Adept Nursing & Rehab Of Ashland
Inspection history, citations, penalties and survey trends for this long-term care facility in Ashland, Nebraska.
- Location
- 1700 Furnas Street, Ashland, Nebraska 68003
- CMS Provider Number
- 285140
- Inspections on file
- 29
- Latest survey
- July 22, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Adept Nursing & Rehab Of Ashland during CMS and state inspections, most recent first.
Two residents received omeprazole after eating breakfast instead of 60 minutes prior as ordered, and one resident did not have their mouth rinsed after using Trelegy Ellipta, resulting in a medication error rate of 12% during observed medication passes. The errors were confirmed by the MA and DON, and were not in accordance with facility policy or medication instructions.
A resident receiving multiple psychotropic medications for anxiety and depression did not have documented education or informed consent for their use, despite facility policy requiring this prior to medication initiation or increase. The DON confirmed the absence of a psychotropic consent form in the resident's record.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to the facility's failure to follow the established care plan.
Two residents requiring noninvasive ventilator support did not have care plans reflecting the use of a Trilogy machine, and staff had not received training or competency testing for its use. Despite physician orders and the presence of the machines at bedside, only some nurses were able to assist residents appropriately, as confirmed by both resident interviews and the DON.
A resident with PTSD and a history of trauma, substance use, and homelessness was admitted without a trauma-based assessment or trauma-informed care plan. The care plan did not address the resident's known triggers or mental health needs, despite facility policy requiring culturally competent and trauma-informed care.
Two residents with cognitive impairment were involved in an altercation, but their Comprehensive Care Plans were not updated to reflect new behavioral interventions or documentation of the incident. The DON confirmed that required documentation and notifications were not completed, despite facility policies mandating timely care plan revisions and individualized behavioral health interventions.
Three residents with known fall risks experienced falls and injuries due to the facility's failure to implement and maintain care plan interventions, including leaving a resident unattended in a dining room, allowing another to attempt a self-transfer without proper equipment, and not ensuring that call lights and personal items were within reach for a resident with repeated falls.
During a COVID outbreak, staff failed to consistently wear masks or wore them incorrectly, and soiled linens were carried against uniforms instead of being bagged. Additionally, reusable dishes from a COVID-positive resident's room were placed in a common dining area, contrary to infection control policy. Staff interviews confirmed these lapses in protocol.
The facility failed to ensure two nurse aides completed the required 12 hours of continuing education to maintain their certification. A review showed that one aide completed 5.5 hours and another 2.5 hours in the past year. This was confirmed by the facility educator, despite the policy requiring 12 hours annually.
The facility failed to maintain safe water temperatures in the Memory Care Unit, with temperatures ranging from 122 to 136 degrees Fahrenheit, exceeding the safe limit of 120 degrees. This issue arose after a new water heater was installed, and the DOM confirmed that water temperatures had not been checked in the MCU since then. The DOM also admitted to not knowing how to calibrate the thermometer used for temperature checks.
The facility failed to ensure proper mechanical ventilation in the Memory Care Unit bathrooms, affecting all 9 resident rooms. Observations noted a strong urine odor, and vents were unable to pull up toilet paper, indicating malfunction. Staff interviews confirmed the vents were not checked or cleaned regularly, and maintenance procedures were inadequate, with no regular checks or Guardian Angel rounds addressing the issue.
The facility failed to provide weekly baths to three residents, despite their cognitive awareness and medical needs. One resident with muscle wasting experienced a nine-day gap between baths, while another with cerebral palsy had inconsistent bathing intervals. A third resident with hemiplegia reported infrequent baths, confirmed by a 15-day gap in records. Interviews with the Administrator and DON acknowledged the failure to meet the facility's bathing expectations.
The facility failed to accurately code the MDS for two residents, resulting in incorrect assessments of severe cognitive impairment with hallucinations and delusions. Despite the MDS entries, there was no supporting documentation in the residents' Behavior and Progress Notes. The Regional Nurse Consultant and DON confirmed the inaccuracies.
The facility failed to ensure routine bowel movements for two residents with severe cognitive impairment and occasional bowel incontinence. One resident had no documented bowel movements for two periods totaling seven days, and another for two periods totaling eleven days. No bowel medications were given, and no assessments were documented. Interviews with the DON and an LPN confirmed the absence of bowel medication orders, lack of bowel movement records, and no system to track residents' bowel movements.
A resident with congestive heart failure, under hospice care, passed away in the facility. Despite the facility's Comprehensive Care Plan requiring notification of hospice and family, the facility did not notify the hospice nurse; the resident's representative made the call instead. Interviews confirmed the facility's failure to follow its post-mortem care policy.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications according to practitioner’s orders and manufacturer’s recommendations, resulting in a medication error rate of 12% based on 25 observed medication administration opportunities. Specifically, two residents received omeprazole after consuming breakfast, despite clear instructions on the medication card to administer the drug 60 minutes prior to meals. Both the medication aide and the Director of Nursing confirmed that the medication was not given at the correct time, as required. Additionally, one resident did not have their mouth rinsed after receiving Trelegy Ellipta, an inhaled medication, contrary to the instructions to rinse the mouth after use. The medication aide acknowledged this omission during the interview, and the Director of Nursing confirmed that the mouth should have been rinsed. The facility’s own Medication Administration policy also requires mouth rinsing after inhaler use and administration of medications within the specified time frame.
Failure to Obtain Informed Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to provide required education and obtain informed consent for the use of psychotropic medications for one resident. Review of the facility's policy indicated that residents, families, or resident representatives must be informed of the benefits, risks, and alternatives to psychotropic medications, including any black box warnings, prior to starting or increasing such medications. For the resident in question, medical records showed active orders and administration of multiple psychotropic medications, including alprazolam, buspirone, sertraline, and trazodone, for conditions such as anxiety and depression. Despite the resident being cognitively intact, as evidenced by a BIMS score of 14, there was no documentation of informed consent for the use of these medications in the resident's medical record. The care plan and medication administration records confirmed ongoing use of these medications, and the DON verified that no psychotropic consent form was present for the resident as required by facility policy and regulation.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Lack of Staff Training and Competency for Trilogy Ventilator Use
Penalty
Summary
The facility failed to provide staff training and competency testing for the use of a Trilogy machine, a noninvasive ventilator, for two residents who required this specialized respiratory support. Record reviews showed that the facility's assessment did not identify the capability or capacity to provide specialized respiratory care or services, despite having a policy in place for noninvasive ventilation. The policy outlined the use of devices such as CPAP, BiPAP, AVAPS, and Trilogy, but there was no evidence that staff were trained or tested for competency in using these machines. For one resident, the medical record indicated a history of chronic hypercapnic respiratory failure, COPD, obstructive sleep apnea, aspergillosis, histoplasmosis, and other lung conditions, with physician orders for specific Trilogy machine settings. The resident's care plan did not mention the use of the Trilogy machine, although the medication administration record showed that noninvasive ventilation was provided as ordered. Observations confirmed the presence of the Trilogy machine in the resident's room, and the DON acknowledged that staff had not received training on its use. Another resident with COPD, idiopathic sleep-related nonobstructive alveolar hypoventilation, and sleep apnea also had physician orders for Trilogy machine use. The care plan referenced CPAP/BiPAP but did not include interventions for the Trilogy machine. The resident reported needing assistance with the Trilogy mask and noted that only some nurses were knowledgeable about its use, while others were not. The DON confirmed the lack of staff training on the Trilogy machine for this resident as well.
Failure to Provide Trauma-Informed Care and Assessment
Penalty
Summary
The facility failed to evaluate and implement interventions to manage trauma triggers for a resident with a self-reported diagnosis of Post Traumatic Stress Disorder (PTSD). Record review showed that the resident had a history of PTSD related to previous domestic abuse, as well as other diagnoses including stroke, hypertension, diabetes mellitus, anxiety disorder, and bipolar disorder. The resident reported specific triggers, such as not liking water poured over the face due to past abuse, and had a history of substance use, homelessness, and legal issues. Despite this, the resident's care plan did not include any focus area related to anxiety, depression, mood, or past traumatic event triggers. Interviews and record reviews confirmed that the facility had not completed a trauma-based assessment or initiated a trauma-informed care plan upon the resident's admission, as required by facility policy. The facility's policy mandates culturally competent and trauma-informed care, including minimizing triggers and re-traumatization for trauma survivors. However, the lack of assessment and care planning for the resident's trauma history and triggers constituted a failure to provide care and services in accordance with these standards.
Failure to Update Care Plans After Resident Altercation
Penalty
Summary
The facility failed to update the Comprehensive Care Plans (CCPs) for two residents following an altercation between them. An incident report documented that one resident, with severe cognitive impairment and a diagnosis of Non-Alzheimer's Dementia, stuck their tongue out at another resident, who then physically grabbed the first resident. Staff immediately separated the residents. However, a review of both residents' progress notes and CCPs revealed no documentation of behaviors or new interventions related to the incident. The CCPs for both residents had not been updated around the time of the altercation, despite one resident having a history of verbal aggression and both having cognitive impairments. During an interview, the DON confirmed that there was no behavior documentation, care plan update, physician notification, or family notification regarding the incident, although these actions should have occurred. Facility policies require that care plans be reviewed and revised as necessary, with updates for new or modified interventions, and that behavioral health services be individualized and person-centered. The lack of documentation and care plan revision following the incident constituted a failure to meet these standards.
Failure to Implement and Maintain Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and maintain effective interventions to prevent falls and accidents for three residents, despite their known risks and care plan directives. One resident with significant cognitive impairment, muscle weakness, and a history of falls was left unattended in a dining room, contrary to care plan instructions. The resident fell from a wheelchair with unlocked brakes, resulting in a hip fracture. Staff interviews confirmed that the resident was left alone, and the only intervention known to the nurse on duty was to offer restroom breaks and snacks, with no active supervision provided at the time of the fall. Another resident, also with a history of falls and impaired mobility, was dependent on staff for transfers and toileting. Despite this, the resident attempted a self-transfer to the toilet when staff were busy, resulting in a fall and subsequent ankle fracture. The care plan required the use of a sit-to-stand lift or Hoyer lift for transfers, but during the incident, a nursing assistant allowed the resident to attempt a pivot transfer without the appropriate equipment or intervention to prevent the fall. The resident and staff confirmed that the transfer was not performed according to the care plan, and the necessary assistive devices were not used. A third resident with muscle weakness, a history of falls, and cognitive awareness experienced multiple falls over several months. Observations revealed that care plan interventions, such as keeping the call light and personal items within reach, were not consistently implemented. The call light was found on the floor and out of reach, the urinal and TV remote were not accessible, and the overbed table was positioned so that the resident could not reach necessary items. These lapses in following the care plan contributed to repeated falls and injuries for the resident.
Failure to Adhere to Infection Control Protocols During COVID Outbreak
Penalty
Summary
Surveyors identified multiple failures in the facility's infection prevention and control practices during a COVID outbreak. Staff were observed not wearing masks, wearing masks incorrectly, or removing masks while providing care or serving food. Specifically, a nursing assistant was seen serving breakfast without a mask, a medication aide removed their mask while speaking during resident care, and another staff member wore a mask under their chin. Interviews with staff, including the LPN, DON, and Infection Preventionist, confirmed that masks were required to be worn properly during the outbreak, but these protocols were not followed. Additional deficiencies were observed in the handling of soiled linens and reusable items. A medication aide was seen carrying dirty linens against their uniform through the hallway instead of placing them in a plastic bag as required by facility policy. Furthermore, reusable breakfast dishes from a COVID-positive resident's room were placed on a table in the dining room, potentially exposing others to contamination. Staff interviews confirmed that these actions were not in compliance with established infection control policies.
Deficiency in Nurse Aide Continuing Education
Penalty
Summary
The facility failed to ensure that two nurse aides, who had been employed for more than one year, completed the required 12 hours of continuing education necessary to maintain their certification. A review of the education records for five staff members revealed that Nurse Aide O, hired on February 2, 2020, had only completed 5.5 hours of continuing education, while Nurse Aide P, hired on April 23, 1995, had completed just 2.5 hours within the past year. This deficiency was confirmed during an interview with the facility educator, who also serves as the Assistant Director of Nursing. The facility's policy, titled 'Nurse Aide Training Program' and dated August 1, 2023, mandates that each nurse aide receive at least 12 hours of in-service training annually, based on their employment date. The responsibility for coordinating and providing this education falls under the Staff Development Coordinator, with oversight from the Director of Nursing. Despite these guidelines, the facility did not meet the continuing education requirements for the two nurse aides, leading to a deficiency in compliance with the licensure reference number 175 NAC 12-006.04B(ii)(1).
Unsafe Water Temperatures in Memory Care Unit
Penalty
Summary
The facility failed to ensure safe water temperatures in the Memory Care Unit (MCU), which had the potential to affect all nine sampled resident rooms. During observations, water temperatures in the resident rooms were found to be significantly above the safe limit of 120 degrees Fahrenheit, with readings ranging from 122 to 136 degrees Fahrenheit. The issue was identified following the installation of a new 100-gallon water heater, which was set at 130 degrees Fahrenheit. The Director of Maintenance (DOM) confirmed that the water temperatures had not been checked in the MCU since the installation of the new water heater. Interviews revealed that the DOM was unaware of how to calibrate the thermometer used for measuring water temperatures and that maintenance staff only checked random bathroom water temperatures monthly. The DOM acknowledged that temperatures over 120 degrees Fahrenheit were too high and should be lower. Additionally, it was confirmed that no specific actions were taken to address water temperature checks in the MCU after the new water heater was installed. The Administrator confirmed that all water from bathroom faucets should be under 120 degrees Fahrenheit and noted that no residents had suffered burns from the water.
Inadequate Ventilation in Memory Care Unit Bathrooms
Penalty
Summary
The facility failed to ensure that the mechanical ventilation in the bathrooms of the Memory Care Unit (MCU) was functioning properly, affecting all 9 resident rooms on the unit. During an observation, a strong and stale urine odor was noted upon entering the MCU, and further inspection revealed that the bathroom vents were unable to pull up a single ply of toilet paper, indicating inadequate ventilation. Interviews with staff, including the Licensed Practical Nurse (LPN), Director of Maintenance (DOM), and Director of Housekeeping (DOH), confirmed that the vents were not functioning and were not regularly checked or cleaned. The facility's maintenance procedures were found to be lacking, as there were no regular maintenance rounds performed, and the Guardian Angel rounds conducted by facility managers did not include checks of the bathroom vents. The DOM confirmed that the ventilation system had not been checked, despite facility instructions to inspect exhaust fans monthly. Additionally, it was revealed that no Guardian Angel Rounds were performed on the MCU in May, and the rounds conducted in April and June did not identify any maintenance concerns. The Administrator confirmed the oversight in checking the ventilation system.
Failure to Provide Weekly Baths to Residents
Penalty
Summary
The facility failed to ensure that residents received baths at least once weekly, as evidenced by the cases of three residents. Resident 87, who was admitted with muscle wasting and atrophy, was documented to have received a bath on 5/29/24 and 6/7/24, resulting in a nine-day gap without a bath. Despite being cognitively intact with a BIMS score of 14, Resident 87 reported not receiving a bath since shortly after admission. Similarly, Resident 7, diagnosed with cerebral palsy and also cognitively intact with a BIMS score of 15, experienced inconsistent bathing, with records showing a bath on 5/9/24 and then not again until 5/26/24, followed by another gap until 6/6/24. Resident 36, who has hemiplegia and hemiparesis following a cerebral infarction, also with a BIMS score of 15, reported that baths were hardly once a week. Documentation confirmed a 15-day gap between baths from 5/22/24 to 6/6/24. Interviews with the facility Administrator and the DON confirmed that the facility's expectation was for residents to receive a bath at least once weekly, which was not met for these residents.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was coded correctly for two residents, leading to inaccuracies in their assessments. For Resident 53, the Quarterly MDS indicated severe cognitive impairment with hallucinations and delusions, despite the absence of documentation supporting these symptoms in the Behavior and Progress Notes from May 1, 2024, through June 13, 2024. The Regional Nurse Consultant confirmed the lack of documentation for hallucinations or delusions during an interview, acknowledging the incorrect marking on the MDS. Similarly, Resident 75's Quarterly MDS also indicated severe cognitive impairment with hallucinations and delusions, yet there was no documentation of these symptoms in the Care Plan or Behavior and Progress Notes from April 1, 2024, through May 1, 2024. The Regional Nurse Consultant confirmed the absence of documentation for hallucinations or delusions during the specified period, indicating an error in the MDS coding. The Director of Nursing confirmed that the facility used the Resident Assessment Instrument manual for guidance to ensure MDS accuracy.
Failure to Ensure Routine Bowel Movements for Residents
Penalty
Summary
The facility failed to ensure routine bowel movements for two residents, both of whom had severe cognitive impairment and were occasionally incontinent of bowels. Resident 53, with a primary diagnosis of Alzheimer's Disease, had no documented bowel movements for two separate periods totaling seven days. Despite a previous hospital admission for a small bowel obstruction, no bowel medications were given, and no bowel assessments were documented during this time. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed the absence of bowel medication orders, lack of bowel movement records, and the absence of bowel assessments. Similarly, Resident 75, also diagnosed with Alzheimer's, had no documented bowel movements for two separate periods totaling eleven days. No PRN bowel medications were administered, and there were no bowel assessments documented. Interviews with the DON and LPN confirmed the lack of bowel movement records and the absence of a system to track residents' bowel movements. The DON acknowledged that without a bowel list, there was no way to know which residents had not had a bowel movement in two or more days, and no bowel movement audits were being conducted in the facility.
Failure to Notify Hospice Provider of Resident's Death
Penalty
Summary
The facility failed to notify a hospice provider regarding the death of a resident who was under hospice care. The resident, who had congestive heart failure, was admitted to hospice on 2/22/24 and passed away in the facility on 3/4/24. The facility's Comprehensive Care Plan for the resident included instructions to notify hospice and family of any changes. However, when the resident passed away at 9:50 PM, the facility did not notify the hospice nurse; instead, the resident's representative made the call to the hospice company. Interviews with the facility's Administrator and Director of Nursing (DON) confirmed that the hospice nurse had been informed earlier in the day that the resident was declining. Despite this, the facility did not follow its own policy for post-mortem care, which required documentation of the date and time of death and notification to the physician, family, funeral home, and hospice. The failure to notify the hospice nurse was acknowledged by both the Administrator and the DON during their interviews.
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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