Kimball County Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Kimball, Nebraska.
- Location
- 810 East 7th Street, Kimball, Nebraska 69145
- CMS Provider Number
- 285256
- Inspections on file
- 20
- Latest survey
- August 27, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Kimball County Manor during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
A resident with moderate cognitive impairment reported being hit by a staff member, but the LPN who received the allegation did not report it or initiate an investigation, instead dismissing the claim as a misconception. The resident provided a detailed description of the alleged perpetrator and expressed fear, while other staff reported ongoing concerns about the conduct of certain aides. Facility policy requiring immediate reporting and investigation of abuse was not followed, resulting in a deficiency.
The facility did not complete required background and nurse aide registry checks for a housekeeper, activities supervisor, and dietary aide before hire or rehire, despite these staff having direct and unsupervised access to residents. Human Resources confirmed the oversight and lack of awareness regarding the requirement for nurse aide registry checks for such staff.
Five nurse aides did not complete the required 12 hours of annual ongoing training, with completed hours ranging from 3.82 to 10.82 and some hours discounted due to duplicate courses. The facility's assessment listed training topics but did not ensure compliance with the annual education requirement, as confirmed by the NHA.
The facility did not develop or implement Enhanced Barrier Precautions (EBP) for residents with indwelling catheters, unresolved wounds, or stage III pressure ulcers. Observations found no PPE indicators outside affected residents' rooms, and staff interviews revealed inconsistent knowledge and lack of training on EBP requirements. Both the DON and Administrator confirmed they were unaware of the EBP regulation and had not enacted related policies.
A review of staff records and interviews revealed that multiple new, rehired, and agency staff did not receive required orientation and training on topics such as resident rights, emergency procedures, adult abuse/neglect, medical emergency directives, and dementia care within two weeks of employment. This lapse was confirmed by both HR and the DON, and affected nearly all sampled staff, potentially impacting all residents in the facility.
The facility did not ensure that nurse aides completed the required 4 hours of annual dementia training, with several aides either lacking any documented training or having completed only a portion of the required hours. The administrator was unaware of this requirement, and the deficiency had the potential to impact all residents.
A resident reported to an LPN that staff had hit them the previous night, but the LPN did not report the allegation to the NHA or State Agency, nor initiate an investigation, believing the claim was not credible. The NHA was unaware of the allegation until later, and the investigation report was submitted to the State Agency seven working days after the incident, exceeding the required timeframe.
Two residents with complex medical and mental health needs did not have complete care plans addressing all their diagnoses and high-risk medications. One resident's care plan lacked non-pharmacological interventions for anxiety and did not mention all prescribed psychotropic medications, while another resident's care plan omitted key conditions such as CHF, diabetes, and the use of antiplatelet and diuretic medications. These omissions were confirmed by facility leadership and did not align with the facility's care planning policy.
A resident with cognitive impairment and mobility needs was provided bed rails at the request of their POA without evidence that alternatives were considered or attempted, and without proper documentation of risk-benefit assessment or informed consent. The DON confirmed that no alternatives were explored prior to bed rail installation, and the facility's policy did not require such steps.
The facility kitchen staff failed to follow proper handwashing and gloving techniques during meal preparation, risking cross-contamination for all 41 residents. Observations showed that a dietary staff member did not wash hands upon entering the kitchen or before changing gloves, and handled various items and food with soiled gloves.
The facility failed to implement proper hand hygiene practices during the distribution of resident laundry and medication administration. A laundry aide did not perform hand hygiene while distributing laundry, and an LPN did not wash hands between medication passes for different residents, contrary to facility policy and CDC guidelines.
The facility failed to implement an antibiotic stewardship program as required by their policy. The ADON confirmed that they only generated a monthly report listing residents on antibiotics but did not track or trend antibiotic use beyond this. Interviews revealed that the facility struggled with implementing the program, potentially affecting all 41 residents.
The facility failed to obtain an end date or rationale for the continued use of antibiotics for three residents, leading to indefinite antibiotic use without proper follow-up or documentation.
The facility had a medication error rate of 14.81%, exceeding the acceptable threshold of 5%. Errors included late administration of medications, failure to follow special instructions, and incorrect mixing of medication fluids.
A facility failed to ensure a resident's DNR order was added to their EHR. Staff confirmed they rely on the EHR for code status, but the resident's advance directive was only in the paper chart, not the EHR, contrary to facility policy.
The facility failed to administer oxygen per physician's orders for two residents. One resident with COPD had their oxygen flow rate set higher than prescribed, and another resident with acute respiratory failure had their oxygen set lower than ordered and was observed with the oxygen tank turned off.
The facility failed to provide a pneumococcal immunization for a resident. A review of the resident's medical records showed a signed consent form indicating the vaccine was received, but it lacked the date and type of vaccine. Interviews revealed that the facility had not verified the resident's previous vaccination status and had not administered the vaccine while the resident was in the facility.
A resident who had signed a consent form to receive the COVID-19 vaccine did not receive the vaccine due to a lapse in scheduling and documentation by the facility's staff.
The facility failed to ensure the use of two-persons while utilizing a Hoyer lift for a resident with severe cognitive impairment and multiple dependencies. Additionally, the facility did not ensure the oxygen concentrator was turned off when not in use, posing a fire hazard.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Report and Investigate Resident Abuse Allegation
Penalty
Summary
The facility failed to protect a resident from abuse after an allegation of staff-to-resident abuse was made. The resident, who had dementia with moderate cognitive impairment and difficulty expressing themselves, reported to an LPN that staff had hit them during the previous night. The LPN did not report the allegation to the Nursing Home Administrator (NHA) or initiate an investigation, as required by facility policy. Instead, the LPN dismissed the resident's report as a dream or misconception of reality, without clear justification for this determination. The resident later provided a detailed description of the alleged perpetrator and expressed fear and distress during interviews. Observations confirmed that a nurse aide matching the resident's description was present in the facility. Additional interviews with staff revealed ongoing concerns about the conduct of certain agency aides, including allegations of yelling at residents, improper feeding, and mishandling of mobility aids. These concerns had reportedly been communicated to supervisory staff but were dismissed or not acted upon. The facility's policies required immediate reporting and investigation of any suspected abuse, as well as protective measures for residents during investigations. However, these procedures were not followed in this case. The NHA and DON were unaware of the abuse allegation until it was brought to their attention by surveyors, and no immediate protective actions were taken for the resident following the initial report. The failure to report and investigate the allegation in accordance with policy resulted in a deficiency at the immediate jeopardy level.
Removal Plan
- DON will do a full head to toe skin assessment on Resident #39, noting any discolorations, bruises, or visible markings on body.
- DON and NHA will place phone call to resident family to inform them of the allegation of abuse and share with them the steps we are taking and findings from skin assessment.
- Alleged perpetrator will not be allowed to return to work until investigation is complete.
- DON will begin investigation into allegation by interviewing staff, residents, and speaking to family members.
- A report with the findings of the investigation will be provided to the State Agency.
- NHA will provide a copy of the Abuse Prohibition Policies and Procedures to all staff currently at facility to review and sign. Copies of this will be provided to all oncoming staff at the start of next shift to be reviewed and signed.
- An all staff Inservice is scheduled to educate staff on the importance of adhering to the Abuse Prohibition Policies and Procedures.
- DON and NHA upon arriving at facility, will read through progress notes for all residents on a daily basis, and immediately investigate any allegation of abuse or neglect. DON and NHA will alternate reading through progress notes on Saturday and Sunday.
- NHA will continue to ensure that all staff are compliant with their mandatory, annual Abuse/Neglect Inservice.
- SSD will conduct spot interviews with residents to ensure residents they feel they are receiving adequate care.
Failure to Complete Required Employee Background and Registry Checks
Penalty
Summary
The facility failed to implement its policies and procedures regarding the screening of potential employees prior to employment. Specifically, for three out of five sampled employees—a housekeeper, an activities supervisor, and a dietary aide—there was no evidence that required background checks, including nurse aide registry checks, were completed before hire or rehire. The facility's policy required checks of the Nebraska License Information System, Adult and Child Abuse Registries, criminal history, and the Nebraska State Patrol Sex Offender Registry, but did not explicitly require a nurse aide registry check for all staff with direct and unsupervised access to residents. Record reviews showed that the dietary aide was rehired without any background or registry checks, and both the housekeeper and activities supervisor did not have nurse aide registry checks completed prior to their hire. Human Resources confirmed these omissions and acknowledged being unaware of the requirement for nurse aide registry checks for staff with direct and unsupervised access to residents. This failure had the potential to affect all residents in the facility, which had a census of 39 at the time.
Failure to Ensure Nurse Aides Complete Required Annual Training Hours
Penalty
Summary
The facility failed to ensure that five sampled nurse aides completed at least 12 hours of ongoing training annually, as required by regulation. Record reviews showed that each of the five nurse aides had not met the minimum training hours based on their individual employment dates. Specifically, the training hours completed by each aide ranged from 3.82 to 10.82 hours within their respective annual periods, with some hours being discounted due to duplicate courses. The facility's assessment listed required training topics but did not provide evidence that the 12-hour annual education requirement was being met for nurse aides. An interview with the Nursing Home Administrator confirmed that the sampled nurse aides had not completed the required ongoing training. The deficiency had the potential to affect all residents in the facility, which had a census of 39 at the time of the survey. No information was provided regarding the medical history or condition of specific residents related to this deficiency.
Failure to Implement Enhanced Barrier Precautions for Residents with High-Risk Conditions
Penalty
Summary
The facility failed to develop and implement Enhanced Barrier Precautions (EBP) policies and procedures as required, specifically for residents with conditions that necessitate such precautions. Record reviews revealed that one resident had an indwelling catheter, another had unresolved wounds, and a third had a stage III pressure ulcer. Observations showed that there were no signs or indicators outside these residents' rooms to alert staff to the need for personal protective equipment (PPE) during high-contact care activities. Interviews with nurse aides indicated inconsistent understanding and application of EBP, with one aide stating EBP was used on everyone, while another denied any residents were on EBP and reported not receiving training regarding PPE use for wounds and catheters. The Director of Nursing and the Administrator both confirmed a lack of awareness and implementation of the EBP regulation, with the DON stating that new regulations are typically monitored by the Administrator, who also denied knowledge of the requirement.
Failure to Provide Timely Orientation and Mandatory Training to Staff
Penalty
Summary
The facility failed to ensure that all new and existing staff members received required initial orientation and training within two weeks of employment, as mandated by state regulations. Record reviews showed that 11 out of 12 sampled employees, including nurse aides, a housekeeper, an activities supervisor, and agency staff, did not complete training on essential topics such as resident rights, emergency procedures, adult abuse/neglect, medical emergency directives, and dementia care within the required timeframe. The facility's own assessment and compliance documents indicated that training on emergency preparedness, resident rights, and abuse and neglect was required, but there was no evidence of training on medical emergency directives. Personnel files and agency attestations further confirmed the lack of timely completion of these trainings for both direct hires and agency staff. Interviews with Human Resources and the Director of Nursing corroborated that several staff members, including those rehired or contracted through agencies, had not completed all required orientation topics. Specifically, there was no evidence that certain staff had completed training on emergency procedures, medical directives, dementia, or adult abuse and neglect within two weeks of starting employment. This deficiency had the potential to affect all residents in the facility, which had a census of 39 at the time of the survey.
Failure to Ensure Required Annual Dementia Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides completed at least 4 hours of annual dementia training as required by state regulations. Record reviews for five nurse aides showed that none had met the mandated training hours within their respective annual periods. Specifically, three nurse aides had no evidence of any dementia training completed during the required timeframe, while two others had only completed one hour each, falling short of the four-hour requirement. The facility's own assessment indicated that all staff would receive dementia training, but there was no documentation to confirm compliance with the specific annual hour requirement. An interview with the Nursing Home Administrator revealed a lack of awareness regarding the requirement for nurse aides to complete at least 4 hours of dementia training each year. The administrator confirmed that the identified nurse aides had not met this requirement. The deficiency had the potential to affect all residents in the facility, which had a census of 39 at the time of the survey.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to immediately investigate and report an allegation of staff-to-resident abuse within 24 hours, and did not submit the investigation to the State Agency (SA) within the required 5 working days. A review of the facility's policy indicated that all abuse allegations must be reported to the SA within 24 hours and a written investigation report submitted within five working days. However, documentation showed that when a resident reported to an LPN that staff had hit them the previous night, the LPN did not report the allegation to the Nursing Home Administrator (NHA) or the SA, nor did they initiate an investigation. The LPN determined the allegation was not credible, believing it to be a dream or misconception, but could not explain how this determination was made. The NHA confirmed that they were unaware of the resident's allegation because it had not been reported by the LPN, and acknowledged that the incident should have been reported and investigated immediately. Additionally, the investigation report was not submitted to the SA until seven working days after the incident, exceeding the required timeframe. The facility census at the time was 39 residents, and the deficiency was identified for one resident who made the abuse allegation.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for two residents. For one resident with Parkinson's disease, dementia, and anxiety disorder, the care plan included the use of antianxiety medications but did not document any non-pharmacological interventions for anxiety, mood, or behavior. The resident had severely impaired cognition and was prescribed multiple psychotropic medications, including alprazolam, buspirone, and trazodone, all for anxiety disorder. The care plan did not mention trazodone or outline any non-pharmaceutical approaches, and this omission was confirmed by the Director of Nursing. For another resident with Alzheimer's disease, congestive heart failure (CHF), atrial fibrillation, diabetes, and a history of stroke, the care plan did not address several significant medical conditions or the use of high-risk medications. The resident was taking an antiplatelet and a diuretic, but the care plan lacked problem areas or interventions related to diabetes, CHF, antiplatelet, or diuretic use. This gap was confirmed by both the Nursing Home Administrator and the Director of Nursing, who acknowledged that these areas should have been included in the care plan. The facility's own policy requires that care plans address all problem areas identified through assessments, including measurable goals and approaches for each issue. In both cases, the care plans did not meet these requirements, as they failed to include all relevant diagnoses, medications, and necessary interventions, resulting in incomplete documentation and planning for the residents' care needs.
Failure to Attempt Alternatives and Document Assessment Prior to Bed Rail Use
Penalty
Summary
The facility failed to attempt the use of appropriate alternatives prior to the installation of bed rails for a resident with dementia, epilepsy, and an anxiety disorder who required maximum assistance with bed mobility and transfers. Documentation showed that the resident's Power of Attorney (POA) requested bilateral half-side bed rails to enhance independent bed mobility, and a potential risk of entrapment was identified. However, there was no evidence that alternatives to bed rails were considered or attempted, nor were contraindications to alternatives identified. The facility's policy did not require the use of alternatives prior to bed rail installation, and the required risk-benefit assessment and documentation of attempted alternatives were missing from the resident's records. Further review revealed that the Bed Side Rails Decision Tree was incomplete, lacking the resident's name and documentation of the decision-making pathway. The DON confirmed that no alternatives were considered or attempted before implementing the bed rails, and the POA was not informed of alternatives or the benefits and likelihood of benefits of bed rails. The deficiency was identified through record reviews and interviews, which demonstrated noncompliance with regulatory requirements for assessing and documenting the use of bed rails.
Failure to Follow Hand Hygiene and Gloving Techniques in Kitchen
Penalty
Summary
The facility kitchen staff failed to utilize proper handwashing and gloving techniques during meal preparation, which had the potential to affect all 41 residents who ate from the kitchen. Observations revealed that Dietary Staff (DS)-B did not wash hands upon entering the kitchen, before putting on gloves, or after changing gloves. DS-B was seen handling various items, including a box of buttermilk biscuit mix, a permanent marker, and refrigerator handles, without performing hand hygiene. Additionally, DS-B touched food items directly with soiled gloves, further increasing the risk of cross-contamination. An interview with DS-B confirmed awareness of the facility's hand hygiene and glove-changing policies, yet these practices were not followed. The facility's policies, last revised in November 2023, clearly stated the need for frequent handwashing and changing gloves to maintain cleanliness. Despite this, DS-B's actions demonstrated a failure to adhere to these standards, leading to the potential for cross-contamination during meal preparation.
Failure to Implement Hand Hygiene Practices
Penalty
Summary
The facility failed to implement proper hand hygiene practices during the distribution of resident laundry and medication administration. Observations revealed that a laundry aide did not perform hand hygiene at any time while distributing personal laundry to multiple resident rooms. The laundry aide confirmed that they had not been instructed to perform hand hygiene since the facility had COVID-19 cases. The facility's policy required hand hygiene after handling contaminated equipment and after contact with objects in the immediate vicinity of the resident, which was not followed by the laundry aide. Additionally, a Licensed Practical Nurse (LPN) did not perform hand hygiene between medication passes for different residents. The LPN was observed not washing hands before beginning medication passes for several residents and even touched one resident while holding another resident's medications. The LPN confirmed awareness of the need to perform hand hygiene between every resident. The facility's policy and CDC guidelines required hand hygiene before and after direct contact with residents and before preparing or handling medications, which were not adhered to by the LPN.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program as required by their policy. The policy outlined specific procedures for ordering antibiotics, including identifying the diagnosis, appropriate antibiotic, dose, duration, and route. It also required nursing staff to track antibiotic use, monitor adherence to evidence-based criteria, and report related data to the Quality Assurance and Assessment (QAA) committee. However, the Assistant Director of Nursing (ADON), who also served as the Infection Preventionist, confirmed that they only generated a monthly report listing residents who had been on antibiotics but did not track or trend antibiotic use beyond this report. Interviews with the Administrator and the ADON revealed that the facility struggled with implementing the antibiotic stewardship program. The ADON admitted that while they could generate a list of residents on antibiotics, they did not monitor clinical outcomes such as rates of C. difficile infections, antibiotic-resistant organisms, or adverse drug events. Additionally, there was no evidence of tracking patterns of antibiotic use or providing reports to the QAA committee, as required by the facility's policy. This failure had the potential to affect all 41 residents in the facility.
Failure to Obtain End Date or Rationale for Continued Antibiotic Use
Penalty
Summary
The facility failed to obtain an end date or rationale for the continued use of antibiotics for three residents. Resident 8, who had severe cognitive impairment and multiple diagnoses including chronic kidney disease and overactive bladder, was on Bactrim for prophylactic UTI use indefinitely without a stop date. The Assistant Director of Nursing confirmed awareness of CDC recommendations against prophylactic antibiotic use but acknowledged the indefinite prescription for Resident 8. Resident 28, with a history of septic shock, UTI, and other urinary issues, was prescribed multiple antibiotics over several months without proper follow-up urinalysis to confirm the necessity of continued antibiotic use. Despite various symptoms and positive urinalysis results, there was no documentation of follow-up tests or a clear rationale for the ongoing antibiotic regimen. The resident continued to take Macrodantin indefinitely without a specific diagnosis or indication. Resident 39, admitted with periorbital cellulitis, was prescribed Doxycycline for an eye infection. Despite the infection being documented as resolved, the antibiotic was continued indefinitely as a prophylactic measure. There was no recent documentation regarding the resident's antibiotic use, adverse reactions, or the status of the eye condition. The lack of monitoring and rationale for continued antibiotic use was evident in the resident's records.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure the medication error rate was less than 5%, resulting in a 14.81% error rate for 4 out of 8 sampled residents. Specifically, Resident 29's levothyroxine was administered at 7:13 AM instead of the prescribed 6:00 AM, and Resident 38's gabapentin was administered at 7:27 AM instead of 6:00 AM. LPN-C admitted to being aware of the policy to administer medications within one hour before or after the prescribed time but was running behind schedule. Additionally, Resident 32's tamsulosin, which was supposed to be administered 30 minutes after breakfast, was given before breakfast while the resident was still awaiting the meal in the dining room. LPN-C confirmed this deviation from the special instructions during an interview. Furthermore, Resident 5's Miralax, which was ordered to be mixed with 8 ounces of fluid, was mixed with only 4 ounces of MedPass liquid before administration. LPN-C confirmed this error during an interview. These observations and interviews indicate a failure to adhere to the facility's medication administration policy, leading to a medication error rate significantly higher than the acceptable threshold of 5%.
Failure to Document Advance Directive in EHR
Penalty
Summary
The facility failed to ensure that a resident's advance directive was added to their electronic health record (EHR). Specifically, Resident 39 had a paper medical chart indicating a Do Not Resuscitate (DNR) order, but this information was not reflected in the EHR, which stated that no advance directive was on file. Interviews with various staff members, including a nurse aide, an LPN, the Assistant Director of Nursing (ADON), and a medical records staff member, confirmed that they would typically look in the EHR to determine a resident's code status. The facility's policy required that any advance directive be documented and included in the resident's medical record, but this was not done for Resident 39.
Failure to Administer Oxygen Per Physician's Orders
Penalty
Summary
The facility failed to ensure oxygen was administered per the physician's orders for two residents. Resident 13, who has COPD and is at risk for respiratory distress, had a physician's order for continuous oxygen at 1-2 LPM to keep saturations above 90%. However, documentation revealed that the oxygen flow rate was consistently set at 3 LPM, and an observation confirmed the oxygen concentrator was set at 2.5 LPM, which is not in accordance with the physician's order. Resident 35, who has a primary medical condition of acute respiratory failure with hypoxia, had a physician's order for continuous oxygen at 3 LPM via nasal cannula. Documentation showed that the oxygen was set at 2 LPM every shift for a month, contrary to the physician's order. An observation revealed that the resident's oxygen tank was set to the OFF position while the resident was using the nasal cannula. The Assistant Director of Nursing confirmed the discrepancy and adjusted the oxygen tank to 2 LPM, which still did not comply with the physician's order.
Failure to Provide Pneumococcal Immunization
Penalty
Summary
The facility failed to provide a pneumococcal immunization for one of the five sampled residents. A review of the facility's policy on influenza and pneumococcal vaccines revealed that residents should be interviewed about their immunization status upon admission, and if the status is unknown, Social Services or Nursing should contact the physician clinic for further records before administering the vaccine. However, a review of Resident 35's medical records showed a signed pneumococcal vaccine consent form indicating the resident had received the vaccine, but the form lacked the date and type of vaccine. Additionally, the form had a handwritten note stating 'may need booster.' Interviews with the Assistant Director of Nursing and Social Services revealed that the facility had not verified whether Resident 35 had previously received the pneumococcal vaccine and that the resident had not received the vaccine while residing in the facility.
Failure to Administer COVID-19 Vaccine
Penalty
Summary
The facility failed to provide a COVID-19 immunization for one resident, despite the resident having signed a consent form indicating their desire to receive the vaccine. A review of the resident's medical records showed that the consent form was signed on 12/11/2023. However, a subsequent review of the resident's immunization records on 5/6/2024 revealed no evidence that the vaccine had been administered. Interviews with the Assistant Director of Nursing and Social Services staff confirmed that the resident had not been scheduled for the vaccination, highlighting a lapse in the facility's process for managing and documenting immunizations.
Failure to Ensure Proper Use of Hoyer Lift and Oxygen Concentrator Safety
Penalty
Summary
The facility failed to ensure the use of two-persons while utilizing a Hoyer lift for a resident with severe cognitive impairment and multiple dependencies. The resident, admitted with diagnoses including Dementia and Chronic Kidney Disease, required assistance for all transfers. Despite the care plan and facility policy mandating a two-person assist for Hoyer lift transfers, a nurse aide was observed transferring the resident alone. The nurse aide admitted to frequently using the Hoyer lift without a second person and acknowledged being aware of the requirement but not trained to operate the lift alone. The Assistant Director of Nursing confirmed the expectation for a two-person assist with the Hoyer lift. Additionally, the facility failed to ensure the oxygen concentrator was turned off when not in use for another resident. Observations revealed the oxygen concentrator was left on with the tubing laying across the bed sheets while the resident was not in the room. This was confirmed as a fire hazard by a Licensed Practical Nurse and a Medication Aide. The facility's failure to adhere to safe oxygen storage practices was evident in multiple observations, posing a significant risk to resident safety.
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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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