Adept Nursing & Rehab Of Central City
Inspection history, citations, penalties and survey trends for this long-term care facility in Central City, Nebraska.
- Location
- 2720 South 17th Avenue, Central City, Nebraska 68826
- CMS Provider Number
- 285147
- Inspections on file
- 21
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Adept Nursing & Rehab Of Central City during CMS and state inspections, most recent first.
A resident with multiple psychiatric diagnoses experienced several episodes of severe behavioral disturbance, including screaming and combative actions. An LPN administered Zyprexa IM twice during one shift in response but did not notify the physician, guardian, or emergency contact about the incident or the resident's later transfer to a hospital, contrary to facility policy. Interviews and record reviews confirmed that required notifications were not made.
Staff failed to consistently use gloves or perform proper hand hygiene when handling ready-to-eat foods, and food items in storage were found unsealed, undated, or without required temperature monitoring. Additionally, hot and cold foods were served outside of safe temperature ranges, with staff demonstrating inconsistent knowledge of required standards. These actions did not comply with facility policies and created the potential for foodborne illness among all residents receiving food from the kitchen.
Surveyors found that four Medication Assistants did not have documented competencies completed as required by facility policy and regulation. Record reviews and interviews with the DON and RDO confirmed the absence of competency documentation for these staff, despite the facility's policy mandating such training and assessment.
A resident with moderate cognitive impairment was admitted without a signed advance directive on file, despite facility policy and regulatory requirements. Record reviews showed no documentation of an advance directive or code status at the time of review, and staff confirmed the document was only received and filed after the deficiency was identified.
The facility did not provide timely Notice of Medicare Non-Coverage (NOMNC) and Advance Beneficiary Notice (ABN) to two residents when their Medicare coverage ended, as required by policy. In one case, the notices were signed after the last covered date, and in another, the notices were not completed at all. Staff interviews and record reviews confirmed these deficiencies.
A resident was discharged from the facility, but staff did not notify the state ombudsman as required. Review of records and staff interviews confirmed that notifications of emergency transfers and discharges were not consistently sent each month, resulting in the omission of the required discharge notification for this resident.
Staff failed to keep a urinary catheter drainage bag below the bladder during a Hoyer lift transfer for a resident with neurogenic bladder, contrary to the care plan and facility policy. Both the MA and NA involved were unsure of proper catheter bag placement, and the DON confirmed the correct procedure was not followed.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed. The facility failed to ensure that dialysis care was provided according to the resident's needs.
Surveyors found that meals were not consistently served at safe and appetizing temperatures, with hot foods below the required 135°F and some dishes appearing unappetizing or in the wrong texture. Several residents, including those with diabetes and swallowing issues, reported dissatisfaction with meal temperature and appearance, and some left food uneaten. The Food Service Manager and Administrator confirmed the deficiencies in food temperature and texture.
The facility did not provide alternative vegetables or fruits to residents who declined or did not select the items initially served, despite residents' dietary needs and preferences. Two residents reported not receiving substitutes for disliked or difficult-to-eat foods, and staff confirmed that only main dish alternatives were available, not sides. This practice was observed during meal service and confirmed by both the Food Service Manager and Administrator.
Surveyors observed strong urine odors and sticky floors in multiple hallways and rooms, with the issue persisting even after housekeeping cleaned affected areas. The DON and Administrator acknowledged the ongoing problem, attributing it to humidity, and facility policies for cleaning and inspection were not effective in resolving the unsanitary conditions.
Three cognitively intact residents who required assistance with mobility and transfers experienced repeated, prolonged delays in call light response, with documented wait times often exceeding 30 minutes and sometimes lasting over an hour. Residents reported frequent long waits for staff assistance, and leadership acknowledged that call light response times were sometimes longer than appropriate, with technical issues occasionally affecting the system.
A resident with obstructive sleep apnea did not receive appropriate follow-up for an Auto-PAP machine due to complaints about the mask being too tight. Despite frequent refusals to use the device and inquiries about a new CPAP, there were no orders addressing these concerns. Staff interviews revealed a lack of awareness and follow-up, contributing to the deficiency in care.
The facility failed to secure a catheter properly, leading to potential cross-contamination for a resident with dementia and other conditions. Additionally, staff did not adhere to hand hygiene protocols during peri care and wound care for three residents. The facility's hand hygiene policy was not followed, as confirmed by staff and the DON.
A facility failed to accurately complete a PASRR for a resident with schizoaffective disorder and PTSD. Despite these diagnoses being documented in medical records, they were omitted from PASRR screenings. Staff interviews confirmed the oversight, acknowledging that the PASRR should have included these diagnoses.
Failure to Notify Physician and Family of Significant Behavioral Changes and Transfer
Penalty
Summary
The facility failed to notify the physician, guardian, and emergency contact of a resident's significant behavioral episodes as required by policy. Record reviews showed that the resident, who had multiple psychiatric diagnoses including bipolar disorder with psychotic features, anorexia nervosa, and major depressive disorder, experienced several episodes of screaming, flailing, hitting, and combative behavior. On one occasion, an LPN was notified by a nurse aide about the resident's episode and administered Zyprexa IM twice during the shift but did not notify the physician, family, or guardian about the incident. Interviews confirmed that the guardian and emergency contact were not informed of these behavioral changes or the subsequent transfer to a hospital until after the events occurred. Facility policy requires prompt notification of the resident, physician, and representative in the event of significant changes in condition, including behavioral deterioration or transfer to another facility. Interviews with facility leadership confirmed that the nurse should have contacted the physician, guardian, and emergency contact regarding the behavioral episodes and transfer. Documentation and interviews with the resident's contacts further confirmed that required notifications were not made in accordance with policy.
Deficient Food Handling, Storage, and Temperature Control
Penalty
Summary
The facility failed to store, prepare, and serve food in a manner that prevents the potential for foodborne illness, as evidenced by multiple observations and staff interviews. Staff were seen handling ready-to-eat foods such as bread, sandwiches, and salad with bare hands, and in some cases, gloves were not used or hand hygiene was not performed before or after glove use. Additionally, staff were observed not washing their hands for the required 20 seconds, and hand hygiene was not performed after touching personal items like cell phones or after removing gloves. The facility's own policies require hand hygiene before donning gloves, after glove removal, and prohibit bare hand contact with food, but these were not consistently followed. Food storage practices were also deficient. Opened bags of macaroni noodles, raw hamburger, bread, spices, and vanilla were found unsealed, undated, or both in dry storage and refrigerators. A milk refrigerator was found without a thermometer, and staff confirmed that thermometers should be present in all refrigerators. These lapses in labeling, sealing, and temperature monitoring are contrary to the facility's food safety policies, which require all food to be stored, labeled, and maintained at safe temperatures. Temperature control of food and fluids was not maintained according to policy or professional standards. Observations showed that hot foods such as cauliflower/broccoli, tuna melt sandwiches, and hamburger patties were served below the required holding temperatures, and milk was found above the safe cold temperature threshold. Staff interviews revealed inconsistent knowledge of the correct temperature standards, with some staff citing different minimum temperatures for hot food. The facility's policy requires hot foods to be held at 135°F or greater and cold foods at or below 41°F, but these standards were not met during the survey.
Failure to Document Medication Assistant Competencies
Penalty
Summary
The facility failed to ensure that all Medication Assistants (MAs) had completed and documented competencies as required by policy and regulation. Record reviews for four sampled MAs revealed that none had documentation of completed competencies for 2024 and 2025. The MAs reviewed had hire dates ranging from 2016 to 2025, indicating that both new and existing staff were affected. Interviews with the Director of Nursing and the Regional Director of Operations confirmed that the facility was unable to provide documentation of the required competencies for these staff members. The facility's Training Requirements policy mandates that all staff, including those under contract and volunteers, must have competencies and skill sets consistent with their expected roles. The Medication Aide Procedure Checklist, which outlines the required skills for MAs, was available, but there was no evidence that the competencies had been completed or documented for the four MAs reviewed. The facility had a census of 58 at the time of the survey.
Failure to Timely Obtain and Document Advance Directive
Penalty
Summary
The facility failed to have a signed advance directive for one resident out of eight sampled, despite requirements to inform and provide written information to all adult residents regarding their right to formulate an advance directive. The resident in question had a moderate cognitive impairment, as indicated by a BIMS score of 11, and had expressed that preferences for customary routine activities were important. Upon admission, the resident was experiencing adjustment issues, and interventions were in place to support their preferences and autonomy. However, a review of the resident's records, including the Minimum Data Set, care plan, clinical census, and electronic medical record, revealed no documentation of an advance directive or code status at the time of review. Further investigation showed that the facility's policy required communication of code status and adherence to residents' rights regarding advance directives. Despite this, the advanced directive for the resident was not present in the medical record and was only located later in the social service office, with documentation indicating it was received and dated after the initial record review. Interviews with facility staff confirmed the delay in obtaining and filing the advance directive, indicating a lapse in ensuring that the resident's rights regarding advance directives were honored in a timely manner.
Failure to Provide Timely Medicare Coverage Termination Notices
Penalty
Summary
The facility failed to provide timely notice of the end of Medicare coverage to two residents, as required by policy and federal regulations. For one resident, the Notice of Medicare Non-Coverage (NOMNC) and Advance Beneficiary Notice (ABN) were not signed until after the last covered date, rather than at least two days prior to the end of Medicare-covered services. This was confirmed by the Regional Business Office Manager, who acknowledged that the required notices were not provided within the appropriate timeframe. For another resident, there was no evidence that the NOMNC or ABN were completed at all when Medicare Part A services ended. The facility's policy states that such notices must be provided at least two days before the end of Medicare coverage to allow residents or their representatives sufficient time to make informed decisions regarding their care and financial responsibility. Record reviews and staff interviews confirmed that these procedures were not followed for the two residents in question.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the state-appointed ombudsman of a resident's discharge as required by regulation. Record review showed that the facility's process for emergency transfers and discharges mandates monthly notification to the ombudsman. However, documentation revealed that notifications were not consistently sent each month, with records only available for two months within the review period. Specifically, the discharge of one resident was not reported to the ombudsman, as confirmed by both record review and staff interviews. The Regional Director of Operations acknowledged that the required notification for the resident's discharge was not completed.
Failure to Maintain Catheter Drainage Bag Below Bladder During Transfer
Penalty
Summary
A deficiency was identified when staff failed to maintain a urinary catheter drainage bag below the level of the bladder for a resident with an indwelling catheter. During a Hoyer lift transfer, the catheter drainage bag was attached to the lift arm hook at the resident's eye level, rather than being kept below the bladder as required by facility policy and the resident's care plan. Both the medication assistant and nursing assistant involved in the transfer were unsure of the correct placement for the catheter bag during the procedure. The resident involved had a history of neuromuscular dysfunction of the bladder and was dependent on staff for most activities of daily living. The care plan specifically noted the need to position the catheter bag and tubing below the bladder to prevent urinary tract infections. At the time of the incident, the resident was being treated for a urinary tract infection with antibiotics. The Director of Nursing confirmed that the catheter drainage bag should be kept below the level of the bladder, in accordance with facility policy.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The report notes that the facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Serve Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to provide residents with nourishing and palatable meals, as required by both facility policy and the Nebraska Food Code. Observations revealed that hot foods were not consistently served at the required temperature of 135°F or higher, with a sample meal showing a sloppy joe at 124.3°F and broccoli and cheese at 132.4°F. The broccoli and cheese dish, intended to be regular texture, appeared ground or pureed and was described as unappetizing in both appearance and texture. Several residents were observed not eating this dish, and interviews confirmed dissatisfaction with the temperature and palatability of the meals. The pears served with the meal were cold, and the appearance of the food was also questioned, with one resident stating the broccoli and cheese looked like someone had thrown up on the plate. Resident interviews further confirmed that hot foods were not always served hot, especially for those who typically ate in their rooms. Residents with various medical conditions, including diabetes, vitamin deficiencies, and swallowing issues, were affected by these inconsistencies. The Food Service Manager acknowledged that the broccoli and cheese dish was not served in the correct texture, and the Administrator confirmed that meal temperatures did not meet required standards. These findings indicate a failure to adhere to established food preparation and service guidelines, impacting the quality and palatability of meals provided to residents.
Failure to Offer Alternate Meal Items for Unselected or Refused Foods
Penalty
Summary
The facility failed to ensure that residents were offered alternative meal items when they chose not to eat the food initially served, as required by their own policy and regulatory standards. Observations during lunch revealed that several residents did not eat the broccoli and cheese dish provided, and review of a sample meal tray showed limited options, with the vegetable appearing unappetizing. Residents received menus in advance to select their meal preferences, but if they did not mark a particular item, such as a vegetable or fruit, no alternative was provided. This practice was confirmed by both residents and the Food Service Manager, who stated that only main dish alternatives were available, and that no substitute vegetables or fruits were offered if the original item was declined or unselected. Interviews with two cognitively intact residents highlighted that they did not receive alternatives for items they disliked or could not eat, such as pears or broccoli, due to personal preference or difficulty eating certain foods. The Food Service Manager and Administrator both acknowledged that the facility did not routinely offer alternative vegetables or fruits, and that residents who did not select these items simply went without them. This failure to provide appropriate alternatives had the potential to affect all residents receiving meals from the kitchen, as it did not accommodate individual dietary needs and preferences as outlined in the facility's policy.
Failure to Maintain Clean and Homelike Environment Due to Persistent Urine Odors
Penalty
Summary
Surveyors found that the facility failed to maintain a clean and homelike environment, as required by policy and regulation. Upon entering the facility, a faint odor of urine was detected at the front door, which became stronger further inside, particularly in the carpeted hallway leading from the east entrance to the main nurses' station, as well as in the south hall and some resident rooms. Specific observations included a private, unoccupied room in the east hallway that smelled strongly of urine and had a sticky floor. Later, after housekeeping mopped the floor in another room on the East Hall, the stickiness increased and the odor of urine became even more pronounced. Interviews with the DON and the Administrator confirmed awareness of the persistent urine odors throughout the hallways and some rooms, attributing the issue to humidity and seasonal changes. Both acknowledged the difficulty in addressing the odors, with the Administrator stating that staff had become accustomed to the smells. Review of facility policies indicated that regular environmental inspections and routine cleaning and disinfection were required, but these measures were not effective in preventing or eliminating the odors and unsanitary conditions observed.
Failure to Promptly Respond to Resident Call Lights
Penalty
Summary
The facility failed to ensure that call lights were answered promptly for three cognitively intact residents who required varying levels of assistance with mobility and activities of daily living. Documentation from the Minimum Data Set (MDS) and call light logs revealed that these residents experienced significant delays, with call lights remaining unanswered for periods ranging from over 20 minutes to more than two hours on multiple occasions throughout the month. These delays were corroborated by resident interviews, where each resident described frequent and prolonged waits for staff assistance, sometimes exceeding an hour. One resident, who had a history of stroke and required moderate assistance to walk, reported that call light response times had temporarily improved after filing a grievance but subsequently worsened again. Call light logs for this resident showed repeated instances of delays, including several occasions where the call light was not answered for over 30 minutes and, in one case, for more than an hour. Another resident, who used a wheelchair due to fall precautions, also reported waiting an hour or more for assistance, particularly when needing to use the restroom. The call light logs for this resident similarly documented multiple extended response times, some exceeding an hour. A third resident, who was unable to walk and required a mechanical lift with two staff members for transfers, described staff sometimes turning off the call light and promising to return, only for the resident to continue waiting. This resident's call light logs included several instances of delays over an hour, with the longest being more than two hours. Interviews with facility leadership confirmed awareness of the issue, with the Director of Nursing and Facility Administrator acknowledging that call light response times were sometimes longer than appropriate and that there had been technical issues with the call light system on certain days.
Failure to Follow Physician's Orders for Auto-PAP
Penalty
Summary
The facility failed to follow up and complete a physician's order for an Auto-PAP machine for a resident diagnosed with obstructive sleep apnea. The resident, who was admitted with a history of using CPAP since 2018, reported that the mask was too tight, which led to frequent refusals to use the device. Despite the resident's complaints and inquiries about a new CPAP, there were no orders addressing these concerns. The resident's use of the Auto-PAP decreased significantly over time, with the resident refusing to use it more often than not. Interviews with staff revealed a lack of awareness and follow-up regarding the resident's refusal to use the Auto-PAP. The RN was unaware if the doctor had been notified about the refusals, and the DON confirmed that the orders for the Auto-PAP should have been placed upon admission. Additionally, there was a lack of follow-up after contacting Midwest Respiratory for recommendations, and the facility's administrator speculated that the resident's beard might be causing the mask to feel tight. This lack of action and communication contributed to the deficiency in providing appropriate treatment and care according to the resident's needs and physician's orders.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to secure a catheter properly, leading to potential cross-contamination during catheter care for Resident 53. During an observation, a registered nurse (RN) was seen changing the catheter bag for Resident 53, who has dementia, neurogenic bladder, intellectual disabilities, and hypothyroidism. The RN dropped the new catheter drainage bag and tubing on the floor twice but continued to use them after wiping with alcohol wipes, which was confirmed by the Infection Control Preventionist as having the potential to cause cross-contamination. Additionally, the facility failed to adhere to proper hand hygiene protocols during peri care and wound care for Residents 53, 26, and 8. A medication aide (MA) did not change gloves or perform hand hygiene after providing pericare to Resident 53, which was confirmed by the MA and the Infection Control Preventionist. Similarly, an RN did not perform hand hygiene between glove changes during wound care for Resident 26, and a licensed practical nurse (LPN) failed to perform hand hygiene before donning gloves and between tasks during wound care for Resident 8. The facility's hand hygiene policy, which requires hand hygiene when moving from a contaminated body site to a clean body site and before donning gloves, was not followed. Interviews with the staff involved and the Director of Nursing (DON) confirmed the lapses in hand hygiene practices, which are crucial to preventing the spread of infection within the facility.
PASRR Screening Deficiency for Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure that a PASRR (Pre-admission Screening and Resident Review) for individuals with a mental disorder or intellectual disability was accurately completed for one resident. This deficiency was identified during a review of records and interviews with staff. The resident in question, who was part of a sample of 20 residents, had a history of schizoaffective disorder, major depressive disorder, and post-traumatic stress disorder (PTSD). Despite these diagnoses being documented in various medical records, they were not accurately reflected in the PASRR screenings conducted on two separate occasions. The PASRR dated 3/30/21 noted major depressive disorder and substance abuse but omitted schizoaffective disorder and PTSD. A subsequent PASRR dated 6/8/22 failed to list any diagnoses. Interviews with the Director of Nursing, Administrator, and Social Service Director confirmed the oversight, acknowledging that the PASRR should have included the resident's diagnoses of schizoaffective disorder and PTSD. The Administrator noted that the PASRR was initially completed at the hospital and was done incorrectly, and the facility's Social Worker did not identify the error.
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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