Adept Nursing & Rehab Of Gretna
Inspection history, citations, penalties and survey trends for this long-term care facility in Gretna, Nebraska.
- Location
- 700 Highway 6, Gretna, Nebraska 68028
- CMS Provider Number
- 285146
- Inspections on file
- 26
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Adept Nursing & Rehab Of Gretna during CMS and state inspections, most recent first.
Surveyors identified that the facility exceeded the acceptable medication error rate when three errors occurred out of 25 opportunities. One resident with edema missed a scheduled morning dose of torsemide 80 mg because the drug was unavailable in the medication cart, not in the medication bank, and had not yet arrived from the pharmacy. Another resident, ordered sucralfate 1 g before meals and at bedtime, received the medication after eating lunch. A third resident, ordered finasteride 5 mg once daily at 8:00 PM for urinary retention, received the dose in the early afternoon instead of at the scheduled time. Staff, including an MA, an LPN, and the DON, confirmed that these missed and wrong-time administrations constituted medication errors under facility policy.
Respiratory care was not provided as ordered for several residents. A cognitively intact resident using a Trilogy NIV had no documented device settings or record of when the mask and tubing were last changed, another resident ordered for continuous oxygen titration had only daily SpO2 checks instead of more frequent monitoring, and two residents had oxygen tubing that was not dated. The DON confirmed the missing settings, limited SpO2 monitoring, and lack of tubing dating.
A resident who was unable to make themselves understood and required extensive assistance with mobility and ADLs was admitted with a documented sacral pressure ulcer. Facility policy required that wound care be provided per physician orders and that a physician be notified to obtain treatment orders when none were present. Despite this, the resident’s records showed no physician order for treatment of the sacral ulcer, and an RN confirmed that the physician had not been notified and that no treatment order had been obtained.
A resident's advance directive was not updated in the medical record. The resident's advance directive information showed a change from wanting CPR to not wanting CPR, but the CCP still listed the resident as Full Code. The resident had a BIMS score of 13, required assistance with multiple ADLs, and was receiving oxygen therapy. An LPN confirmed the discrepancy between the advance directive information and the CCP.
Psychotropic medication monitoring deficiencies were identified for multiple residents. One resident with bipolar disorder, MDD with psychotic symptoms, and GAD received Seroquel and sertraline, but the EMR, MAR, and TAR did not show specific target behaviors or side effect monitoring despite behavioral concerns being listed in the care plan. Another resident with schizoaffective disorder, bipolar type, received multiple psychotropic medications, but no target behaviors were documented, and the DON confirmed this. The report also noted missing AIMS testing for one resident and lack of sleep pattern monitoring for hypnotic use in three residents.
A resident’s CCP was not revised to reflect the correct advance directive status after Hospice admission and a DNR order were obtained. The resident had a BIMS score of 14, required extensive to total ADL assistance, and was receiving Hospice services, but the CCP still listed full code and advance directive entries showing no change. The SW confirmed the CCP should have been updated to no code after the facility received the DNR paperwork and Hospice documents.
Failure to implement an ordered fluid restriction was identified for a resident with moderate cognitive impairment. The MAR documented a 1500 ml fluid restriction, but the CCP and DMT did not include the restriction, and the order was not divided between Dietary and Nursing Services per policy. The resident was observed with water and soda, stated the restriction was not being enforced, a NA was unaware of the order, and the DON confirmed it was not implemented.
A pharmacist identified that a resident receiving Xarelto was also ordered ibuprofen, an NSAID, and recommended discontinuing the ibuprofen because anticoagulants combined with NSAIDs can increase bleeding risk. The physician disagreed with the recommendation, but the chart did not include a clear clinical rationale for continuing ibuprofen, and the DON confirmed the rationale was not documented.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
The facility did not ensure that water temperatures for bathing and showering remained at or below 110°F, as required to prevent accidents. Multiple logs and direct observations showed water temperatures in excess of this limit in several bathhouses and tubs. Over twenty cognitively impaired residents regularly used these bathing areas, and staff confirmed the facility lacked a specific policy for tub bathing.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
Staff failed to promptly assess, monitor, and implement interventions for two residents at risk for pressure ulcers, resulting in the development and worsening of pressure injuries. In both cases, wounds were not measured or treated in a timely manner, and required interventions were not initiated according to facility policy.
The facility did not provide bathing services according to the stated preferences of four residents, each of whom required significant assistance and had documented requests for two baths or showers per week. Despite varying cognitive and physical needs, these residents received fewer baths or showers than preferred, contrary to facility policy supporting resident self-determination, as confirmed by the DON.
Staff failed to promptly notify the medical practitioner of new pressure ulcers for two residents, resulting in a lack of timely treatment orders. One cognitively intact resident developed a stage 3 pressure ulcer that was not reported for further treatment, while another resident's wounds were not communicated to the practitioner until the day of the survey, contrary to facility policy.
The facility did not post daily nurse staffing information as required by its policy and federal guidelines. Observations showed that the necessary details, including the facility name, date, census, and staff hours, were missing. The DON confirmed the oversight, affecting all 44 residents.
The facility was found to have multiple environmental deficiencies in resident rooms, including scrapes on walls, stained floors, cracked sinks, and non-functioning lights. These issues were confirmed by the Maintenance Director, who noted that no active work orders were in place to address them.
The facility failed to secure residents' medications and treatments in medication carts, as observed on multiple occasions. Unlocked and unattended medication carts were found in various locations, and a Registered Nurse left a treatment cart unlocked while performing treatments. The facility's policy mandates that all drugs and biologicals be stored in locked compartments, which was not followed.
The facility failed to obtain treatment orders for pressure ulcers for two residents. One resident had a pressure ulcer on the left lateral foot, and another had an unstageable pressure wound on the left heel. Observations and interviews confirmed the absence of treatment orders for both residents.
Medication Administration Errors Exceeding 5% Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 25 opportunities, resulting in a 12% error rate. Facility policy required medications to be administered according to physician orders, manufacturer specifications, and accepted professional standards, and specified that missed doses and wrong-time administrations are medication errors. For one resident with an order for torsemide 80 mg by mouth in the morning for edema, observation showed the medication was unavailable at the scheduled administration time. The medication aide stated they would notify the charge nurse to obtain the drug from the facility’s medication bank. The LPN later confirmed that torsemide 80 mg was not available in the medication bank, the pharmacy had been notified, and by the afternoon the medication had still not arrived, resulting in a missed dose, which was acknowledged as a medication error. Another resident had a physician’s order for sucralfate 1 g by mouth before meals and at bedtime. Observation showed the medication aide administered the sucralfate after the resident had already eaten lunch, and the aide confirmed it should have been given before the meal. A third resident had an order for finasteride 5 mg by mouth once daily, scheduled for 8:00 PM. Observation revealed that the medication aide administered the finasteride at 1:00 PM instead of the ordered 8:00 PM time. The DON confirmed that this medication should have been administered at 8:00 PM and that both missed doses and medications given at the wrong time are considered medication errors under facility policy.
Respiratory Care Deficiencies With Ventilator Settings, Oxygen Monitoring, and Tubing Dating
Penalty
Summary
Safe and appropriate respiratory care was not provided for multiple residents who were receiving oxygen therapy or noninvasive ventilation. The facility’s policy required noninvasive ventilation to be provided according to practitioner orders and current standards of practice, with equipment replaced routinely and face mask and tubing changed every 3 months. The oxygen administration policy required oxygen to be administered according to orders and care plans, with monitoring of oxygen saturation levels as ordered and oxygen tubing and mask/cannula changed weekly and as needed, with equipment dated when changed. For one resident who was cognitively intact and receiving a Trilogy noninvasive ventilator at bedtime with heated humidity and 4 liters of oxygen bled in, the order summary did not include settings for the Trilogy device or orders for replacement of the face mask and tubing. The DON confirmed the settings were not obtained from the practitioner and the facility had no record of when the face mask and tubing were last changed. For another resident who was cognitively intact and had an order for oxygen titrated from 2 to 4 liters to keep oxygen saturations greater than 90% continuously via nasal cannula, the record showed only daily oxygen saturation monitoring. The DON confirmed the staff would need to check oxygen saturations more than once a day and at least shiftly to ensure the resident was receiving the correct flow to maintain the ordered saturation level. Two additional residents had oxygen tubing that was not dated. One resident with COPD, obstructive sleep apnea, respiratory failure with hypoxia, and dependence on supplemental oxygen had orders for oxygen at 2 liters per minute via nasal cannula to keep oxygen saturation above 88% and oxygen at 1 liter per minute at night; observations showed oxygen in place, but the tubing had no date marking when it was changed. Another resident with severe cognitive impairment and total dependence for all ADLs had an order for oxygen via nasal cannula at 4 liters per minute, and observations showed the tubing was not dated. The DON confirmed the oxygen tubing was not dated and should be dated when changed, changed weekly, and documented on the TAR.
Failure to Obtain Treatment Orders for Identified Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to obtain physician orders for treatment of an identified pressure ulcer. Facility policy on Wound Treatment Management, dated 08-2025, required that wound treatments be provided in accordance with physician orders, including cleansing method, dressing type, and frequency, and that in the absence of treatment orders the licensed nurse would notify the physician to obtain such orders. Record review showed that a resident, admitted on a specified date and assessed via the MDS as unable to make themselves understood and needing partial to total assistance with mobility, ADLs, and toileting, had a sacral pressure ulcer measuring 2.0 by 1.0 cm documented on an admission/readmission assessment dated 01-09-2026. However, review of the resident’s Order Summary printed on 03-02-2026 revealed no treatment order for the sacral pressure ulcer. In an interview, an RN confirmed the resident had a sacral pressure ulcer, that the physician had not been notified, and that an order for treatment had not been obtained as required.
Advance Directive Not Updated in Medical Record
Penalty
Summary
The facility failed to update advance directives in the medical record for 1 of 17 residents sampled. The facility policy titled Communication of Code Status stated that residents' rights to request, refuse, or discontinue treatment and to formulate an advance directive would be honored, and that when an order was written regarding the presence or absence of an advance directive, the directions would be clearly documented in designated sections of the medical record, including Full Code and Do Not Resuscitate status. Resident 1's MDS showed a BIMS score of 13, indicating cognitive intactness, and the resident required varying levels of assistance with dressing, hygiene, bed mobility, toileting, bathing, and transfers, and was receiving oxygen therapy. The resident's advance directive information showed a change from wishing CPR to not wanting CPR, but the CCP printed on 03-02-2026 still listed the resident as Full Code. An interview with an LPN confirmed there was a discrepancy between the advance directive information and the CCP and that there should not have been one.
Psychotropic Medication Monitoring Deficiencies
Penalty
Summary
The facility failed to identify and monitor specific target behaviors and side effects for psychotropic medication use for two residents, failed to ensure AIMS testing had been completed for one resident, and failed to monitor and evaluate sleep patterns for the continued use of hypnotic medications for three residents. The deficiency was identified during review of five residents selected from a census of 40, and the cited issue involved unnecessary medication use under 175 NAC 12-006.05(G). One resident had diagnoses including bipolar disorder, major depressive disorder with psychotic symptoms, and generalized anxiety disorder. The resident’s record showed orders for Seroquel in divided doses for anxiety and delusions, along with sertraline for major depressive disorder. The care plan identified psychotropic drug use and behavioral concerns such as refusing caregiver suggestions, arguing, making false accusations, and making racially inappropriate statements, with interventions to monitor for effectiveness and side effects. However, review of the EMR, MAR, and TAR showed no specific side effects identified and no behavior monitoring documented related to the antipsychotic and antidepressant use. Another resident had a diagnosis of schizoaffective disorder, bipolar type, and records showed use of multiple psychotropic medications, including buspirone, clonazepam, duloxetine, escitalopram, and quetiapine. The care plan for psychotropic drug use did not list any target behaviors. The DON confirmed there were no target behaviors documented for this resident. The report also states that AIMS testing had not been completed for Resident 6 and that sleep patterns were not monitored and evaluated for the continued use of hypnotic medications for three residents, but no additional details were provided in the report for those findings.
Care Plan Not Updated for DNR Status
Penalty
Summary
The facility failed to review and revise Resident 8’s Comprehensive Care Plan to reflect the correct advance directive status after the resident was admitted to Hospice services and a Do Not Resuscitate order was obtained. Resident 8 had an original admission date of 06/08/2023 and was re-admitted to Medicaid Hospice Services on 2/19/26. The significant change MDS dated 2/27/26 showed a BIMS score of 14, indicating the resident was cognitively intact, and documented that the resident required extensive to total assistance with activities of daily living and was receiving Hospice services. Record review showed Hospice admission documents dated 2/19/26 identified a diagnosis of Cerebral Infarction, and a DNR order document dated 2/19/26 was signed by Resident 8’s legally authorized representative, who indicated that the resident did want a DNR order. Physician orders also included a Do Not Resuscitate order dated 2/19/26. However, the Comprehensive Care Plan dated January 2026 still stated that the resident was full code and included advance directive entries indicating no change in advance directive status. During interview on 03/04/2026, the facility Social Worker confirmed that the care plan had not been updated to include a no code status and should have been changed after the resident went on Hospice and the facility received the DNR order and signed Hospice documents.
Failure to Implement Ordered Fluid Restriction
Penalty
Summary
Failure to implement a fluid restriction was identified for one resident with an order for 1500 ml of fluids per day. Record review showed the resident had a BIMS score of 12, indicating moderate cognitive impairment, and required extensive assistance with toileting, bathing, and lower body dressing, as well as limited assistance with upper body dressing, bed mobility, and transfers. The resident's MAR for February 2026 documented the fluid restriction, but the restriction was not divided between Dietary and Nursing Services as described in the facility policy. The resident's comprehensive care plan did not include the fluid restriction, and the dietary meal ticket also lacked information about the restriction or how much fluid the resident should receive with each meal. During observation, the resident was seen with a cup of water at lunch and later had a medium soda and a water pitcher that was half gone. The resident stated the fluid restriction was not being enforced, a NA said they were not aware of the restriction, and the DON confirmed the fluid restriction was not implemented and should have been.
Missing Rationale for Continued Ibuprofen Use
Penalty
Summary
The facility failed to ensure a rationale was documented for the continued use of ibuprofen for Resident 43, despite a pharmacist identifying that the resident was receiving Xarelto and ibuprofen, a nonsteroidal anti-inflammatory drug. The facility’s medication regimen review policy required a licensed pharmacist to review each resident’s drug regimen monthly, including the medical chart, and to document any irregularities or the absence of irregularities. The pharmacist’s recommendation to the prescriber stated that anticoagulants in combination with NSAIDs can increase the risk of bleeding and recommended discontinuing ibuprofen. Record review showed Resident 43 had a BIMS score of 15/15 with no behaviors noted and was independent with most activities of daily living, requiring partial/moderate assistance only with showering/bathing. Physician orders included ibuprofen 200 mg capsules, with one order for 400 mg by mouth twice daily for pain and another order for 400 mg by mouth every 12 hours as needed for pain. The physician response to the pharmacist’s recommendation was marked disagree, and the prescriber’s comment stated, "Take 400mg Ibuprofen every 12 hours as needed for pain," but the DON confirmed in interview that the prescriber had not documented the rationale for ibuprofen.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Maintain Safe Bathing Water Temperatures
Penalty
Summary
The facility failed to ensure that bathing and showering water temperatures did not exceed 110 degrees Fahrenheit, as required to prevent potential accidents. Multiple records and logs reviewed showed that water temperatures in various bathhouses and tubs consistently ranged from 111.4 to 116.4 degrees Fahrenheit, exceeding the facility's stated maximum safe bathing temperature. Observations conducted with the Regional Lead Maintenance confirmed that water temperatures in both the 100-hall and 200-hall bathhouses were above the 110-degree threshold. The facility's policies referenced a safe water temperature range of 98.6 to 120 degrees Fahrenheit, but staff interviews confirmed that the maximum for bathing should be 110 degrees Fahrenheit, and this standard was not met. The Resident Listing Report indicated that out of 45 residents, 22 were cognitively impaired and bathed in the bathhouses where the elevated water temperatures were recorded. Staff interviews confirmed that these residents, due to cognitive impairment, would be particularly vulnerable to the effects of excessively hot water. The facility did not have a policy specific to bathing in a tub, and the maintenance staff was responsible for checking and logging water temperatures, which were found to be above the safe limit on multiple occasions.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
Facility staff failed to evaluate, monitor, and implement timely interventions for pressure ulcer prevention and wound healing for two residents. One resident, admitted with a right hip fracture and existing skin issues including a surgical incision, maceration to the sacrum, and redness on the left heel, was assessed as at risk for pressure ulcers and required pressure-relieving surfaces. Despite these risks, there was no evidence that staff implemented interventions to prevent further skin breakdown on the left heel. The resident subsequently developed a stage 3 pressure ulcer on the left heel, which worsened over time. Treatment orders were not obtained promptly, and wound care was not initiated until several days after the ulcer was identified, resulting in a decline in the wound's condition. Another resident, with moderate cognitive impairment and extensive care needs, was also identified as at risk for pressure ulcers and had interventions in place on the care plan, such as regular repositioning and pressure-reducing surfaces. However, an open area was noted on the left side of the back, and later, open wounds were observed on both the left back and sacrum. There was no documentation of wound resolution, no treatment orders for these wounds, and the wounds had not been measured or assessed as required. Staff confirmed that these wounds had not been properly evaluated or treated. The facility's own policy requires a systematic approach to pressure injury prevention and management, including prompt assessment, intervention, and monitoring. However, in both cases, staff did not follow these protocols, resulting in unaddressed and worsening pressure ulcers. The deficiencies were confirmed through record review, staff interviews, and direct observation.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to provide bathing services in accordance with the preferences of four residents, as identified through interviews and record reviews. Each resident had documented preferences for receiving two baths or showers per week, as indicated in their care plans or preference forms. However, facility records for March and April 2025 showed that these residents did not receive the number of baths or showers they preferred. For example, one resident with severe cognitive impairment and requiring total assistance for bathing received only five baths over an eight-week period, instead of the expected sixteen. Another resident, who was cognitively intact and required extensive assistance, received only three baths over a five-week period, instead of the expected ten. Similar discrepancies were found for the other two residents, with one resident refusing a bath on one occasion, but otherwise not receiving the preferred number of showers. The residents involved had varying levels of cognitive and physical impairment, as assessed by the Minimum Data Set (MDS), and all required significant assistance with bathing and other activities of daily living. The facility's own policy emphasized the right of residents to self-determination and to make choices about their care, including bathing schedules. Despite this, the facility did not honor the residents' stated preferences for bathing frequency, as confirmed by the Director of Nursing during an interview. This failure to provide care in accordance with resident choice constitutes a deficiency in supporting resident rights and self-determination.
Failure to Notify Practitioner of New Pressure Ulcers
Penalty
Summary
Facility staff failed to notify the medical practitioner of new pressure ulcers for two residents. For one resident, staff identified a skin issue on the left heel and obtained a one-time order to wash and cover the wound, but when a Nurse Practitioner assessed the area the following day and identified it as a stage 3 pressure ulcer, no treatment orders were obtained, and the practitioner was not notified to request further treatment. The resident was cognitively intact and required varying levels of assistance with daily activities. For another resident, staff noted an open area on the left side of the back, but there were no treatment orders for this wound or for a wound on the sacrum, as confirmed by a review of the treatment administration record. The DON confirmed that the practitioner was not notified of the wound until the day of the survey. The facility's policy requires prompt notification of the practitioner and resident representative when a change in condition necessitates new or altered treatment, which was not followed in these cases.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with its policy and federal requirements to post daily nurse staffing information at the beginning of each shift. This information should include the facility name, date, current resident census, and the total number and actual hours worked by Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides responsible for resident care. Observations on multiple dates revealed that the required nurse staffing information was not posted anywhere in the facility, which could potentially affect all 44 residents residing there. The Director of Nursing confirmed during an interview that the daily nurse staffing information had not been posted as required. The facility's policy, dated August 2023, mandates that this information be made readily available in a readable format to residents and visitors, updated to reflect any staff absences, and maintained for a minimum of 18 months. Despite these guidelines, the facility did not adhere to the policy, resulting in a deficiency noted by the surveyors.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and homelike environment in several resident rooms, as observed during an inspection. Specific issues included scrapes on walls behind beds and in bathrooms, stained areas of the floor around toilet bases, and scrapes on closet doors in multiple rooms. Additionally, there were cracked bathroom sinks, closet doors pulled off tracks, cracks in linoleum, and missing or loose transition strips between bathrooms and rooms. Some rooms also had non-functioning lights above beds, loose toilet roll holders, and ventilation covers coated with a gray fuzzy substance. These deficiencies were confirmed during an environmental tour with the Regional Director of Operations and the Maintenance Director. The Maintenance Director acknowledged the need for cleaning and repairs but confirmed that there were no active work orders for the identified concerns. The facility's census at the time was 44, with 33 occupied resident rooms, and the issues were noted in 9 of these rooms.
Failure to Secure Medications and Treatments in Medication Carts
Penalty
Summary
The facility failed to secure residents' medications and treatments in medication carts, as observed on multiple occasions. On 5/1/24 at 6:52 AM, a medication cart next to an office was found unlocked and unattended. Further observations revealed two additional unlocked and unattended carts down the 200 hall. At 7:13 AM, a Registered Nurse (RN) was seen entering a resident's room for a treatment, leaving the treatment cart unlocked in the hallway. Again, at 8:32 AM, the same RN was performing a treatment in another resident's room with the door open, leaving the treatment cart unlocked and out of view in the hallway. The RN confirmed that the cart should not be left unlocked and unattended, explaining that the cart was left unlocked when the RN went to let someone into the building without locking it first. An interview with the Administrator on 5/2/24 at 8:40 AM revealed that the facility has 15 self-ambulatory residents, 7 of whom have cognitive impairments. The Administrator confirmed that medication and treatment carts should be locked unless a nurse is actively preparing a treatment or medication. The facility's policy on medication storage mandates that all drugs and biologicals be stored in locked compartments under proper conditions, which was not adhered to in these instances.
Failure to Obtain Treatment Orders for Pressure Ulcers
Penalty
Summary
The facility staff failed to obtain treatment orders for pressure ulcers for two residents. Resident 1 was readmitted to the facility with a pressure ulcer on the left lateral foot, but the facility did not evaluate the skin condition or obtain treatment orders. Observations revealed the presence of eschar on the left lateral foot, but no treatment orders were found in the medical records, progress notes, care plan, or medication administration records. Interviews with the RN and ADON confirmed the absence of treatment orders for the wound on Resident 1's left foot. Similarly, Resident 3 was admitted to the facility with a pressure wound on the left heel, but no treatment orders were documented. The wound was observed to be unstageable with moderate serosanguineous drainage. Interviews and record reviews confirmed that there were no orders for wound care for Resident 3's left heel. Both cases highlight the facility's failure to obtain necessary treatment orders for pressure ulcers, leading to deficiencies in care.
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Surveyors found that the facility did not maintain a medication error rate below 5%, identifying multiple late and improperly timed medication administrations and a missing medication. A medication aide gave a cholesterol medication and wound-healing supplements significantly later than their scheduled times, and another aide administered acetaminophen well outside the ordered time window and could not obtain a prescribed dose of Ingrezza because it had not arrived from the pharmacy. An LPN administered fast-acting Humalog insulin before a meal when no food was available and was unaware of the required timing of insulin in relation to meals, while the facility’s insulin policy lacked guidance on meal-related timing despite manufacturer instructions specifying administration within 15 minutes before or immediately after eating.
A resident with severe cognitive impairment, a history of CVA, and total dependence for ADLs developed a new right ankle wound and a new DTI to the left heel. Facility policy and licensure rules require immediate notification of the resident representative and physician for significant changes in condition, but review of progress notes showed no documentation that the representative was informed. An LPN confirmed the representative was not updated about the new wounds, despite the requirement to do so.
A family member filed a written grievance about a staff member’s attitude toward a resident and the family member, but the facility did not complete the grievance documentation or ensure timely communication of the specific resolution. The grievance form lacked documented resolution and administrator review, the ADM was initially unaware of the grievance, and the SW delayed completing the form while awaiting permanent interventions from nursing leadership. Although staff reported discussing a general resolution with the resident and family, the family member later stated they had not been informed of the actual grievance resolution, and the grievance form was not fully completed until well beyond the facility’s stated 10–14 day timeframe for resolving grievances.
The facility failed to report an allegation of physical abuse to law enforcement as required by its abuse reporting policy. A cognitively intact resident with dementia, anxiety, bipolar disorder, and major depressive disorder reported refusing a shower when a NA placed a lift sling under them, after which the situation escalated and both the resident and the NA exchanged punches. Skin assessments documented multiple new bruises on both of the resident’s arms and hands that were not present the prior day. Although facility policy required timely notification of law enforcement for such allegations, documentation in the abuse report form and EHR showed no law enforcement notification, and facility leadership confirmed that the incident and bruising were not reported to police.
A resident receiving hospice services with a condition expected to limit life expectancy had a DNR order requested by their representative and entered into the medical orders, but the comprehensive care plan (CCP) was not updated to reflect this change in code status. Facility policy required the CCP to be reviewed and revised by the interdisciplinary team following MDS assessments, yet the CCP continued to show an earlier full code status instead of the current DNR. The SSS acknowledged that the code status should have been updated when the change was made.
A resident with ESRD on dialysis, Type 2 DM, A-fib, COPD, and CHF, and requiring total assistance with ADLs, had physician orders for sacral and coccyx skin care, including cleansing, application of preventative ointment up to four times daily and PRN, and use of a sacral mepilex dressing. The order appeared on the Order Listing Report but was absent from the Nurse Administration Record, so staff were not cued to provide the treatment. During observed incontinence care, the resident’s sacral area was pink and no mepilex dressing was in place. An LPN confirmed the treatment was ordered but not provided and attributed the omission to a possible electronic medical record glitch.
Two residents at risk for or with existing pressure ulcers did not receive appropriate, individualized pressure ulcer prevention and treatment. One resident with hemiplegia, severe cognitive impairment, total ADL dependence, and incontinence developed multiple heel and ankle wounds after initial blanchable redness was noted; ordered Prevalon boots were repeatedly unavailable, the order to use them at all times was not promptly updated in the NAR, a turning schedule was not entered into the EHR, tissue analytics were missed on a scheduled date, and a nutrition consult and initiation of ordered supplements for wound healing were significantly delayed. Another resident with a stage 2 pressure ulcer was repeatedly observed on a DermaFloat LAL mattress left on the firmest setting, and the DON confirmed staff had not followed the manufacturer’s instructions to adjust and verify the mattress setting to prevent bottoming out.
A resident with ESRD on dialysis, along with multiple comorbidities including CHF, COPD, A-fib, and Type 2 DM, had physician orders and a care plan for a therapeutic renal diet, a 1200 ml/day fluid restriction divided across meals and med passes, and no water pitcher in the room, consistent with facility policy for dialysis residents. Observations showed a full water pitcher at the bedside and meal trays providing more than the ordered 240 ml of fluid per meal, while documentation also reflected conflicting fluid restriction amounts. Staff confirmed the resident had been offered more fluid than ordered and that a water pitcher had been present. In addition, on a dialysis day, multiple scheduled 9 a.m. medications were not administered because the resident was away at dialysis and the facility had not coordinated medication timing around dialysis services, contrary to its own policy.
The facility failed to respond to resident call lights within its stated goal of 7 minutes, with documented response times exceeding 30 minutes for multiple residents. A cognitively intact resident reported being left on the toilet for extended periods, and call system data showed call lights active for well over an hour on several occasions. Another resident with moderately impaired cognition had call lights unanswered for more than an hour, including after returning from dialysis. A third cognitively intact resident reported waiting up to two hours, with records confirming multiple call light activations lasting over an hour. The DON acknowledged that call light times over 30 minutes were not timely.
A resident with ESRD on thrice-weekly dialysis, along with DM2, A-fib, COPD, and CHF and moderate cognitive impairment, did not receive scheduled morning medications, including metoprolol and linagliptin, while away at dialysis. The MAR documented that the 9 AM metoprolol dose was not given because the resident was away from the facility without medications, and a progress note confirmed that morning medications were not administered due to the dialysis appointment. The DON later confirmed these omissions and identified them as medication errors.
Failure to Maintain Acceptable Medication Error Rate and Proper Medication Timing
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 5 errors out of 39 opportunities, resulting in a 12.82% error rate. The facility’s policy allowed medications to be given within one hour before or after the scheduled time, but staff did not adhere to this window. One medication aide administered pravastatin 10 mg to a resident at 8:52 PM when it was scheduled for 7:00 PM, and confirmed it was given late. The same aide also administered LiquaCel 30 cc and Juven 1 packet to another resident at 9:20 PM, despite orders for these supplements to be given twice daily with morning and evening medications at 8:00 AM and 7:00 PM, and confirmed these were also late. Additional errors involved improper timing and availability of medications. An LPN administered 4 units of Humalog, a fast-acting mealtime insulin ordered to be given before meals, to a resident at 7:37 AM when the resident had no food present and did not receive a meal tray until 8:18 AM; the LPN stated they did not know how quickly food should be provided after fast-acting insulin. The facility’s insulin policy lacked guidance on timing relative to meals, while the manufacturer’s prescribing information specified administration within 15 minutes before or immediately after a meal. Another medication aide administered acetaminophen 500 mg (two tablets) at 7:30 AM instead of the scheduled 6:00 AM dose and was unable to locate the resident’s ordered Ingrezza 80 mg capsule, confirming the medication had not arrived from the pharmacy and required reordering. The DON confirmed that the acetaminophen should have been given at 6:00 AM.
Failure to Notify Resident Representative of New Wounds
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition, specifically the development of new wounds. The facility’s policy titled "Change in Condition" dated 05-21-2023 states that changes in a resident’s condition or treatment are to be immediately shared with the resident and/or resident representative and reported to the attending physician or delegate. The policy requires notification of the resident, resident representative, and physician for events such as accidents resulting in injury with potential need for physician intervention, significant changes in physical, mental, or psychosocial status, and the need to significantly alter treatment. Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) also requires immediate notification of the resident, the resident’s doctor, and a family member of situations that affect the resident. Record review showed that one resident, admitted on a specified date, had a history of cerebrovascular accident (stroke) affecting the right side, severe cognitive impairment with a BIMS score of 5, total dependence for toileting, hygiene, dressing, bed mobility, transfers, and bathing, frequent urinary incontinence, and constant bowel incontinence, and did not have a pressure ulcer at the time of the MDS dated 01-26-2026. A Tissue Analytics Document dated 03-03-2026 revealed the resident had developed a new wound on the right ankle and a new deep tissue injury to the left heel. Progress notes contained no indication that the resident’s representative was informed of these new wounds. In an interview, an LPN confirmed that the resident’s representative was not updated about the new wounds and acknowledged that they should have been.
Failure to Timely Complete and Communicate Grievance Resolution
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to resolve and communicate the resolution of a grievance submitted on behalf of a resident. The facility’s written policy required Social Services and department managers to investigate written grievances, submit a written report of findings to the administrator, and ensure the resident or complainant was informed of the investigation findings and corrective actions in a timely manner, with documentation on the grievance form. A family member filed a written grievance concerning a staff member’s attitude toward the resident and the family member. The initial grievance form obtained from the social worker showed the grievance was received, but the sections for resolution and administrator review were incomplete, and the administrator reported being unaware of the grievance until it was brought to attention by surveyors. Interviews revealed that the social worker left the grievance form incomplete because they were waiting for permanent interventions from nursing leadership and did not document the final, grievance-specific resolution until much later. The social services supervisor stated the grievance was being processed, and the assistant DON reported speaking with the staff member involved, who denied the allegation, and removing that staff member from the resident’s care. Although facility staff reported that grievance resolution had been provided to the resident and family through a one-to-one discussion, the resident’s family member later stated they had not been notified of the grievance resolution. The administrator indicated that a reasonable timeframe for grievance resolution, including completion and review of the form, was 10–14 days, but the grievance form was not fully completed until nearly two months after the grievance was filed, and the permanent, grievance-specific resolution was not communicated to the family at the time the grievance was initially addressed.
Failure to Report Alleged Physical Abuse and Resulting Bruising to Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of physical abuse to law enforcement within the required timeframe. Facility policy, revised 08/08/2024, required the administrator or designee to notify multiple entities, including law enforcement, no later than two hours after an allegation involving serious bodily injury or within 24 hours if there was no serious bodily injury. The policy also specified notification of the state licensing authority, Ombudsman, resident representative, APS, the resident’s attending physician, and the facility medical director. Despite this written requirement, documentation showed that law enforcement was not notified following an allegation of physical abuse involving a resident. The resident involved had been admitted in 2019 and had diagnoses including moderate vascular dementia with agitation, generalized anxiety disorder, bipolar disorder, and major depressive disorder. A recent MDS showed a BIMS score of 15, indicating the resident was cognitively intact, and noted episodes of care rejection but no documented physical behavioral symptoms toward others. On the date of the incident, a NA entered the resident’s room, placed a lift sling under the resident, and informed the resident they would be taking a shower; the resident reported refusing the bath and stated that the situation escalated into both the resident and the NA exchanging punches. Subsequent skin assessments documented multiple bruises on both upper extremities that were not present the day before. A Potential Resident Abuse Report Form and the EHR contained no evidence that law enforcement was notified, and both the Administrator and Social Services Supervisor confirmed in interviews that the allegation of physical abuse and associated bruising were not reported to law enforcement, contrary to facility policy and reporting requirements.
Failure to Update Comprehensive Care Plan to Reflect Current DNR Status
Penalty
Summary
The facility failed to update a resident’s comprehensive care plan (CCP) to reflect the current resuscitation status after a change in code status was ordered. Facility policy on Comprehensive Care Plans, last reviewed/revised on 09/02/2025, required the CCP to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Record review showed that the resident was admitted on 09/23/2024, had a condition or chronic disease that may result in a life expectancy of less than six months, and was receiving hospice services. A Do-Not-Resuscitate (DNR) order dated 04/03/2026 documented that the resident’s representative requested DNR status, and an order listing report showed a DNR order dated 04/22/2026. However, the resident’s CCP printed on 04/28/2026 at 9:18 AM still reflected a “full code, do not resuscitate” status dated 10/02/2024, indicating the CCP had not been updated to match the current DNR order. In an interview, the Social Services Supervisor confirmed that the code status should have been updated at the time of the code status change.
Failure to Implement Physician-Ordered Sacral Skin Treatment
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered skin integrity interventions for a resident with multiple comorbidities. The resident’s MDS dated 03-24-2026 documented End Stage Renal Disease with dialysis dependence, Type 2 Diabetes Mellitus, A-Fib, COPD, and Chronic Heart Failure, as well as moderate cognitive impairment with a BIMS score of 12. The resident required setup and cleanup assistance with eating and total assistance with hygiene, toileting, bathing, dressing, bed mobility, and transfers, and was receiving dialysis services. The physician’s order, as shown on the Order Listing Report printed 04-28-2026, directed staff to cleanse the buttocks and coccyx with foam soap and water, pat dry, apply preventative ointment up to four times daily and as needed for soiling, and secure the area with a sacral mepilex dressing. Despite this order, the Nurse Administration Record for April 2026 contained no entry for the ordered wound care to the buttocks and coccyx, meaning the treatment was not listed to cue staff for administration. During an observation of incontinence care on 04-30-2026 at 10:40 AM, the resident’s sacral area showed pink skin discoloration and there was no mepilex dressing present on the sacral or coccyx area, indicating the ordered treatment had not been provided. In an interview later that day at 2:30 PM, an LPN confirmed that the resident was supposed to receive wound care to the sacral and coccyx area, acknowledged that the treatment had not been provided, and stated there must have been a glitch in the electronic medical record program because the order did not appear on the NAR.
Failure to Implement and Adjust Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
The deficiency involves the facility’s failure to develop, implement, and reevaluate effective interventions to prevent pressure ulcer development and to promote wound healing for two residents at risk or with existing pressure injuries. Facility policy required Braden Scale risk assessments on admission, weekly for four weeks, then quarterly or with significant change, and mandated a systematic approach including prompt assessment and treatment, monitoring, and modification of interventions as needed. The policy also required that interventions be adjusted when risk changed, when new or recurrent pressure injuries developed, when there was lack of healing progression, or when residents were non-compliant. The Braden Scale reference used by the facility defined scores of 10–12 as high risk and 13–14 as moderate risk for pressure ulcer development. One resident with a history of stroke, right-sided hemiplegia, severe cognitive impairment, total dependence for ADLs, and bowel and bladder incontinence was identified as at moderate to high risk for pressure ulcer development on admission, with a baseline care plan including a pressure-relieving wheelchair cushion and a comprehensive care plan identifying high risk for skin breakdown. The care plan listed general interventions such as Braden evaluations, observation and documentation of skin condition, use of a special mattress, skin hygiene, and nutritional and lab monitoring. A skin check initially showed no pressure ulcers, but a subsequent skin check documented blanchable redness to the right heel. An order was in place for Prevalon boots to be worn in bed, but progress notes over several consecutive days documented that the boots were not available, and heels were instead floated on a pillow. A pressure ulcer on the right heel was then identified, and later tissue analytics showed the wound had significantly enlarged, with additional findings of a new dark area consistent with a deep tissue injury on the right heel, a new wound on the right ankle possibly related to pressure or boot straps, and a deep tissue injury on the left heel. Practitioner instructions were to protect the heels at all times, including when out of bed and to avoid resting the feet on foot pedals, but the medication/nurse administration record was not updated to reflect the “at all times” order until many days after it was given. For this same resident, the facility did not promptly obtain a nutritional evaluation for wound healing, as the dietician’s assessment and recommendation for a nutritional supplement occurred several weeks after the first pressure ulcer was identified, and the ordered supplement was not started until several days after the recommendation. Tissue analytics documentation was also not completed on one of the scheduled dates, and interviews with nursing staff confirmed that a turning/repositioning schedule was not entered into the electronic health record to cue staff, despite the resident’s high risk and existing wounds. Staff interviews further confirmed that the resident was non-compliant with Prevalon boots and that the interdisciplinary team had not re-evaluated pressure-relief interventions for the feet during this period. Another resident, cognitively intact but totally dependent for bed mobility, transfers, and personal care, and always incontinent of bowel and bladder, was assessed as at risk for pressure ulcers and already had a stage 2 pressure ulcer. This resident was observed on multiple occasions lying in bed on a Joerns DermaFloat low air loss mattress that was consistently set at the firmest setting. The manufacturer’s instructions for this mattress required individualized adjustment of the comfort setting using a hand-check method to prevent bottoming out and directed that the proper setting be documented and re-evaluated as the resident’s condition warranted. The DON confirmed that the facility had not followed the mattress manual for setup for this resident and could not confirm that the mattress was at the correct setting to prevent bottoming out as described in the manual.
Failure to Adhere to Dialysis Resident Fluid Restriction and Medication Scheduling
Penalty
Summary
Surveyors identified that the facility failed to follow its own policy for dialysis residents and to adhere to physician-ordered fluid restrictions and medication timing for one dialysis-dependent resident. The facility’s policy required that dialysis residents receive fluids only as ordered by the physician, that nursing and dietary staff organize the division and distribution of fluids, that no water pitcher be present when restricted, and that medications be administered before departure and after return from dialysis so as not to interfere with treatment. The resident had end stage renal disease on dialysis, Type 2 diabetes mellitus, atrial fibrillation, COPD, and chronic heart failure, with a care plan and orders specifying a therapeutic diet, low potassium, no added salt, double protein, and a 1200 ml/day fluid restriction divided as 240 ml at each meal and 120 ml with each med pass, and no water pitcher in the room. Despite these orders and care plan interventions, observations showed a 600 ml water pitcher in the room filled to the 500 ml mark, and lunch trays that included a 240 ml milk carton plus additional juice and ice, exceeding the ordered 240 ml fluid allotment at meals. Record review further showed conflicting fluid restriction documentation, with an After Visit Summary listing a 1500 ml fluid restriction while the facility’s orders and care plan reflected a 1200 ml restriction, and staff interviews confirmed that the resident had been offered more than the ordered 240 ml of fluid with meals and that a water pitcher had been present contrary to the care plan. Additionally, the facility failed to coordinate medication administration around dialysis treatments. The Medication Administration Record documented that multiple scheduled 9 a.m. medications, including atorvastatin, fluticasone nasal spray, linagliptin, sennosides-docusate, metoprolol tartrate, mucinex ER, carboxymethylcellulose eye drops, and ipratropium-albuterol inhalation solution, were not given on a dialysis day because the resident was away from the facility without medications. The DON confirmed that these medications were omitted due to the resident being at dialysis and acknowledged not knowing that medication administration should be scheduled around dialysis services, contrary to the facility’s dialysis care policy.
Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely response to resident call lights, with multiple documented instances of response times far exceeding 30 minutes. One cognitively intact resident (BIMS score 13) reported being left on the toilet for a very long time in mid-January and again on a later date in April, though for a somewhat shorter period. Alarm Average Response Time Reports (AARTR) showed that this resident’s call light remained on for 167 minutes and 51 seconds on one January date, and for 46 minutes and 32 seconds and 73 minutes and 34 seconds during two separate call light activations in April. Another resident with moderately impaired cognition (BIMS score 12) had a family member report that the resident had to wait an hour to be laid down after dialysis. AARTR data for this resident showed call light durations of 61 minutes and 38 seconds and 76 minutes and 33 seconds on separate occasions in April. A third cognitively intact resident (BIMS score 15) reported having waited as long as two hours for a call light to be answered, and AARTR records documented call light durations of 65 minutes and 18 seconds and 63 minutes on two separate occasions. The DON stated that the facility’s goal for call light response was 7 minutes and confirmed that call light times over 30 minutes were not timely.
Failure to Administer Ordered Medications During Dialysis Absence
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when required medications were not administered as ordered while the resident was away from the facility for dialysis. The resident had multiple serious diagnoses, including end stage renal disease requiring dialysis, type 2 diabetes mellitus, atrial fibrillation, COPD, and chronic heart failure, and was assessed with moderate cognitive impairment. The resident required extensive assistance with most activities of daily living and was receiving dialysis services three times weekly. The comprehensive care plan documented scheduled dialysis on Monday, Wednesday, and Friday. On a documented dialysis day, the resident did not receive the scheduled 9 AM dose of metoprolol tartrate 25 mg because the resident was away from the facility without medications. The medication administration record showed a code indicating the medication was not given due to the resident being away, and a progress note stated that morning medications were not administered because the resident was at dialysis that morning. Later, the physician ordered metoprolol to be given after the resident’s heart rate was found to be 116. In an interview, the DON confirmed that the resident did not receive metoprolol and linagliptin on that date and acknowledged that the omission constituted a medication error.
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