Adept Nursing & Rehab Of Sutherland
Inspection history, citations, penalties and survey trends for this long-term care facility in Sutherland, Nebraska.
- Location
- 333 Maple Street, Sutherland, Nebraska 69165
- CMS Provider Number
- 285141
- Inspections on file
- 26
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 13 (2 serious)
Citation history
Health deficiencies cited at Adept Nursing & Rehab Of Sutherland during CMS and state inspections, most recent first.
Unsafe Hot Water Temperatures in Resident Areas: Surveyors found multiple resident bathroom sinks and a SCU dining room sink with water temperatures above the facility’s safe limit of 120 degrees Fahrenheit. Affected residents had diagnoses including dementia, Alzheimer’s disease, hemiplegia, and alcohol-related neurologic degeneration, with several showing severe or moderate cognitive impairment and varying levels of independent mobility. Staff interviews and record review showed residents could access these sinks independently at times, and maintenance acknowledged the building’s water was heated by the same water heater.
Improper Food Preparation and Diluted Pureed Meat: A cook prepared spinach bake and pureed pork inconsistently with the written recipes. The spinach bake was made with ingredient amounts that did not match the facility recipe, and the pureed pork was mixed with too little pork base before being blended and thickened for residents on a pureed diet.
Food Storage, Cross-Contamination, and Expired Food Handling Deficiencies: The facility had repeated freezer temperatures above 0°F across multiple freezers, with logs that did not identify which freezer each record belonged to. During kitchen observation, a cook handled raw hamburger patties and then continued food prep with the same gloves while touching rolls, packaging, utensils, and buns before removing gloves and performing hand hygiene. Surveyors also found expired juices and other foods that were undated, liquefied, or otherwise no longer suitable for consumption.
A resident with COPD, DM2, schizophrenia, bipolar disorder, depression, and anxiety had orders for clonazepam PRN and lamotrigine at HS, but the EMR contained no evidence of informed consent or documentation that benefits and side effects were explained for either psychotropic medication. The ADON confirmed the missing consent in the resident's record.
Missing End Date for PRN Psychotropic Medication: A resident with COPD, DM2, schizophrenia, bipolar disorder, depression, and anxiety had a PRN clonazepam order for anxiety with no end date. The pharmacist noted PRN psychotropic meds should have a stop date unless the provider documents a clinical rationale and new duration, and the ADON confirmed the MAR/record lacked an end date.
Failure to follow bowel protocol for a resident with chronic idiopathic constipation. The resident had standing orders for daily stool softener and PRN polyethylene glycol, but records showed multiple days without a BM, no evidence the PRN laxative was given, and no documented bowel assessment or interventions by nursing staff. The ADON confirmed the resident was not assessed or treated for constipation during the month reviewed.
Failure to ensure physician review of pharmacist medication recommendations: A resident with major depressive disorder, PTSD, Alzheimer’s disease, stroke, paranoid schizophrenia, and conversion disorder was receiving desvenlafaxine and quetiapine. The pharmacist issued repeated GDR recommendations during monthly MRRs, but there was no physician response for several months. The facility policy required the DON to forward irregularities and refax if no response was received, and the ADON confirmed nursing handled the faxing but could not explain next steps after a second unanswered fax.
Failure to evaluate decision-making resources for a resident with cognitive impairment. The resident had COPD, DM2, schizophrenia, bipolar disorder, depression, anxiety, and a cognitive communication deficit, with BIMS scores declining to severely impaired levels and no POA or guardian on file. A family member reported prior co-guardianship had been dissolved years earlier, and the SSD confirmed there was no documentation of discussions about the resident’s capacity, cognitive decline, or attempts to appoint a POA.
A resident with Parkinson's Disease, traumatic brain injury, and schizo-affective disorder was not properly assessed for elopement risk, leading to two incidents where the resident exited the facility without staff knowledge or assistive devices. The care plan was not updated after these events, and required incident documentation and reassessment were not completed, resulting in a deficiency.
The facility did not complete required competency assessments for eight out of nine sampled staff, including medication aides, nurse aides, RNs, and LPNs. This failure was confirmed by the DON and affected all residents in the facility.
A resident with multiple diagnoses, including Parkinson's Disease and a history of traumatic brain injury, exited the facility without staff knowledge or their assistive device on two occasions. Despite care plans requiring supervision and interventions for safety, no incident report or investigation was completed for the first elopement, and required notifications to the administrator, APS, and the state agency were not made for either event. The DON confirmed that facility policy was not followed.
A resident with cognitive impairment and a recent hip surgery experienced ongoing moderate to severe pain that was not adequately managed, as staff failed to consistently assess, document, and implement both pharmacological and non-pharmacological interventions. Despite available PRN pain medications and care plan directives, staff did not administer medications as needed, did not document non-pharmacological measures, and did not notify the physician or revise the pain management plan when interventions were ineffective. Staff interviews confirmed these lapses in pain management and communication.
A resident with cognitive impairment and a history of hip surgery experienced ongoing moderate to severe pain that was not relieved by PRN Tylenol and Tramadol. Despite repeated documentation of ineffective pain control, staff did not notify the physician as required by facility policy and state regulations. Nursing staff and the DON confirmed that physician notification should have occurred when pain was not controlled.
A resident with a history of stroke, chronic pain syndrome, opioid abuse, anxiety, and depression experienced ongoing pain that was documented in their MDS assessment, including a pain rating of 8/10 and frequent limitations in daily activities. Despite these findings and a triggered CAA for pain, the facility did not include a pain management focus in the care plan until prompted by surveyors, as confirmed by both nursing staff and the DON.
A resident with dementia and moderate cognitive impairment experienced ongoing pain and behavioral symptoms. Staff administered psychotropic medications such as Ativan and Seroquel without consistently assessing for underlying causes or attempting non-pharmacological interventions, despite facility policy requiring these steps. Documentation showed pain was often unmanaged, and staff did not notify the provider about ongoing pain before obtaining psychotropic medication orders. The DON confirmed that expected protocols were not followed, resulting in unnecessary use of psychotropic medications.
The facility failed to properly store and label refrigerated food items, as observed during a kitchen tour. Unlabeled and undated items included salad mix, shredded carrots, and various opened bottles of dressings and juices, some showing spoilage. The Dietary Manager confirmed these items should have been labeled and discarded if not compliant with the facility's food safety policy. Additionally, a half-empty bottle of Diet Coke, likely belonging to an employee, was improperly stored in the residents' food refrigerator.
A facility failed to accurately code the MDS for a resident with pressure ulcers, resulting in a deficiency. The resident, admitted with Type 2 Diabetes Mellitus and an unstageable pressure ulcer, had discrepancies in their MDS documentation. The MDS inaccurately recorded zero unstageable pressure ulcers upon admission, despite the presence of pressure ulcers noted in the weekly wound assessment. The MDS/Care Plan Coordinator confirmed the incorrect coding.
A facility failed to develop a comprehensive care plan for a resident with chronic respiratory failure, COPD, heart failure, and diabetes. The resident required varying levels of assistance for ADLs, but the care plan lacked specific interventions for these needs. The DON confirmed the care plan was not comprehensive, failing to meet regulatory standards.
A resident with COPD was not administered oxygen according to the physician's order of 1 LPM. Observations showed the oxygen concentrator set at 2 LPM. Staff interviews revealed a lack of awareness of the correct order, leading to improper respiratory care.
A facility failed to follow infection control protocols during catheter care for a resident on Enhanced Barrier Precautions. Two nurse aides did not perform proper hand hygiene or change gloves after cleaning a soiled area, and they did not wear the required PPE. Interviews confirmed these lapses, highlighting a deficiency in infection control practices.
The facility did not develop baseline care plans within 48 hours of admission for two residents, as required. One resident had conditions including depression and COPD, while another had atrial flutter and respiratory failure. The DON confirmed the delay in completing the care plans.
A resident with multiple health conditions fell during a transfer, but the facility failed to update the care plan with the fall details or new interventions. The resident's transfer method was changed post-fall, but this was not documented. The DON confirmed the care plan was not updated as per facility protocol.
A resident with dementia and constipation did not receive prescribed interventions for constipation, resulting in multiple episodes of no bowel movements over several days. The facility's MAR showed no documentation of administered laxatives, and there were no progress notes on the resident's condition. The DON confirmed the lack of a written bowel management policy and the failure of nursing staff to implement the existing process.
A facility failed to maintain a medication error rate below 5%, with a 16% error rate observed. Errors included incorrect administration of Advair Diskus, Azelastine HCL Solution, and Alendronate Sodium, as well as delayed blood glucose monitoring for a resident with asthma and allergies. These errors were confirmed by the MA and DON.
A resident was injured when a shower chair tipped over due to inadequate safety checks and lack of staff education on its use. The resident preferred using a shower chair for transport to the bath house, but the facility did not assess the safety of this practice or educate staff on potential risks, leading to an incident where the chair's wheels caught on a threshold, causing the resident to fall.
The facility failed to provide adequate grooming assistance to three residents, resulting in unkempt hair, unshaved facial hair, and long, jagged toenails. Despite care plans and facility policies, staff did not consistently meet the residents' grooming needs.
A facility failed to accurately code dialysis treatment on the MDS for a resident with End Stage Renal Disease, despite the resident receiving dialysis three times a week. The DON confirmed that the MDS assessments should have indicated the dialysis treatment, but they did not on three separate occasions.
The facility failed to update a resident's care plan to reflect the discontinuation of daily dressing changes and the removal of stitches after the removal of a right subclavian catheter. The care plan still indicated the need for daily dressing changes and the presence of stitches, despite these no longer being applicable.
The facility failed to follow physician orders to remove a dressing from a resident's AV fistula site and document the condition of the site. The resident, dependent on renal dialysis, had an undated dressing observed on multiple occasions, and the required monitoring and documentation were not consistently completed.
Facility staff failed to perform proper wound care for two residents, leading to potential cross-contamination and infection. The LPNs did not set up clean fields or establish areas for soiled supplies, and the DON confirmed a lack of staff training and accessible policies.
Unsafe Hot Water Temperatures in Resident Areas
Penalty
Summary
The facility failed to ensure that water temperatures in resident restroom sinks and a resident-accessible dining room sink remained at 120 degrees Fahrenheit or below. Surveyors observed multiple sinks in resident rooms and in the SCU dining room with water temperatures above the facility’s stated safe range, including readings of 132.1, 137.8, 136, 133, 133, 124.3, and 136.6 degrees Fahrenheit. The report states that 6 of 6 sampled residents were affected: Residents 9, 15, 26, 29, 38, and 40. Resident 15 had a primary diagnosis of hemiplegia, resided in the SCU, and had severe cognitive impairment with a BIMS score of 3/15. The resident used a wheelchair for mobility and was independent with wheeling self at least 150 feet. Resident 26 had dementia, resided in the SCU, had severe cognitive impairment with a BIMS score of 0/15, used a walker, required supervision with toileting hygiene, and was able to ambulate at least 150 feet independently. Resident 29 also had dementia, resided in the SCU, had a BIMS score of 0/15, used a walker, and required supervision for walking and toileting. Resident 9 had dementia, resided in the SCU, had a BIMS score of 0/15, did not use a mobility device, required supervision with toileting hygiene, and was able to walk at least 150 feet independently. Resident 40 had Alzheimer’s disease, resided in the SCU, had moderate cognitive impairment with a BIMS score of 10/15, used a wheelchair, and was independent with wheeling self at least 150 feet. Resident 38 had degeneration of the nervous system due to alcohol, resided in the SCU, had moderate cognitive impairment with a BIMS score of 8/15, was independent with toileting, required set up/clean up assistance with personal hygiene, and was able to ambulate at least 150 feet independently. Staff interviews indicated these residents were independently mobile or entered their bathrooms without staff assistance at times, and maintenance confirmed the facility’s water temperatures were intended to be no more than 120 degrees Fahrenheit.
Improper Food Preparation and Diluted Pureed Meat
Penalty
Summary
The facility failed to prepare foods according to the recipe, including pureed foods, for residents on a pureed diet. During kitchen observation, Cook-B prepared spinach bake by chopping 1.5 lbs of raw bacon, measuring 32 oz of sour cream, cracking and whisking 30 eggs, and using 12 lbs of spinach that had been drained, then combining these ingredients with salt, pepper, and sauteed onions before baking them. A facility recipe for spinach bake listed different ingredient amounts for 46 servings, including chopped frozen spinach, raw bacon, sour cream, and eggs, and the dietary manager confirmed the dish was not prepared as written. The facility also failed to prepare pureed pork correctly for residents prescribed a pureed diet. Cook-B and Cook-A mixed pork base with hot tap water using 1 tablespoon of pork base in 1 gallon of water, then added that mixture to the pork tenderloin and later pureed the meat with some of the pork base water. Cook-A then added an unmeasured amount of thickener and blended the mixture again before placing it in the steam table. The pork base container directions called for 1 teaspoon of base to 8 oz of boiling water or the entire container to 5 gallons of boiling water, and the dietary manager confirmed that not enough pork base had been added before the mixture was used for the pureed meat served to the three residents on a pureed diet.
Food Storage, Cross-Contamination, and Expired Food Handling Deficiencies
Penalty
Summary
The facility failed to ensure that freezers were maintained at 0 degrees Fahrenheit or below. Review of temperature records for the walk-in freezer, upright deep-freeze, and refrigerator/freezer combination showed repeated temperatures above 0 degrees across multiple months, with many documented readings ranging from 1 to 21 degrees Fahrenheit. The records did not identify which freezer each log corresponded to, and the dietary manager confirmed this was the routine practice. The dietary manager also confirmed that no temperature logs were available prior to September 2025 because monitoring began after the manager was hired, and acknowledged that the freezers should have been at 0 degrees Fahrenheit or below. On 3/2/26, observation of the upright deep-freezer showed ice creams, pies, and a cake, and the ice cream containers could be depressed or squished. The freezer portion of the refrigerator/freezer in the kitchen also contained food containers that could be squished. During an interview on 3/4/26, the dietary manager confirmed that all three freezers were not at 0 degrees Fahrenheit for most days recorded between September 2025 and the time of survey and should have been. The facility also failed to prevent potential cross contamination during food preparation. During a continuous kitchen observation, Cook-B handled raw hamburger patties from the walk-in freezer, placed them in a skillet, and continued working with the same gloves while handling rolls, touching packaging and film, using a spatula to flip the patties, and handling buns before removing gloves and performing hand hygiene. In addition, the facility failed to use or discard foods before expiration or when no longer suitable for consumption. Observations found expired tomato juice and prune juice, an undated bag of cut bananas with moisture in the bag, opened hard-boiled eggs that were partly liquefied, and an expired latte mix. The dietary manager confirmed these items were beyond expiration or no longer suitable for consumption and should have been discarded.
Missing Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consent was obtained for one resident's psychotropic medications. The resident was admitted with diagnoses including COPD, type 2 diabetes mellitus, schizophrenia, bipolar disorder, depression, and anxiety. Record review showed physician orders for clonazepam 0.5 mg by mouth every 12 hours as needed for anxiety and lamotrigine 200 mg by mouth at bedtime for bipolar disorder. Progress notes indicated the resident was taking clonazepam, but the electronic medical record contained no evidence that consent was obtained or that the benefits and side effects were explained for either clonazepam or lamotrigine. During interview, the ADON confirmed there was no consent in the resident's medical record for these psychotropic medications and stated there should have been.
Missing End Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure there was a duration for a psychotropic medication order for one resident. Resident 1 was admitted with diagnoses including COPD, type 2 diabetes mellitus, schizophrenia, bipolar disorder, depression, and anxiety. A review of the resident’s medication orders in PCC showed an order for clonazepam 0.5 mg by mouth every 12 hours as needed for anxiety, with an order date of 01/28/2026 and no end date. A review of the facility’s pharmacist recommendation to prescriber, dated 1/30/26, showed the pharmacist recommended a stop date for the clonazepam order and noted that PRN psychotropic medications should have a 14-day stop unless the provider documents a clinical rationale and a new duration for use. The provider response was marked disagree, with anxiety documented as the clinical rationale on 2/10/26. During an interview on 3/05/2026 at 9:35 AM, the ADON stated there was no end date in the resident’s medical record for the PRN psychotropic medication clonazepam and there should have been.
Failure to Follow Bowel Protocol for Resident with Chronic Constipation
Penalty
Summary
The facility failed to follow its bowel protocol for Resident 29, who had a diagnosis of chronic idiopathic constipation. The resident’s record showed standing orders for docusate sodium daily to prevent constipation and polyethylene glycol as needed for constipation. The facility’s bowel routine required prune juice after 2 days without a bowel movement, milk of magnesia after 3 days, daily bowel sound documentation starting on day 3 until a bowel movement occurred, a suppository after 4 days, and physician notification if the suppository was refused or ineffective. Record review showed Resident 29 had no bowel movements for 6 days from 2/5/2026 through 2/10/2026 and for 4 days from 2/15/2026 through 2/18/2026. The MAR showed no evidence that the as-needed polyethylene glycol was administered in February 2026, and the progress notes contained no evidence that the resident was assessed or that bowel-related interventions were implemented. During interview, the ADON confirmed the facility did not assess Resident 29 or provide the as-needed medication to treat constipation during the month of February.
Failure to Ensure Physician Review of Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure the attending physician reviewed and acted upon, or provided a rationale for not acting upon, pharmacist recommendations made during monthly medication regimen reviews for one resident. Resident 33 was admitted with diagnoses including major depressive disorder, post-traumatic stress disorder, Alzheimer’s disease with late onset, cerebral infarction, paranoid schizophrenia, and conversion disorder with seizures or convulsions. The resident’s medication orders included desvenlafaxine ER 50 mg daily for major depressive disorder and quetiapine fumarate 12.5 mg at bedtime for paranoid schizophrenia. Record review showed medication regimen review recommendations from the pharmacist on 12/24/2024, 1/27/2025, and 2/25/2025 for a gradual dose reduction, with no physician response until 3/29/2025. The facility’s Medication Regimen Review Policy stated that the consulting pharmacist reviews each resident’s medication regimen monthly, recommendations are sent in writing to the DON, and the DON is responsible for forwarding them to the prescribing practitioner and the Medical Director; if no response is received in 14 days, the facility is to refax the remaining letters after two attempts and may request Medical Director review. During interview, the ADON confirmed nursing was responsible for faxing pharmacy recommendations to the prescribing physician and stated that if there was no response to the first fax, staff would fax the recommendation a second time, but was unable to provide next steps if the physician still did not respond.
Failure to Evaluate Decision-Making Resources for Cognitively Impaired Resident
Penalty
Summary
The facility failed to evaluate resources related to decision-making for one resident with cognitive impairment. The resident had diagnoses including COPD, Type 2 diabetes mellitus, schizophrenia, bipolar disorder, depression, anxiety, and cognitive communication deficit. The record showed the resident was documented as making decisions on their own behalf and had no POA or guardian on file, while BIMS scores fluctuated from 13-15 down to 0 out of 15 over multiple assessments, including several scores below 11 and two scores of 0. A family member told surveyors the resident had previously had two co-guardians for 14 years because of severe mental illness, but the guardianship was legally dissolved in 2017 or 2018 and the family member had not been a decision-maker since then. The resident’s chart also showed a nursing note stating there was no current POA on file, and the care plan included interventions related to impaired cognition and determining whether the resident could make their own medical decisions. The Social Services Designee confirmed the facility had tried to get the resident to appoint a POA, but there was no documentation of that communication, and there was no documentation discussing the resident’s decision-making capacity, decreased BIMS scores, or cognitive decline with medical providers.
Failure to Assess and Prevent Resident Elopement
Penalty
Summary
A deficiency occurred when the facility failed to accurately assess a resident for elopement risk, did not provide appropriate interventions to prevent elopement, and did not implement new interventions after repeated incidents. The resident in question had a history of Parkinson's Disease, traumatic brain injury, and schizo-affective disorder, and was admitted with a care plan that allowed for independent outdoor activity. Despite documentation indicating the resident required supervision or assistance with mobility, the admission assessment incorrectly stated the resident was not at risk for elopement, as it was believed the resident could not exit the facility independently. The resident was able to leave the facility without staff knowledge or the use of assistive devices on two separate occasions. On one occasion, the resident exited the building without signing out or notifying staff, and on another, the resident was found by police sitting in the road outside the facility. After the first incident, the resident was not reassessed for elopement risk, and no incident or accident report was completed as required by facility policy. The care plan was not updated to reflect the resident's actual risk or to implement new interventions after these events. Interviews with the DON confirmed that the initial assessment was inaccurate and that the resident's known history of independent exits from previous living situations was not properly considered. The facility's failure to reassess the resident after the first elopement, to complete required documentation, and to update the care plan or implement further interventions directly contributed to the repeated elopement incidents.
Failure to Complete Staff Competency Assessments
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had completed required competency assessments to demonstrate proficiency in the care and services they provide to residents. Record reviews revealed that eight out of nine sampled staff members, including medication aides, nurse aides, registered nurses, and licensed practical nurses, did not have documented competencies on file. These staff members had been hired at various times, but none had completed competency evaluations either upon hire or annually as required. Interviews with staff and the Director of Nursing confirmed that the necessary competency assessments had not been conducted for these individuals. The Director of Nursing acknowledged that staff should have completed competencies both at the time of hire and on an annual basis, but this process was not followed. The lack of completed competencies had the potential to affect all residents in the facility, which had a census of 41 at the time of the survey.
Failure to Investigate and Report Resident Elopement Incidents
Penalty
Summary
The facility failed to investigate and report possible incidents of abuse or neglect for one resident, as required by both facility policy and regulatory standards. Specifically, a resident with diagnoses including Parkinson's Disease, a history of traumatic brain injury, and schizo-affective disorder exited the facility without staff knowledge or their assistive device on two separate occasions. On one occasion, the resident was found by police sitting in the road outside the facility without having signed out or notified staff. Documentation showed that the resident was cognitively intact and had expressed a strong preference for going outside, but care plans required supervision and specific interventions for mobility and safety. Despite these incidents meeting the facility's definition of elopement, no incident report or investigation was completed for the first occurrence, and the required notifications to the administrator, Adult Protective Services, and the state regulatory agency were not made for either event. The Director of Nursing confirmed that these incidents constituted elopement and acknowledged that facility policy was not followed, as neither an immediate investigation nor timely reporting occurred as mandated.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with a history of cognitive impairment, dementia, a recent hip fracture and surgery, and other comorbidities. Despite documented orders and a care plan that included both pharmacological and non-pharmacological interventions for pain, staff did not consistently assess, implement, monitor, or revise pain management strategies as required. The resident frequently exhibited moderate to severe pain, both verbally and through non-verbal indicators such as restlessness, facial grimacing, and behavioral outbursts, yet there was repeated lack of documentation and evidence that appropriate interventions were provided. Records showed that the resident often had available PRN pain medications, such as Tylenol and Tramadol, which were not administered despite ongoing reports of pain. Non-pharmacological interventions, although listed in the care plan, were rarely documented as being attempted or implemented. When pain medications were administered and found to be ineffective, there was no evidence that staff consistently followed up with additional interventions or notified the physician in a timely manner. The resident's pain management regimen was not reassessed or adjusted despite ongoing reports of ineffective pain control and persistent pain behaviors. Interviews with staff, including nursing assistants, RNs, and the DON, confirmed that pain was not adequately managed and that staff did not always follow the facility's pain management policy. There were also missed opportunities to communicate pain management concerns to the physician or rounding providers, and staff did not consistently assess for pain when the resident exhibited behaviors that could be related to pain. The deficiency was further substantiated by the DON's confirmation of multiple instances where interventions were not implemented or documented, and where follow-up with the physician did not occur as expected.
Failure to Notify Physician of Ineffective Pain Management
Penalty
Summary
The facility failed to notify a resident's physician of ongoing, inadequately controlled pain, as required by both facility policy and state regulations. The resident in question had a history of cognitive communication deficit, dementia, transient ischemic attack, and a hip joint replacement, and was admitted with orders for PRN Tylenol and Tramadol for pain management. Despite repeated documentation in the medical record of moderate to severe pain persisting after administration of these medications, there was no evidence that the physician was notified of the ineffective pain control during multiple instances over a period of several weeks. Facility policies required staff to inform the physician when pain was not adequately controlled and to consider revising the pain regimen. The resident's care plan also included interventions to evaluate the effectiveness of pain treatment and to report pain not at or below the resident's acceptable level to the physician. Progress notes repeatedly documented moderate to severe pain after PRN medications were given, with specific pain scores ranging from 5/10 to 10/10, and noted that both PRN Tylenol and Tramadol were ineffective at times. Despite these findings, there was no documentation that the physician was notified of the ongoing pain or that pain management was discussed, except for one instance where the physician was notified of behavior but not specifically about pain management. Interviews with nursing staff and the DON confirmed that the physician should have been notified when pain was not controlled by PRN medications, and that this notification did not occur as required. The deficiency was identified through record review and staff interviews, which established that the facility did not follow its own policies or regulatory requirements regarding physician notification for ineffective pain management.
Failure to Develop and Implement Comprehensive Pain Management Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing pain management for a resident with a history of stroke, chronic pain syndrome, opioid abuse, anxiety, and depression. Upon admission, the resident's Minimum Data Set (MDS) assessment indicated the presence of ongoing pain, with the resident rating their pain as 8 out of 10. The assessment also revealed that pain occasionally interfered with sleep, rarely affected therapy, and frequently limited daily activities. The Care Assessment Area (CAA) for pain was triggered, indicating the need for a care plan focus on pain management. Despite these findings, a review of the resident's care plan showed that no focus area for pain had been included as of several weeks after admission. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed that the care plan did not address pain management until the day of the surveyor's inquiry, despite the resident's ongoing pain and relevant diagnoses. This omission was not in accordance with the facility's policy, which requires the development of a person-centered care plan with measurable objectives and timeframes for all identified needs.
Failure to Assess Underlying Causes Before Psychotropic Medication Use
Penalty
Summary
The facility failed to assess and evaluate the underlying causes of behavioral symptoms in a resident prior to initiating or continuing psychotropic medications, as required by both facility policy and regulatory standards. The resident in question had a history of cognitive impairment, dementia, and pain, and was admitted with multiple diagnoses including a cognitive communication deficit and a history of hip replacement. Despite documented moderate pain and behavioral symptoms, there was no evidence that staff consistently attempted non-pharmacological interventions or thoroughly assessed for underlying causes, such as pain, before administering psychotropic medications. Record reviews revealed that the resident experienced ongoing pain, with frequent reports of high pain scores and observable nonverbal indicators such as restlessness, facial expressions, and protective postures. Staff administered PRN pain medications, but documentation showed these were often ineffective, and there was a lack of follow-up or additional interventions to address the resident's pain. Behavioral incidents, including physical and verbal outbursts, were managed with psychotropic medications like Ativan and Seroquel, but there was no evidence that staff attempted non-pharmacological interventions or notified the provider about the resident's ongoing pain prior to obtaining these medication orders. Interviews with staff and the DON confirmed that the resident's behaviors could have been related to uncontrolled pain and that expected protocols, such as assessment during behavioral episodes, implementation of non-pharmacological interventions, and physician notification, were not followed. The facility's failure to identify and address the underlying causes of the resident's behaviors, particularly pain, led to the unnecessary use of psychotropic medications without adequate attempts at alternative interventions.
Improper Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to proper food storage and labeling practices, as observed during a kitchen tour. Several refrigerated items were found unlabeled and undated, including bulk bags of salad mix, shredded carrots, and various opened bottles of salad dressings and juices. Some of these items, such as the salad mix, showed signs of spoilage, with lettuce turning brown and carrots becoming mushy with liquid in the bag. Additionally, a squirt bottle of ranch dressing was found with an uncovered spout, and a partially used bottle of soy sauce was opened and not dated. These observations indicate a failure to comply with the 2017 Nebraska Food Code, which requires food held for more than 24 hours to be clearly marked with a consumption or discard date. The Dietary Manager confirmed during an interview that the items should have been labeled with an open date and discarded if not labeled as required. The facility's policy on food safety requirements mandates that refrigerated items be labeled, dated, and covered in tight containers, which was not followed in this instance. Furthermore, the interview revealed that the salad dressings should be discarded within 30-60 days of being opened, and the presence of a half-empty bottle of Diet Coke, likely belonging to an employee, was improperly stored in the residents' food refrigerator. These lapses in food safety practices had the potential to affect all 39 residents who consumed food from the facility's kitchen.
Incorrect MDS Coding for Pressure Ulcers
Penalty
Summary
The facility failed to correctly code the Minimum Data Set (MDS) for a resident's pressure ulcers, leading to a deficiency. Resident 24, who was admitted with diagnoses including Type 2 Diabetes Mellitus with Hyperglycemia and an unstageable pressure ulcer on the left heel, had discrepancies in their MDS documentation. The quarterly MDS inaccurately recorded that the resident had zero unstageable pressure ulcers upon admission, despite the presence of pressure ulcers on the right buttock, left buttock, and left heel as noted in the weekly wound assessment. An interview with the MDS/Care Plan Coordinator confirmed that the MDS section M was incorrectly marked, failing to accurately reflect the resident's condition.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as Resident 97, who was admitted with multiple diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease, heart failure, and diabetes. The resident's admission Minimum Data Set (MDS) indicated varying levels of assistance required for activities of daily living (ADLs), such as substantial assistance for toileting, bathing, and personal hygiene, total assistance for lower body dressing, and moderate assistance for transfers. Despite these needs, the care plan for Resident 97 lacked specific interventions to address these ADLs, with only a general intervention for therapy to screen, evaluate, and treat as needed. The deficiency was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the care plan was not comprehensive and did not include specific interventions detailing the amount of assistance required for each ADL. This oversight in the care planning process resulted in a failure to adequately document and plan for the resident's needs, as required by the facility's policy and regulatory standards.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to administer oxygen according to the prescriber's orders for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD). The resident was admitted with a care plan that included an intervention for oxygen therapy as ordered by the physician. The physician's order, dated 12/17/2024, specified continuous oxygen at 1 Liter Per Minute (LPM) via nasal cannula. However, observations on multiple occasions revealed that the resident's portable oxygen concentrator was set to 2 LPM, contrary to the prescribed order. Interviews with facility staff indicated a lack of awareness and understanding of the resident's oxygen order. A Medication Aide was unsure of the order and needed to consult with a Registered Nurse (RN). The RN initially believed the order was for 2 LPM but confirmed after checking that it was indeed for 1 LPM. This discrepancy in oxygen administration was identified during observations and interviews, highlighting a failure in following the physician's orders for the resident's respiratory care.
Inadequate Infection Control During Catheter Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols during catheter care for a resident. Observations revealed that two nurse aides, NA-C and NA-D, did not perform hand hygiene or change gloves after cleansing a visibly soiled area before proceeding with perineal and catheter care. The resident was on Enhanced Barrier Precautions due to their catheter, which required the use of personal protective equipment (PPE) such as gowns and masks during high-contact care activities. However, the nurse aides did not wear the required PPE while providing care. Interviews with the nurse aides confirmed the lapses in protocol. NA-C acknowledged that they did not perform hand hygiene for the recommended 20 seconds or change gloves after cleaning a soiled area, and they did not track their scrub time. NA-D also confirmed the failure to wear the required gown and mask and the inadequate hand hygiene practices. The facility's policy on Enhanced Barrier Precautions was not followed, leading to a deficiency in infection control practices.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop baseline care plans within 48 hours of admission for two residents, as required by their policy. Resident 9 was admitted with diagnoses including depression, repeated falls, difficulty swallowing, and Chronic Obstructive Pulmonary Disease. However, the baseline care plan for this resident was signed more than 48 hours after admission. Similarly, Resident 96, who was admitted with conditions such as atrial flutter, acute and chronic respiratory failure, difficulty in walking, depression, high blood pressure, and a history of falls, also had a baseline care plan signed beyond the 48-hour requirement. The Director of Nursing confirmed that the baseline care plans for both residents were not completed within the stipulated timeframe.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the comprehensive care plan for a resident following a fall, as required by regulatory standards. The resident, who has a history of amyotrophic lateral sclerosis, unspecified osteoarthritis, hereditary and idiopathic neuropathy, muscle wasting and atrophy, and generalized muscle weakness, experienced a fall during a transfer from the toilet to a wheelchair. Despite the fall occurring, the care plan was not updated to reflect the incident or to include new interventions to prevent future falls. The resident reported feeling their legs giving out before the fall and expressed concerns to staff, which were not heeded. After the fall, the resident's method of transfer was changed from using a walker and wheelchair to a Hoyer lift, but this change was not documented in the care plan. The Director of Nursing confirmed that the care plan was not updated with the fall details or new interventions, which is a deviation from the facility's standard process following a fall.
Failure to Administer Constipation Interventions
Penalty
Summary
The facility failed to provide necessary interventions for constipation for a resident diagnosed with dementia and constipation. The resident was admitted on 8/3/2023 and had severe cognitive impairment, requiring moderate assistance with toileting. The care plan included interventions such as administering medication as ordered, monitoring response to medication, and reporting irregularities in bowel patterns to the physician. Despite these interventions, the resident experienced multiple episodes of constipation, with no bowel movements recorded for several days in October, November, and December 2024. The Medication Administration Record (MAR) showed no documentation of the administration of prescribed laxatives, Milk of Magnesia and Bisacodyl, during these periods of constipation. Additionally, there were no progress notes regarding the resident's constipation or any interventions taken. Interviews with the Director of Nursing (DON) revealed that the facility lacked a written bowel management policy, and the existing process was not being utilized effectively by the nursing staff. The DON confirmed the absence of interventions and progress notes for the resident's constipation, which was expected to be completed.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by a 16% error rate observed during a survey. This was based on 26 medication opportunities, where 4 errors were identified, affecting one resident out of a sample of three. The errors included improper administration of medications and failure to follow prescribed protocols. Specifically, the medication aide (MA-A) did not ensure that the resident rinsed their mouth after using Advair Diskus, administered an incorrect dosage of Azelastine HCL Solution by giving two sprays per nostril instead of one, and did not administer Alendronate Sodium 30 minutes before breakfast as required. Additionally, the blood glucose monitoring was not conducted before meals as prescribed. The resident involved had a medical history that included asthma, allergies, and a need for blood glucose monitoring. The errors in medication administration were confirmed through interviews with the MA-A and the Director of Nursing (DON), who acknowledged the discrepancies in the administration of the medications and the failure to adhere to the prescribed timing and dosage instructions. The DON confirmed that the nasal spray was administered incorrectly, the mouth rinse was omitted, the timing for Alendronate was not followed, and the blood sugar checks were delayed, all contributing to the medication error rate exceeding the acceptable threshold.
Failure to Ensure Safety in Bath Chair Use
Penalty
Summary
The facility failed to implement necessary safety checks, education, or hazard assessments for the use of a bath chair, affecting Resident 4. Interviews with staff revealed that Resident 4 preferred to be transported in a shower chair from their room to the bath house, contrary to the usual practice of using a wheelchair. Despite feeling safety concerns, Bath Aide C continued to use the shower chair without reporting these concerns to maintenance or management. On 09/20/2024, an incident occurred where Resident 4 fell forward from the shower chair when its wheels caught on the floor threshold, resulting in the resident being taken to the hospital. The care plan for Resident 4 did not include any safety goals or interventions for handling the resident in the shower chair. Interviews with the Facility Administrator and the Director of Nursing confirmed that no assessments were conducted to ensure the resident's safety when using the bath/shower chair, and no education on the associated safety risks was provided to the staff. The facility's protocol for resident bathing did not address the specific safety concerns related to the use of shower chairs, contributing to the incident.
Failure to Provide Adequate Grooming Assistance
Penalty
Summary
The facility failed to provide adequate assistance with grooming to three residents, leading to deficiencies in personal hygiene. Resident 1, who had moderate cognitive impairment and required extensive assistance with personal hygiene, was observed multiple times with unkempt hair and food debris on their clothing. Despite the care plan indicating the need for substantial assistance, the resident's grooming needs were not met consistently. Resident 12, who required setup or clean-up assistance for personal hygiene, was observed with long grey facial hair on multiple occasions. Although the resident preferred to have their facial hair shaved off and received baths twice a week, the staff failed to shave the resident's facial hair as per the facility's grooming policy. Interviews with the resident and staff confirmed that the grooming assistance was not provided as required. Resident 15, who had cognitive deficits and was dependent on staff for personal hygiene, was observed with long, thick, yellow, and jagged toenails, with one toenail split down the middle. Despite the facility's policy to offer nail trimming during baths, the resident's toenails were not trimmed. Interviews with the DON and an LPN confirmed the condition of the resident's toenails and the lack of proper grooming care. The resident expressed their inability to trim their own toenails and the desire for assistance, which was not provided by the staff.
Failure to Accurately Code Dialysis on MDS
Penalty
Summary
The facility failed to accurately code dialysis treatment on the Minimum Data Set (MDS) for a resident diagnosed with End Stage Renal Disease and Dependence on Renal Dialysis. The resident was admitted to the facility and received dialysis treatment on Mondays, Wednesdays, and Fridays at a dialysis center. Despite this, the MDS assessments completed on three separate occasions did not indicate that the resident was receiving dialysis treatment in Section O, as required by federal regulations and the facility's policy on MDS 3.0 Completion. The Director of Nursing (DON) confirmed during an interview that the resident had been receiving dialysis treatment prior to their admission and that all MDS assessments since admission should have reflected this treatment. However, the MDS assessments dated 12/1/23, 1/16/24, and 1/23/24 failed to indicate dialysis treatment in Section O. This oversight was identified through a record review and interview process, highlighting a lapse in the facility's adherence to accurate and comprehensive resident assessments.
Failure to Revise Care Plan
Penalty
Summary
The facility failed to revise the care plan for a resident with End Stage Renal Disease (ESRD) and dependence on renal dialysis. The resident was admitted with a right subclavian catheter, which was removed on 12/20/2023, and initially had an order for daily dressing changes to the catheter removal site. However, this order was discontinued on 2/1/2024. Despite the discontinuation, the resident's care plan still indicated the need for daily dressing changes and the presence of stitches, which were no longer applicable. An interview with the Director of Nursing (DON) confirmed that the resident no longer had stitches or an order for daily dressing changes, yet the care plan had not been updated to reflect these changes. This discrepancy was identified during a record review on 2/14/2024. The facility's policy mandates that the comprehensive care plan be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment, which was not adhered to in this case.
Failure to Follow Physician Orders and Document AV Fistula Care
Penalty
Summary
The facility failed to adhere to the physician's order to remove the dressing from a resident's arteriovenous (AV) fistula site four hours after dialysis treatment and to document the condition of the site. The resident, who was admitted with End Stage Renal Disease and dependence on renal dialysis, had an undated dressing on their AV fistula site, which was observed on multiple occasions. The Treatment Administration Record (TAR) for January and February 2024 showed multiple instances where the required monitoring and documentation of the AV fistula site were not completed as ordered. Additionally, the facility's policy on Hemodialysis Access Care was not followed, as there was no documentation of the condition of the dressing or observations post-dialysis in the resident's medical record. During an interview, the Director of Nursing (DON) confirmed that the dressing was likely applied the day before and that there was no date on the dressing. The facility's failure to remove the dressing and document the condition of the AV fistula site as required affected the resident's care. The resident's care plan also indicated the need for regular assessment of the AV shunt for bruit and thrill, which was not consistently documented in the TAR. This lack of adherence to physician orders and facility policy led to the deficiency noted in the report.
Inadequate Wound Care Practices
Penalty
Summary
The facility staff failed to perform wound care in a manner that prevents potential cross-contamination and infection. For Resident 2, who had a stage III pressure ulcer on the sacral region, the LPN did not set up a clean field for wound care supplies and placed dressing supplies on the resident's bed. The LPN also used soiled gauze and gloves to open a wound dressing package and did not sanitize the top of a storage bin that had visible moist spots from the old dressing. The LPN confirmed they did not follow the facility's Clean Dressing Change policy and did not establish an area for soiled products to be placed. For Resident 9, who required daily suprapubic catheter care, the LPN also failed to set up a clean field and placed wound treatment supplies on the resident's bed. The LPN did not use a trashcan or trash bag for soiled supplies and placed them on the bed. The LPN confirmed they did not follow the facility's Clean Dressing Change policy and was not aware of the facility's policy and procedure for wound care. The LPN mentioned that the resident's bed table was full of items, and they did the best they could with the available resources. The Director of Nursing (DON) revealed that they had not completed any competencies or skills checklists on staff caring for residents with wounds. Additionally, there was no accessible binder or manual with policies and procedures at the nurse's station, and the policies could not be accessed electronically. The DON had to contact the company that took over the facility to request policies and procedures, indicating inconsistency in policy availability and staff training.
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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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