Emerald Nursing & Rehab Columbus
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Nebraska.
- Location
- 2855 40th Avenue, Columbus, Nebraska 68601
- CMS Provider Number
- 285092
- Inspections on file
- 24
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Emerald Nursing & Rehab Columbus during CMS and state inspections, most recent first.
A resident with type 2 DM did not receive two scheduled weekly Mounjaro injections as ordered, with no documentation in the EMAR or progress notes explaining the omissions, no entry on the incident log, and no notification to the PCP, despite facility policies requiring documentation and rationale for missed medications. In a separate incident, an LPN administering ordered long-acting and short-acting insulin via insulin pens to another resident with type 2 DM failed to prime the pens and did not hold them in place at the injection site for the required time, contrary to the facility’s clinical checklist and expectations confirmed by the DON.
Surveyors found that staff did not consistently follow EBP, hand hygiene, or glucometer disinfection policies. A resident with MRSA/MDRO history and MASD had an EBP sign and care plan requiring gown and gloves for high-contact care, yet staff performed peri care and transfers wearing only gloves, and several aides and the IP showed inconsistent understanding of which residents were on EBP and what constituted high-contact care. Multiple staff, including MAs, were observed donning and changing gloves for cares such as insulin administration and peri care without performing required hand hygiene, and one aide noted the absence of hand sanitizer in resident rooms. An LPN used the same glucometer on two residents without cleaning or disinfecting it between uses, contrary to facility policy, and later stored the device still un-sanitized in the medication cart.
The facility did not complete or display the required daily nurse staffing postings for a census of 75 residents, despite a policy requiring posting of the facility name, date, census, and total number and hours worked by nursing staff at the start of each shift. During a walk-through, surveyors observed that no daily nurse staffing information was posted, and the DON confirmed it was missing and should have been present, with only 1 nurse scheduled for days and 1 for nights. The RNC reported that daily staffing postings had not been done for about two weeks due to turnover in the scheduler position, and the new Scheduling Coordinator stated they were unaware that completing and posting daily nurse staffing information was part of their responsibilities.
A resident with multiple health conditions and stage 3 pressure ulcers did not receive the prescribed dressing change as ordered. An LPN was observed using a different treatment than what was ordered, applying skin prep and Medi-honey instead of the required wound cleanser and Triad paste. The LPN confirmed the mistake during an interview.
The facility failed to use required PPE and proper hand hygiene during care for two residents on Enhanced Barrier Precautions due to pressure ulcers. Staff did not wear gowns during high-contact activities, and a nurse did not change gloves or perform hand hygiene during wound care, as confirmed by the DON.
The facility did not implement its Legionella Water Management Program, failing to take measures to prevent Legionella growth in the water system. Interviews revealed that the maintenance department was not performing required actions, and the Administrator confirmed the absence of documentation for such measures, potentially affecting all 73 residents.
The facility failed to maintain a clean and safe environment, with issues such as missing baseboards, gouges, and holes in drywall, and a loose transition strip in resident rooms and corridors. These deficiencies were confirmed by the Administrator, and the Maintenance Director noted that the areas of concern had not been identified prior to the tour.
The facility failed to employ a Certified Dietary Manager and maintain sufficient staffing, leading to unsanitary conditions in the kitchen. Observations included sticky floors, food debris, and unclean equipment. Interviews revealed that routine cleaning was not completed due to staffing issues, and the Dietary Manager was not certified and often occupied with cooking duties. The Administrator confirmed the unacceptable conditions and lack of routine cleaning evidence.
The facility's kitchen environment and equipment were not maintained to prevent foodborne illness, affecting all residents. Observations revealed sticky floors, food debris, and soiled equipment. The Dietary Manager lacked certification, and routine cleaning was not completed due to staffing issues. The Administrator confirmed the unacceptable conditions.
A resident with cognitive impairment and a history of falls experienced multiple falls due to the facility's failure to consistently implement and revise fall interventions. Despite the facility's policy, interventions such as placing the bed in the lowest position, using a fall mat, and ensuring the call light was within reach were not consistently applied. Observations and interviews revealed inconsistencies in the use of fall mats and alarms, contributing to the resident's ongoing fall risk.
A resident was prescribed Cefadroxil indefinitely without proper clinical justification, despite the removal of an indwelling Foley catheter and multiple consultations with healthcare providers. The facility's Antibiotic Stewardship Policy was not effectively implemented, leading to the resident receiving unnecessary medication for an extended period.
The facility staff failed to maintain a medication error rate below 5%, with 6 errors observed out of 27 medications administered, resulting in a 22.22% error rate. Three residents received medications without food, contrary to their prescribed orders. The DON confirmed that medications should have been administered with food during breakfast.
The facility failed to serve breakfast room trays at the proper temperature, affecting two residents. Scrambled eggs were prepared at 182°F but were served at significantly lower temperatures of 78°F and 74°F. The trays were prepared and left by the Nurse's Station for 40 minutes before being distributed. A dietary aide confirmed the eggs should have been served at a minimum of 140°F.
The facility failed to provide regular bathing services for three residents, as required by their care plans and facility policy. Residents experienced multiple instances where the time between baths exceeded seven days, with gaps ranging from 8 to 29 days. Staff interviews revealed that the facility's expectation was for residents to receive baths at least once every seven days, but this was not always happening due to staffing issues. The facility administrator confirmed the deficiency.
The facility failed to provide sufficient nursing staff for bathing, affecting three residents who experienced significant gaps between baths, sometimes extending to 29 days. Staff interviews and records confirmed that residents were supposed to receive weekly baths, but this was not always happening due to staffing issues.
Failure to Administer and Document Diabetes Medications per Orders and Standards
Penalty
Summary
The deficiency involves failures in medication administration and documentation for residents with type 2 diabetes. Facility policy on Medication Administration requires that medications be given in the correct dose, at the scheduled time, by the correct route, and that administration be documented in the MAR as soon as the medication is given, with a reason documented if a dose is omitted. The Medication Errors policy requires documentation of the rationale for each medication not administered. For one cognitively intact resident with type 2 diabetes, the order summary showed a standing order for a weekly subcutaneous Mounjaro injection starting in mid-November. The EMAR showed that the Mounjaro injections were not administered on two specific dates. The resident confirmed not receiving the injections on at least two occasions and expressed concern about the missed doses after a prior diabetes medication had been discontinued. There were no progress notes addressing the missed injections, no documentation of a medication error on the facility’s incident log, and no notification to the resident’s primary care provider. A second deficiency involved improper insulin administration technique using insulin pens. The facility’s clinical performance checklist for administering insulin via insulin pen requires attaching a new needle, priming the pen by dialing to 2 units and expelling insulin to remove air bubbles, and then administering the injection by inserting the needle, slowly depressing the injection knob, and holding the pen in place at the injection site for 6–10 seconds before removal. One resident with type 2 diabetes had orders for long-acting insulin in the morning and at night, and short-acting insulin on a sliding scale before meals and at bedtime based on blood glucose levels. During an observation of an LPN preparing and administering insulin to this resident, the LPN verified the ordered doses, cleaned the rubber stopper, dialed the correct units for both long-acting and short-acting insulin, and injected both doses into the resident’s upper arm. However, during this observed administration, the LPN did not prime either insulin pen before dialing up and injecting the ordered doses and did not hold either pen at the injection site for the required 6–10 seconds after depressing the plunger. The LPN later confirmed that neither pen had been primed and that the pens were not held in place after injection as required by the facility’s checklist. The DON confirmed that the resident with the missed Mounjaro injections did not receive the scheduled doses on the two identified dates, that there was no documentation in the progress notes regarding the missed injections, that the primary care provider was not notified, and that no incident or medication error report was filed for these events. The DON also confirmed that the facility’s expectation is that insulin pens be primed prior to use and held in place for at least 10 seconds after injection to ensure accurate dosing, which did not occur in the observed administration.
Failure to Follow EBP, Hand Hygiene, and Glucometer Disinfection Protocols
Penalty
Summary
Surveyors identified that the facility failed to follow its own Enhanced Barrier Precautions (EBP) and hand hygiene policies, as well as its glucometer disinfection procedures. For a resident with a history of MRSA and MDRO infection and Moisture Associated Skin Damage (MASD) on the back of the thighs, an EBP sign at the room door instructed staff to wear gown and gloves for high-contact care such as hygiene and brief changes. The resident’s comprehensive care plan also directed staff to wear gowns and gloves during high-contact care. However, during peri care, a nursing assistant wore gloves but did not don a gown, despite gowns and gloves being available in the room. The nursing assistant reported being unsure if a gown was required, and other nursing assistants demonstrated inconsistent understanding of which residents were on EBP and which activities, such as peri care and oral care, were considered high-contact. The infection preventionist later confirmed that peri care is a high-contact activity requiring gown and gloves for residents on EBP, and the resident reported that staff do not wear gowns during peri care or transfers. Surveyors also observed multiple failures in hand hygiene practices despite facility policies requiring hand hygiene before and after resident contact, and before donning and after removing gloves. Medication aides were seen putting on gloves to provide care, including insulin administration, without performing hand hygiene beforehand, and one aide changed gloves without performing hand hygiene between glove changes. Another observation showed staff transferring a resident to the toilet, performing peri care, and changing the resident’s brief without performing hand hygiene before gloving or when changing gloves. One nursing assistant confirmed there was no hand sanitizer in resident rooms and that they did not have any. Staff interviewed acknowledged that they should have performed hand hygiene before putting on gloves and when changing gloves. The administrator confirmed that no audits were being conducted on EBP or handwashing practices, while the infection preventionist stated that the facility’s expectation was hand hygiene before and after all resident care and with all glove use. In addition, the facility did not follow its policies for cleaning and disinfecting blood glucose monitors between residents. The policies required cleaning and disinfecting the glucometer after each use, including using a disinfectant wipe and allowing appropriate drying time, to prevent transmission of bloodborne diseases. During medication administration, an LPN obtained a blood glucose level for one resident, then placed the glucometer on the medication cart without cleaning or disinfecting it. The same un-sanitized glucometer was then used to obtain a blood glucose level for another resident, again without any cleaning or disinfection between uses, and was later stored in the medication cart drawer still un-sanitized. The LPN confirmed that the glucometer had not been cleaned or disinfected and acknowledged it should have been, and the DON stated that the facility’s expectation was that glucometers are cleaned and disinfected between each resident use.
Failure to Complete and Post Required Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the required Daily Nurse Staff Posting was completed and displayed as specified in its policy, which required posting of the facility name, current date, current census, and total number and actual hours worked for nursing staff at the beginning of each shift and maintaining these postings for 18 months. During an observation on 4/28/2026 at 9:37 AM, surveyors found no daily nursing staff posting anywhere in the facility. In an interview at the same time, the DON confirmed that the daily nurse posting was not posted and acknowledged it should have been. The DON further confirmed that the facility census was 75, with 1 nurse scheduled for the day shift and 1 nurse scheduled for the night shift. In a subsequent interview on 4/28/2026 at 12:48 PM, the Regional Nurse Consultant stated that the facility had not performed the required daily staff posting for the previous two weeks due to turnover in the scheduler position. On 4/29/2026 at 8:10 AM, the Scheduling Coordinator reported having started in the role on 4/8/2026 and being unaware that the daily nurse staffing information was required to be completed or posted. No additional resident-specific medical histories or conditions were described in the report beyond the facility census of 75 residents.
Failure to Follow Dressing Change Orders for Pressure Ulcer
Penalty
Summary
The facility failed to adhere to a practitioner's orders for a dressing change for a resident with pressure ulcers. The resident, who was admitted with multiple health conditions including anemia, high blood pressure, diabetes, anxiety, manic depression, and chronic obstructive pulmonary disease, was assessed to have short- and long-term memory loss, severely impaired decision-making skills, and required total assistance with daily activities. The resident had two unhealed stage 3 pressure ulcers upon admission, and the care plan indicated skin integrity issues due to being bedridden for 28 days prior to admission. On a specific date, an LPN was observed performing wound care on the resident's coccyx pressure ulcer. The LPN did not follow the prescribed order, which required cleansing with a wound cleanser and applying Triad paste twice daily. Instead, the LPN used a skin prep and Medi-honey, which was not in accordance with the practitioner's orders. The LPN later confirmed the error during an interview, acknowledging the incorrect dressing change procedure.
Inadequate PPE Use and Hand Hygiene in Resident Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control program by not utilizing the required Personal Protective Equipment (PPE) during direct care activities for two residents on Enhanced Barrier Precautions (EBP). Specifically, staff members did not wear gowns when performing high-contact care activities for Residents 3 and 4, who were on EBP due to pressure ulcers. During an observation, Nurse Aide (NA)-D and Medication Aide (MA)-E did not wear gowns while transferring Resident 3 from a wheelchair to a bed and changing bed linens. Similarly, NA-M did not wear a gown while assisting Resident 4 with dressing, transferring, and toileting. Additionally, the facility did not follow proper hand hygiene and gloving techniques during wound care for Resident 3. Registered Nurse (RN)-F failed to change gloves after removing a dressing and applying barrier cream to Resident 3's pressure ulcer. RN-F also did not perform hand hygiene before assisting with other care activities. These actions were confirmed by the Director of Nursing (DON), who acknowledged that the staff should have adhered to the facility's policies on PPE use and hand hygiene to prevent potential cross-contamination.
Failure to Implement Legionella Water Management Program
Penalty
Summary
The facility failed to implement its Legionella Water Management Program, which is crucial for preventing water-borne illnesses such as Legionnaire's disease. The policy, last revised in January 2024, outlined the formation of an interdisciplinary water management team and detailed procedures to identify and mitigate areas in the water system that could foster the growth of Legionella bacteria. However, interviews with the Maintenance Director and the Infection Preventionist revealed that no measures were being taken to prevent the growth of Legionella, and the maintenance department, which was responsible for these measures, was not performing them. The Administrator confirmed that there was no documentation of any actions taken to prevent Legionella growth, indicating a complete lack of implementation of the water management policy. This deficiency had the potential to affect all 73 residents of the facility, as the policy was designed to reduce the risk of Legionnaire's disease by monitoring and controlling the water system effectively. The absence of documentation and action suggests a significant oversight in the facility's infection prevention and control program.
Environmental Deficiencies in Resident Rooms and Corridors
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by the observations made during an environmental tour. The tour revealed several deficiencies in the cleanliness and condition of the facility's walls, floors, and baseboards in five resident rooms and the Northwest corridor. Specific issues included missing baseboards, scrapes, gouges, and holes in the drywall in various rooms, as well as a loose transition stop strip with exposed and discolored flooring. These deficiencies were confirmed by the facility's Administrator during the tour. The Maintenance Director (MD) indicated that a patch panel had been affixed to a wall in one of the rooms due to the wall caving in. However, the MD also reported that the areas of concern had not been identified prior to the environmental tour, despite the existence of a Maintenance Request Log kept at the Nurse's Station. This suggests a lack of proactive maintenance and monitoring of the facility's environment, leading to the observed deficiencies.
Deficiency in Kitchen Cleanliness and Staffing
Penalty
Summary
The facility failed to employ a Certified Dietary Manager (CDM) and maintain sufficient staffing to ensure the cleanliness of the kitchen environment, food preparation equipment, and storage equipment, potentially affecting all 73 residents who consumed food prepared by the facility. The job description for the Manager of Dining Services outlined responsibilities including managing the dietary department, ensuring food was prepared and served according to regulations, and maintaining cleanliness and safety standards. However, during an inspection, numerous deficiencies were observed in the kitchen's cleanliness and maintenance. During a tour of the primary kitchen, surveyors noted several unsanitary conditions, including a sticky floor, food debris in grout, and a thick black substance coating various surfaces. The fire suppression system and oven doors were covered in sticky and burnt substances, respectively. Additionally, the food steamer was leaking water, and the walls were coated in a brown sticky substance. Cooking pots were covered in black carbon buildup, and the air return covers had chipping paint and rust. The dry food storage area and walk-in freezer had boxes of food stored directly on the floor, and food service carts were covered in food debris. Interviews with the Dietary Manager and staff revealed that routine cleaning was not being completed due to staffing issues, and the Dietary Manager was not certified and often occupied with cooking duties. The facility Administrator confirmed the unacceptable conditions and acknowledged the lack of evidence for routine cleaning. The Administrator also confirmed that the Dietary Manager had not completed the required training and was frequently involved in cooking, which hindered the maintenance of the kitchen environment and equipment.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen environment, food storage, and preparation equipment in a manner that prevents the potential for foodborne illness, affecting all residents who consumed food prepared by the facility. During an initial tour of the primary kitchen, several deficiencies were observed, including a sticky floor, food debris in grout, and a thick black substance coating the floor beneath various kitchen equipment. The fire suppression system and oven doors were coated with sticky and burnt substances, respectively. Additionally, the food steamer was leaking water into a pan, which was overflowing and cloudy, and the walls adjacent to the oven were covered in a brown sticky substance. Further observations revealed that cooking pots were coated with black carbon buildup, air return covers had chipping paint and rust, and bins of flour and sugar were contaminated by drippings from the food steamer. The reach-in refrigerators and freezers had handprints, smears, and frozen substances, with food boxes stored directly on the floor in both dry and walk-in storage areas. Food service carts and equipment wheels were heavily soiled, and the secondary kitchen exhibited similar issues, including a sticky floor, soiled ice machine, and lime buildup in the dishwashing room. Interviews with the Dietary Manager (DM) and Dietary Staff (DS) revealed that routine cleaning was not being completed due to staffing concerns, and the DM lacked current certification. The facility Administrator confirmed the unacceptable condition of the kitchen and acknowledged that the DM was frequently cooking, which hindered the maintenance of the kitchen environment and equipment. The facility had no evidence of routine cleaning being conducted.
Failure to Implement and Revise Fall Interventions
Penalty
Summary
The facility failed to implement and revise fall interventions for a resident, leading to multiple falls. The resident, who had a history of adult failure to thrive, previous heart attack, and pain, was assessed as having moderately impaired cognition and displayed various behaviors such as verbal and physical aggression, self-harm, and rejection of care. The resident was dependent on assistance for dressing, bed mobility, and transfers, and had experienced a fall without injury since the last assessment. The facility's fall management policy required assessing fall risk at admission, quarterly, or after a fall, and implementing individualized interventions. However, the facility did not consistently follow this policy. The resident experienced several falls, with investigations revealing that interventions such as placing the bed in the lowest position, using a fall mat, and ensuring the call light was within reach were not consistently implemented. Additionally, there was a lack of documentation and communication regarding the removal of the fall mat and the failure to develop new interventions after subsequent falls. Observations and interviews indicated that the resident's call light was often not within reach, and the use of fall mats and alarms was inconsistent. The Director of Nursing confirmed that new interventions were not developed after certain falls and that the fall mat was removed without proper documentation. This lack of consistent implementation and revision of fall interventions contributed to the ongoing risk of falls for the resident.
Failure to Address Unnecessary Long-term Antibiotic Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically concerning the long-term use of the antibiotic Cefadroxil. The resident, who had an indwelling Foley catheter, was prescribed Cefadroxil indefinitely by a urologist after cloudy urine was observed. However, there was no urinalysis conducted to support the clinical use of the antibiotic. Despite the removal of the catheter and multiple consultations with both the primary physician and the urologist, the continued use of Cefadroxil was not adequately addressed. The consultant pharmacist repeatedly recommended reviewing the necessity of the antibiotic, but the primary physician deferred the decision to the urologist, who also failed to provide a clear directive. The resident's medical record showed that the Cefadroxil was prescribed without a specified duration, and the facility's Antibiotic Stewardship Policy was not effectively implemented. The policy required tracking antibiotic use, ensuring pharmacy review, and monitoring for adverse reactions, but these measures were not sufficiently followed. The resident continued to receive Cefadroxil without a stop date, and the facility did not receive any information regarding a pending urine culture that could have informed the necessity of the antibiotic. This oversight led to the resident receiving unnecessary medication for an extended period without proper clinical justification.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility staff failed to maintain a medication error rate below 5%, as required by their policy. During observations, 27 medications were administered, resulting in 6 errors, which equates to an error rate of 22.22%. These errors involved three residents, who were not given their medications in accordance with the prescriber's orders. Specifically, the medications were not administered with food as required, which is a deviation from the prescribed method of administration. Resident 5 was prescribed Metformin to be taken with food, but the medication was administered without offering food. Similarly, Resident 19 was given Glimepiride, Metformin, Potassium Chloride, and Aspirin without food or a full glass of water, contrary to the orders. Resident 68 was prescribed Meloxicam to be taken with food, but it was administered without food. The Director of Nursing confirmed that these medications should have been administered with food during the breakfast meal, indicating a lapse in following the prescribed medication administration protocol.
Improper Temperature of Breakfast Trays
Penalty
Summary
The facility failed to ensure that room trays were palatable and served at the proper temperature, affecting two residents out of four who received a breakfast room tray. The facility's Beginning Food Cooking Temperatures log indicated that all hot food should be served at a minimum of 140 degrees Fahrenheit. However, on the morning of July 15, 2024, scrambled eggs were prepared with an initial temperature of 182 degrees Fahrenheit but were later served at significantly lower temperatures. Observations revealed that a serving cart with breakfast trays was positioned next to the Nurse's Station at 8:10 AM, and the trays were not distributed until 8:50 AM. When the trays were finally delivered, the scrambled eggs on Resident 34's tray were measured at 78 degrees Fahrenheit, and Resident 66's scrambled eggs were at 74 degrees Fahrenheit. An interview with a dietary aide confirmed that the scrambled eggs should have been served at a minimum of 140 degrees Fahrenheit, and the trays had been prepared between 7:30 AM and 7:45 AM before being placed by the Nurse's Station for distribution.
Failure to Provide Regular Bathing Services
Penalty
Summary
The facility failed to provide regular bathing services for three residents, as required by their care plans and facility policy. Resident 1, who had severe cognitive impairment and required total assistance with bathing, experienced multiple instances where the time between baths exceeded seven days, with gaps ranging from 8 to 29 days. Resident 4, who was cognitively intact but required moderate assistance with bathing, also had several instances where the time between baths exceeded seven days, with gaps ranging from 14 to 21 days. Resident 5, who had severe cognitive impairment and required assistance with bathing, experienced similar issues, with gaps between baths ranging from 10 to 21 days. These deficiencies were confirmed through record reviews and interviews with staff and residents. Interviews with various staff members, including LPNs, Medication Aides, and Nursing Assistants, revealed that the facility's expectation was for residents to receive baths at least once every seven days. However, this was not always happening due to staffing issues. A confidential resident interview also revealed that the resident had gone three weeks without a bath in February and had requested to have two baths weekly. The facility administrator confirmed that residents were expected to receive weekly baths, and acknowledged that Residents 1, 4, and 5 were not receiving baths as scheduled.
Failure to Provide Sufficient Nursing Staff for Bathing
Penalty
Summary
The facility failed to provide sufficient nursing staff for the provision of bathing for three residents, which had the potential to affect all residents. During a confidential interview, a resident revealed not receiving baths on a regular schedule, going three weeks without a bath in February. The resident had severe cognitive impairment and required total assistance with bathing. The review of the resident's Minimum Data Set (MDS) and care plan confirmed the need for regular bathing assistance, but documentation showed multiple instances where the time between baths exceeded seven days, sometimes extending to 29 days apart. Similar deficiencies were found for two other residents, one with cerebral palsy and another with severe cognitive impairment, both requiring assistance with bathing and experiencing significant gaps between baths, ranging from 10 to 21 days apart. The facility's nursing assignment records from November 1, 2023, to April 30, 2024, revealed numerous dates without a bath aide scheduled and multiple instances where two or more staff members did not report to work. Interviews with various staff members confirmed that residents were supposed to receive baths at least once every seven days, but this was not always happening due to staffing issues. The administrator confirmed that the expectation was for residents to receive weekly baths and acknowledged that the residents in question were not getting their baths completed weekly. The bath aide was often reassigned to other duties when there were staff call-ins, further contributing to the deficiency in providing regular bathing assistance.
Latest citations in Nebraska
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
