Wakefield Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wakefield, Nebraska.
- Location
- 306 Ash Street, Wakefield, Nebraska 68784
- CMS Provider Number
- 285209
- Inspections on file
- 19
- Latest survey
- July 22, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Wakefield Health Care Center during CMS and state inspections, most recent first.
The facility did not attempt or document required Gradual Dose Reductions (GDRs) for antipsychotic medications in two residents with dementia and behavioral disturbances, and allowed as-needed Haldol to be administered to another resident beyond the 14-day limit without proper evaluation. These actions were not in accordance with facility policy or federal regulations regarding psychotropic medication use.
Staff failed to secure medications by leaving them unattended on the medication cart, leaving the cart unlocked, and leaving the narcotic key in the lock without supervision. Additionally, medication aides did not properly supervise two residents during medication administration, relying only on verbal confirmation that medications were taken. The DON confirmed these practices were not in line with facility policy.
The facility did not perform or document required neurological assessments after unwitnessed falls for two residents, including one with severe cognitive impairment and on anticoagulant therapy. Despite facility policy mandating specific post-fall neurological checks and documentation, multiple assessments were missed or incomplete following several incidents. Interviews with staff and the DON confirmed that the established protocol was not followed.
Two residents with dementia, depression, and anxiety were prescribed multiple psychoactive medications, including Lorazepam, Mirtazapine, Zoloft, Lexapro, and Trazadone, without any documented attempts or consideration of Gradual Dose Reductions (GDRs) over the past year. Facility policy and federal regulations required GDRs to be attempted unless clinically contraindicated, but the DON confirmed that no such actions were taken or documented.
The facility failed to manage psychotropic medications properly for several residents. A resident received PRN antipsychotic medication beyond the 14-day limit without physician review. Another resident's gradual dose reduction for Clonazepam was delayed by 57 days despite a recommendation. Additionally, a resident continued to receive PRN Lorazepam without a clinical rationale for over three months.
The facility failed to implement enhanced barrier precautions for a resident with non-healing pressure ulcers and did not adhere to standard precautions for hand hygiene and glove use. Staff did not wash hands or change gloves appropriately, and reusable equipment was not cleaned between uses. The Director of Nursing and Administrator confirmed these deficiencies.
The facility failed to provide two residents with the required Advanced Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage, which are necessary to inform them of the discontinuation of Medicare Part A coverage and their right to appeal. There was no documented evidence that these notices were given in a timely manner, nor were there records of the residents' decisions regarding appeals or financial responsibility. Interviews confirmed the notices were not received before the services ended.
The facility failed to protect residents from potential abuse, as a staff member accused of abuse was allowed to continue working their shift, contrary to policy. Two residents with cognitive impairments were involved, with one case reported to Adult Protective Services. The facility's response did not align with their policy, potentially compromising resident safety.
The facility failed to timely report and investigate two incidents involving residents. One resident with severe cognitive impairment eloped, and the report was delayed beyond the required timeframe. Another resident with Alzheimer's dementia fell, sustaining a head injury, but no written investigation was completed or submitted. Interviews confirmed these deficiencies.
A facility failed to ensure appropriate use of antibiotics for a resident, who was on long-term Bactrim for chronic UTIs without a specified duration or supporting documentation. The resident's care plan lacked an indication for the antibiotic, and the DON confirmed the order was for palliative care without a stop date.
A facility failed to maintain a medication error rate below 5%, with errors affecting two residents. One resident received omeprazole nearly two hours late, after breakfast, contrary to the prescribed time. Another resident's insulin was administered without expelling air from the pen, risking an inaccurate dose. Both errors were confirmed by the RN involved.
A resident's insulin medication was incorrectly labeled, indicating a dosage of 11 units instead of the prescribed 7 units. The facility's policy requires proper labeling and verification before administration, but the label lacked a pink sticker to indicate a change in dosage, which had been in effect for over two months. An RN confirmed the discrepancy during an observation.
The facility failed to conduct required state Nurse Aide registry checks for two employees, Housekeeper-M and Transportation Aide-L, before their employment, violating policy and state regulations. This oversight, confirmed by a business office staff member, had the potential to affect all 33 residents, as it could allow individuals with a history of misconduct to work in the facility.
Failure to Ensure Gradual Dose Reductions and Timely Review of Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary psychotropic medications, specifically antipsychotics, as required by both facility policy and federal regulations. For two residents with dementia and behavioral disturbances, the facility did not attempt or document Gradual Dose Reductions (GDRs) for their prescribed Seroquel, despite these residents having been on the medication since admission. The care plans and medication administration records for these residents showed ongoing use of antipsychotic medication without evidence of GDRs being addressed or attempted over the previous year. The Director of Nursing confirmed that no GDRs had been attempted or documented for these residents during this period. Additionally, another resident with severe cognitive impairment and multiple diagnoses, including dementia, heart disease, anxiety, and depression, was prescribed Haldol as needed for agitation, aggression, or restlessness. The as-needed order for Haldol was continued and administered beyond the 14-day limit without documented evaluation by the primary care provider for appropriateness, as required by facility policy. The Director of Nursing confirmed that the medication was administered past the 14-day limit. These actions were inconsistent with the facility's own policy and regulatory requirements regarding the use and review of psychotropic medications.
Failure to Secure Medications and Supervise Administration
Penalty
Summary
Facility staff failed to ensure the safe storage and supervision of medications in accordance with professional standards and facility policy. Observations revealed that medications were left unattended on top of the medication cart, and the cart itself was left unlocked and unsupervised in multiple instances. The key to the narcotic lock box was left in the lock with no nurse present, and staff were observed walking away from the cart while it remained accessible to others. These actions were in direct violation of the facility's own policies, which require all drugs and biologicals to be stored in locked compartments and not left unattended. Additionally, staff did not properly supervise residents during medication administration. On several occasions, medication aides placed medication cups in front of residents and walked away without ensuring the medications were taken, relying solely on verbal confirmation from the residents. Interviews with staff confirmed that residents were not supervised during medication administration, and the Director of Nursing acknowledged that medications should be locked and residents should not receive medications without staff supervision. These failures were observed among a sample of 19 residents, with a facility census of 31.
Failure to Complete Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to complete neurological assessments as required by its own policy following unwitnessed falls for two residents. The policy, last revised in October 2010, mandates neurological checks after unwitnessed falls, falls with suspected head injury, or when indicated by resident condition. These checks include assessments of orientation, speech, vital signs, pupil reactions, and motor ability, and must be documented in the resident's medical record with specific timing and details. Staff interviews confirmed that the protocol was not followed, and the Director of Nursing acknowledged the lapses. One resident with severe cognitive impairment, multiple diagnoses including heart disease and dementia, and on anticoagulant therapy, experienced several unwitnessed falls. For each incident, required neurological assessments at specified intervals (every 15 minutes, 30 minutes, hourly, and per shift) were missing from the documentation. The resident's care plan identified them as high risk for falls and in need of extensive assistance, yet the facility failed to document or perform the required post-fall neurological checks on multiple occasions. Another resident, cognitively intact but with multiple medical conditions and at risk for falls, also experienced unwitnessed falls. After these incidents, the facility failed to complete and document neurological assessments and vital signs as required. Incident reports and post-fall assessment forms showed missing or incomplete documentation for the required checks. The DON confirmed that staff did not follow the facility's neurological assessment protocol after these falls.
Failure to Attempt Gradual Dose Reductions for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that two residents' drug regimens were free from unnecessary medications by not attempting or addressing Gradual Dose Reductions (GDRs) for their psychoactive medications. Facility policy required that behavior interventions be evaluated before using psychotropic medications, and that GDRs be attempted unless clinically contraindicated, in accordance with federal regulations. For both residents, who had diagnoses including dementia with behavioral disturbances, depression, and anxiety, there was no evidence in their medical records that GDRs were attempted or considered over the previous year for medications such as Lorazepam, Mirtazapine, Zoloft, Lexapro, and Trazadone. Record reviews showed that one resident was receiving Mirtazapine, Zoloft, and Lorazepam, while another was on Lexapro, Lorazepam, and Trazadone, with no documentation of GDRs being addressed. The Director of Nursing confirmed during interview that no GDRs had been attempted or addressed for these residents' psychoactive medications in the past year, which was inconsistent with both facility policy and regulatory requirements.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to adhere to regulations regarding the administration and management of psychotropic medications for several residents. For Resident 12, the facility did not ensure that an as-needed (PRN) antipsychotic medication order was limited to 14 days in duration. The resident, who had severe cognitive impairment and multiple diagnoses including dementia and depression, received Haloperidol without a stop date, and the medication was administered on multiple occasions beyond the 14-day limit without a physician's review. Resident 18, diagnosed with anxiety disorder, depression, manic depression, schizophrenia, and diabetes, was prescribed Clonazepam for anxiety. Despite a recommendation from a Nurse Practitioner to reduce the dosage due to potential tolerance, the facility did not implement the new order for a gradual dose reduction until 57 days later. This delay occurred even though the Primary Care Provider had signed off on the recommendation. For Resident 25, who had severe cognitive impairment and diagnoses including Alzheimer's disease and depression, the facility failed to provide a clinical rationale for the continued use of PRN Lorazepam. Despite recommendations from the Consultant Pharmacist to re-evaluate the medication and determine a duration date, the facility continued to administer the medication without documented justification for over three months.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with non-healing pressure ulcers, as required by their policy. Despite the resident's ongoing pressure ulcers, there was no signage or additional personal protective equipment (PPE) available in the resident's room to indicate EBP was in place. A nursing assistant confirmed that the resident had not been placed on EBP, and the Director of Nursing and Administrator acknowledged that the resident should have been on EBP due to the non-healing pressure ulcers. Additionally, the facility did not adhere to standard precautions regarding hand hygiene and glove use. Observations revealed that staff did not wash hands or change gloves at appropriate intervals during resident care, leading to potential cross-contamination. For instance, a medication assistant handled soiled linens without proper bagging and transported them through the facility, and another staff member used the same gloves for multiple tasks without changing them, including handling clean items after touching soiled ones. The facility also failed to properly clean reusable equipment between resident uses. A Hoyer lift was used on multiple residents without being cleaned in between, as confirmed by staff interviews. The Director of Nursing and Administrator confirmed that soiled linens should be bagged, and equipment like the Hoyer lift should be cleaned between uses to prevent cross-contamination.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to provide two residents, identified as Resident 5 and Resident 18, with the necessary Advanced Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage, which are required by the Centers for Medicare & Medicaid Services (CMS) regulations. These notices are crucial for informing residents or their representatives about the discontinuation of Medicare Part A coverage, potential financial responsibilities, and their right to appeal the decision. The facility's policy mandates that the ABN be given at least 48 hours in advance of any services likely to be denied by Medicare, and it must include specific details such as the resident's name, service description, reason for denial, estimated costs, and options for the resident to choose regarding the services. However, there was no documented evidence that these notices were provided to the residents or their representatives in a timely manner, nor was there any record of their decision to appeal or accept financial responsibility. For Resident 5, the skilled care services were no longer covered beginning on April 27, 2024, but there was no evidence of the resident or representative's decision regarding the appeal or billing options, nor was there a signature indicating receipt of the notice. Similarly, for Resident 18, the skilled care services ended on February 20, 2024, without documented evidence of the resident or representative's receipt and acknowledgment of the notice. Interviews with the representatives of both residents confirmed that they did not receive the necessary forms before the services ended. Additionally, a Business Office staff member confirmed that there was no verification of the notices being provided to the representatives before the service end dates, and no documented evidence of the residents' choices regarding continued services or appeals.
Failure to Protect Residents from Alleged Abuse
Penalty
Summary
The facility failed to protect residents from potential abuse, as evidenced by an incident involving two residents and an allegation of staff-to-resident abuse. The facility's policy on abuse, neglect, and misappropriation outlines procedures for handling such allegations, including immediate removal of the accused staff from the facility and ensuring the resident's protection. However, in this case, the accused staff member was allowed to continue working for the remainder of their shift, although they were restricted from entering the rooms of the residents who made the accusations. This decision was confirmed by both the LPN and the Administrator, indicating a failure to adhere to the facility's policy and adequately protect all residents. Resident 2, who had moderate cognitive impairment and required extensive assistance with daily activities, was involved in the incident, but there was no documentation in their progress notes regarding the alleged incident. Resident 5, who had severe cognitive impairment and required substantial assistance, was the subject of a verbal abuse allegation reported to Adult Protective Services. Despite the serious nature of these allegations, the facility's response did not align with their policy, as the accused staff member was not immediately removed from the facility, potentially compromising the safety of all residents.
Failure to Timely Report and Investigate Incidents
Penalty
Summary
The facility failed to complete and submit timely investigations for two separate incidents involving residents. In the first case, a resident with severe cognitive impairment and multiple diagnoses, including Parkinson's Disease and dementia, eloped from the facility. The incident occurred on 8/27/24, but the report was not submitted to the State Agency until 9/5/24, missing the required five working days deadline. The Director of Nursing confirmed the delay in reporting during an interview. In the second incident, another resident with Alzheimer's dementia and severe cognitive impairment experienced a fall with injury. The resident fell backward, striking their head on a dresser, resulting in profuse bleeding and requiring emergency room evaluation. Although Adult Protective Services were notified, the facility did not complete or submit a written investigation to the State Agency. Interviews with the Director of Nursing and the Administrator confirmed the lack of a written investigation for this incident.
Failure to Ensure Appropriate Use of Antibiotics
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications, specifically concerning the long-term use of an antibiotic for one resident. The facility's policy on Antibiotic Stewardship, reviewed in June 2024, aimed to monitor and promote the appropriate use of antibiotics, requiring prescribers to provide complete orders including drug name, dose, frequency, duration, route, and indications of use. However, for Resident 18, there was an order for Bactrim Double Strength to be taken daily for chronic urinary tract infections without a specified duration or supporting documentation for clinical use based on laboratory results. Resident 18's Minimum Data Set (MDS) indicated multiple diagnoses, including anxiety, depression, diabetes, manic depression, and schizophrenia, and the resident was receiving several medications, including an antibiotic, daily. The resident's care plan did not reflect an active or chronic infection or an indication for the long-term use of the antibiotic. During an interview, the Director of Nursing confirmed that the resident was on a prophylactic antibiotic, ordered by Hospice for palliative care, but there was no specified stop date or duration for its continued use.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by observations, record reviews, and interviews. During the administration of 28 medications, two errors were identified, resulting in a medication error rate of 7.14%. These errors affected two of the four sampled residents. The first error involved Resident 4, who was prescribed omeprazole 40 mg to be taken 60 minutes before meals at 7:30 AM. However, the medication was administered by RN-B at 9:25 AM, nearly two hours after the prescribed time, and after the resident had already eaten breakfast. The second error involved Resident 23, who was prescribed Novolog FlexPen insulin, 7 units subcutaneously, to be administered three times a day with meals. RN-B failed to follow the manufacturer's instructions for preparing the insulin pen, which required expelling 2 units of air before administering the dose. Instead, RN-B directly administered the 7 units without expelling air, potentially leading to an inaccurate dose. Both errors were confirmed through interviews with RN-B, who acknowledged the deviations from the prescribed procedures.
Incorrect Insulin Labeling for a Resident
Penalty
Summary
The facility failed to ensure that an insulin medication was labeled correctly for one of the sampled residents. The facility's policy on the storage of medications, which was reviewed in April 2024, mandates that drug containers with missing, incomplete, improper, or incorrect labels should be returned to the pharmacy for proper labeling before storage. Additionally, the policy on administering medications requires the individual administering the medication to check the label three times to verify the right resident, medication, dosage, time, and route of administration before giving the medication. During an observation, a registered nurse (RN) administered insulin to a resident using a Novolog FlexPen. The label on the insulin indicated a dosage of 11 units to be given subcutaneously three times a day, 15 minutes before a meal. However, the RN administered 7 units, as per the physician's order recorded in the Medication Administration Record (MAR), which was correct. The RN confirmed that the label on the medication was incorrect and should have had a pink sticker to alert staff of a change in the medication instruction, which had occurred over two months prior. The absence of this sticker was confirmed during the observation and interview with the RN.
Failure to Conduct Required Nurse Aide Registry Checks
Penalty
Summary
The facility failed to complete the required state Nurse Aide registry checks for two of the five sampled employees, which is a violation of the facility's policy and state regulations. The policy mandates that the facility must not employ individuals who have been found guilty of abuse, neglect, exploitation, or misappropriation of property, and requires background checks to be conducted prior to or at the time of employment. However, upon review, it was found that the facility did not check the state Nurse Aide registry for Housekeeper-M, hired on March 18, 2024, and Transportation Aide-L, hired on May 15, 2024, for any negative findings related to abuse, neglect, exploitation, or misappropriation of property. An interview with a business office staff member confirmed that the state Nurse Aide registry was not checked for these two employees before their start dates, and both had been working in the facility since their respective hire dates. This oversight had the potential to affect all residents, as the facility census was 33 at the time of the report. The failure to conduct these checks is a significant lapse in ensuring the safety and well-being of the residents, as it could allow individuals with a history of misconduct to be employed in the facility.
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.
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