked cabinet with a large quantity of medications without any record keeping. The DON confirmed the absence of required documentation, putting the medications at risk of potential loss or theft.
The facility failed to maintain food service equipment cleanliness, allowed outdated food to be available for consumption, and did not ensure staff adhered to safe handling of ready-to-eat food. Observations included a nurse aide handling food with bare hands and significant cleanliness issues in the kitchen, including a grease-coated stove and overdue fire suppression system inspection.
A resident was transferred to the hospital after a fall, but the facility failed to provide the required written bed hold notification to the resident or their representative. The DON confirmed the notification was not given as per policy.
The facility failed to complete a PASARR for two residents after they were diagnosed with serious mental disorders and received antipsychotic medications. This was confirmed through medical records and staff interviews.
Failure to Timely Report Resident Elopement to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an elopement to the State Agency as required by its reporting policy and state licensure regulations. The facility’s undated policy titled “Reporting requirements” states that whoever first identifies or is notified of a potential self-report event must immediately notify the DON and Administrator after ensuring safety, and that the Administrator or DON will then proceed with required notifications and investigations. Record review of the facility’s reports to the State Agency showed that the elopement incident involving one resident was not reported within the required timeframes. The resident involved had a BIMS score of 5 on the MDS, indicating severe cognitive impairment, required total assistance with toileting, and extensive assistance with dressing and hygiene, but could walk 150 feet independently. Progress notes documented that the resident opened the back door of the facility and went out into the parking lot; the door alarm sounded and the resident was redirected back into the facility. A nursing assistant reported hearing a door alarm, checking the front door and finding no one exiting, then checking the back door, which was closed, and upon opening it observed the resident walking in the back parking lot. In an interview, the DON confirmed that the facility had not reported this elopement to the State Agency and acknowledged that it should have been reported.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program as required by its own policies and regulatory standards. Although the facility had established protocols and policies for antibiotic stewardship, including the use of infection screening evaluations, laboratory testing, and monitoring of antibiotic use, these were not followed in practice. A review of infection surveillance records for a one-year period revealed that there were no documented culture results, no data on pathogens, and no evidence of review to determine if antibiotic prescribing met established criteria. During an interview, the Infection Preventionist confirmed that the facility had not identified, tracked, or analyzed organisms found through laboratory testing to assess whether antibiotic use was appropriate or met treatment criteria. This lack of monitoring and documentation meant that the facility could not ensure antibiotics were being used according to best practices, as outlined in their own policies and procedures. The deficiency had the potential to affect all residents in the facility, which had a census of 45 at the time of the survey.
Failure to Provide Timely Care, Medication, and Monitoring per Physician Orders
Penalty
Summary
The facility failed to provide timely and appropriate treatment and care according to physician orders and residents' needs in several instances. For one resident, laboratory work was not obtained in a timely manner, with significant delays between the ordering and collection of blood and stool tests. Documentation was lacking regarding when orders were received, when labs were obtained, and when results were communicated to the provider. The DON confirmed that staff did not document refusals, collection, or notification of lab results as required by facility policy. In multiple cases, residents did not receive prescribed medications due to unavailability, and there was no evidence that the facility took appropriate steps to address the situation. One resident missed seven days of an anticoagulant medication, while another missed several days of blood pressure medication, aspirin, and electrolyte replacement. The facility did not document efforts to determine the cause of the unavailability, did not notify the physician, and did not monitor the residents for adverse effects during the period the medications were not administered. The DON confirmed these lapses and the absence of required documentation and follow-up. Additional deficiencies included failure to monitor and document a resident's fluid restriction, with intake exceeding the prescribed limit on multiple occasions and no evidence of physician notification or documentation of the reason for the restriction. Another resident did not receive prescribed eye drops or compression garments as ordered, with delays in obtaining the necessary supplies and lack of timely physician notification. Furthermore, a resident with a pressure injury did not have weekly wound assessments or documentation as required by facility policy. These failures were confirmed through interviews and record reviews.
Failure to Implement and Monitor Fall Prevention and Safe Transfer Interventions
Penalty
Summary
Staff failed to utilize safe transfer techniques and follow individualized care plans for multiple residents, resulting in an unsafe environment. For one resident with left-sided hemiplegia and a history of stroke, staff did not consistently use two staff members during mechanical lift transfers as required by the care plan and facility policy. Observations showed that the resident's left arm was not properly supported during transfers, and staff confirmed that two-person assistance was not always provided, despite education on this requirement. Several residents at risk for falls did not have their care plan interventions implemented or revised as needed. One resident with severe cognitive impairment and contractures had a mesh stop sign and body pillow ordered as fall interventions, but these were repeatedly not in place during observations. The DON confirmed that these interventions were not consistently implemented after falls. Another resident with dementia and a history of falls was left unattended in their wheelchair without required alarms in place, and staff confirmed that the resident was sometimes left alone despite care plan instructions. Additional deficiencies included a resident who was to be laid down after meals as a fall prevention measure, but this was not consistently done within the expected timeframe. Another resident with a history of falls and high fall risk did not have new interventions implemented after multiple falls, despite care plan reviews and incident reports. These failures to implement, monitor, and revise fall prevention interventions and safe transfer practices directly contributed to the facility's noncompliance with accident prevention requirements.
Failure to Document Clinical Rationale for Not Attempting Gradual Dose Reductions
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDR) for psychotropic medications were addressed in a timely manner and that clinical rationales for not attempting GDRs were documented, as required by policy. For one resident with a history of serious mental illness, including anxiety, bipolar disorder, and schizophrenia, the record showed ongoing administration of anti-psychotic, anti-depressant, and anti-anxiety medications. Although a GDR for Venlafaxine was marked as contraindicated by the prescriber, there was no documented clinical rationale provided for this decision. Another resident, admitted with diagnoses including stroke, high blood pressure, seizure disorder, and depression, was receiving daily antidepressant medications. The consultant pharmacist made multiple recommendations over several months for GDRs of Prozac and Trazadone. While the physician declined the GDRs, there was no evidence that a clinical rationale was documented to explain why the reductions were not clinically appropriate. Eventually, only the Trazadone dose was reduced, with no documentation regarding the Prozac. A third resident, with diagnoses of debility, heart failure, previous stroke, depression, and anemia, was also receiving daily antianxiety and antidepressant medications. The consultant pharmacist repeatedly recommended GDRs for Buspar and Remeron, but the prescriber did not order dose reductions and failed to provide a clinical rationale for not doing so. Interviews with the DON confirmed the absence of required documentation for all three residents, despite multiple pharmacist recommendations and follow-up communications.
Failure to Date Opened Insulin Pens for Multiple Residents
Penalty
Summary
The facility failed to ensure that multi-dose insulin pens for four residents were dated when first opened, as required by both facility policy and professional standards. During an observation of the medication carts, it was found that insulin pens for these residents did not have dates indicating when they had been accessed. The facility's policies specify that all multi-use vials must be dated upon first use and discarded within 28 days unless otherwise specified by the manufacturer. Record reviews confirmed that these residents had orders for various types of insulin, including Glargine, Novolog, and Insulin Aspart, administered on scheduled and sliding scale regimens for diabetes management. Interviews with an LPN and the Director of Nursing confirmed that insulin is required to be dated when opened to prevent use beyond the recommended period. The lack of dating on the insulin pens meant there was no way to ensure the insulin was not being used past the effective date, which is contrary to both facility policy and accepted professional practice. The facility census at the time was 45, and six residents were identified as receiving insulin injections.
Infection Control Deficiencies: Hand Hygiene, PPE, and Equipment Cleaning
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection prevention and control practices, specifically related to hand hygiene, use of personal protective equipment (PPE), and cleaning/disinfection of shared equipment. Staff were observed failing to perform hand hygiene at critical points, such as before donning gloves, after removing soiled gloves, and between resident contacts. In several instances, staff did not provide complete perineal care to residents who were incontinent, and failed to change gloves or perform hand hygiene when required by facility policy. For example, during care for a resident with cancer, dementia, and incontinence, staff did not wash hands before or after glove use, did not provide full perineal hygiene, and did not disinfect the mechanical lift after use. The report also documents failures in the use of Enhanced Barrier Precautions (EBP) for residents with a history of multidrug-resistant organisms (MDROs), wounds, or indwelling medical devices. Staff did not consistently wear required PPE, such as gowns and gloves, during high-contact care activities for residents on EBP. In one case, a medication aide assisted a resident with a history of MRSA with toileting and perineal care without wearing a gown and failed to change gloves or perform hand hygiene at appropriate intervals. Another instance involved a nurse not removing PPE before exiting a resident's room and placing potentially contaminated items on the medication cart without a barrier or cleaning. Additionally, the facility failed to clean and disinfect mechanical lifts between resident uses, as required by policy. Multiple staff members confirmed during interviews that lifts were not cleaned after transferring residents, including those with cognitive impairments and those dependent on staff for mobility. These lapses in infection control practices were observed across several residents and staff, indicating a systemic failure to adhere to established protocols designed to prevent cross-contamination and the spread of infection within the facility.
Failure to Use Privacy Bag for Catheter Compromises Resident Dignity
Penalty
Summary
Staff failed to ensure the use of a privacy bag for a resident's catheter drainage bag, as required by facility policy. Multiple observations over several days showed the resident's catheter bag hanging on their walker without a privacy cover, making it visible from the hallway. This occurred both when the resident was in bed and when the catheter bag was attached to the walker, with no privacy bag in use during any of the observed times. The resident involved had an indwelling catheter due to neurogenic bladder and other medical conditions, including renal disease, anxiety, depression, and schizophrenia. The resident's care plan specified that the catheter bag and tubing should be kept below the bladder and away from the entrance room door, but did not address the use of a privacy bag. Interviews with the DON confirmed that dignity bags were expected to be used for all residents with catheters, but this was not done for this resident.
Failure to Notify Practitioners of Missed Medications and Non-Compliance with Care Orders
Penalty
Summary
The facility failed to notify practitioners regarding significant changes and issues affecting two residents. For one resident with severe cognitive impairment and multiple diagnoses including cancer, atrial fibrillation, and malnutrition, the facility did not administer a prescribed anticoagulant (Xarelto) for seven consecutive days. Despite the facility's policy requiring physician notification when medications are unavailable or missed, the resident's practitioner was not informed of the missed doses. Another resident, who had orders for fluid restriction, steroid eye drops post-cataract surgery, and thigh-high compression garments, experienced multiple lapses in care. The facility did not notify the physician when the resident repeatedly exceeded fluid intake limits, missed multiple doses of prescribed eye drops, and went without compression garments for over a month while waiting for a larger size. Although the physician was eventually notified of increased edema and the absence of compression garments, this notification was delayed, and there was no documented follow-up with the physician after the initial contact.
Failure to Document GDR Rationale and Limit PRN Antipsychotic Orders
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDR) for psychotropic medications were properly documented with a clinical rationale when not attempted for a resident with serious mental illness. Specifically, a resident with diagnoses of anxiety, bipolar disorder, and schizophrenia was receiving multiple psychotropic medications, including Haloperidol, Quetiapine, Clonazepam, and Lorazepam. Although GDRs for these medications were marked as contraindicated in communications with the prescribing provider, there was no documented clinical rationale in the resident's medical record explaining why dose reductions were not attempted. Additionally, the facility did not comply with requirements for limiting as-needed (PRN) antipsychotic medication orders to 14 days for another resident with severe cognitive impairment and diagnoses including Alzheimer's disease, dementia, anxiety, and depression. The resident was receiving a PRN antipsychotic combination (ABH gel) for agitation and restlessness, with the order in place and administered intermittently over several months. Despite repeated recommendations from the consultant pharmacist to add a stop date and renew the order every 14 days, the facility continued to administer the medication without proper renewal or documentation of appropriateness by the prescribing practitioner. Interviews with the Director of Nursing confirmed the lack of required documentation for both the clinical rationale for not attempting GDRs and the failure to renew PRN antipsychotic orders as mandated. These actions were inconsistent with the facility's own policy and regulatory requirements regarding the use and management of psychotropic medications.
Failure to Provide Pressure Ulcer Treatment Upon Admission
Penalty
Summary
Facility staff failed to obtain and provide pressure ulcer treatment for a resident who was admitted from the hospital with a stage II pressure ulcer to the sacral region. Upon admission, the resident's medical record and skin assessment documented the presence of a 3.5 cm by 2.8 cm pressure ulcer with a depth of 1.5 cm, and the hospital discharge summary indicated the need for dressing changes 1-2 times daily. Despite these findings, there was no evidence in the electronic medical record from admission through discharge that any treatment was ordered or completed for the pressure ulcer. The resident, who had diagnoses including chronic pain, adult failure to thrive, malnutrition, and alcohol use, reported to staff that the wound was not being treated or assessed. The resident subsequently decided to leave the facility, citing the lack of wound care as the reason. An interview with the DON confirmed that no admission orders for wound care were obtained, staff did not contact the resident's physician for a treatment order, and the facility did not have a current policy for pressure ulcer care and management.
Failure to Implement Water Management Program
Penalty
Summary
The facility failed to develop and implement a water management program that included a risk assessment and control measures/testing protocols to address potential hazards. The facility's policy, dated 9/2022, indicated the need for a water management plan to reduce the risk of Legionella and other opportunistic pathogens in the water system. However, a review of the facility's water management program revealed no documentation of a risk assessment or implementation of control measures and testing protocols. During an interview, the administrator confirmed that no risk assessment had been completed and no control measures or testing protocols were in place to address potential hazards. This deficiency had the potential to affect all 34 residents in the facility.
Failure to Address and Resolve Resident Grievances
Penalty
Summary
The facility failed to maintain a system to identify repeat resident grievances and ensure sustainable resolutions of resident concerns. The facility's grievance policy stated that residents had the right to voice grievances without fear of reprisal and that the facility would ensure prompt resolution and keep residents informed throughout the process. However, a review of the Resident Council Meeting Minutes from March 2023 through April 2024 revealed recurring concerns such as cold food, untimely call light responses, missing laundry, and inadequate snack options. There was no evidence that the facility discussed old business or included what actions were taken to resolve previous concerns in subsequent meetings. The facility's grievance log from June 2023 through April 2024 showed multiple grievances related to call light response times, food options, snack cart availability, treatment and medication concerns, missing laundry items, and the availability of fresh water/ice. Despite these documented grievances, there was no evidence that the facility had implemented corrective actions or sustained resolutions to prevent repeat concerns. Interviews with Resident Council Representatives confirmed that the facility had not come up with solutions to grievances or followed up with residents to ensure the resolutions were acceptable. The facility Administrator confirmed that the facility had not implemented a grievance process that consistently identified repeat grievances or ensured sustainable resolutions. The facility also lacked evidence of presenting sustainable resolutions to the Resident Council to ensure the resolutions were acceptable to those involved in the grievance process. This failure to address and resolve resident grievances led to ongoing dissatisfaction and repeated concerns among the residents.
Failure to Document Medications Awaiting Destruction
Penalty
Summary
The facility failed to ensure proper accounting and documentation for medications awaiting destruction for eight residents. An observation of the medication storage room revealed a locked cabinet labeled 'destroyed medications' containing a large quantity of medications without any record keeping or accounting. The facility policy requires a Non-Controlled Medication Destruction Record to be maintained for all non-controlled drugs destroyed, verified by the consultant pharmacist, and include specific information such as the name and address of the facility, date medication destroyed, prescription number, name, strength, and quantity of the medication being destroyed, and signatures of persons witnessing the destruction. However, this documentation was missing for the medications of Residents 12, 138, 139, 140, 141, 142, 143, and 144. During an interview, the Director of Nurses (DON) confirmed the absence of documentation for the medications awaiting destruction, which included various medications such as Bisacodyl, Insulin Aspart, Insulin Lantus, Milk of Magnesia, Aloe Vesta, Maalox, Antacid-antigas, Lasix, Melatonin, Tylenol, Aspercreme, zinc oxide cream, Baza cream, Biofreeze gel, Desitin cream, Vaseline jelly, triamcinolone cream, Nystatin cream, Betamethasone cream, Nystatin powder, Gabapentin, and Omeprazole. The lack of required documentation put the residents' medications at risk of potential loss or theft, as there was no record of the residents' names, dates, medication names, dosages, and quantities of each medication.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food service equipment was cleaned and maintained, outdated food was not available for consumption, and staff adhered to safe handling of ready-to-eat food. During an observation, a nurse aide was seen handling a resident's toast and bacon with bare hands, which is against the facility's policy. Additionally, a large container of egg salad dated beyond the allowable three days was found in the walk-in refrigerator. The dietary aide confirmed that leftovers should be disposed of after three days, indicating a lapse in following the facility's food safety protocols. Further inspection revealed significant cleanliness issues in the kitchen. The stove/oven had a buildup of grease and grime, and the fire suppression system was overdue for inspection and cleaning. The piping above the stove was also coated with grease and debris. The facility lacked evidence of a cleaning schedule for food service equipment, and the cook confirmed that cleaning was done only when staff had time. The Corporate Certified Dietary Manager acknowledged these deficiencies, confirming that staff should not handle ready-to-eat food with bare hands and that the leftover egg salad should not have been available for consumption.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide Resident 35 or the resident's representative with the required bed hold notification when the resident was transferred to the hospital. The facility's policy mandates that written notice be given at the time of transfer, specifying the duration of the bed-hold policy and information about the resident's return. Resident 35 was transferred to the hospital after a fall, but there was no documented evidence that the resident or the resident's representative received the required written notification. The Director of Nurses confirmed that the notification was not provided as required by the facility's policy.
Failure to Complete PASARR for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) was completed for two residents after they were diagnosed with serious mental disorders and received antipsychotic medications. Resident 22 was diagnosed with Post Traumatic Stress Disorder (PTSD) on 3/14/23 and had been taking an antipsychotic medication (Seroquel) since 2/13/24. Despite these significant changes, no new PASARR was completed for Resident 22. This was confirmed by both the Social Services Director and a Registered Nurse during interviews on 4/17/24. Similarly, Resident 24, who had diagnoses of anxiety disorder, depression, bipolar disorder, psychotic disorder, and Alzheimer's disease, was receiving antipsychotic and antidepressant medications. The resident's medical records indicated that they had been taking Quetiapine for bipolar disorder since 3/14/23. However, there was no documentation that a new PASARR had been completed following the new diagnosis of bipolar disorder. This oversight was confirmed by a Registered Nurse during interviews on 4/17/24.
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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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