Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Adept Nursing & Rehab Of South Sioux City during CMS and state inspections, most recent first.
A resident with multiple serious diagnoses, including ESRD, heart failure, cellulitis, hepatic encephalopathy, and morbid obesity, experienced progressive changes in condition, including loss of appetite, refusal of all meals, lethargy, weakness, and an SpO2 of 88%, followed by findings of a pale appearance and a bright red, edematous, warm, and tender stump that was later diagnosed as cellulitis. Despite a facility policy requiring prompt physician notification for significant changes in condition, the MD was not notified until the following day when the stump changes were observed and the resident was then sent to the ED. Separately, the same resident’s weight increased from 390 to 415 pounds over a short period, representing a significant weight gain without a prescribed weight‑gain regimen, and there was no evidence that the physician was notified of this weight change.
A resident with CHF, atrial fibrillation, hypertension, and renal insufficiency was not weighed as ordered on two consecutive days after admission, despite physician orders for daily weights to monitor the effects of diuretic therapy. Both the ADON and DON confirmed the omission.
Delayed call light response times were documented throughout the facility. A resident was observed waiting 26 minutes for a call light response, and the resident reported staff often took over 15 minutes to respond. Device activity records showed multiple call lights in several rooms unanswered for 15 to 59 minutes, and residents at council said call lights were not answered in an acceptable time frame. The DON and Administrator confirmed the facility expected staff to answer call lights within 15 minutes.
Missing Clinical Rationale for Psychotropic Medication Gradual Dose Reductions: The facility failed to document clinical rationale for not attempting GDRs for psychotropic meds. A resident with dementia, anxiety, and depression remained on Buspar and Quetiapine without documented rationale; another resident with dementia and bipolar disorder remained on Effexor XR without documented rationale; and a third resident with Parkinson’s disease, CKD, diabetes, MDD, anxiety, dementia, and schizophrenia remained on Sertraline without documented rationale. The DON confirmed the missing documentation.
A resident with dementia, anxiety, and depression was given quetiapine and buspirone before signed informed consent was obtained for the psychotropic meds. The facility policy required the resident or RP to be informed in advance of the risks, benefits, and alternatives, but an RN stated consent was being requested after meds were started, and the DON confirmed there was no evidence consent was obtained before administration.
A resident with ESRD, stroke, diabetes, CKD, and recurrent UTI risk was receiving Nitrofurantoin for UTI prophylaxis without a stop date, while also being started on Cefdinir for a current UTI. The facility’s antibiotic stewardship policy required antibiotic orders to include dose, duration, and indication, but the MAR showed the prophylactic antibiotic lacked a documented duration. An LPN and the DON confirmed the missing stop date and that the resident had a current UTI.
Failure to use required PPE during EBP wound care. A resident with diabetes, CKD/ESRD, stroke-related paralysis, and chronic open foot ulcers was on EBP with PPE available outside the room. An RN and NA performed wound treatment and assisted with care using gloves only, without gowns, and both later confirmed gowns should have been worn; the DON also confirmed PPE should have been used during treatment to the resident's open foot areas.
A resident with severe cognitive impairment and an ear infection experienced a delay in treatment due to the facility's failure to promptly notify a physician of a change in condition. Despite attempts to contact the resident's medical practitioner and an alternate, there was no follow-up documentation or response until an antibiotic was ordered days later.
The facility experienced significant delays in responding to residents' call lights due to a shortage of pagers and walkie-talkies. A resident with a history of cerebral infarction and a fracture waited over two hours for assistance after activating the call light, with several other instances of delayed responses noted. Staff interviews confirmed the lack of necessary equipment, and the facility's call light monitoring system was inadequate, contributing to the deficiency.
A resident with a bleeding wound on blood thinners experienced a significant delay in receiving care due to a call light not being answered for over two hours. Despite the facility's expectation for call lights to be answered within 15-20 minutes, the resident's call light was not addressed until a family member intervened. The resident's care plan included monitoring the wound, but there was a lack of timely documentation and intervention, leading to a deficiency in care.
The facility's kitchen was found to have multiple food safety and sanitation deficiencies, affecting 48 of 49 residents. Observations included undated and unlabeled food items, frost buildup on the freezer door, and dirty surfaces in the dishwashing area. The kitchen preparation area had dust and grease buildup, and the flooring was uncleanable due to unsealed patches. These issues were confirmed by the Certified Dietary Manager, indicating a failure to comply with Nebraska Food Code regulations.
The facility failed to maintain a clean and comfortable environment, with stained carpets, a strong urine smell in a room, and dusty ventilation covers. Additionally, a shared toilet lacked doors, and a privacy curtain was missing, compromising resident privacy.
Facility staff failed to perform hand hygiene after glove changes during care for two residents, leading to potential cross-contamination. Observations showed that staff placed washcloths in the sink and used them without barriers, and did not perform hand hygiene between glove changes. Interviews confirmed these practices contradicted facility policies, and the DON acknowledged the risk of cross-contamination.
The facility failed to provide timely written notification of hospital transfers for a resident and their representative, and did not notify the Ombudsman for two residents. One resident was transferred twice without receiving a bed hold notice, and the Ombudsman was not informed of another resident's hospital transfers. The Social Services Director and Designee confirmed these lapses.
The facility failed to provide written bed hold notices to two residents during hospital transfers, as required by policy. One resident was transferred twice without receiving a notice, and another resident did not receive notices for two of their transfers. The Social Services Director confirmed these omissions.
A facility failed to accurately complete a PASARR for a resident admitted with Unspecified Dementia, Generalized Anxiety Disorder, Major Depressive Disorder, and Delusional Disorder. The PASARR Level 1 screening incorrectly assessed the resident as having no diagnosis of SMI or ID/RC. The Social Services Director confirmed the inaccuracy, noting that a Level 2 screen was necessary based on the resident's diagnoses.
A resident with multiple health conditions did not receive timely skin evaluations and treatments as per the prescribed schedule. The resident's records showed missing documentation for skin assessments, and evaluations revealed worsening skin maceration. Despite treatment orders for skin breakdown prevention, there was inconsistent documentation and adherence to the treatment schedule.
A facility failed to follow the prescribed wound care treatment for a resident's left heel ulcer. The treatment administration record indicated a daily skin prep order, but a nurse applied Betadine instead. The DON confirmed the treatment should have been skin prep, and the nurse was unaware of the current order.
A resident with severe cognitive impairment and multiple health conditions experienced a fall due to the facility's failure to implement recommended interventions. Staff were observed transferring the resident without using Dycem to prevent slipping, despite it being documented in the care plan. Interviews revealed staff were unaware of this intervention.
A resident with moderately impaired cognition was prescribed Novasource renal formula at a specific rate, but it was administered via gravity without a physician's order. Nursing staff, including an LPN and RN, were unaware of the correct formula, rate, and flush amount, and the DON confirmed the lack of a physician's order for gravity administration.
A facility failed to identify and monitor specific behaviors for a resident receiving psychotropic medications. Despite the resident being cognitively intact and having multiple diagnoses, including bipolar disorder, the facility did not document targeted behaviors in the resident's medical records or care plan. This was confirmed by the DON, indicating non-compliance with the facility's policy on psychotropic medication use.
Failure to Notify Physician of Change in Condition and Significant Weight Gain
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s physician of significant changes in condition, including symptoms related to cellulitis and a substantial weight gain. The facility’s own “Notification of Changes” policy required prompt physician consultation and notification of the resident and representative for significant physical changes, deterioration in health status, or circumstances requiring alteration of treatment. The resident had multiple serious diagnoses, including alcohol cirrhosis of the liver, anemia, end stage renal disease, depression, cellulitis, hepatic encephalopathy, morbid obesity, and heart failure. The MDS dated 2/18/26 documented that the resident’s cognition was intact, the resident reported feeling down or depressed, and had a weight of 411 pounds with a weight gain of 5% or more in the last month or 10% or more in the last six months, without being on a prescribed weight gain regimen. Nursing progress notes showed that on 11/28/25 staff documented that the resident did not look good, had loss of appetite, did not eat breakfast, and was very drowsy. Throughout that day, the resident refused lunch and dinner due to poor appetite, reported feeling tired with little energy, remained lethargic and weak, and refused hospitalization when suggested by staff. Later that evening, the resident’s oxygen saturation was documented at 88%, and there was no further documented assessment after 9:53 PM until 10:30 AM the next day, when the resident was noted to be pale with flushed cheeks and a left stump that was bright red, edematous, warm, and tender; only then was the physician notified and the resident sent to the emergency room, where the resident was admitted for cellulitis. Additionally, weight records showed an increase from 390 pounds on 2/3/26 to 412 pounds on 2/10/26 (a 22‑pound, 6% gain in one week), and then 415 pounds on 2/12/26, with no evidence that the physician was notified of this significant weight gain.
Failure to Complete Ordered Daily Weights for Resident on Diuretic Therapy
Penalty
Summary
The facility failed to follow physician's orders for a resident who had multiple significant health conditions, including atrial fibrillation, congestive heart failure (CHF), hypertension, and renal insufficiency. The resident was prescribed a diuretic for CHF and had admission orders for daily weights for four days, followed by weekly weights for four weeks, to monitor the effects of the medication. Record review showed that the resident's daily weights were not completed on two consecutive days as ordered. This was confirmed by both the Assistant Director of Nursing and the Director of Nursing, who acknowledged that the required weights were not obtained on the specified dates.
Delayed Call Light Response Times
Penalty
Summary
The facility failed to ensure adequate staffing related to call light response times and did not have enough staff available to meet resident needs as reflected in repeated delays in answering call lights. The facility assessment, revised 6/6/25, stated it was used to make staffing decisions to ensure sufficient staff to care for residents based on assessments and plans of care, but the report documented multiple call light activations that remained unanswered well beyond the facility’s expected 15-minute response time. On 8/17/25, Resident 53’s call light was observed on at 9:04 AM, the resident was hollering for help at 9:20 AM, and the call light was not answered until 9:31 AM, for a total of 26 minutes. Resident 53 reported that staff often took over 15 minutes to answer the call light. Review of the Device Activity Report showed multiple additional call light response times over 15 minutes for Resident 53 and for random rooms from 8/18/25 through 8/20/25, including several responses lasting more than 20, 30, 40, and up to 59 minutes. Residents at the Resident Council meeting stated call lights were not answered in an acceptable time frame, and the DON and Administrator confirmed that staff were expected to answer call lights within 15 minutes and that call lights had remained on longer than that.
Missing Clinical Rationale for Psychotropic Medication Gradual Dose Reductions
Penalty
Summary
The facility failed to ensure that gradual dose reductions were attempted or that documented clinical contraindications were completed for psychotropic medications. The deficiency was identified during record review and interviews, and involved the required monthly pharmacist drug regimen review process and the facility’s psychotropic medication policy, which stated that residents receiving psychotropic medications should have gradual dose reductions unless clinically contraindicated. For Resident 1, the record showed diagnoses of dementia, anxiety, and depression, and use of antipsychotic and antianxiety medications. The consultant recommendations to the physician documented that Buspar 5 mg daily, started 5/31/24, and Quetiapine 25 mg daily, started 7/17/24, were continued without attempting a gradual dose reduction, but no clinical rationale was documented. The same issue was repeated in later consultant recommendations, and the DON confirmed that there was no documented clinical rationale for not attempting dose reduction for these psychotropic medications despite the pharmacist recommendations. For Resident 2, the record showed diagnoses of dementia and bipolar disorder and use of antidepressant medication. The consultant recommendation to the physician documented that Effexor XR 75 mg daily, started 10/19/23, was continued without a gradual dose reduction, but no clinical rationale was documented. For Resident 23, the record showed diagnoses including Parkinson’s disease, chronic kidney disease, diabetes, major depressive disorder, anxiety, dementia without behaviors, and schizophrenia, and use of psychotropic medications. The medication review report showed Sertraline 50 mg daily for major depressive disorder, and the consultant recommendation stated there was no documented rationale for continued use; the DON confirmed there was no rationale documented for continued use of Sertraline.
Failure to Obtain Informed Consent Before Starting Psychotropic Medications
Penalty
Summary
The facility failed to obtain signed informed consent for psychotropic medications before they were started for a resident with dementia, anxiety, and depression. The resident’s record showed use of antipsychotic and antianxiety medications, and the medication administration record showed quetiapine 25 mg daily and buspirone 5 mg daily were started on 5/6/25. The facility policy required residents or their representatives to be informed in advance of the risks, benefits, and alternatives for psychotropic medications and to have the right to accept or decline initiation or increases before the medications were used. The resident’s psychotropic medication informed consent was dated 5/20/25, which was 15 days after the readmission orders for quetiapine and buspirone had already been started and given. During interview, an RN stated the facility was requesting consent for psychotropic medications but was not waiting to obtain that consent before starting the medications. The DON later confirmed there was no evidence the facility obtained informed consent prior to administering quetiapine and buspirone to the resident.
Missing Stop Date for Antibiotic Prophylaxis
Penalty
Summary
The facility failed to ensure Resident 16’s drug regimen was free from unnecessary drugs because a documented duration of use was not included for an antibiotic. The facility’s Antibiotic Stewardship Program stated that all antibiotic prescriptions were to specify the dose, duration, and indication for use, and that antibiotic orders were to be reviewed for appropriateness. Resident 16’s MDS dated 7/16/25 showed the resident was admitted with end stage kidney failure, stroke, depression, and asthma, was dependent with dressing and toileting, needed assistance with personal hygiene, was always incontinent, and was cognitively intact. Resident 16’s care plan identified the resident as at risk for recurrent UTI and noted paralysis due to stroke, diabetes, chronic kidney disease, end stage renal disease, and dependence on dialysis. The MAR for August 2025 showed Nitrofurantoin 100 mg orally daily for a history of UTIs and prophylaxis, ordered 6/28/25 with no stop date, and Cefdinir 300 mg twice daily for 7 days for a UTI ordered 8/18/25. An LPN confirmed the Nitrofurantoin had no stop date and was being given for prophylaxis, and further confirmed the resident had a current UTI and was started on an additional antibiotic. The DON also confirmed antibiotics should have a stop date and that Resident 16 had a current UTI and was started on an additional antibiotic.
Failure to Use Required PPE During EBP Wound Care
Penalty
Summary
The facility failed to utilize the required PPE, specifically gowns and gloves, during care for a resident on Enhanced Barrier Precautions (EBP). The resident had cognitive intactness, required assistance with toileting, dressing, and hygiene, and had diagnoses including renal disease, diabetes, non-Alzheimer's dementia, Parkinson's disease, anxiety, depression, paralysis due to a stroke, chronic kidney disease, end stage renal disease, dependence on dialysis, and a non-pressure chronic ulcer of part of the right foot. The resident also had open lesions to at least one foot and chronic open areas to the feet and toes, including numerous diabetic ulcers, with an order for EBP due to wounds. During observation, the resident had an EBP sign posted outside the room and a PPE caddy on the back of the room door. On 8/19/25 at 9:55 AM, an RN and a nursing assistant performed hand hygiene, applied gloves, and entered the room, but neither wore gowns while completing wound treatments to the resident's open foot areas. The nursing assistant assisted by holding the resident's leg up during the treatment. After the care was completed, both staff removed their gloves and performed hand hygiene. The RN confirmed the resident was on EBP and that gowns should have been worn during the dressing change and care, and the DON later confirmed PPE should have been worn during treatment to the resident's open areas on the feet.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident, leading to a delay in treatment. The resident, who had severe cognitive impairment as indicated by a Brief Interview of Mental Status (BIMS) score of 4, required extensive assistance with daily activities. On October 7, 2024, the resident exhibited a fever of 101.5 degrees and had tenderness and drainage from the left ear, suggesting an ear infection. The facility attempted to contact the resident's medical practitioner, who was unavailable, and was advised to reach out to an alternate practitioner. Despite the resident's ongoing symptoms, there was no documentation of follow-up actions on October 8, 2024, and no response was received from the alternate practitioner by October 9, 2024. A fax was sent to the original medical practitioner, but the facility did not receive a response until October 10, 2024, when an antibiotic was finally ordered. The facility administrator confirmed that there was a delay in treatment and acknowledged that the facility should have contacted the practitioner again the following day if no response was received.
Delayed Response to Call Lights Due to Equipment Shortage
Penalty
Summary
The facility failed to ensure that staff were promptly notified of residents' calls for assistance, as evidenced by multiple instances of delayed response times to call lights. Resident 3, who was cognitively intact and had a history of cerebral infarction and a fracture, experienced significant delays in receiving assistance. On one occasion, Resident 3 activated the call light at 6:27 AM due to bleeding from a scratch and waited over two hours without a response, eventually requiring a family member to intervene. The call light log showed several other instances where Resident 3's calls went unanswered for extended periods, ranging from 23 to 114 minutes. Further review of call light activity reports for other residents revealed similar issues. Resident 2 experienced delays ranging from 22 to 65 minutes, while Resident 1 had call light response times ranging from 28 to 44 minutes. Observations indicated that the facility's call light monitoring system was inadequate, with monitors placed in locations not visible to staff working in various hallways. Staff interviews confirmed that they lacked pagers or walkie-talkies, which hindered their ability to promptly respond to call lights. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the shortage of pagers and walkie-talkies, which contributed to the delayed response times. The Administrator was unaware of the pager shortage and confirmed that staff had to leave their work areas to check call light monitors. The facility's expectation was for call lights to be answered within 15-20 minutes, but the current system and equipment shortages made it difficult to meet this standard, leading to the identified deficiency.
Delayed Response to Resident's Bleeding Wound
Penalty
Summary
The facility staff failed to provide timely care for a resident with a change in the condition of a wound. The resident, who was cognitively intact, had a cat scratch on the right forearm that was bleeding. Despite activating the call light at 6:27 AM, the resident waited for over two hours without receiving assistance, leading to the involvement of a family member who arrived at the facility to find help. The call light was not answered until 8:21 AM, which was significantly longer than the facility's expected response time of 15-20 minutes. The resident's medical history included a cerebral infarction and a fracture of the left fibula, and they were on blood thinners, which contributed to the bleeding issue. The care plan included monitoring the wound and reporting any abnormalities, but there was a lack of documentation and timely intervention when the wound continued to bleed. The resident's progress notes indicated multiple instances of bleeding and dressing changes, but there was no documentation on one of the days, and the provider was not contacted promptly. Interviews with facility staff revealed that the LPNs were not aware of the call light being on due to a lack of communication devices like pagers or walkies. The Director of Nursing confirmed that the provider should have been contacted earlier, and additional monitoring should have been conducted after the initial bleeding was noted. The delay in responding to the call light and the lack of timely medical intervention contributed to the deficiency in care provided to the resident.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in their kitchen, which had the potential to affect 48 of the 49 residents who consumed meals prepared there. During an initial kitchen tour, several deficiencies were observed, including an open and undated gallon of milk in the walk-in refrigerator, visible frost and ice buildup on the walk-in freezer door, and unlabeled and undated food items such as frozen egg patties or waffles, sandwiches, meat salad, and sour cream. Additionally, the dry storage area had boxes sitting on the floor, an open bag of lemonade drink mix, and an open bag of cocoa powder. The dishwashing area was found to have a dirty steel metal grate with dust, food debris, and grease buildup, as well as oxidized deposits on the dishwasher. Further observations revealed additional issues, such as unlabeled and undated food items like sour cream, hot dogs, and cottage cheese. The kitchen preparation area had dust, dirt, and grease buildup in the seams of the linoleum flooring, and the ice machine lid had a flakey substance. The dry storage room floor had dried food debris, and the kitchen flooring had unsealed patches, making it an uncleanable surface. These findings were confirmed by the Certified Dietary Manager, who acknowledged the need for cleaning, repair, and correction of the listed items. The Nebraska Food Code regulations were referenced, highlighting the requirement for nonfood-contact surfaces to be easily cleanable and for food to be stored in a manner that protects it from contamination.
Environmental Deficiencies in Facility Maintenance
Penalty
Summary
The facility staff failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by several deficiencies observed during an environmental tour. The carpets in the center hallway, south hallway, and the common area between the 400 north and south hallways were found to have irregularly shaped discolored blotches and streaked linear lines, indicating high traffic use and lack of proper maintenance. Additionally, a strong urine smell was detected in one of the rooms, with the Maintenance Director confirming that the odor originated from the floor. This suggests inadequate cleaning and sanitation practices in the facility. Further observations revealed that the ventilation covers in rooms 310, 402, and 405 were covered with a gray, fuzzy substance resembling dust, indicating a lack of regular cleaning. Moreover, a shared toilet between certain rooms lacked doors, compromising the privacy of the residents. A privacy curtain was also missing on one side of a shared toilet in another room, as confirmed by the Maintenance Director. These findings highlight the facility's failure to ensure a homelike environment and respect the residents' right to privacy.
Failure in Hand Hygiene and Cross-Contamination Prevention
Penalty
Summary
The facility staff failed to perform proper hand hygiene after glove changes during peri care, catheter care, and wound care, leading to potential cross-contamination. Observations revealed that Nurse Assistant (NA) D and NA E did not perform hand hygiene after glove changes while providing care to Resident 1, who required maximal assistance due to conditions such as heart failure, diabetes, schizophrenia, and morbid obesity. NA D placed washcloths in the sink, which were then used without a barrier, and failed to perform hand hygiene after removing soiled gloves. Similarly, NA E did not change gloves or perform hand hygiene after handling potentially contaminated items. In another instance, NA E and Registered Nurse (RN) A provided personal and wound care to Resident 21, who was a carrier of Methicillin Resistant Staph Aureus (MRSA) and required maximal assistance. Both staff members placed washcloths in the sink basin and used them without performing hand hygiene between glove changes. RN A used washcloths from the sink basin to clean various body areas and applied powder without changing gloves or performing hand hygiene, which could lead to cross-contamination. Interviews with the staff confirmed the failure to perform hand hygiene and the inappropriate use of the sink basin for washcloths, which contradicted the facility's policies on perineal care and hand hygiene. The Director of Nursing acknowledged that these practices could cause cross-contamination and confirmed that hand hygiene should have been performed after glove changes.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification of transfer to the hospital for Resident 252 and their representative, as well as failed to notify the Office of the State Long-Term Care Ombudsman for both Resident 252 and another resident. Resident 252 experienced a fall and was transferred to the hospital twice without receiving a bed hold notice at the time of transfer or shortly thereafter. The Social Services Director confirmed that the facility did not provide the required notifications to the resident or their representative. Additionally, the facility did not notify the Ombudsman of Resident 1's hospital transfers on two separate occasions. The Social Service Designee confirmed that the Ombudsman was not informed of these transfers. The facility's policy requires that residents and their representatives be informed of the bed hold option at the time of emergency transfer, with written details provided as soon as possible, which was not adhered to in these cases.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide a written notice of a bed hold to two residents during their transfers to the hospital. Resident 252 experienced a fall and was transferred to the hospital twice, once at night and once the following day, without receiving a bed hold notice at either time. The facility's policy requires that residents or their representatives be informed of the bed hold option at the time of emergency transfer, with written details provided as soon as possible. However, the Social Services Director confirmed that no such notification was given to Resident 252 or their representative during these transfers. Similarly, Resident 1 was transferred to the hospital multiple times, but the facility did not provide a bed hold notice for two of these transfers. The facility's policy mandates that a written notice specifying the duration of the bed hold policy and information about the resident's return to the next available bed be provided at the time of transfer. An interview with the Social Services Director confirmed that Resident 1 and their representative did not receive the required bed hold notices for the specified hospital transfers.
Inaccurate PASARR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to accurately complete a Preadmission Screening Resident Review (PASARR) for a resident, identified as Resident 34, who was admitted with diagnoses including Unspecified Dementia, Generalized Anxiety Disorder, Major Depressive Disorder, and Delusional Disorder. The PASARR Level 1 screening form dated July 12, 2023, incorrectly assessed the resident as having no diagnosis or suspicion of Serious Mental Illness (SMI) or Intellectual Disability or Related Condition (ID/RC). This inaccuracy was confirmed during an interview with the Social Services Director, who acknowledged that based on the resident's admission diagnoses, a PASARR Level 2 screen should have been completed. The facility's policy on coordinating assessments with the PASARR program was in place but not followed in this instance.
Failure to Conduct Timely Skin Evaluations and Treatments
Penalty
Summary
The facility staff failed to conduct timely skin evaluations and provide wound treatments according to the prescribed schedule for a resident. The resident, who was admitted with diagnoses including morbid obesity, alcoholic cirrhosis, and an above-knee amputation, required maximal assistance for personal hygiene and was dependent on staff for transfers. Despite having intact cognition, the resident's electronic health record showed missing documentation for skin assessments on specific dates, and subsequent evaluations revealed worsening skin maceration in multiple areas. Additionally, there was a failure to adhere to the treatment schedule for skin breakdown prevention. The treatment administration record indicated orders for twice-daily application of house powder and Nystatin powder to prevent fungal infections and soreness. However, observations confirmed that treatments were not consistently documented, and the facility's wound treatment management policy emphasized the importance of following physician orders and documenting treatments. The Director of Nursing confirmed the lack of skin assessments after a certain date, highlighting a lapse in the facility's adherence to care protocols.
Failure to Implement Ordered Wound Care Treatment
Penalty
Summary
The facility failed to implement the ordered treatment for a resident's wound care, specifically for a left heel ulcer. The treatment administration record for June 2024 indicated an order for daily skin prep on the resident's left heel, dated 6/5/2024. However, on 6/26/2024, a registered nurse (RN-A) was observed applying Betadine to the resident's left heel instead of the prescribed skin prep. During an interview, the Director of Nursing confirmed that the treatment should have been performed as ordered, and RN-A admitted to not being aware of the current order for the resident's left heel.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent recurring falls for a resident with severe cognitive impairment and multiple health conditions, including End Stage Renal Disease, Heart Failure, Diabetes Mellitus, and Depression. The resident required varying levels of assistance for daily activities and had previously experienced a fall while being transported in a wheelchair. The interdisciplinary team identified the cause of the fall as the resident sitting on a lift sling during transport and recommended using Dycem to prevent slipping. During an observation, staff members were seen transferring the resident into a wheelchair without using the Dycem as instructed. Interviews with the staff involved revealed they were unaware of the intervention to place Dycem under the wheelchair cushion and between the sling and the resident. The Director of Nursing confirmed that the intervention was documented in the resident's care plan, but it was not followed by the staff.
Failure to Follow Physician's Orders for Tube Feeding Administration
Penalty
Summary
The facility failed to adhere to physician's orders for the administration of tube feeding for a resident identified as having moderately impaired cognition. The resident was prescribed Novasource renal formula to be administered at a rate of 65 milliliters per hour for 12 hours. However, during an observation, it was found that the resident's tube feeding was being administered via gravity, with no indication of the rate or duration of administration. The gravity set bag was dated from the previous day and contained an unidentified formula, with 50 milliliters remaining. Interviews with the nursing staff, including an LPN and an RN, revealed a lack of knowledge regarding the formula being used, the prescribed rate, and the necessary flush amount after feeding. Both nurses were unable to locate a physician's order for administering the tube feeding by gravity. The Director of Nursing also confirmed the absence of a physician's order for this method of administration and was unaware that the tube feeding was being conducted in this manner.
Failure to Monitor Targeted Behaviors for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that targeted behaviors were identified and monitored for a resident receiving psychotropic medications. Specifically, Resident 4, who was cognitively intact and had multiple diagnoses including bipolar disorder, was prescribed Lithium Carbonate and Risperidone. However, the facility did not document specific behaviors to be monitored in the resident's medical records, care plan, or medication administration records. This lack of documentation was confirmed during an interview with the Director of Nursing. The facility's policy on the use of psychotropic medications requires that the indications for medication use, as well as the effects on the resident's well-being, be evaluated and documented. Despite this policy, the facility did not adhere to these guidelines for Resident 4, as there were no specific target behaviors identified or monitored. This oversight was noted in the resident's care plan and other medical records, which lacked documentation of the resident's response to the medications and progress towards therapeutic goals.
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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 South Sioux City
How nearby facilities compare on the same public inspection record.
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|---|---|---|---|---|
| Continental Springs, Llc | 0.5 mi | ★★★★★ | 10 | 0 |
| St Luke's Regional Medical Center Snf | 2.7 mi | ★★★★★ | 0 | 0 |
| Casa De Paz Health Care Center | 3.8 mi | ★★★★★ | 11 | 0 |
| Westwood Specialty Care | 4.1 mi | ★★★★★ | 16 | 0 |
| Holy Spirit Retirement Home | 4.1 mi | ★★★★★ | 10 | 0 |
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