Adept Nursing & Rehab Of Waverly
Inspection history, citations, penalties and survey trends for this long-term care facility in Waverly, Nebraska.
- Location
- 11041 North 137th St, Waverly, Nebraska 68462
- CMS Provider Number
- 285143
- Inspections on file
- 24
- Latest survey
- June 24, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Adept Nursing & Rehab Of Waverly during CMS and state inspections, most recent first.
Two residents with diabetes did not receive their prescribed insulin before meals as ordered, with doses given late and outside of scheduled times. LPNs and the DON confirmed the insulin was not administered according to physician orders or facility policy, and documentation showed missed or delayed doses. Facility policies and manufacturer guidelines for insulin administration were not followed, resulting in significant medication errors.
Ceiling vent covers in several common areas, including the entrance foyer, conference room, nurse's station, dining room entrance, and two hallways, were observed to have a brown fuzzy substance on them. Multiple facility leaders confirmed the vents were not clean, and there was confusion over whether maintenance or housekeeping was responsible for cleaning. No work order was in place for vent cleaning, and the issue had not been addressed despite being reported.
A resident with chronic respiratory conditions was provided oxygen therapy using a concentrator that displayed a warning light indicating substandard oxygen purity. The device was set at a higher flow rate than ordered by the provider, and staff did not immediately replace the malfunctioning equipment. The resident experienced fluctuating oxygen saturation levels and respiratory distress until the concentrator was eventually exchanged for a functioning unit.
The facility did not post daily nursing staffing information on multiple occasions, as observed on several dates. Interviews with the Administrator and HR confirmed the absence of postings and the lack of a policy for daily staffing information.
The facility failed to ensure proper handwashing practices among dietary staff, with observations showing handwashing for less than the required 20 seconds. Additionally, the kitchen environment was not maintained, with a gray fuzzy substance on vents and light fixtures, and cracked ceiling plaster. These deficiencies could affect 45 residents consuming food from the kitchen.
The facility failed to maintain a safe and clean environment, with deficiencies observed in 14 resident rooms, including malfunctioning ceiling fans, damaged walls, and missing maintenance reports. Interviews confirmed the issues and revealed a lack of policy on environmental needs.
A long-term care facility was found to have a medication error rate of 35%, affecting three residents. Errors included administering insulin without prior blood glucose testing, withholding insulin without physician parameters, and improper medication administration by an orienting nurse. The Director of Nursing confirmed these as significant errors.
The facility failed to ensure proper insulin administration for two residents, leading to significant medication errors. One resident received insulin without required blood glucose checks, and another did not receive insulin as ordered due to incorrect assumptions by staff. Additionally, a resident received medications without proper verification, breaching protocol.
A facility failed to report an abuse investigation involving a resident to the State Agency within the required 5 working days. The incident occurred on 10/22/2024, but the report was not sent until 6 working days later. The Administrator confirmed the delay, which was against the facility's policy.
A facility failed to complete an admission MDS for a resident within the required time frame. The resident was admitted, and the MDS was started but not completed within the 13-day requirement. This was confirmed by interviews with the MDS Coordinator and the DON.
A resident with a history of falls and multiple medical conditions experienced another fall, but the facility failed to implement new interventions to prevent future incidents. Despite the resident's cognitive awareness and previous fall in August, the care plan was not updated after a fall in October. The facility did not conduct an incident report or investigation, and existing interventions were not revised.
A long-term care facility failed to ensure proper use of PPE and hand hygiene in Enhanced Barrier Precautions rooms, affecting multiple residents. Staff did not wear gowns during high-contact care activities, and hand hygiene was not performed according to policy. Additionally, a resident's BiPAP filter was not cleaned or replaced as required, leading to potential cross-contamination.
The facility failed to ensure daily weights were completed according to physician's orders for four residents, despite their medical conditions requiring such monitoring. Records showed multiple instances where weights were not recorded, and interviews confirmed the oversight.
The facility failed to maintain adequate nursing staff levels, resulting in residents not receiving regular baths as per their preferences. Observations and interviews confirmed that residents were not bathed regularly due to staff shortages, with the bath aide often reassigned to other duties. The facility's staffing schedule showed multiple instances of being short-staffed, contributing to the deficiency in providing adequate bathing care.
The facility failed to monitor and document wounds for two residents, leading to a deficiency. One resident with a surgical wound and another with a diabetic foot ulcer had incomplete records regarding wound characteristics, such as tissue type, drainage, and signs of infection. Interviews confirmed the lack of comprehensive documentation, violating the facility's wound management policies.
A resident with paraplegia and spina bifida developed a pressure ulcer that was inadequately monitored and documented by facility staff. Despite interventions, weekly skin evaluations lacked necessary details, and a late entry indicated delayed wound nurse assessments. An observation revealed the ulcer's condition, and the ADON confirmed incomplete monitoring.
The facility failed to follow protocol in determining the death of two residents. A resident was mistakenly pronounced dead and sent to a funeral home, where it was discovered they were still alive. Another resident's death was not properly documented, with no evidence of vital signs assessment. These incidents highlight a critical lapse in protocol adherence, resulting in immediate jeopardy.
The facility staff failed to evaluate, implement practitioner's orders, and notify emergency medical personnel for a resident with multiple diagnoses, leading to a delay in emergency care and the resident's death. The ADON and LPN did not act promptly to send the resident to the hospital despite receiving orders from the provider.
A facility failed to safely transport a resident, resulting in the resident sliding out of their wheelchair during transport. The incident was not documented, and no safety assessments were conducted for the resident's use of the transportation van.
The facility failed to ensure staff donned and doffed required PPE for COVID-19 TBP rooms, properly sanitized COVID-19 testing surfaces, and adhered to hand hygiene and wound care protocols. Observations revealed staff entering TBP rooms without PPE, improper handling of COVID-19 test cards, and inadequate wound care practices.
Failure to Administer Insulin as Ordered Results in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that insulin was administered as ordered for two residents with diabetes, resulting in significant medication errors. For one resident, the care plan identified a risk for blood sugar alterations and required insulin administration before meals. However, the resident's electronic medication record showed that NovoLOG insulin, scheduled for 6:30 AM, was not administered until 9:19 AM, after the resident had already eaten breakfast. Additionally, the Basaglar insulin, also ordered for the morning, was not documented as given. Interviews with the LPN and DON confirmed that the insulin was not administered within the ordered parameters, and the resident confirmed not receiving insulin prior to eating. For the second resident, who also had a diagnosis of diabetes and was independent in daily activities, the treatment administration record indicated an order for Insulin Aspart to be given before meals at 6:30 AM. The electronic medication record showed that the insulin was administered at 7:58 AM, which was after the scheduled time. The LPN confirmed the late administration, and the DON verified that the insulin was not given as ordered. Observations confirmed that the resident was eating breakfast in the dining room during this period. Facility policies required insulin to be administered in accordance with physician orders, coordinated with mealtimes, and in compliance with the six rights of medication administration. Manufacturer guidelines for NovoLOG specified that the medication should be taken 5-10 minutes before eating. The failure to administer insulin as ordered and within the specified timeframes for both residents constituted significant medication errors, as confirmed by staff interviews and documentation review.
Failure to Clean and Sanitize Ceiling Vent Covers in Common Areas
Penalty
Summary
The facility failed to ensure that ceiling ventilation covers in multiple common areas were cleaned and sanitized, as required by their Routine Cleaning and Disinfection policy. Observations on two consecutive days revealed that flat ceiling vents in the entrance foyer, conference room, above the nurse's station, at the entrance to the dining room, and at the ends of two halls all had a brown fuzzy substance on them. These findings were confirmed during walkthroughs with the Regional Maintenance Director, Regional Director of Operations, and the Administrator. Interviews with facility leadership revealed confusion regarding responsibility for cleaning the vents. The Regional Maintenance Director stated that maintenance was not assigned to clean the vents, considering it a housekeeping concern, and noted that the contracted cleaning company had not addressed the issue despite being notified. The Administrator, however, confirmed that maintenance was responsible for vent cleaning and acknowledged the vents should have been clean. There was no work order in the system for maintenance to complete this task at the time of the observations. The deficiency had the potential to affect all 46 residents in the facility.
Failure to Ensure Proper Functioning and Use of Oxygen Concentrator
Penalty
Summary
A resident with a history of COPD, chronic respiratory failure, pneumonia, and nicotine dependence required continuous oxygen therapy to maintain oxygen saturation above 90%, as ordered by the attending physician. The most recent physician order specified oxygen at 2 liters per minute (l/m) at all times. The resident was moderately cognitively impaired and dependent on staff for several activities of daily living. The care plan and medical records indicated the need for continuous oxygen, but did not specify the exact setting in the care plan. On multiple occasions, the resident's oxygen concentrator was observed to be malfunctioning, as indicated by a yellow warning light on the device, which, according to the manufacturer's manual, signified that the machine was producing substandard oxygen purity and required immediate attention. Despite this warning, the resident continued to receive oxygen from the malfunctioning concentrator, and the device was set at 4 l/m, which was not in accordance with the most recent physician order of 2 l/m. The resident's oxygen saturation levels fluctuated, with some readings below the target threshold, and the resident exhibited signs of respiratory distress, including rapid, shallow breathing and difficulty speaking. Staff interviews confirmed awareness of the malfunctioning equipment and the discrepancy between the ordered and delivered oxygen flow rates. The oxygen concentrator was not replaced until after the issue was brought to the attention of the Director of Nursing. The resident's condition improved after the concentrator was exchanged for a functioning device, but the deficiency centered on the failure to ensure the oxygen concentrator was operating properly and that oxygen was administered according to the provider's orders.
Failure to Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to ensure the daily posting of nursing staffing information was current and complete, which had the potential to affect all residents. Observations on December 2nd, 3rd, and 4th, 2024, revealed missing postings for the daily census sheet. Interviews with the Administrator and Human Resources confirmed the absence of these postings for the specified dates. Additionally, the Administrator admitted that the facility did not have a policy in place for daily nursing staffing posting.
Deficiencies in Handwashing and Kitchen Maintenance
Penalty
Summary
The facility failed to ensure proper handwashing practices among dietary staff, which is crucial to prevent foodborne illnesses. Observations revealed that a cook, referred to as Cook-A, consistently performed handwashing for less than the required 20 seconds before and after handling food and changing gloves. This was confirmed by both Cook-A and the facility's Registered Dietician (RD) during interviews. Additionally, a dietary aide was observed washing hands for only 14 seconds after handling dirty dishes. The facility's handwashing guidelines clearly state that handwashing should be performed for at least 20 seconds to prevent the spread of bacteria. The facility also failed to maintain a clean and safe kitchen environment. Observations noted that the kitchen ceiling ventilation covers, light fixtures, and walls were not in safe condition, with a gray fuzzy substance present around vents and on light fixtures. The ceiling plaster was bubbled and cracked, and there was a large crack in the wall above the food preparation sink. These conditions were confirmed by the RD, who acknowledged the need for repairs and cleaning. The deficiencies in handwashing practices and kitchen maintenance had the potential to affect 45 residents who consumed food from the kitchen.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple deficiencies observed during an environmental tour. The surveyors identified issues in 14 resident rooms, including malfunctioning ceiling fans covered in a gray fuzzy substance, holes in drywall, and walls with missing paint. Additionally, there was a strong smell of urine in one room, a broken plastic nightlight cover, a missing door frame side, a missing call light cord in a bathroom, and a heater/air conditioner unit with missing wall sections allowing cold air to enter the building. The presence of a flyswatter hanging on a hallway wall and multiple screws, nails, and hooks without decor in the hallways further contributed to the unkempt environment. Interviews with the facility Administrator (ADM) and Corporate Nurse (CN) confirmed the environmental concerns and revealed that the TELS system, intended to monitor maintenance issues, did not have corresponding reports for the identified deficiencies. The ADM acknowledged the need for repairs and cleaning but also disclosed that the facility lacked a policy on environmental needs. These findings indicate a systemic failure to address and document maintenance issues, compromising the residents' right to a safe and comfortable living environment.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with observations revealing a 35% error rate. This deficiency affected three residents, including Resident 21, who was administered insulin without prior blood glucose testing as required by the physician's order. The nurse responsible for administering the insulin confirmed the oversight, and the Director of Nursing acknowledged it as a significant medication error. Resident 10, who has a history of type 2 diabetes and other medical conditions, did not receive the prescribed Insulin Lispro due to a nurse's incorrect decision to withhold it based on blood glucose levels, despite the absence of such parameters in the physician's order. The nurse confirmed the error, and the Director of Nursing recognized it as a significant medication error. Resident 199 was administered medications by a nurse who did not dispense them, violating the facility's medication administration policy. The nurse was still in orientation and lacked access to the medication administration record, leading to a failure to verify the six rights of medication administration. The Director of Nursing confirmed that this was inappropriate practice.
Significant Medication Errors in Insulin Administration
Penalty
Summary
The facility failed to ensure the proper administration of insulin for two residents, leading to significant medication errors. Resident 21, who has a history of uncontrolled type 2 diabetes, COPD, and other conditions, was administered insulin without checking blood glucose levels as required by the physician's orders. On one occasion, insulin was given when the blood glucose level was below the specified threshold, and on another occasion, the nurse failed to check the blood glucose level before administering insulin, which was later found to be above the threshold. Resident 10, who also has type 2 diabetes and other medical conditions, did not receive insulin as ordered due to the nurse's incorrect assumption that insulin should be withheld if blood glucose levels were below 100 mg/dl, despite no such parameter being specified in the orders. This led to multiple instances where insulin was not administered as prescribed, including when blood glucose levels were within the range that required insulin administration according to the sliding scale order. Additionally, there was a failure in following the six rights of medication administration for another resident, Resident 199. An LPN dispensed medications and handed them to an RN, who was still orienting and did not have access to the medication administration record (MAR), to administer. The RN did not verify the medications against the MAR or check the six rights before administration, leading to a breach in medication administration protocol.
Delayed Reporting of Abuse Investigation
Penalty
Summary
The facility failed to ensure that an abuse investigation involving a resident was reported to the State Agency within the required timeframe. The facility's policy mandates that the Administrator must confirm the initial report was received by government agencies and report the investigation results within 5 working days of the incident. However, the investigation of potential staff-to-resident abuse, which occurred on 10/22/2024, was not emailed to the State Agency until 10/29/2024, which was 6 working days after the event. This delay was confirmed by the Administrator during an interview, acknowledging the failure to meet the 5 working day requirement.
Failure to Complete Admission MDS Timely
Penalty
Summary
The facility failed to complete an admission Minimum Data Set (MDS) for one of the sampled residents, identified as Resident 196, within the required time frames. Resident 196 was admitted on October 21, 2024, and the MDS was initiated on November 6, 2024, but not completed. This delay was confirmed through interviews with the Minimum Data Set Coordinator and the Director of Nursing on December 4, 2024. According to the CMS's RAI Version 3.0 Manual 2024, the MDS Completion Date must be no later than 13 days after the resident's entry date, which was not adhered to in this case.
Failure to Implement New Fall Prevention Interventions
Penalty
Summary
The facility failed to implement new interventions to prevent falls for a resident, identified as Resident 10, who had a history of falls. The resident, who was cognitively aware with a BIMS score of 13, had multiple medical diagnoses including hemiplegia, hemiparesis, congestive heart failure, chronic obstructive pulmonary disease, and peripheral vascular disease. Despite these conditions and a previous fall in August 2024, the facility did not update the resident's care plan with new interventions following another fall on October 22, 2024. The existing intervention of using a wedge under the resident in bed, which was implemented after the August fall, was not revised or supplemented with additional measures after the October incident. The facility's failure to document and investigate the fall on October 22, 2024, further contributed to the deficiency. Interviews with the Director of Nursing and the Administrator confirmed that no incident report or investigation was conducted for the fall, and no new fall prevention strategies were implemented. Observations revealed that the resident was found on the floor beside the bed, and although the resident was assessed with no new injuries, the lack of a new intervention to prevent future falls was evident. The facility's Incident and Accidents policy, which emphasizes the need for immediate interventions and corrective actions, was not adhered to in this case.
Infection Control and PPE Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper use of Personal Protective Equipment (PPE) in an Enhanced Barrier Precautions (EBP) room for a resident requiring such precautions due to an ostomy, pressure injury, and urinary catheters. During an observation, a registered nurse (RN) performed wound care without donning a gown, which is required for high-contact care activities in EBP rooms. The RN confirmed the omission of the gown during an interview, and the Director of Nursing (DON) acknowledged that the expectation for PPE use includes wearing gloves, gowns, and face shields if necessary during wound care. Additionally, the facility did not ensure proper hand hygiene was performed by staff during care for two residents. One resident with a urinary indwelling catheter and a knee wound did not receive care with the required hand hygiene standards. The RN performed hand hygiene for less than the required 20 seconds and did not wear a gown during wound care. The DON confirmed the expectations for hand washing and PPE use were not met. Another resident's catheter care was observed with similar deficiencies, where nurse aides did not perform hand hygiene adequately and used the same gloves to handle clean wipes, which was confirmed as inappropriate by the DON. The facility also failed to maintain the cleanliness of a resident's BiPAP machine, specifically the disposable filter, which was observed to be dark gray and coated with a fuzzy substance. The resident confirmed that the filter had not been cleaned or replaced, and the DON acknowledged the oversight. The facility's policy required the replacement of disposable filters twice monthly, which was not adhered to, leading to the deficiency.
Failure to Monitor Daily Weights as Ordered
Penalty
Summary
The facility failed to ensure that daily weights were completed according to physician's orders for four residents. The facility's Weight Monitoring policy required a weight monitoring schedule to be developed upon admission and, if clinically indicated, to monitor weights daily. However, the records for Residents 1, 3, 5, and 6 showed that daily weights were not consistently recorded as ordered by their physicians. Resident 1, who had diagnoses including Acute Systolic Heart Failure and Morbid Obesity, was supposed to have daily weights taken in the morning. However, only one weight was recorded during their stay. Similarly, Resident 3, with conditions such as CHF and brain cancer, was ordered to have daily weights before breakfast, but multiple dates were missing from the records. Resident 5, diagnosed with Schizoaffective Disorder and COPD, also had missing weight records despite the physician's order for daily weights before breakfast. Resident 6, who had Paranoid Schizophrenia and COPD, was also supposed to have daily weights taken before breakfast, but the records showed numerous dates where weights were not recorded. Interviews with the facility's Regional Clinical Nurse confirmed that the weights for these residents were not taken daily as required by the physician's orders. The failure to adhere to the weight monitoring schedule as per physician's orders constitutes a deficiency in the facility's care practices.
Inadequate Staffing Leads to Bathing Deficiency
Penalty
Summary
The facility failed to maintain adequate nursing staff levels to meet the bathing needs of residents, as evidenced by the lack of regular bathing for four sampled residents. The facility's policy stated that residents should receive showers as per request or according to the facility's schedule, but a review of the Bath QAPI revealed that residents were not receiving the minimum of two baths per week. Interviews with staff, including a Nursing Assistant, Medication Aide, and Registered Nurse, confirmed that the facility was short-staffed, leading to the bath aide being reassigned to other duties, resulting in incomplete bathing tasks. Resident 3, who was cognitively intact and required substantial assistance with bathing, reported receiving only one bath in the previous 30 days. Observations noted the resident's hair was greasy, indicating inadequate personal hygiene care. Similarly, Resident 4, who was dependent on staff for bathing, had not been offered a bath in the previous 30 days, and observations showed the resident's hair was greasy and unkempt. Interviews with family members confirmed the lack of sufficient staff to provide regular bathing. The facility's staffing schedule revealed multiple instances of being short-staffed across various shifts, with no scheduled bath aide on certain days. The Director of Nursing confirmed the absence of bathing logs and acknowledged that bathing preferences were not being completed. The facility's assessment identified specific staffing needs, but the actual staffing levels did not meet these requirements, contributing to the deficiency in providing adequate bathing care for residents.
Deficiency in Wound Monitoring and Documentation
Penalty
Summary
The facility failed to adequately monitor and document the condition of wounds for two residents, leading to a deficiency in care. Resident 5, who was admitted with a history of septicemia, diabetes, and osteomyelitis, had a surgical wound on the left heel that required regular monitoring and documentation as per the comprehensive care plan. However, the facility's records showed a lack of detailed documentation regarding the wound's characteristics, such as tissue type, color, drainage, signs of infection, and peri-wound skin condition, across multiple weekly evaluations and progress notes. Similarly, Resident 8, who was admitted with cellulitis, septicemia, and diabetes, had a diabetic foot ulcer and other open lesions that required careful monitoring. Despite the care plan's directives for weekly skin checks and wound monitoring, the facility failed to document essential details about the wounds, including measurements and signs of infection, in the weekly skin evaluations and progress notes. Observations during wound care revealed that measurements were not taken, and the documentation was incomplete. Interviews with the LPN and the Assistant Director of Nursing confirmed the lack of comprehensive wound documentation for both residents. The facility's policies on wound treatment management and skin assessment were not adhered to, resulting in incomplete records and a failure to meet professional standards of quality care for the residents' wounds.
Failure to Monitor and Document Pressure Ulcer Care
Penalty
Summary
The facility staff failed to adequately monitor and document the condition of a pressure ulcer for a resident, identified as Resident 10, who was admitted to the facility with significant medical conditions including paraplegia and spina bifida. The resident had functional limitations in the range of motion to both lower extremities and required total assistance with bed mobility and transfers. The resident was identified with an unstageable pressure ulcer that was not present upon admission, and the facility provided pressure-reducing devices and other interventions. Despite these interventions, the facility's documentation was lacking. The resident's weekly skin evaluations from mid-June to the end of July did not include necessary details such as wound observation, measurements, type of tissue, color of the wound bed, drainage, signs and symptoms of infection, condition of peri-wound skin, and odor. A late entry in the progress notes indicated that the resident was seen by a wound nurse on two occasions, but the documentation was not timely or comprehensive. An observation in early August revealed that the resident's sacral ulcer was not actively draining but had slough and rolled wound edges, with surrounding skin reddened. The Assistant Director of Nursing confirmed that the monitoring of the pressure ulcer was not completed for the resident, indicating a deficiency in the facility's care and documentation practices.
Failure to Properly Determine Death of Residents
Penalty
Summary
The facility failed to follow proper protocol in determining the death of two residents, leading to significant deficiencies. In the case of Resident 1, the resident was pronounced dead by RN-A without a complete assessment of vital signs, as required by the facility's protocol. The RN did not obtain a blood pressure reading and failed to have a second licensed nurse verify the absence of vital signs. Consequently, the resident was mistakenly sent to a funeral home, where it was discovered that the resident was still alive. For Resident 2, there was no documented evidence that an assessment was completed to determine the absence of vital signs at the time of death. The nursing progress notes lacked documentation of the vital signs assessment, and the Record of Death was not completed according to the facility's process. This oversight indicates a failure to adhere to the established procedures for confirming a resident's death. These incidents highlight a critical lapse in the facility's adherence to its own protocols for determining death, resulting in immediate jeopardy. The lack of proper assessment and verification of vital signs in both cases underscores the need for strict compliance with established procedures to ensure accurate determination of death and appropriate handling of residents' bodies.
Removal Plan
- Immediate Corrective Actions included the RN on duty was suspended pending an investigation to determine processes and procedures were followed to determine end of life. The RN was educated by the DON or designee and followed by suspension.
- The DON or designee began educating current staff and agency staff on the following processes: The process for determining the death of a resident with an updated guidance tool. Change of condition.
- At Morning Stand up the leadership team will discuss any new hires and agency staff, to verify that they were educated in the above procedures. This will be audited by the Administrator/DON or designee.
- The updated guidance tool will be utilized on suspected deaths.
- All new staff will be educated by DON or designee on the above processes during orientation to the building.
- Education will continue until clinical staff are educated prior to their next scheduled shift on the processes listed above. This will be completed by the DON or designee.
- All staff will be re-educated on the process listed above during the all-staff meeting by the DON or designee.
Failure to Implement Practitioner's Orders and Notify Emergency Medical Personnel
Penalty
Summary
The facility staff failed to evaluate, implement practitioner's orders, and initiate notification of emergency medical personnel for a change in condition for one resident. The resident had multiple diagnoses, including pulmonary hypertension, congested heart failure, atrial fibrillation, venous insufficiency, essential hypertension, and altered mental status. The resident's advanced directive indicated a wish to receive CPR. On the day of the incident, the resident experienced discomfort related to an indwelling catheter, which was addressed by the Assistant Director of Nursing (ADON). Shortly after, the resident became unresponsive, and the ADON was informed of the resident's condition change and instructed to send the resident to the hospital by the provider. However, the resident was not sent to the hospital promptly, and CPR was initiated only after the resident became dusky and unresponsive. Emergency Medical Services (EMS) arrived and continued CPR, but the resident expired shortly after. Interviews with the family member, facility staff, and the Advanced Practice Registered Nurse (APRN) revealed that the ADON was aware of the resident's condition change and had received orders to send the resident to the hospital. The Licensed Practical Nurse (LPN) on duty did not follow the facility policy and failed to notify the provider of the resident's condition. The ADON and LPN did not act promptly to send the resident to the hospital, resulting in a delay in emergency care. The Director of Nursing (DON) confirmed that the provider should have been called when the resident's blood pressure was critically low and that the resident should have been sent to the hospital as per the APRN's orders. The facility's policy on Medical Emergency Response was not followed, as the nurse did not stay with the resident, designate a staff member to announce a Code Blue, or call 911 immediately. The facility's abatement plan included suspending the LPN pending investigation, educating current and agency staff on the relevant policies, and ensuring all new staff receive education on these policies during orientation.
Removal Plan
- LPN-A did not follow the facility policy and was suspended pending the outcome of the facility investigation
- began educating current staff and agency staff on the policies listed below
- education will continue until all staff are educated on policies listed below
- all staff will be reeducated on the policies listed below during the all-staff meeting
- Medical Emergency Response- calling 911 immediately
- CPR Policy
- Change of condition
- all new staff will be educated on the above policies during orientation to the building
- all new agency staff will be educated on the above policies during general orientation to the building
Failure to Safely Transport Resident
Penalty
Summary
The facility failed to safely transport a resident, resulting in the resident sliding out of their wheelchair during transport. On 1/31/2024, Van Driver-E transported Resident 1 to a hospital appointment. While on the interstate, another vehicle crossed into the facility van's lane, causing Van Driver-E to slam on the brakes. Resident 1 informed the driver that they were sliding out of the wheelchair and ended up sitting on the foot pedals. Van Driver-E pulled off the interstate to check on Resident 1 and observed that the right restraint belt had pulled out of the floor mount latch. The driver then continued to the hospital, where emergency room staff called the local Fire and Rescue to assist in lifting Resident 1. The resident was evaluated in the emergency room and was found to have a knee contusion and neck strain but did not sustain injuries from sliding out of the wheelchair to the floor in the van. The facility's records did not document the van incident or any assessment of Resident 1 upon their return to the facility. Additionally, there was no documentation indicating that the facility evaluated Resident 1 for safety within the transportation van. Interviews with Resident 1's family members confirmed the incident, and the Therapy Director revealed that no safety assessments were completed for residents using the transportation van. The Regional Director also confirmed the lack of safety assessments for the transportation van for Resident 1.
Failure to Follow PPE, Sanitization, and Wound Care Protocols
Penalty
Summary
The facility failed to ensure staff donned and doffed the required PPE when entering a resident's room marked for transmission-based precautions (TBP) for COVID-19. Observations revealed that staff members, including a Licensed Practical Nurse (LPN) and Nursing Assistants (NAs), entered or leaned into TBP rooms without wearing the necessary PPE such as masks, gowns, gloves, and eye protection. Interviews with the staff indicated a lack of awareness or adherence to the TBP protocols, which was confirmed by the Director of Nursing (DON). This failure had the potential to affect all 49 residents in the facility, as the facility census was 49 at the time of the surveyor's visit. The facility also failed to ensure proper sanitization and handling of COVID-19 testing surfaces and materials. Observations showed that a Registered Nurse (RN) placed COVID-19 test cards on unsanitized surfaces and did not use barriers to prevent cross-contamination. Additionally, the RN did not wait the required 15 minutes before reading the test results, instead reading them prematurely. The DON confirmed that the RN should have sanitized the surfaces and waited the full 15 minutes before reading the test results. Furthermore, the facility did not adhere to proper hand hygiene and wound care protocols. An LPN was observed performing wound care on a resident with vascular wounds without changing gloves or performing hand hygiene between different wound sites. The LPN used the same towel to dry multiple wounds and did not change gloves between handling different body parts. The DON confirmed that the LPN should have performed hand hygiene and changed gloves between each wound site and when moving from one foot to the other.
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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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