Adept Nursing & Rehab Of North Platte
Inspection history, citations, penalties and survey trends for this long-term care facility in North Platte, Nebraska.
- Location
- 510 Centennial Circle, North Platte, Nebraska 69101
- CMS Provider Number
- 285094
- Inspections on file
- 23
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Adept Nursing & Rehab Of North Platte during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow physician orders or its own policies for timely medication procurement and administration for four residents. One resident returned from the hospital on comfort measures with new PRN orders for atropine, lorazepam, and morphine for secretions, anxiety, pain, and air hunger, but the comfort kit medications were not available, clarification was not obtained, and morphine was not administered until the next day. Other residents admitted with multiple chronic conditions, including AFib, VTE history, COPD, diabetes, hypothyroidism, heart failure, and psychiatric disorders, had numerous scheduled medications either started late or given inconsistently, as documented on the MARs and in progress notes stating medications were not available or still pending from the pharmacy. Residents interviewed reported no negative impact, but the DON and Administrator acknowledged they knew medications for new and readmitted residents were not being delivered consistently or timely and that they had not notified the physician when medications were unavailable or not dispensed as ordered.
The facility failed to provide routine medications in a timely manner for four of five sampled residents, despite a policy requiring a systemic approach to obtain and administer medications, including starting new orders within 24 hours and maintaining an emergency supply. An LPN reported that the contracted pharmacy’s deliveries did not arrive promptly, and the DON and Administrator acknowledged knowing that medications for newly admitted residents were not delivered consistently or on time. They also stated that physicians were not notified when medications were not dispensed per policy and that there was no process to follow up when medications were unavailable and no local pharmacy option if deliveries were delayed.
Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
Two residents experienced significant medication errors when ordered drugs were not available or not initiated as required. One resident with dental pain and infection had an antibiotic ordered by a dentist and faxed to the pharmacy, but the order was never entered into the electronic record, and the first dose was not given as scheduled. Another resident with Type 2 DM had a standing weekly Ozempic injection order, but the last administering nurse did not reorder the medication after the prior dose, leaving no dose available on the next due date. These failures occurred despite facility policies requiring timely initiation of new medications and reordering when supplies were low.
Multiple deficiencies were identified in dietary services, including improper labeling and storage of food items, failure of staff to wear required beard covers, storage of clean utensils near chemicals, handling of ready-to-eat foods without gloves, and use of a handwashing sink for food preparation water. These actions were inconsistent with facility policy and food safety codes, potentially affecting all residents.
A resident's discharge record lacked the required recapitulation summary of their stay, as the facility's process did not include this documentation and the SSD was unaware of the regulatory requirement.
A resident with moderate cognitive impairment was found to have bed canes in use without documentation or care plan inclusion, despite facility policy requiring clinical indication for such equipment. The resident was unaware of the reason for the bed canes, and the ADON confirmed the omission in the care plan.
A resident admitted after ankle surgery for osteomyelitis and cellulitis did not have wound care orders or a documented weight-bearing status upon admission. The dressing was not changed or assessed, and staff were unclear about mobility restrictions, resulting in a lack of appropriate wound care and guidance.
Two residents experienced significant weight loss due to the facility's failure to provide necessary assistance and interventions during meals. Despite care plans indicating nutritional risk and the need for prompting or set-up help, staff did not consistently assist or cue residents, and meal intake was often poorly documented. Providers and the dietitian were not promptly notified of ongoing weight loss, and staff lacked clear guidelines for addressing inadequate food intake.
A resident with multiple medical conditions and total dependence on staff for care was repeatedly observed in bed, wearing the same soiled gown, with unkempt hair and without proper assistance for daily activities. Staff interviews confirmed that required morning and evening cares, including dressing and grooming, were not provided as expected, and the resident was not assisted to get out of bed despite being alert and not actively dying.
Two nurse aides did not don the required PPE, except for gloves, while providing high-contact perineal and catheter care to a resident with a urinary catheter, despite an EBP sign on the door and knowledge of the facility's infection control policy. Both the aides and the DON confirmed that the required PPE should have been used during this care.
The facility failed to identify causative factors and implement interventions for falls for three residents and did not develop interventions for a resident at risk for elopement. One resident with vascular dementia experienced multiple falls without appropriate interventions, leading to hospitalizations. Another resident with severe cognitive impairment had repeated falls without causative factors being identified or appropriate interventions. A third resident's fall lacked root cause analysis and interventions, while a resident at risk for elopement had no care plan focus or interventions, and staff were unaware of the risk.
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing pain management, assistance with daily activities, and specific medical needs such as ostomy and dialysis care. These omissions were identified through record reviews, observations, and interviews, highlighting a lack of updated and complete care plans for residents with various medical conditions.
The facility failed to administer medications at the correct times for three residents, resulting in a medication error rate of 12%. A resident received Novolog after starting a meal, another received glipizide while eating, and a third received Prostat late due to a request. These errors were confirmed by staff interviews.
The facility failed to prevent cross-contamination by leaving clean linen carts uncovered and unattended during laundry distribution. Additionally, a resident's nebulizer mask was not cleaned or stored properly, as it was found with residue and undated, contrary to the facility's policy.
A facility failed to accurately code a resident's MDS, indicating full dependency for transfers, while observations and staff interviews showed the resident required limited to extensive assistance from one staff member. The MDS Coordinator was unsure why the resident was coded as dependent, despite documentation showing otherwise.
A resident did not have a TSH lab test completed as ordered by the physician. The resident was admitted in November 2023 and had an order for an annual TSH test starting in September 2022. Despite having a medication order for Levothyroxine, the last TSH lab was conducted in September 2022, and no further tests were found. The DON confirmed the oversight.
A facility failed to follow its dialysis care policy for a resident, as there was no documentation of required assessments for the AV graft site or dialysis catheter. Interviews revealed that nursing staff did not routinely check dialysis sites or document assessments, as confirmed by the DON. This resulted in a lack of necessary assessments and documentation for the resident's dialysis care.
A facility failed to provide a clinically valid rationale for continuing a psychotropic medication for a resident. The facility's policy requires gradual dose reductions unless contraindicated. A pharmacist recommended a dosage reduction for the resident's sertraline, but the physician claimed it was contraindicated without a valid clinical reason. The DON confirmed the rationale was not clinical.
Failure to Obtain and Administer Ordered Medications Timely for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and its own policies for medication availability and administration for four of five sampled residents. Facility policies on pain management and medication reordering required a systematic approach to assess and manage pain, obtain medications in a timely manner, and begin new medications within 24 hours unless otherwise specified. The policies also required that stat medications be available through an emergency supply and that pharmaceutical services be provided accurately and safely to meet each resident’s needs. For one resident who returned from the hospital with comfort measures in place, the discharge summary noted that the resident was approved for comfort measures and had highly unstable vital signs. New orders from the hospital included sublingual atropine, lorazepam, and morphine sulfate concentrate to be given every hour as needed for secretions, anxiety, pain, or air hunger. Progress notes documented that on the day of return from the hospital, staff identified that the frequency of comfort kit medications was missing from transition orders, contacted the physician’s office, and were told no nurse or clinician manager was available, and that the pharmacy would not process the orders without the missing information. No new orders were obtained at that time, and the MAR showed that morphine was not provided until the following day. A medication aide reported that the resident was sleeping and did not appear to be in pain, and that family requested round-the-clock morphine, but the comfort kit medications were not available. The DON and Administrator acknowledged that medications were not being delivered consistently and timely for newly admitted or recently hospitalized residents and that the physician had not been notified when medications were unavailable or not dispensed per orders and policy. For another resident admitted in March, the order summary listed multiple scheduled medications for conditions including paroxysmal atrial fibrillation, hypertension, diabetes, hypothyroidism, hypomagnesemia, hypokalemia, chronic pulmonary edema, hyperlipidemia, and GERD, as well as PRN medications for pain and wheezing. The MAR for March showed that many of these medications were either not started on the admission date or not given consistently for several days, including amlodipine, apixaban, atorvastatin, carvedilol, furosemide, hydralazine, Jardiance, levothyroxine, magnesium, metformin, pantoprazole, potassium, valsartan, and an inhaled medication. Progress notes indicated that medications were either not available or the facility was still waiting on them. The resident reported no negative impact from the missed medications. The DON and Administrator again stated they were aware of delays in medication delivery and that the physician had not been notified when medications were not available or administered as ordered. A third resident admitted in April had orders for multiple medications related to VTE history, COPD, chronic pain, diabetes, bipolar disorder, hypotension, allergies, hypokalemia, restless legs syndrome, PTSD-related nightmares, essential tremor, heart failure, and major depressive disorder, as well as an inhaled medication for COPD. The April MAR showed that several medications, including apixaban, empagliflozin, lamotrigine, midodrine, montelukast, potassium, pramipexole, prazosin, primidone, and ziprasidone, were either not started on the admission date or not given consistently until one to two days later. This resident also reported no negative impact from the missed medications. The DON and Administrator reiterated their knowledge of inconsistent and untimely medication delivery and their failure to notify the physician when medications were not available or dispensed per orders and policy. A fourth resident admitted in April had orders for levothyroxine, memantine, ropinirole, and rivaroxaban for hypothyroidism, dementia, restless legs syndrome, and atrial fibrillation. The April MAR showed that levothyroxine and memantine were not provided until two days after admission, and that ropinirole and rivaroxaban were not provided consistently since admission. As with the other residents, the DON and Administrator acknowledged awareness that medications for newly admitted and recently hospitalized residents were not being delivered consistently and timely, and that they had not notified the physician when medications were unavailable or not administered according to physician orders and facility policy.
Failure to Ensure Timely Provision of Routine Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide routine medications in a timely manner to meet the needs of residents, as required by its own Medication Reordering policy and regulatory standards. Record review showed that for four of five sampled residents, routine medications were not provided as needed. The facility’s policy, dated 1/8/26, states that it will use a systemic approach to obtain routine and emergency medications, ensure acquisition is completed in a timely manner so medications are administered on time, begin new orders within 24 hours unless otherwise specified by the physician, and maintain a stat/emergency supply in an emergency box. Despite this policy, the medications ordered for residents did not arrive promptly, and newly admitted residents did not consistently receive their medications in a timely manner. In interviews, an LPN reported that the pharmacy delivers in the evening and is supposed to deliver every day, but medications ordered do not come right away. The DON and the Administrator acknowledged they were aware that medications were not being delivered consistently and timely for newly admitted residents, and they further stated that physicians were not notified when medications were not dispensed according to facility policy and procedure. They also revealed there was no process in place to follow up when needed medications were not available and that there was no local pharmacy option to obtain medications if they were not delivered the same day or the next day. These actions and inactions resulted in the failure to provide routine medications for four of the five sampled residents in a facility with a census of 66.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Failure to Ensure Timely Initiation and Continuation of Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically related to timely initiation and continuation of ordered medications. Facility policy required that medications be obtained and administered in a timely manner, with new orders to be started within 24 hours unless otherwise specified, and that nurses reorder medications when six or fewer doses remained. Despite this, the process for entering and obtaining medications from the pharmacy did not function as intended, resulting in missed doses for two residents. For one resident admitted with dental pain and infection, a dentist evaluated the resident and prescribed Augmentin to be given twice daily for 10 days, with the medication to be delivered by the pharmacy. The LPN on duty documented faxing the new antibiotic order to the pharmacy on the day of the dental visit. The following morning, when the resident complained of significant jaw pain and stated they had not received the antibiotic, the LPN confirmed there was no antibiotic listed in the resident’s electronic orders and contacted the pharmacy. The pharmacy reported the medication was at the facility, but the order had not yet been entered into the medical record, and the resident had not received the first dose the day it was ordered. For another resident with a primary diagnosis of Type 2 Diabetes Mellitus, the Medication Administration Record showed an ongoing order for Ozempic 2 mg to be injected once weekly at 7:00 AM. On the scheduled administration date, the LPN was unable to locate the Ozempic on the medication cart or in the medication storage room and confirmed that the injection due that morning could not be given. The LPN later verified that the last person who administered the weekly Ozempic dose had not reordered the medication when the previous dose was given, contrary to facility practice for once-weekly medications. The DON confirmed that the last nurse to administer the Ozempic was responsible for reordering it and that this had not occurred, resulting in a missed scheduled dose.
Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards, as evidenced by multiple observations and interviews. In the kitchen, concentrated juice containers were not labeled with open dates, and some items were kept past their recommended shelf life, contrary to facility policy and manufacturer guidelines. Additionally, syrup and juice products were found with expired or missing open dates, and the Dietary Manager confirmed these items were not safe or suitable for resident use. Staff in the kitchen, including the Dietary Manager, cooks, and dietary aides, were observed not wearing beard covers despite having facial hair, which was inconsistent with facility policy requiring hair restraints for staff with facial hair longer than a quarter inch. Clean grill cleaning tools were stored in an uncovered pan next to cleaning chemicals under a sink used for dirty dishes, violating both facility policy and the Nebraska Food Code regarding the separation of clean and dirty items and the storage of toxic materials. Further, a cook was observed handling ready-to-eat food, such as sandwich buns, with bare hands instead of wearing gloves, despite facility policy mandating glove use for direct contact with ready-to-eat foods. Water for food preparation and the steam table was dispensed from a handwashing sink, which is prohibited by the Nebraska Food Code, and staff were unaware of this requirement. These actions and inactions had the potential to affect all residents in the facility.
Failure to Document Required Recapitulation Summary at Discharge
Penalty
Summary
The facility failed to document a recapitulation, which is a complete summary of a resident's stay from admission to discharge, for a resident who initiated their own discharge. Record review showed that the discharge summary and plan of care for this resident did not include the required recapitulation summary. During an interview, the Social Service Director confirmed that the recapitulation summary was not part of the facility's discharge process and that they were unaware of the regulatory requirement for this documentation.
Failure to Include Repositioning Bars in Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan addressing the use of repositioning bars for a resident with moderate cognitive impairment. Record review showed that the facility's policy requires positioning rails to be used only when clinically indicated. The resident was observed with two bed canes on the bed, but there was no documentation in the care plan regarding their use. The resident was unaware of the reason for the bed canes and stated they were present upon admission. The Assistant Director of Nursing confirmed that the care plan did not include the use of bed canes, despite their presence and the resident's assessed needs.
Failure to Assess Wound and Obtain Wound Care Orders
Penalty
Summary
The facility failed to assess a wound and obtain appropriate wound care orders for a resident who was admitted following right ankle surgery for osteomyelitis and cellulitis. Upon admission, there was no documentation of wound care orders or clarification of the resident's weight-bearing status in the physician orders. The resident reported that their dressing had not been changed since arrival and that no one had examined the wound. Nursing staff confirmed that no dressing change or wound assessment had occurred since admission, and there was no order specifying the resident's weight-bearing status. Further interviews revealed uncertainty among staff regarding the resident's transfer status, with some believing the resident was non-weight bearing but lacking confirmation. The Rehab Services Director later produced hospital discharge paperwork indicating a non-weight bearing order, but this information had not been incorporated into the facility's orders or communicated to the care team. As a result, the resident did not receive the necessary wound care or clear guidance on mobility restrictions as required by their condition and post-surgical needs.
Failure to Implement Interventions to Prevent Resident Weight Loss
Penalty
Summary
The facility failed to implement appropriate interventions to prevent significant weight loss in two residents, despite clear evidence of nutritional risk and inadequate food and fluid intake. For one resident with dementia, records showed a 12.1% weight loss over three months, with the care plan identifying nutritional risk and requiring prompting, cueing, and set-up assistance for meals. Observations revealed that this resident was not assisted during meals, was seated too far from the table, and consumed less than 25% of their food at lunch without staff intervention. Additionally, there was no evidence that the facility contacted a provider or dietitian regarding the resident's ongoing weight loss, and meal intake documentation was incomplete for several meals. Another resident, admitted with a femur fracture, experienced a 5.9% weight loss in one month. The care plan required dietitian evaluation and set-up or clean-up assistance with eating. However, documentation showed frequent meal refusals or minimal intake, and staff did not consistently provide assistance or cueing during meals. Observations indicated that the resident was left with a meal tray out of reach and in a poor eating position for over an hour without staff intervention. The provider was not notified of the weight loss, and the dietitian did not review the resident's case during a recent consultation. Interviews with staff revealed a lack of clear guidelines for addressing poor meal intake and inconsistent understanding of which residents required assistance. Staff relied on care plans and meal slips for information but did not consistently offer or provide assistance when residents were not eating. The facility's approach to addressing poor intake and weight loss was described as case-by-case, with no evidence of timely or effective interventions for the residents identified in the report.
Failure to Assist Dependent Resident with Activities of Daily Living
Penalty
Summary
Staff failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was dependent on staff for care. The resident, admitted with diagnoses including acute kidney failure, COPD, muscle weakness, repeated falls, and anxiety, was documented as requiring set-up assistance with eating and being dependent for all other cares such as dressing, bathing, toileting, and transferring. Observations over two days showed the resident remained in bed, wearing the same soiled hospital gown, with disheveled hair and an unkempt appearance. The resident's oxygen tubing was repeatedly found draped over the abdomen and not in use, despite the concentrator being on. The bedside table was noted to be unclean at one point. The resident reported not being assisted to get up for meals and indicated that staff did not get them up, stating there was "no need to." Interviews with staff confirmed that the resident was totally dependent on staff for care and that expectations included assisting all residents with morning and evening cares, including dressing, grooming, and getting out of bed. Staff acknowledged that the resident was not actively dying and was alert enough to get out of bed, but had not been assisted to do so. The DON confirmed that the resident should not be left in a gown for staff convenience, that daily care and documentation of refusals were required, and that a more rigorous repositioning schedule should be implemented if the resident chose to remain in bed. The failure to provide these required cares constituted a deficiency in meeting the resident's needs for assistance with ADLs.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Nurse aides failed to follow the facility's Enhanced Barrier Precautions (EBP) policy while providing high-contact care to a resident with a urinary catheter. The EBP policy, dated 4/1/24, required the use of gowns, gloves, and masks during high-contact activities such as dressing, bathing, transferring, hygiene, changing linens, changing briefs or assisting with toileting, device care, and wound care. During an observation, two nurse aides transferred a resident from a wheelchair to a bed using a hoyer lift and performed perineal and catheter care. Although an EBP sign was posted on the resident's door, indicating the need for PPE, the aides only wore gloves during care and did not don the required gowns or masks. Interviews with both nurse aides confirmed their knowledge of the EBP policy and its requirements, as well as their awareness that the resident was on EBP due to the urinary catheter. Both acknowledged that they should have applied the required PPE prior to providing care. The Director of Nursing also confirmed that staff are expected to use PPE for all high-contact care activities and that the aides did not follow this expectation during the observed incident.
Failure to Address Fall and Elopement Risks
Penalty
Summary
The facility failed to identify causative factors and implement new interventions for falls for three residents and did not develop interventions for one resident at risk for elopement. Resident 1, who had vascular dementia and repeated falls, experienced multiple falls without appropriate interventions being implemented. The facility's policy did not include identifying causative factors of falls, and the care plan for Resident 1 lacked updates after falls, leading to repeated incidents and hospitalizations. Resident 4, with severe cognitive impairment and repeated falls, also experienced multiple falls without causative factors being identified or appropriate interventions being implemented. The facility's failure to identify causative factors and implement suitable interventions resulted in repeated falls for Resident 4, with some interventions being duplicates or inappropriate for the identified causes. Resident 3, with moderate cognitive impairment and repeated falls, had a fall where the root cause analysis and interventions were not completed. Additionally, Resident 5, who was at risk for elopement, was not provided with a care plan focus, goals, or interventions related to elopement, and staff were unaware of the resident's risk and the presence of a Wanderguard.
Removal Plan
- Fall assessment upon admission
- Elopement assessment upon admission
- Environmental check for Residents 3 and 4 to ensure room is free of clutter and fall hazards, with new interventions implemented as indicated
- Resident 5 Wander guarded location and functionality order to monitor was placed on the TAR and Care Plan updated to reflect elopement risk
- All staff present will be educated regarding fall prevention, root cause analysis, and elopement, and all other staff will be educated prior to working their next shift
- A Fall Risk assessment will be completed on all HC residents, and any resident identified as at risk for falls will have appropriate interventions implemented and care plan updated
- An Elopement assessment will be completed on all HC residents, and any resident identified as at risk for elopement will have appropriate interventions implemented and care plan updated
- Fall Care Plan created upon admission and reviewed quarterly and as indicated by Fall assessment score
- Residents at risk for falls will have fall care plans (baseline initially) and comprehensive care plan with interventions in place
- With each fall, a post fall assessment will be completed, and a root cause analysis will be completed to determine the cause of the fall, and appropriate interventions will be added to prevent a recurrence
- Residents at high risk for elopement as identified by the Elopement assessment score will be provided a wander guard, they will be added to the elopement binder, and an order for monitoring the device will be placed in the orders (location and functionality) every day and night shift
- Risk for elopement will be placed on the care plan with interventions
- Staff will be educated on the location of the Elopement book at the nurse's station, a reminder sign will be added to the staff bulletin board, and a list posted on the facility bulletin board in PCC
- Falls will be reviewed daily in Daily Clinical
- Administrator or Designee will utilize the fall review checklist to audit fall review, Root Cause analysis, and intervention implementation
- Falls will be reviewed weekly in Risk meeting to ensure interventions are effective and if not, new interventions will be implemented
- Administrator or Designee will audit fall review in risk
- Elopement assessment scores will be reviewed upon admission in Daily Clinical
- Administrator or Designee will audit Elopement assessment scores to ensure appropriate interventions are in place
Deficiencies in Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, as evidenced by record reviews, observations, and interviews. Resident 22's care plan did not address their pain management needs, despite having multiple diagnoses related to pain and receiving various pain medications. The care plan lacked interventions for both routine and as-needed medications, which was acknowledged by the facility leadership as an issue of outdated information. Resident 48's care plan was incomplete, missing critical information regarding assistance needs for activities of daily living such as eating, ambulation, dressing, personal hygiene, and bathing. Similarly, Resident 54's care plan did not include necessary details about assistance needs for eating, toileting, dressing, personal hygiene, or bathing, despite the resident's documented requirements for such assistance. Additional deficiencies were noted for other residents. Resident 28's care plan did not address the limited range of motion and need for positioning devices for their left hand, which was observed to be closed and without protective devices. Resident 29's care plan lacked documentation of their ostomy care, despite the presence of an ostomy bag and the resident's acknowledgment of staff care. Lastly, Resident 30's care plan did not include focus or interventions for dialysis, even though the resident had a diagnosis of End Stage Renal Disease and was receiving dialysis care.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medications were administered at the correct times for three residents, resulting in a medication error rate of 12%, which exceeds the acceptable threshold of less than 5%. Resident 10 was supposed to receive Novolog 15 minutes before meals, but it was administered after the resident had already started eating. Similarly, Resident 21 was to receive glipizide 30 minutes before meals, but it was given while the resident was eating. These errors were confirmed through interviews with the staff involved. Additionally, Resident 11 was supposed to receive Prostat at 9:00 AM, but it was administered late at 11:54 AM because the resident requested it be given at lunch. This deviation from the prescribed schedule was also confirmed by the medication aide. These instances highlight the facility's failure to adhere to medication administration schedules as per physician orders, contributing to the high medication error rate.
Infection Control Deficiencies in Laundry and Nebulizer Equipment
Penalty
Summary
The facility failed to distribute residents' laundry in a manner that prevented potential cross-contamination. Observations revealed that the Laundry Supervisor (LS) distributed clean laundry without using protective coverings. The LS left the clean linen cart uncovered and unattended while delivering laundry to resident rooms, which was against the facility's Infection Prevention and Control Program policy. This policy required that clean linen be delivered on covered carts with the covers down to prevent the spread of infection. Additionally, the facility did not ensure the cleanliness of nebulizer equipment for Resident 29, who had a diagnosis of lobar pneumonia and was at risk for respiratory issues. The nebulizer mask was observed to be unassembled, undated, and with dry whitish residue on the inside, indicating it was not cleaned as per the facility's Nebulizer Therapy Policy. This policy required the nebulizer mask to be cleaned with soap and water after each use and stored properly. The Director of Nursing confirmed the mask's condition and acknowledged that it did not meet the facility's expectations for cleanliness and storage.
Inaccurate MDS Coding for Resident Assistance Level
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) for one resident was accurately coded to reflect the current level of assistance required. Specifically, Resident 13's MDS indicated that the resident was dependent on staff for transfers, meaning the helper does all the effort, or that two or more helpers are required. However, observations and interviews revealed discrepancies in this assessment. During an observation, a nurse aide assisted Resident 13 in transferring from bed to wheelchair, with the resident actively participating by sitting up and scooting to the edge of the bed. Interviews with staff indicated that Resident 13 required limited to extensive assistance from one staff member for transfers, rather than being fully dependent. The MDS Coordinator, responsible for completing Section GG of the MDS, relied on interviews with nurse aides and information from the therapy department. The coordinator also mentioned using a new assessment tool available in the electronic medical record system. Despite these resources, the coordinator was unsure why Resident 13 was coded as dependent, suggesting that behaviors requiring two staff assistance might have influenced the coding. However, the facility's documentation for the months leading up to the survey consistently showed that Resident 13 required only limited to extensive assistance from one staff member for transfers.
Failure to Complete Annual TSH Lab Test for Resident
Penalty
Summary
The facility failed to ensure that a resident had laboratory tests completed as per the physician's order. Resident 5, who was admitted to the facility on November 14, 2023, had a physician's order for an annual Thyroid-stimulating hormone (TSH) lab test. The order was documented in the Treatment Administration Review (TAR) for June 2023, with a start date of September 15, 2022. Additionally, the Medication Administration Review (MAR) for June 2023 included an order for 75 mcg of Levothyroxine to be administered daily, indicating a need for thyroid management. However, a review of the resident's medical chart revealed that the last TSH lab results were dated September 16, 2022, and no subsequent TSH labs were found. The Director of Nursing (DON) confirmed in an interview on June 24, 2024, that the TSH lab had not been completed since September 16, 2022.
Failure to Follow Dialysis Care Protocols
Penalty
Summary
The facility failed to adhere to its policy for providing safe and appropriate dialysis care for a resident requiring such services. The policy, dated 8/1/23, mandates that the dialysis access site be checked before and after dialysis treatments, with the dialysis graft auscultated every shift for patency by listening for a bruit/thrill. Additionally, external dialysis catheters should be assessed every shift to ensure the catheter dressing is intact and not soiled. However, a review of Resident 30's records from 3/2/24 to 6/25/24 revealed no documentation of assessments for the bruit/thrill of the AV graft site, monitoring for signs or symptoms of infection, drainage, or dressing status for the resident's two dialysis access sites, or the application of ointment prior to dialysis. Interviews conducted with Resident 30 and facility staff further confirmed these deficiencies. Resident 30 reported that nursing staff did not routinely check the dialysis sites, listen for a bruit/thrill, or remove the dressing upon return to the facility. A Registered Nurse acknowledged that nursing staff are responsible for assessing dialysis sites and documenting these assessments, but the Director of Nursing confirmed the absence of such documentation in the treatment record or nurses' notes for Resident 30. This lack of adherence to the facility's dialysis care policy resulted in a failure to provide the necessary assessments and documentation for the resident's dialysis care.
Failure to Provide Clinical Rationale for Psychotropic Medication Continuance
Penalty
Summary
The facility failed to obtain a clinically valid rationale for the continuance of a psychotropic medication for one resident. The facility's policy on the use of psychotropic medication, last revised on 4/24/2023, requires residents to receive gradual dose reductions unless clinically contraindicated. A review of the Minimum Data Set (MDS) for the resident, who was cognitively intact with a Brief Interview for Mental Status score of 14, revealed an order for sertraline 100 mg. The pharmacist identified the need for a dosage reduction, but the physician responded that a reduction was clinically contraindicated without providing a valid clinical rationale. An interview with the Director of Nursing confirmed that the rationale provided was not clinical.
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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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