Crowell Memorial Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Blair, Nebraska.
- Location
- 245 South 22nd Street, Blair, Nebraska 68008
- CMS Provider Number
- 285210
- Inspections on file
- 28
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Crowell Memorial Home during CMS and state inspections, most recent first.
Surveyors found that staff did not follow care-planned fall prevention and transfer interventions for three residents at high risk for falls. One resident, fully dependent for transfers and previously injured in a fall, was care-planned for Hoyer lift transfers only but was instead manually transferred from the toilet to a w/c without a gait belt, resulting in a fall and pelvic fracture. Another resident, totally dependent for transfers and toileting with a high fall risk score, was observed in bed without the required fall mat in place and without the fall alarm moved from the w/c to the bed. A third cognitively intact resident, care-planned to be transferred to the bathroom by w/c with a gait belt and to have blue Dycem under the w/c gel cushion, was instead ambulated to the bathroom with a walker, and the Dycem was missing; the NA reported not knowing the resident was to be taken by w/c, and the DON confirmed ambulation should not have occurred.
The facility failed to report a significant injury to the state agency as required by its abuse, neglect, and exploitation policy and state regulations. A resident with significant cognitive and functional impairments, requiring extensive to total assistance with transfers and ADLs, fell while being assisted from the toilet to a wheelchair and was sent to the ED. The resident returned to the ED the next day with hip pain and clinical signs of leg rotation and shortening, and was diagnosed with a closed pelvic fracture. Despite policy requirements for timely reporting of serious injuries, the DON and administrator acknowledged that the incident and resulting pelvic fracture were not reported to the state agency because they believed it was not a new injury.
Staff did not implement required fall prevention interventions for a resident with multiple risk factors, including not using a pressure detection alarm as outlined in the care plan. The resident, who had impaired cognition and needed assistance with daily activities, was found on the floor without the alarm in place, despite staff acknowledging it should have been used.
A resident with Parkinson's disease and constipation was not consistently monitored for bowel movements, and required interventions such as prune juice and Miralax were not administered as per protocol. Staff interviews confirmed inconsistent documentation and communication, resulting in the resident experiencing multiple days without a recorded bowel movement and eventual hospital admission.
A resident prescribed risperidone for bipolar disorder did not receive a Gradual Dose Reduction (GDR) as recommended by pharmacy review. The attending physician disagreed with the recommendation but failed to provide a documented rationale, and the facility did not ensure this explanation was obtained, contrary to policy.
Two residents with limited range of motion and mobility impairments did not receive restorative care services as outlined in their care plans, with documentation showing that prescribed bed mobility and PROM exercises were only provided on two days during the month. The DON confirmed the lack of consistent restorative care and the absence of a facility policy for restorative services.
A resident with respiratory conditions had undated oxygen tubing, and staff confirmed there was no system to track respiratory supply changes. For another resident with a gastrostomy tube, a hospice aide provided high-contact care without donning a gown as required by Enhanced Barrier Precautions, despite clear signage. Additionally, a medication aide administered eye drops to a resident without performing hand hygiene before gloving, in violation of facility policy.
A resident with intact cognition and a history of psychiatric conditions reported that a nurse aide requested money and made a threatening remark when refused, leading to the resident feeling fearful. The DON was informed of the incident but did not report it to APS or DHHS as required, citing the belief that it was not abuse and that the resident did not want to file a grievance.
A resident with intact cognition and multiple psychiatric and medical diagnoses reported that a nurse aide requested money and made a comment implying withdrawal of care, leading the resident to feel fearful. Although the DON was informed and spoke with both parties, a thorough written investigation was not completed as required by facility policy.
Staff failed to individualize and document the use of physical restraints for three residents with severe cognitive impairment and mobility issues, placing them in Merry Walkers they could not remove themselves from, without proper assessment, documentation, or care planning as required by facility policy. Interviews confirmed the lack of risk/benefit analysis, ongoing re-evaluation, and appropriate coding of the devices as restraints.
Two residents with severe cognitive impairment were regularly placed in a Merry Walker device, which they could not remove themselves from without assistance. Staff interviews and documentation confirmed that the use of the device was not coded as a restraint on the MDS or consistently addressed in care plans, despite nursing staff acknowledging it should have been documented as such.
The facility did not provide adequate supervision or maintain functional elopement prevention systems for residents with severe cognitive impairment and wandering behaviors. A resident was able to access a stairwell and fall after staff failed to respond to activated alarms, and multiple Wanderguard units were found to be nonfunctional, with staff not responding to substitute doorbell alarms. Other residents at risk for elopement were not consistently monitored or had incomplete care plan documentation.
The facility did not ensure dietary staff wore proper beard restraints that fully enclosed all facial hair during meal service observations. The Dietary Manager and a Dietary Aide were observed with beard restraints that did not fully enclose all facial hair, posing potential contamination risks. Additionally, issues were found in kitchen and dining area sanitation and storage practices, including unlabeled and undated food items, lack of covers for hot dish storage units, presence of food particles and dirt buildup, and equipment maintenance concerns such as nicks on the electric slicer blade and dried-on food spatters on the commercial mixer guard.
The facility failed to maintain the cleanliness and condition of walls, floors, fixtures, ceilings, and baseboards in 24 resident rooms and the 2nd floor north hallway nurses station. Observations revealed scrapes on walls, broken toilet tanks, cracked caulking, water stains, dirt buildup, and other issues. The Maintenance Director confirmed the need for cleaning and repairs, noting that these concerns had not been previously identified.
The facility failed to maintain a medication error rate of less than 5%, resulting in a 7.69% error rate. A medication assistant crushed and administered medications to a resident despite 'do not crush' instructions, leading to the error.
A resident with an indwelling catheter had their catheter care mishandled by a nursing assistant, who placed wipes in a contaminated sink basin and on a handrail before use. Additionally, the resident's catheter bag was found uncovered and touching a floor mat, contrary to facility policy.
The facility failed to conduct APS and CPS registry checks for a newly hired Nursing Assistant (NA G). Despite the facility's policy requiring these checks before employment, NA G's file lacked the necessary documentation. This was confirmed through record review and interviews with the Administrator and Administrative Assistant.
Failure to Follow Care-Planned Fall Prevention and Transfer Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions and transfer methods for multiple residents identified as being at risk for falls. The facility’s fall prevention policy requires standardized fall risk assessments, categorization into risk levels, and implementation of individualized interventions based on high- or low/moderate-risk protocols, with ongoing monitoring and care plan revision. Despite this, surveyors found that for several residents, the interventions and transfer methods specified in their comprehensive care plans were not followed in practice. For one resident with significant ADL dependence, incontinence, and a history of a fall with major injury and pelvic fracture, the comprehensive care plan specified that all transfers were to be done with a Hoyer lift. Progress notes and incident documentation showed that this resident was instead transferred from the toilet to a wheelchair by a nursing assistant without a gait belt, contrary to the care plan. The resident fell during this transfer, complained of pain, and was later found to have a closed fracture of the pelvis. The DON confirmed that the resident had not been transferred properly and that the pelvic fracture resulted from this event. Another resident, who required total assistance with transfers, toileting, hygiene, dressing, bed mobility, and bathing, had a care plan identifying a high fall risk with a fall risk score of 15 and multiple fall prevention approaches, including use of a fall mat next to the bed and a fall alarm when in bed. During observation, this resident was found lying in bed with the fall mat leaning against the wall at the foot of the bed and no fall alarm in place. The nursing assistant confirmed that the fall mat was not next to the bed and that the fall alarm had not been moved from the wheelchair to the bed as required. A third resident, cognitively intact but requiring assistance with transfers and occasionally incontinent, had a fall risk score of 13 and a care plan specifying transfer to the bathroom by wheelchair with a gait belt and use of blue Dycem between the wheelchair seat and gel cushion to prevent slipping. Observations showed the resident being ambulated to the bathroom with a walker and gait belt instead of being taken by wheelchair, and the blue Dycem was absent from the wheelchair. The nursing assistant involved stated they were not aware the resident was to be taken to the bathroom by wheelchair, and the DON confirmed the resident should not have been ambulated.
Failure to Report Resident Fall With Pelvic Fracture to State Agency
Penalty
Summary
The facility failed to timely report a significant injury related to a fall to the state agency as required by its abuse, neglect, and exploitation policy and state regulations. The facility’s written policy, dated 09-23-2022, required procedures for identifying possible abuse, neglect, and exploitation, including physical injury of unknown source, and mandated reporting of all alleged violations to the administrator, state agency, adult protective services, and other required agencies within specified time frames. These time frames were defined as immediately, but no later than 2 hours when events involve abuse or result in serious bodily injury, and no later than 24 hours when events do not involve abuse and do not result in serious bodily injury. Record review showed that one resident had significant functional and cognitive impairments, including being rarely able to make self-understood, always incontinent of bowel and bladder, requiring extensive assistance with toilet transfers, and total assistance with lower body dressing, personal hygiene, bed mobility, and transfers. Progress notes documented that this resident fell on 12-19-2025 while being transferred from the toilet to a wheelchair, complained of left knee pain, and was sent to the emergency room. The following day, the resident complained of left hip pain, with staff noting the left leg was rotated inward and shorter than the right, leading to hospital transfer and admission for a possible pelvic fracture. Hospital records and the after-visit summary confirmed a closed fracture of the left inferior pubic ramus (pelvic fracture). In interviews, the DON and the administrator confirmed that this fall with pelvic fracture was not reported to the state agency because the facility believed it was not a new injury.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
Facility staff failed to implement assessed interventions to prevent falls for a resident with multiple risk factors, including Parkinson's disease, spinal stenosis, lumbar radiculopathy, hypertension, muscle weakness, and depression. The resident was assessed as having moderately impaired cognition and required partial to moderate assistance with several activities of daily living. The care plan identified the resident as being at risk for falls and included interventions such as the use of a pressure detection (pd) alarm in the wheelchair or bed due to the resident's non-compliance with calling for assistance. On the date of the incident, the resident was found on the floor, and documentation revealed that the call light was within reach, but the required wheelchair or bed/chair alarm was not in use at the time. Interviews with both an RN and the DON confirmed that the alarm should have been in place according to the care plan, but it was not implemented when the fall occurred.
Failure to Monitor and Intervene for Bowel Function
Penalty
Summary
The facility failed to ensure proper monitoring and intervention for bowel function for one resident with a diagnosis of Parkinson's disease and constipation, who also had a history of fecal impaction. According to the facility's bowel program, nursing staff were required to monitor bowel movements every shift and implement a stepwise intervention protocol, including the administration of prune juice, oral laxatives, and suppositories as needed, with physician notification if no bowel movement occurred after three days. Documentation revealed that the resident went multiple periods of four days without a recorded bowel movement, and the required interventions, including the administration of Miralax as ordered, were not provided during the month in question. Interviews with nursing and dietary staff confirmed inconsistent monitoring and communication regarding bowel management. Staff reported that the bowel movement tracking was not consistently completed, and dietary staff were not routinely informed about which residents required prune juice. The DON acknowledged that the documentation was incomplete and that the resident should have received interventions according to the protocol. The resident was eventually admitted to the hospital, and the deficiency was attributed to the lack of consistent monitoring and failure to follow the established bowel management procedures.
Lack of Rationale for Not Reducing Psychotropic Medication
Penalty
Summary
The facility failed to provide a rationale for not conducting a Gradual Dose Reduction (GDR) of a psychotropic medication for one resident. Record review showed that the resident, who was cognitively intact with a BIMS score of 13/15, was prescribed risperidone for bipolar disorder. A pharmacy review recommended a reduction in the medication dosage, but the primary physician disagreed with this recommendation and did not document a rationale for the decision. Further review of the facility's pharmacy policy indicated that when a physician rejects a pharmacy recommendation, an explanation must be provided. In this case, the Director of Nursing confirmed that no rationale was documented by the physician for not implementing the GDR. The facility did not follow its own policy requiring documentation of the physician's reasoning when declining a pharmacy recommendation.
Failure to Provide Restorative Care as Care Planned for Residents with Limited ROM
Penalty
Summary
The facility failed to provide restorative care services as outlined in the care plans for two residents with limited range of motion (ROM) and mobility issues. One resident, who was unable to complete a cognitive assessment and had diagnoses including muscle wasting, contracture of the left hand, and anoxic brain damage, was care planned to receive bed mobility and passive range of motion (PROM) exercises at least 2-3 times per week. However, documentation showed that these exercises were only provided on two days during the month of June. The Director of Nursing (DON) confirmed that only two days were marked for restorative care for this resident in that month. Another resident, who was cognitively intact and had hemiplegia and hemiparesis following a cerebral infarction, was also care planned to receive bed mobility and PROM exercises at least 2-3 times per week. Similarly, records indicated that this resident received the prescribed exercises only on two days in June. The DON confirmed the lack of restorative care documentation for this resident as well and acknowledged that the facility did not have a restorative care policy in place.
Failure to Date Oxygen Tubing, Adhere to Enhanced Barrier Precautions, and Perform Hand Hygiene
Penalty
Summary
The facility failed to properly date and track oxygen tubing for a resident with multiple respiratory diagnoses, including dyspnea, congestive heart failure, obstructive sleep apnea, and acute and chronic respiratory failure. Observations over several days revealed that the resident's oxygen tubing and nasal cannula were not marked with the date they were placed, and interviews with nursing staff and the DON confirmed that there was no method in place for tracking the change of respiratory supplies, despite a policy that tubing should be changed weekly. Additionally, the facility did not ensure that staff followed Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube who required assistance with all activities of daily living. Despite signage indicating the need for gown and glove use during high-contact care activities, a hospice nurse aide was observed providing toileting, hygiene, and transfer assistance without donning a gown, in direct violation of the posted EBP requirements. This was confirmed by both the aide and the facility wound nurse during interviews. The facility also failed to enforce proper hand hygiene practices during medication administration. An observation showed a medication aide preparing and administering eye drops to a resident without performing hand hygiene prior to donning gloves, contrary to facility policy. The aide confirmed in an interview that hand hygiene was not performed before gloving, as required.
Failure to Timely Report Alleged Misappropriation to Authorities
Penalty
Summary
The facility failed to report an allegation of misappropriation involving a resident within the required timeframe to Adult Protective Services (APS) and the Department of Health and Human Services (DHHS). According to facility policy, all alleged violations, including misappropriation of resident property, must be reported immediately, but not later than 2 hours if abuse or serious bodily injury is involved, or within 24 hours otherwise. The incident involved a nurse aide (NA-B) who told a resident that they owed the aide five dollars. The resident did not give the money and later reported feeling fearful of the aide, who allegedly responded by saying, 'see if I do anything for you anymore.' The resident reported the incident to a nurse and left a voicemail for the Director of Nursing (DON). The DON confirmed knowledge of the incident, spoke with both the resident and the aide, and instructed the aide not to enter the resident's room. However, the DON did not report the incident to APS or DHHS, stating that it was not considered abuse and that the resident did not wish to file a grievance. The failure to report the allegation as required by policy and regulation constituted the deficiency. The resident involved had a history of psychiatric and mood disorders, including psychosis, major depressive disorder, schizophrenia, and anxiety, but was assessed as having intact cognition and moderate depression at the time of the incident.
Failure to Investigate Alleged Misappropriation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation involving one resident. According to facility policy, any alleged violation, including misappropriation of resident property, requires an immediate and comprehensive investigation, including identification and interviews of all involved parties and complete documentation. In this case, a resident with intact cognition and a history of psychiatric and medical conditions reported to staff and left a voicemail for the DON that a nurse aide had told the resident they owed the aide five dollars and subsequently made a comment implying withdrawal of assistance. The resident expressed fear of the aide following the incident. The DON acknowledged awareness of the incident and confirmed speaking with both the resident and the nurse aide on the day of the report. The DON instructed the aide not to enter the resident's room but did not conduct a thorough written investigation, as required by facility policy. The DON stated the aide was joking and did not believe the incident constituted abuse or required reporting, especially since the resident did not wish to file a grievance. As a result, the facility did not complete the necessary investigative steps or documentation for the alleged misappropriation.
Failure to Individualize and Document Use of Physical Restraints
Penalty
Summary
Facility staff failed to ensure the individualized use of physical restraints for three residents, as required by both facility policy and state regulations. The facility's policy mandates that before a restraint is used, there must be identification of a specific medical symptom, documentation of the duration and monitoring of restraint use, evaluation of less restrictive alternatives, and ongoing re-evaluation of the need for the restraint. However, for all three residents sampled, these requirements were not met. The use of Merry Walkers, which are considered restraints if the resident cannot remove themselves, was not properly assessed, documented, or care planned as restraints. One resident with dementia and severe cognitive impairment was regularly placed in a Merry Walker and could not remove themselves from the device. Staff interviews confirmed that the resident was unable to exit the Merry Walker independently, and the device was not coded as a restraint on the MDS or included in the care plan as such. There was no documentation of risk/benefit discussions with the resident's representative, and the physical therapist had not re-evaluated the need for the device since the initial assessment. The resident experienced a fall while in the Merry Walker, resulting in multiple bruises and a hospital transfer. Two other residents, both with severe cognitive impairment and mobility issues, were also placed in Merry Walkers without proper documentation or individualized assessment. Staff confirmed that these residents could not remove themselves from the devices, and there was no evidence of risk/benefit analysis or ongoing re-evaluation. The devices were not identified as restraints in the residents' records, and the required documentation and care planning were absent. The DON and other staff acknowledged these deficiencies during interviews.
Failure to Accurately Code Use of Restraints on MDS
Penalty
Summary
The facility failed to accurately code the use of restraints on the Minimum Data Set (MDS) for two residents who utilized a Merry Walker device. Both residents had severe cognitive impairment, as indicated by low BIMS scores, and required assistance for ambulation. Documentation and interviews revealed that both residents were regularly placed in the Merry Walker, could not remove themselves from the device independently, and were supervised or assisted by staff for mobility and toileting. Despite this, the use of the Merry Walker was not identified or coded as a restraint on the MDS, nor was it consistently addressed in the care plans as a restraint. Staff interviews confirmed that the residents were unable to exit the Merry Walker without assistance, and that the device was used for extended periods throughout the day. Registered nursing staff acknowledged during interviews that the Merry Walker should have been documented as a restraint on the MDS and included in the care plan, but this was not done. The failure to accurately assess and code the use of the Merry Walker as a restraint constituted the deficiency identified during the survey.
Failure to Prevent Elopement and Maintain Functional Safety Alarms
Penalty
Summary
The facility failed to provide adequate supervision and maintain functional safety systems to prevent elopement and accidents for residents with severe cognitive impairment and a history of wandering. One resident with dementia and a BIMS score indicating severe cognitive impairment was left unsupervised, allowing the resident to pass through alarmed doors and access a stairwell, resulting in a fall down two flights of stairs. The alarms on the doors and the resident's Wanderguard device were activated, but staff did not respond appropriately to the alarms, and the resident was found on the stair landing with multiple bruises. Other residents at risk for elopement were also not adequately protected. One resident with a history of wandering and a BIMS score indicating severe cognitive impairment had a Wanderguard bracelet in place, but this intervention was not documented in the care plan. Another resident with severe cognitive impairment and a history of wandering had a Wanderguard bracelet, but there was no documentation of wandering behaviors in the progress notes, despite care plan interventions requiring monitoring and documentation. Additionally, multiple Wanderguard alarm units on the first floor were found to be nonfunctional for extended periods, with staff and maintenance aware of the issue. Doorbell alarms were installed as a substitute, but staff did not respond when these alarms sounded during observations. The lack of functioning elopement prevention systems and inadequate staff response to alarms contributed to the failure to ensure a safe environment and adequate supervision for residents at risk of elopement.
Dietary Staff Beard Restraint and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure compliance with dietary staff wearing proper beard restraints that fully enclosed all facial hair during meal service observations. The Dietary Manager and a Dietary Aide were observed with beard restraints that did not fully enclose all hair on the face, potentially leading to contamination risks. Additionally, the storage and sanitation practices in the kitchen and dining areas were found to be substandard. Issues included unlabeled and undated food items, lack of covers for hot dish storage units, presence of food particles and buildup of dirt in various areas, and equipment maintenance concerns such as nicks on the electric slicer blade and dried-on food spatters on the large commercial mixer guard. Observations during meal services on multiple occasions highlighted the non-compliance with proper beard restraints by staff members, including the Dietary Manager and a Dietary Aide. The failure to fully enclose all facial hair could pose risks of contamination during food preparation and service. Furthermore, storage and sanitation concerns were identified in various areas of the kitchen and dining room, including unlabeled food items, lack of covers for hot dish storage, presence of food particles, and equipment maintenance issues like nicks on the electric slicer blade and dried-on food spatters on the large commercial mixer guard.
Facility Fails to Maintain Cleanliness and Condition of Resident Rooms and Common Areas
Penalty
Summary
The facility failed to maintain the cleanliness and condition of walls, floors, fixtures, ceilings, and baseboards in 24 of 59 occupied resident rooms and the 2nd floor north hallway nurses station. Observations during an environmental tour revealed several scrapes on walls in various rooms, broken and cracked toilet tanks, cracked caulking, water stains, and plaster peeling on bathroom ceilings. Additionally, there were brown stains and dirt buildup around the base of toilets, large stains on floors, cracked linoleum, burned-out light bulbs, broken cable TV outlet covers, loose baseboards, heavy dirt buildup along bathroom walls and corners, and dead bugs inside light fixtures. These deficiencies were confirmed by the Maintenance Director (MD) during the tour, who acknowledged that no work orders had been placed for the identified areas and that these concerns had not been previously identified. The specific rooms affected included rooms 102, 105, 106, 113, 116, 122, 123, 125, 131, 132, 134, 144, 146, 158, 159, 162, 203, 205, 212, 215, 225, 233, 236, and 238. The issues ranged from scrapes on walls, broken toilet tanks, cracked caulking, water stains, and dirt buildup to more severe problems like large cracks in walls and heavy dirt and wax buildup. The MD confirmed the need for cleaning and repairs but noted that these issues had not been previously identified or addressed, indicating a lapse in the facility's maintenance and cleanliness protocols.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 7.69% error rate. This deficiency affected one resident (Resident 44) out of three sampled residents. During an observation, Medication Assistant (MA) D was seen preparing medications for Resident 44. MA D crushed both an 81 mg delayed-release aspirin tablet and a 100 mg DOK tablet, despite the medication orders explicitly stating that these medications should not be crushed. The crushed medications were then mixed with pudding and administered to Resident 44. This action was confirmed as a medication error by both MA D and the Assistant Director of Nursing (ADON). The facility's policy on medication administration also clearly states that medications should be administered as ordered and in accordance with manufacturer specifications, including not crushing medications that have 'do not crush' instructions. Record reviews of Resident 44's active orders and the medication cards confirmed that both the aspirin and DOK tablets had 'do not crush' instructions. The facility's policy on medication administration, dated 04-09-2024, was reviewed and it was found to include guidelines that medications should be administered as ordered and in accordance with manufacturer specifications. The failure to adhere to these guidelines led to the medication errors observed. The facility census at the time was 60 residents.
Improper Handling of Catheter and Linens
Penalty
Summary
The facility failed to handle linens and a catheter drainage bag in a manner to prevent potential cross-contamination for one resident. Resident 44, who had a diagnosis of Chronic Kidney Disease Stage 3 and an indwelling catheter following a recent hospitalization for Acute Kidney Injury, was observed receiving catheter care from Nursing Assistant C. During the procedure, NA C placed wipes in a contaminated sink basin and then on a handrail before using them to clean the catheter insertion site and tubing. This practice was confirmed by NA C and the Assistant Director of Nursing as inappropriate and potentially cross-contaminating. Additionally, Resident 44's indwelling catheter bag was observed hanging uncovered on the bed frame and touching a floor mat. This was confirmed by Nursing Assistant B and the facility Infection Preventionist as improper handling that could lead to cross-contamination. The facility's policy on catheter care and infection prevention clearly states that catheter bags should not touch the floor and that linens should be handled in a manner to prevent infection spread. The Assistant Director of Nursing confirmed that these practices were not followed, leading to the deficiency.
Failure to Conduct APS and CPS Registry Checks for New Hire
Penalty
Summary
The facility failed to conduct adult and child protective service (APS and CPS) registry checks upon hire for a newly employed Nursing Assistant (NA G). NA G was hired on March 4, 2024, but the employee file did not contain the results from the required APS and CPS registry checks. This deficiency was identified during a record review and confirmed through interviews with the Administrator and the Administrative Assistant. Both acknowledged that APS and CPS registry checks are mandatory upon hire and that employees should not commence work until the results are received. The facility's policy on Background Investigations, dated June 2015, mandates that personal reference checks, driving record investigations, and background investigations, including APS and CPS registry checks, be conducted for all personnel. Despite this policy, the required checks were not completed for NA G. The policy also specifies that the Administrative Assistant is responsible for conducting these background investigations in compliance with the Omnibus Budget Reconciliation Act of 1987. The failure to adhere to this policy resulted in the deficiency noted in the report.
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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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