Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Nathan Richard Health Care Center during CMS and state inspections, most recent first.
A resident with dementia, TBI, and anxiety repeatedly used derogatory language, including calling others "re****ed," toward and around peers and staff over an extended period. Although the care plan listed general behavior and psychosocial interventions, it was not promptly or specifically updated after early documented incidents, and there was no ongoing documentation of behavior monitoring or evaluation of intervention effectiveness. Staff interviews revealed that the resident’s inappropriate language had increased from occasional to daily, that other residents complained and avoided the resident, and that one resident requested transfer due to the language. CNAs and CMTs reported that redirection was the only intervention used, behavior notes were not consistently documented, and they were unaware of additional strategies. The SSD and Administrator acknowledged repetitive verbal behaviors and offers of counseling but did not document these behavioral health services, and a facility assessment indicated no services were needed despite ongoing issues, demonstrating a failure to provide and document necessary behavioral health care and services.
Two residents were involved in a verbal altercation where one threatened to kill the other, and staff recognized this as verbal and emotional abuse. Despite facility policy and regulatory requirements to report such allegations to DHSS within two hours, the DON and Administrator did not report the incident, as they did not initially consider the threat serious. Multiple staff interviews confirmed awareness of reporting protocols, but the mandated process was not followed.
A resident experienced a significant decline in condition, becoming unresponsive and unable to care for themselves. Despite this, the LTC facility staff failed to promptly send the resident to the hospital, did not follow up with the physician, and neglected to contact the medical director. The resident was eventually hospitalized for high potassium and elevated labs. Facility policies on notifying clinicians and documenting changes were not followed, contributing to the delay in care.
A resident developed a facility-acquired wound due to inadequate pressure ulcer care and documentation. The staff failed to conduct consistent wound assessments, track wounds weekly, and administer treatments as ordered. The resident, initially at risk but without pressure ulcers, developed cellulitis and blisters after a fall and improper use of an elastic bandage. The condition worsened to a stage IV ulcer with exposed tendon, leading to a wound care consultation and consideration for amputation.
The facility failed to provide sufficient RN and DON hours, requiring the DON to work as a charge nurse, which hindered her ability to fulfill her primary duties. The DON was responsible for various tasks, including wound care and infection prevention, but was unable to complete documentation and competency evaluations due to staffing shortages. The administrator was aware of the situation but expected the DON to complete her duties.
The facility failed to maintain proper food safety and sanitation practices, including inadequate labeling and dating of food, lack of hair and beard restraints for kitchen staff, and insufficient hand hygiene and equipment sanitation. Additionally, resident room refrigerators contained expired and spoiled food, indicating a lack of regular monitoring. These deficiencies pose potential health risks to residents.
The facility did not have a written transfer agreement with a hospital, which is essential for ensuring residents' timely hospital admission and information exchange. Despite attempts to establish agreements with local hospitals after a change in ownership, the facility received no response. Instead, it maintained agreements with other nursing homes and churches for emergency evacuation.
The facility failed to conduct competency evaluations for CNAs as part of the required in-service education. Despite having mandatory in-services and online training, there was no record of completed competencies. Interviews with staff, including a CNA, the DON, and the Administrator, confirmed the absence of competency evaluations, such as handwashing demonstrations.
The facility failed to conduct required criminal background checks and other screenings for several staff members, including two RNs and a dietary aide, before they began working with residents. This oversight violated the facility's abuse and neglect prevention policies, as checks were either delayed or not documented. Interviews revealed a lack of awareness and oversight in ensuring compliance with these policies.
The facility failed to maintain an effective infection control program, with staff not practicing proper hand hygiene and infection practices during wound and catheter care. Enhanced Barrier Precautions (EBP) were not consistently followed, and there were delays in TB testing for new staff. Observations showed improper handling of catheter bags and inconsistent use of gowns and gloves, with staff interviews revealing a lack of understanding of EBP protocols.
The facility failed to implement an effective antibiotic stewardship program, as it did not track or monitor antibiotic usage for residents on antibiotics for various infections. A resident with lymphoma and diabetes was on antibiotics for cellulitis, another with chronic respiratory failure and diabetes was on antibiotics for UTI prevention, and a third with UTI and bacteremia was on antibiotics for UTI and pneumonia. The Director of Nursing admitted to not maintaining an infection log after a physician left the facility.
A facility failed to obtain timely blood tests for a resident with schizophrenia, hypertension, and COPD, as per physician orders. The facility's policy required diagnostic services to be provided and results communicated within 24 hours, but staff did not document the completion or results of several ordered tests. Interviews revealed issues with lab order processes and communication, contributing to the oversight.
A resident with chronic kidney disease did not receive prescribed bumetanide due to its unavailability in the facility. Staff failed to reorder the medication or notify the physician about missed doses. The DON was unaware of the issue, and the facility lacked a clear policy for obtaining medications, leading to a deficiency in pharmaceutical services.
A facility failed to ensure timely physician response to pharmacist recommendations for a resident's medication review. The pharmacist suggested discontinuing oxybutynin chloride due to its anticholinergic side effects and switching to Gemtesa, but the physician did not address this. The resident, with multiple diagnoses, experienced a fall, and there was no documentation of follow-up in the medical record for several months.
A facility experienced a medication error rate of 5.56% due to two incidents. A CMT crushed extended-release potassium chloride tablets for a resident with hypokalemia, contrary to policy and drug warnings. Another resident with chronic kidney disease did not receive their prescribed bumetanide due to pharmacy unavailability, and the CMT failed to notify the DON. The Administrator expected staff to ensure medication availability.
A facility failed to document a resident's change in condition and transfer to the hospital, resulting in an incomplete medical record. The resident, with conditions such as hypertension and edema, was discharged to the hospital due to decreased function and decline in activities of living. Interviews with staff confirmed the lack of documentation, which was against the facility's policy.
The facility failed to ensure pneumococcal vaccinations were offered and documented for two residents, despite signed consents. The DON, responsible for administering vaccines, had not provided any since 2021, prioritizing flu vaccines instead. The SSD used a new consent form but lacked follow-up documentation. The Administrator expected vaccines to be ordered if requested, but the deficiency arose from inadequate documentation and administration.
Failure to Monitor and Address Resident’s Ongoing Inappropriate Verbal Behaviors
Penalty
Summary
Facility staff failed to ensure a resident with dementia, traumatic brain injury, and anxiety received necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being. The resident’s care plan identified psychosocial needs and behaviors such as yelling and repeating self, with interventions including avoidance of confrontation, maintaining routine, PRN medication for anxiety or agitation, monitoring for agitation, and ensuring safety. However, the annual MDS documented no verbal or behavioral symptoms directed toward others, despite later evidence of ongoing inappropriate language. A nurse’s note on 02/06/26 described the resident using the term “re****” about the secured unit in general during an argument with another resident, which upset the other resident and required staff to separate them. The care plan was not updated at that time to reflect this specific behavior or to add targeted interventions. A psychiatric evaluation on 02/10/26 documented a minor verbal altercation and use of inappropriate language, with staff redirection and the psychiatrist determining the resident was at baseline and making no care or medication changes. From 02/10/26 to 03/10/26, the medical record contained no documentation of behavior monitoring or evaluation of the effectiveness of interventions, despite staff later reporting that the resident’s use of the word “re****” had become a daily occurrence and was upsetting other residents. A subsequent psychiatric follow-up on 03/10/26 again noted no reported behavioral disturbances and no changes in care, and from 03/10/26 to 03/13/26 there was again no documentation of behavior monitoring or intervention effectiveness. On 03/14/26, a nurse’s note recorded that the resident called another resident a “re****” and then began talking about wanting divorce papers, indicating continued and escalating inappropriate language directed at or around peers. Following the 03/14/26 incident, the care plan was updated to add that the resident called peers names and to include general interventions such as administering medications as ordered, providing PRN medications when non-pharmacological interventions were ineffective, providing positive feedback, notifying guardian/physician as needed, seeking psychiatric consultation as needed, and encouraging the resident to go to more private areas to voice concerns. A PRN order for hydroxyzine for anxiety was added, but the March MAR showed no administrations of this PRN, and from 03/14/26 to 03/19/26 there was still no documentation of behavior monitoring or evaluation of intervention effectiveness. Multiple CNAs and CMTs reported that the resident used the word “re****” frequently—described as daily or weekly—in general conversation and sometimes directly toward other residents, that other residents complained and avoided the resident, and that one resident requested transfer due to the language. Staff consistently stated that redirection was the only intervention used, that they did not know of additional interventions, and that behavior notes were not being documented for each incident as required. The SSD and Administrator acknowledged offering counseling and discussing behaviors with the resident but admitted they did not document offers of counseling or additional behavioral services, and the SSD did not document offers of additional counseling despite repetitive behaviors. The facility’s own policy required accurate documentation of behavior changes, monitoring of frequency and triggers, and routine evaluation and modification of the care plan, but interviews and record review showed these processes were not implemented for this resident’s ongoing inappropriate verbal behaviors. Interviews with residents further confirmed the pattern of behavior and its impact. One resident reported observing the subject resident calling another resident “slow and re****ed” in the hallway, which prompted a confrontation and staff intervention, and stated that the subject resident often said that everyone there was “re****ed” and that no one should have to hear such language. Another resident, who was moved off the secured unit, recalled being called names and picked on by another resident and feeling upset at the time. Staff interviews indicated that administrative staff, including the Administrator and DON, were aware of the inappropriate language and agitation, but there were no documented new or enhanced behavioral interventions, no systematic behavior monitoring, and no consistent documentation of behavioral services offered. The Social Services Director acknowledged the resident had repetitive verbal behaviors and that counseling had been offered and declined, but these offers and any ongoing behavioral health efforts were not documented. A facility assessment form dated 03/18/26 marked that no services were needed, despite the ongoing behavioral issues described by staff and residents. Overall, the deficiency arose from the facility’s failure to have and implement an effective process to monitor repetitive inappropriate verbal behaviors, failure to consistently document behaviors and their frequency, failure to document and adjust interventions in the care plan in a timely manner after repeated incidents, and failure to document behavioral health services offered or provided. This resulted in ongoing use of derogatory language by the resident toward and around other residents and staff, with multiple complaints and observable distress among peers, without corresponding behavioral health documentation, monitoring, or clearly defined, documented interventions as required by the facility’s Behavioral Health Services Policy.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure that all allegations of possible abuse were reported to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. Specifically, the facility did not report a verbal altercation and threat involving two residents, despite facility policy and federal regulations requiring immediate reporting of such incidents. The incident involved one resident telling another that they would kill them, which was recognized by multiple staff members as verbal and emotional abuse and a reportable event. The events leading to the deficiency began when two residents, who were previously in a relationship, experienced a breakup that escalated into verbal altercations. One resident reported to staff that the other had threatened to kill them during an argument. This information was communicated to the Director of Nursing (DON), who did not immediately report the incident to the Administrator or DHSS, as required. The DON initially did not consider the threat serious due to the residents' ongoing arguments and relationship history, and only later reconsidered the severity of the incident. The Administrator was eventually informed but also failed to report the incident to DHSS, believing it was not a credible threat. Interviews with staff, including CNAs, a CMT, an LPN, and the Activity Director, revealed that they understood the requirement to report such allegations immediately and considered the threat to be abuse. Despite this, the DON and Administrator did not follow through with the mandated reporting process. The facility's own investigation confirmed that the incident was not reported to DHSS, and staff interviews corroborated that the reporting protocol was not followed as outlined in facility policy and regulatory requirements.
Failure to Address Change in Resident's Condition
Penalty
Summary
The facility failed to address a significant change in condition for a resident, who was initially alert, oriented, and cognitively intact. The resident experienced a decline, becoming unable to respond to questions, feed themselves, or express their desires. Despite these changes, the staff did not send the resident to the hospital immediately, failed to follow up with the physician when a message was not returned, and did not contact the medical director on the day the changes were observed. The resident was eventually sent to the hospital the following day after contact with a Nurse Practitioner, where they were admitted for high potassium and elevated labs. The facility's policies on Notification of Changes and Notifying Clinicians were not adhered to, as staff did not promptly inform the resident's physician or the resident's representative about the significant change in condition. The policies required that the clinician be notified of changes in conditions, emergent situations, and deviations from baseline, which did not occur in this case. The staff also failed to document attempts to contact the physician or the medical director, and there was no evidence of a full assessment of the resident's condition by the DON. Interviews with staff and the resident's family member revealed that the resident had been fluctuating between alertness and lethargy, and there was a known preference for hospital care that was not documented in the care plan. The DON and other staff members were aware of the resident's deteriorating condition but did not take appropriate action to ensure timely medical intervention. The resident's primary care physician and the medical director were not contacted as per protocol, leading to a delay in necessary medical care.
Failure in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident who had a facility-acquired wound. The staff did not have processes in place to ensure consistent, accurate, and thorough wound assessments were completed upon discovery and weekly. Additionally, there was a failure to complete weekly wound tracking, accurate and timely entries of wound treatments, and to complete wound treatments as ordered. This resulted in a resident developing a facility-acquired wound that required treatment by a wound care specialist and was considered for foot amputation. The resident, who was admitted with diagnoses including schizophrenia, chronic kidney disease, and hypertension, was at risk of developing pressure ulcers. Initially, the resident had no unhealed pressure ulcers. However, after a fall, the resident developed an avulsion fracture in the right ankle, which was not initially treated with specific orders. The resident requested an elastic bandage for pain relief, which was applied without a physician's order and left in place for two days, leading to cellulitis and blister formation. The facility staff failed to document the use of the elastic bandage or monitor the skin condition under it. Subsequent assessments by the Director of Nursing (DON) revealed blisters and discoloration on the resident's right foot and heel, but the size of the affected areas was not documented. Orders for wound care and antibiotics were inconsistently transcribed and administered, with several instances of missed documentation and treatment. The resident's condition deteriorated, with the wound progressing to a stage IV ulcer with exposed tendon, leading to a consultation with a wound care clinic where amputation was considered. Throughout this period, the facility failed to update the resident's care plan with the new wound conditions and related treatments.
Inadequate Staffing Impacts DON's Duties
Penalty
Summary
The facility failed to ensure consistent and sufficient Registered Nurse (RN) and Director of Nursing (DON) hours, which impacted the DON's ability to fulfill her duties effectively. The DON was frequently required to work as the charge nurse due to a shortage of nursing staff, which diverted her from her primary responsibilities. The facility's job description for the DON included overseeing nursing staff, establishing departmental goals, and implementing healthcare policies. However, the DON was unable to complete these tasks as she was also responsible for monitoring wounds, maintaining nursing operations, and overseeing the infection prevention program. The DON reported that she had to perform wound care for all residents and was unable to keep up with documentation and competency evaluations for nursing aides due to the staffing shortage. The DON's additional responsibilities included monitoring the pharmacy and antibiotic stewardship program, tasks that were previously supported by an Assistant Director of Nursing (ADON). The absence of an ADON and the need to cover charge nurse shifts hindered the DON's ability to manage the facility's nursing operations effectively. The facility's administrator was aware of the situation but expected the DON to complete her duties despite the staffing challenges. This deficiency highlights the facility's failure to provide adequate staffing to allow the DON to perform her essential duties, which are critical for maintaining the quality of care and compliance with healthcare regulations.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to proper food storage, preparation, and sanitation practices, leading to potential contamination risks. Observations revealed that food items in the walk-in refrigerator and freezer were not consistently labeled or dated, with some items showing signs of spoilage. Staff interviews confirmed that there was a lack of consistent responsibility for ensuring food items were properly sealed, labeled, and dated, which is crucial for maintaining food safety standards. Additionally, the facility did not enforce the use of hair and beard restraints among kitchen staff, as required by the FDA Food Code. Multiple staff members, including the Dietary Manager, were observed with facial hair not contained in beard nets while in the kitchen. This oversight increases the risk of hair contamination in food, which could compromise the safety and quality of meals served to residents. The facility also failed to maintain proper hand hygiene and equipment sanitation practices. Staff were observed not washing hands or changing gloves between tasks, and equipment such as thermometers and food processors were not adequately sanitized between uses. Furthermore, resident room refrigerators contained expired and spoiled food items, indicating a lack of regular monitoring and cleaning by facility staff. These deficiencies collectively pose significant health risks to residents, as they could lead to foodborne illnesses.
Lack of Hospital Transfer Agreement
Penalty
Summary
The facility failed to maintain a written transfer agreement with a hospital, which is necessary to ensure residents' timely admission to a hospital when medically appropriate and to facilitate the exchange of information between providers. The facility, with a census of 59, did not have a policy or a written transfer agreement with a community hospital. During an interview, the Administrator admitted to being unable to locate such an agreement. The facility had attempted to establish agreements with two local hospitals after a change in ownership in 2020 but received no response. Instead, the facility had transfer agreements with other nursing homes and churches for emergency evacuation.
Facility Lacks CNA Competency Evaluations
Penalty
Summary
The facility failed to provide continued training for certified nursing aides (CNAs) that included competency evaluation as part of the required minimum 12 hours of in-service education per year. The facility, with a census of 59, did not have a policy related to in-service training. A review of the facility's in-service training records showed no CNA competency evaluations were conducted. Interviews with staff, including a CNA, the Director of Nursing (DON), the Corporate Nurse, and the Administrator, revealed that while in-services and training were conducted, there were no competency evaluations completed. The DON and Corporate Nurse confirmed that essential competencies, such as handwashing return demonstrations, were not completed at the facility. The Administrator acknowledged that although there were mandatory in-services and online training assigned, there was no record of competencies being completed.
Failure to Conduct Required Background Checks for Staff
Penalty
Summary
The facility failed to implement its abuse and neglect prevention policies by not completing required criminal background checks (CBC) and other necessary screenings for several staff members. Specifically, the facility did not conduct CBCs for five staff members, including a maintenance worker, two registered nurses, a dietary aide, and a housekeeper. Additionally, the facility failed to perform Employee Disqualification List (EDL) checks for three staff members and did not complete Nurse Aide (NA) Registry checks for two registered nurses. These checks are crucial to ensure that staff members do not have a history of abuse, neglect, or other disqualifying offenses. The facility's policy mandates that the Human Resources Department conduct pre-employment screenings, including CBCs, EDL checks, and NA Registry checks, before hiring any staff. However, the review of personnel records revealed that these checks were either delayed or not documented as completed before the staff began working with residents. For instance, the CBC for Maintenance J was documented after the start date, and the EDL and NA Registry checks for RN E and RN F were either completed late or not documented at all. Interviews with the Business Office Manager and the Administrator highlighted a lack of awareness and oversight in ensuring that all necessary checks were completed before staff began working with residents. The Business Office Manager admitted to not completing the NA Registry checks for nurses and acknowledged delays in printing and documenting the results of background checks. The Administrator was unaware of these lapses, indicating a breakdown in communication and adherence to the facility's policies designed to prevent abuse and neglect.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility staff failed to establish and maintain an effective infection control program, as evidenced by multiple instances of improper hand hygiene and infection practices. During wound care for three residents, the Director of Nursing (DON) did not consistently wash or sanitize hands before donning gloves, failed to don a gown, and did not follow proper procedures for handling wound care supplies. For instance, the DON entered residents' rooms without washing hands, placed wound care supplies on unsanitized surfaces, and changed gloves without sanitizing hands in between. Additionally, there was a lack of signage for Enhanced Barrier Precautions (EBP) on resident doors, and gowns were not consistently worn during high-contact care activities. The facility also failed to adhere to EBP protocols for residents with multidrug-resistant organisms (MDROs) or those with chronic wounds and indwelling medical devices. Staff did not consistently use gowns and gloves as required during high-contact care activities, such as wound care and catheter care. Observations showed that catheter bags were improperly placed on the floor, and staff handled them without washing hands or donning gloves. Interviews with staff revealed a lack of understanding and inconsistent implementation of EBP, with some staff unaware of the requirements for wearing gowns during certain care activities. Furthermore, the facility did not complete the first step of a two-step tuberculosis (TB) skin screening test in a timely manner for four staff members before they began working with residents. Personnel records showed delays in administering and reading TB tests, contrary to the facility's policy that requires testing before staff start work. Interviews with the Business Office Manager, MDS Coordinator, and Administrator highlighted a lack of clarity and adherence to the policy regarding TB testing for new hires.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of tracking and monitoring of residents on antibiotics. The facility's policy required the antibiotic steward to maintain an infection log and track antibiotic usage, but this was not done for three residents who were on antibiotics for various infections. The Director of Nursing, who was also the Infection Preventionist, admitted to not keeping a record of antibiotics after a former physician left the facility. Resident #13 had a history of lymphoma, peripheral vascular disease, type 2 diabetes mellitus, and schizophrenia. The resident was on antibiotics for a right foot cellulitis and infection, but the facility did not maintain an infection log or tracking documentation for the antibiotic usage. Similarly, Resident #31, with a history of chronic respiratory failure, type 2 diabetes mellitus, heart failure, and UTIs, was on antibiotics for UTI prevention and treatment, but the facility failed to provide tracking documentation. Resident #45, diagnosed with UTI, type 2 diabetes mellitus, bacteremia, and cellulitis, was also on antibiotics for a UTI and pneumonia. The facility did not maintain an infection log or tracking documentation for this resident's antibiotic usage. The Director of Nursing acknowledged the lack of antibiotic review and tracking, attributing it to the absence of an Assistant Director of Nursing and the departure of a former physician.
Failure to Obtain Timely Blood Tests for Resident
Penalty
Summary
The facility failed to ensure that all residents received care according to professional standards of practice, specifically in obtaining ordered blood tests in a timely manner for one resident. The facility's policy required that diagnostic services be provided as per physician orders and that results be communicated to the ordering physician within 24 hours. However, for one resident, the facility did not document obtaining or the results of several ordered blood tests, including a complete blood count, comprehensive metabolic panel, A1C, depakote level, lipid panel, and hepatic panel. The resident involved had diagnoses including schizophrenia, hypertension, and chronic obstructive pulmonary disease. Despite having orders for specific blood tests to be conducted at regular intervals, the facility staff failed to document the completion or results of these tests. Interviews with staff revealed a lack of clear processes and communication regarding the entry and tracking of lab orders, contributing to the oversight. The Director of Nursing (DON) and Licensed Practical Nurse (LPN) interviews highlighted issues with the lab order process, including the entry of orders into the computer system and communication with the lab company. The DON noted that the facility had a new physician who entered their own lab orders without informing her, leading to missed entries in the lab website. The facility's process for managing lab orders was inconsistent, resulting in the failure to perform the necessary diagnostic tests for the resident as ordered.
Failure to Administer Medication Due to Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with chronic kidney disease stage 5, who was prescribed bumetanide, a diuretic medication. The medication was not administered as ordered on multiple occasions due to its unavailability in the facility. Staff documented the absence of the medication on the Medication Administration Record (MAR) but did not document any steps taken to obtain the medication or notify the physician about the missed doses. Interviews revealed that the Certified Medication Technicians (CMTs) were responsible for reordering medications, but there was a lack of clarity and communication regarding the process, leading to the medication not being reordered or obtained in a timely manner. The Director of Nursing (DON) was unaware of the missed doses and stated that if informed, she would have contacted the facility pharmacy to obtain the medication. The facility did not have a policy regarding pharmacy services or obtaining medications, contributing to the oversight. The Administrator expected staff to notify the DON if a medication was unavailable, but this protocol was not followed. The lack of a systematic approach to medication management and communication breakdowns among staff led to the deficiency in pharmaceutical services for the resident.
Failure to Address Pharmacist Recommendations for Medication Review
Penalty
Summary
The facility failed to ensure timely physician response to pharmacist recommendations during the monthly drug regimen review for a resident. The pharmacist recommended discontinuing oxybutynin chloride, an anticholinergic medication not recommended for the elderly due to its side effects, and suggested switching to Gemtesa. However, the physician did not address this recommendation, and there was no documentation of follow-up by the staff in the resident's medical record for several months. The resident, who had multiple diagnoses including cervical disc disorder, heart failure, and chronic pain, experienced a fall with no injury, which was documented in the care plan. Despite the pharmacist's repeated recommendations and the resident's risk for falls due to the medication, the facility did not have a policy in place for the pharmacy medication review and recommendation process, and the Director of Nursing was unaware of the specific recommendation until much later.
Medication Administration Errors Lead to 5.56% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 5.56%. This was due to two specific incidents involving medication administration errors. In the first incident, a Certified Medication Technician (CMT) crushed extended-release potassium chloride tablets for a resident with hypokalemia, despite facility policy and drug warnings indicating that such tablets should not be crushed. The CMT was unaware of a list of medications that should not be crushed, and the Director of Nursing (DON) confirmed that potassium chloride should be administered in liquid or powder form instead. In the second incident, another resident with chronic kidney disease did not receive their prescribed bumetanide medication because it was unavailable from the pharmacy. The CMT administering the medication did not notify the DON about the unavailability, and the DON was unaware of the missed administration. The facility's Administrator expected staff to notify the DON and ensure the medication was obtained for administration.
Failure to Document Resident's Change in Condition and Hospital Transfer
Penalty
Summary
The facility failed to maintain a complete medical record for a resident when staff did not document a change in condition and subsequent transfer to the hospital. The resident, who had diagnoses including essential hypertension, edema, and the presence of a cardiac pacemaker, was discharged to the hospital for a medical reason, decreased level of function, and recent decline in activities of living functioning physically. However, the staff did not document this change of condition or the transfer in the resident's progress notes. Interviews with the Care Plan Coordinator, Director of Nursing, and the Administrator confirmed that the nurse should have documented the change in condition and the transfer to the hospital in the progress notes. The facility's policy requires documentation of the reason for any facility-initiated transfer or discharge, but this was not adhered to in this instance, leading to an incomplete medical record for the resident.
Failure to Document and Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to develop and implement policies to ensure that all residents were offered pneumococcal vaccinations, as evidenced by the lack of documentation for two residents. Resident #11, who was admitted with diagnoses including diabetes mellitus, high blood pressure, anemia, and muscle weakness, had a signed consent for the pneumococcal vaccine. However, there was no documentation of the vaccine being administered or any orders for its administration between the due date and the survey date. Similarly, Resident #31, with diagnoses including chronic respiratory failure, type 2 diabetes mellitus, heart failure, high blood pressure, and acute kidney failure, had signed consent for the vaccine, but there was no documentation of administration or orders for the vaccine. Interviews with the Director of Nursing (DON) revealed that although consents were signed, the facility had not administered any pneumococcal vaccines since 2021. The DON, who was also the Infection Preventionist, stated that the facility prioritized flu vaccines and had not yet administered pneumonia vaccines. The DON mentioned that if residents requested the vaccine elsewhere, such as at a VA clinic, they would facilitate this, but there was no documentation to support these actions. The Social Service Director (SSD) indicated that a new vaccine consent form was being used, but there was confusion about its implementation. The SSD mentioned that they filled out the new form and asked residents if they wanted the vaccine, but there was no follow-up documentation. The Administrator expected vaccines to be ordered and provided if requested by residents, but the lack of documentation and follow-through on vaccine administration led to the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Nevada
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medicalodges Nevada | 1.6 mi | ★★★★★ | 0 | 0 |
| Moore Few Care Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Community Springs Healthcare Facility | 18.1 mi | ★★★★★ | 0 | 0 |
| Medicalodges Fort Scott | 20.1 mi | ★★★★★ | 8 | 0 |
| Truman Healthcare & Rehabilitation Center | 24.5 mi | ★★★★★ | 6 | 0 |
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