Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Emerald Nursing & Rehab Lakeview during CMS and state inspections, most recent first.
Code status records did not match physician-signed advance directives for two residents. One resident’s signed form showed Full Code, but the admission record, care plan, and EHR profile showed DNR/DNI. Another resident with ESRD on dialysis, COPD, and CHF had a signed Full Code form, but the care plan, admission record, EHR profile, and paper report sheet showed DNR/DNI. Staff said they relied on the EHR code status during an emergency, and the DON confirmed the mismatches.
Failure to document required annual continuing education for nurse aides and medication aides. The facility policy required at least 12 hours of in-service training each year based on hire date, including dementia care and abuse prevention topics. Record review showed that several medication aides had training records without documented hours, and one had no documented training for the full year. The DON confirmed there was no documentation that the required 12 hours had been completed.
Unsanitary and Poorly Maintained Resident and Common Areas: Multiple resident rooms and common areas had visible soiling, broken fixtures, missing tile, peeling materials, loose heater covers, and other disrepair. Surveyors observed dark buildup around toilets and thresholds, cobwebs and debris in a courtyard area, an out-of-service sink taped shut, an unlit hallway fixture, stained shower areas, and a weathered pest box with debris buildup.
Non-Operational Bathroom Ventilation Systems: The facility failed to ensure bathroom ventilation was working in 12 resident bathrooms. During an observation, the vent in a 500-hall bathroom did not pull tissue, confirming it was non-operational, and staff confirmed there was no window in the bathroom. The MS stated ventilation checks were not part of the maintenance program and was unaware the vents were not working; the FA was also unaware, and the RDO stated there was no policy for ventilation monitoring.
A facility failed to maintain resident dignity when opened incontinence products were left in plain view and two residents were observed with body parts and soiled clothing visible to others. One resident with a stroke and bowel incontinence had opened briefs on a dresser visible from the hallway, while another resident with diabetes and mild cognitive impairment was seen in a wheelchair with buttock and incontinence product exposed and a soiled hospital gown. Staff confirmed incontinence supplies should be stored out of sight and residents' clothing and body parts should not be visible.
Failure to Notify Ombudsman and Provide Bed-Hold Notice: The facility did not notify the state ombudsman of resident transfers in and out, and did not consistently provide written bed-hold information to a resident or the resident’s RP at the time of hospital transfer. Records showed multiple transfers, but no evidence that the required bed-hold notice was given during the transfers, and the BOM confirmed the notifications were not completed consistently.
A resident admitted after a stroke with good rehab potential was not provided ongoing PT or OT to maintain function after therapy was stopped due to behavioral conflicts with therapists. The resident reported receiving only a couple of therapy sessions, feeling weaker, and being left in bed, while the NA said the resident was dependent for all ADLs and not walking. The DOR and DON confirmed that no restorative or exercise program was put in place after therapy ended, despite the facility’s usual practice to do so.
A resident with dementia had a choking episode during breakfast, but the record did not show a full assessment, vital signs, lung sounds, or provider notification after the change in condition. The resident later had increased swallowing and breathing difficulty and was found without blood pressure or pulse. In a separate case, an admitted resident with CHF, COPD, fluid overload, and type 2 DM did not receive ordered insulin lispro on multiple occasions and missed a scheduled Tresiba Flex dose; the DON confirmed the physician was not notified.
A resident’s initial 30-day face-to-face visit after admission was completed by a PA instead of the physician. The admission record listed the physician, PA, and NP as care providers, and the DON confirmed that the first required visit after admission must be done by the physician.
Staff failed to follow infection control practices during resident care, including not wearing the required gown and gloves for high-contact care for a resident on EBP, not sanitizing a Hoyer lift after use, not cleaning a glucometer after each use, and not changing a piston syringe for tube feeding care as ordered. The DON and other staff confirmed inconsistent practices and that the required equipment changes and cleaning were not being done as directed.
The facility failed to maintain a clean and homelike environment, with issues such as cobwebs, peeling paint, missing light fixture covers, and unsecured materials in the ceiling. A rocking chair lacked a cushion, exposing frayed material. The Facility Administrator confirmed these deficiencies and acknowledged the absence of a written action plan to address them, affecting 11 of 69 residents.
The facility failed to follow the written menu by serving meals with incorrect portion sizes, specifically using a 6-ounce scoop instead of the required 8-ounce for chicken pot pie. This affected the nutritional intake of 13 residents, as confirmed by staff interviews and observations.
The facility failed to ensure proper infection control during laundry delivery, as laundry aides did not perform hand sanitization between resident room visits, risking cross-contamination. Despite knowing the protocol, aides repeatedly handled clothing without sanitizing hands, and clothing was carried against uniforms. Interviews with the DON and IP confirmed the expectation for hand hygiene, highlighting a deficiency in infection prevention practices.
A resident with a history of Allergic Rhinitis and Chronic Sinusitis received Mucinex for a cough without a nurse's assessment. The resident's cough worsened, but no respiratory assessment was conducted. The LPN was unaware of the resident's concerns, and the DON confirmed the lack of policies for follow-up on as-needed medications and focused assessments for acute conditions.
A facility failed to routinely assess and monitor a pressure ulcer in a resident with multiple health issues, including spastic quadriplegic cerebral palsy and severe intellectual disabilities. Despite having wound care orders, the facility did not document wound descriptions or measurements in the Weekly Skin Assessment for November. A wound consultation revealed concerns about the right knee ulceration, leading to the resident being started on antibiotics for cellulitis. The facility's policy required detailed documentation of pressure ulcers, which was not followed, resulting in the deficiency.
A facility failed to implement interventions for a resident with contractures in the left hand, leading to pain and interference with daily activities. Despite previous occupational therapy and recommendations for self-care, the facility did not provide necessary assistance or interventions after unsuccessful Botox treatments.
A facility failed to maintain a medication error rate below 5%, with errors affecting two residents. One resident received eye drops routinely instead of as needed, contrary to the label instructions. Another resident had Diclofenac Gel applied to their back instead of their knees, as per the physician's order. These discrepancies were confirmed by the DON.
A resident with severe protein-calorie malnutrition did not receive the physician-ordered double protein servings at meals. Despite the care plan and dietary orders specifying increased protein, the dietary aide served only one portion of protein. Interviews confirmed the resident received less than prescribed, and the facility administrator acknowledged the dietary order for double protein servings.
Code Status Records Did Not Match Signed Advance Directives
Penalty
Summary
The facility failed to ensure that the resident choice for CPR matched the physician-signed advance directive for two residents. For one resident, the physician-signed Advance Directive Code Status form indicated Full Code, but the admission record, care profile page, and care plan all showed DNR/DNI. Staff interviewed stated they would rely on the electronic resident care profile to determine code status during a cardiac or respiratory arrest, and the DON confirmed that the care profile for this resident was incorrect and did not match the resident’s choice for CPR. The second resident had diagnoses including end stage renal disease, COPD, and chronic diastolic heart failure, and the MDS showed the resident received dialysis. The resident returned from the hospital after fistula revision and signed a full code status, and the form was signed by the medical provider. However, the care plan report, admission record, and electronic resident care profile all showed DNR/DNI. RN staff stated they would check the resident care profile or paper report sheet for code status, and the paper report sheet documented the resident as DNR. The DON confirmed that the resident care profile showed DNR and did not match the resident’s choice for CPR. The report also states that the facility considered newly admitted residents as full code until the signed Advance Directive Code Status form was received back from the physician, but for these two residents the documented code status in the chart and electronic profile did not match the physician-signed advance directive. The deficiency was identified during record review and staff interviews, and the surveyor determined the violation was at the immediate jeopardy level.
Failure to Document Required Annual Continuing Education for Nurse Aides and Medication Aides
Penalty
Summary
The facility failed to ensure that nurse aides and medication aides completed at least 12 hours of continuing education annually for 5 of 5 sampled staff. The facility policy required at least 12 hours of in-service training annually based on each employee’s hire date, with training documentation forwarded to Human Resources and maintained in personnel files. The policy also listed required topics including effective communication, dementia management and care of cognitively impaired residents, abuse, neglect, and exploitation prevention, quality assurance, resident rights, infection prevention and control, compliance and ethics, safety and emergency procedures, and behavioral health. Record review showed that Medication Aide-I, Medication Aide-J, Medication Aide-L, and Medication Aide-M had training documents for their last full year based on hire date, but the documents did not include the amount of time allotted for the education, so the hours completed could not be calculated. Medication Aide-K had no documented training for the last full year based on hire date. The DON confirmed that nurse aides and medication aides were required to complete a minimum of 12 hours of continuing education annually based on hire date and confirmed that the facility had no documentation showing that these staff members completed the required hours.
Unsanitary and Poorly Maintained Resident and Common Areas
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable interior and exterior environment for 16 residents. During observations with the Facility Administrator, Maintenance Supervisor, and Housekeeping Supervisor, multiple resident areas were found with visible soiling and disrepair, including broken toilet paper holders, dark buildup on bathroom thresholds and around toilets, grey fuzzy buildup in ventilation, cobwebs covering a call light, loose and soiled base heater covers, peeling molding, missing floor tile, worn toilet seats, and black scratches along room edges. One resident room had a toilet not sealed to the floor and sitting on spacers/risers with missing tiles visible beneath it, and another room had missing paint on the door exposing underlying layers. Common areas and other facility spaces were also observed in poor condition. The dining room courtyard door area contained cobwebs, yard waste, trash, and bird poop, and Housekeeping stated outdoor areas were not cleaned until warmer weather. A sink in the main dining area was covered with a tray and taped shut because it was not in operation, and the Maintenance Supervisor confirmed the tape was used to prevent use. Additional observations included an overhead light out in the 300 hall with a ballast needing replacement, a bathhouse with stained floors and buildup in grout, heater units, and shower stalls, an unoperational bathroom ventilation fan with water-stained ceiling tiles in an unoccupied room, and a weathered pest box at the front of the building with debris buildup.
Non-Operational Bathroom Ventilation Systems
Penalty
Summary
The facility failed to ensure the ventilation system was in working order in 12 resident bathrooms in rooms 501, 502, 503, 504, 505, 506, 508, 510, 511, 512, 513, and 514 out of 24 sampled resident rooms. During an observation with the Facility Administrator, Maintenance Supervisor, and Housekeeping Supervisor, the bathroom ventilation system in room 500-hall did not pull when a 1-ply tissue was pressed against it, confirming the vent was non-operational, and staff confirmed there was no window in the bathroom. The Maintenance Supervisor stated that no one checks the ventilation system and that it is not part of the maintenance program, and also said he was unaware the system was not working and that no one had alerted him. The Facility Administrator also stated being unaware that the ventilation system was not working, and did not deny that the listed bathrooms were not operational. The Regional Director of Operation stated the facility did not have a policy on ventilation monitoring.
Resident dignity not maintained with visible incontinence supplies and exposed body parts
Penalty
Summary
The facility failed to ensure resident dignity by leaving opened packages of incontinent products in plain view and by allowing residents' body parts and soiled clothing to remain visible to others. The deficiency was cited under 175 NAC 12-006.05(S) based on record review, observation, and interview for 2 residents out of 2 sampled residents in a census of 74. Resident 2 was admitted with a diagnosis of stroke affecting the left side of the body. The admission MDS showed a BIMS score of 15, indicating the resident was cognitively intact, and documented dependence on staff for toilet use and personal hygiene, always incontinent of bowel, and without a toileting program. On multiple observations, an opened blue and white package of incontinence products was seen sitting on top of the dresser at the foot of the resident's bed with the room door open and visible from the hallway. RN-C confirmed that resident incontinence products should be stored out of sight of the public. Resident 5 was admitted with diagnoses including type 2 diabetes and mild cognitive impairment. The quarterly MDS showed a BIMS score of 15, dependence on staff for toilet use and personal hygiene, occasional bowel incontinence, and no bowel toileting program. On repeated observations, the resident was sitting in a wheelchair in front of an open room door with the buttock and incontinence product visible between the wheelchair back and seat. The resident was also wearing a hospital gown with a T-shirt underneath, and the gown was observed to have dried fluid spills and food particles on the front. Open packages of incontinence products were also observed at the foot of the bed. The resident stated the gown was worn for comfort and that it had not always been changed daily, and MA-A and the ADON confirmed that clothing should be changed daily or when soiled and that incontinence products and body parts should not be visible to the public.
Failure to Notify Ombudsman and Provide Bed-Hold Notice
Penalty
Summary
The facility failed to notify the local state ombudsman of resident transfers in and out of the facility for one resident and failed to provide written bed-hold information to the resident or the resident’s responsible party at the time of transfer for one resident. Review of the facility’s transfer/discharge notice showed that the facility intended to send a copy of transfer or discharge notices to the state ombudsman, and the Business Office Manager confirmed in interview that they were responsible for compiling transfer information but were behind on sending and communicating it as required. The BOM also confirmed the facility was not in compliance with the regulation requiring notification of the state ombudsman of resident transfers into and from the facility. Review of the facility’s bed-hold policy showed that written information was to be provided to the resident and/or resident representative before transferring a resident to the hospital. Review of the resident’s progress notes and transfer documentation showed multiple hospital transfers, but there was no evidence that the resident or responsible party were notified about bed hold at the time of transfer. The facility document regarding the transfer stated that residents or legal representatives would be informed of the bed-hold policy upon admission and when leaving for hospitalization, but the document was signed only by the BOM. In interview, the BOM stated that bed-hold paperwork was completed when they were in the office and notified of the transfer, that they called the responsible party and mailed the notification, and that this was not completed consistently at the time of transfer.
Failure to Maintain Resident Functional Ability After Therapy Discontinued
Penalty
Summary
The facility failed to provide treatment and services to maintain or restore a resident’s level of functional ability for one resident who was admitted after a stroke affecting the left side of the body. The resident’s admission MDS showed a BIMS score of 14, indicating the resident was cognitively intact, and documented dependence on staff for transfers and toileting assistance, with substantial to maximum assistance needed for bed mobility. The facility policy stated that residents’ ADL abilities should not deteriorate unless deterioration is unavoidable and that a maintenance and restorative program should be provided to help residents achieve and maintain the highest practicable outcome. The resident stated they were admitted for rehabilitation and planned to receive therapy before returning home, but reported having only a couple of therapy sessions since admission and feeling weaker and not improving. The resident also stated that after a verbal outburst during one therapy session, they were told therapy would not work further with them until their behavior improved. The resident said they felt like they were being left in bed and not receiving the help needed to get better. Record review showed the resident had been referred for PT, OT, and ST with good rehabilitation potential, and a PT note documented the resident was able to perform bed mobility and ambulate with assistance before admission. The NA stated the resident was not receiving therapy or restorative services and was dependent for all ADLs, only getting out of bed to bathe and not walking. The DOR and DON confirmed PT and OT were discontinued because of the resident’s behavior toward therapists, and both confirmed that no restorative or exercise program was implemented after therapy ended, despite this being the facility’s normal practice to maintain function and prevent decline.
Failure to assess choking episode and missed insulin administrations
Penalty
Summary
The facility failed to thoroughly assess a resident after a choking episode and failed to notify the provider of the change in condition. Resident 83 was admitted with dementia and had a quarterly MDS indicating the resident required supervision or touching assistance with eating. On 12/27/2025, progress notes documented that the resident choked during breakfast and appeared to be putting too much food in the mouth, with a trial of soft foods noted. The record did not show a documented assessment after the choking episode, and there was no documentation that the provider was notified of the choking event or the change in diet. Later the same day, progress notes documented that the resident’s responsible party was notified that the resident had increased difficulty swallowing and breathing, was declining supplemental oxygen, and wanted to go to the emergency room. The note did not document that an assessment of the resident’s condition was performed at that time. Vital signs documentation for that date was also absent. The resident was later found to have no blood pressure or pulse, and the DON confirmed there was no documentation that the resident was fully assessed after the choking episode and that the provider was not notified. The facility also failed to follow practitioner orders for Resident 89’s insulin medications. Resident 89 was admitted with CHF, fluid overload, COPD, and type 2 diabetes, and had orders for insulin lispro before meals and at bedtime based on sliding scale parameters, as well as Tresiba Flex 7 units daily. The MAR and progress notes showed insulin lispro was not administered before meals and at bedtime on multiple occasions, and Tresiba Flex was not administered on 1/22/2026. The DON confirmed the medications were not available because of prior authorization needs and missing parameters, and confirmed the physician was not aware that the resident had not received insulin lispro or Tresiba Flex.
Physician Did Not Complete Initial 30-Day Visit
Penalty
Summary
The facility failed to ensure that the physician completed the resident’s initial 30-day face-to-face visit after admission for 1 of 3 residents reviewed. Resident 47 was admitted on 8/15/25, and the admission record listed the physician, a physician assistant, and a nurse practitioner as care providers. Record review showed that the 30-day follow-up visit on 10/9/25 was performed by the physician assistant rather than the physician. The facility policy stated that the resident must be seen at least once every 30 days for the first 90 days after admission, and federal regulation cited in the report stated that a PA, NP, or CNS may not perform the initial comprehensive visit in place of the physician. During interview, the DON confirmed that the initial 30-day visit after admission is required to be completed by the physician and that Resident 47’s initial visit was completed by the physician assistant instead.
Infection Control and PPE Failures During Resident Care
Penalty
Summary
The facility failed to ensure staff used the required PPE and infection control practices during care for a resident on enhanced barrier precautions. Resident 4 had diagnoses including pressure ulcers, morbid obesity, cellulitis of the left lower limb, and lymphedema. The resident also had an order to irrigate a Foley catheter every 30 days and as needed. A door sign posted on the resident’s room directed staff to clean their hands and to wear gloves and a gown for high-contact care activities, including hygiene, changing briefs, device care, and wound care. During an observation of care for Resident 4, nurse aide and medication aide staff assisted with transfers and personal care without being observed washing hands before care and without wearing gowns. One staff member prepared cut briefs for areas of the body that were weeping, applied cream to the underside of the left leg and left hip where open, moist, red areas were observed, and placed cut briefs over those areas. Another nurse entered the room wearing gloves only while a Hoyer lift was in use. The lift was removed from the room and placed in the hallway without being sanitized after use. Staff later stated they did not know a gown was necessary, and one nurse stated a gown was not thought necessary unless catheter care was being done. The assistant director of nursing stated staff needed to wear a gown and gloves when completing transfers and cares for Resident 4. The facility also failed to follow consistent infection control practices for glucometer cleaning and for disposable medical care equipment used with tube feeding care. During observation, a nurse used a glucometer to obtain a blood sugar for Resident 76, discarded the test strip with visible blood into a sharps container, and placed the glucometer into a medication cart drawer. The nurse stated the glucometer was only cleaned when visibly soiled, while another nurse stated glucometers are to be cleaned after each use. The DON and clinical nurse consultant stated they were not aware of a cleaning policy for glucometers when they were not shared between residents, and confirmed the nurses were not following the same practice. In addition, Resident 2 had an order for a new flushing cup and piston syringe every night shift, but during observation the piston syringe in use was dated 1/25/26 even though it was still being used on 1/28/26, and the DON confirmed it had not been changed as ordered.
Facility Environment Deficiencies
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several observations made during a walkthrough. Cobwebs with debris were found in the windows of the Activities room in the secured care unit. Additionally, chipped and peeling paint exposing unsealed wood was observed on the door frames of multiple resident rooms, including rooms 411, 404, 405, 403, 207, 209, 102, 107, and 108. A missing light fixture cover was noted in the ceiling of the Activities room, and various pieces of material in different shades of white were attached with black screws to the ceiling surrounding the vent in a bathroom. In the hallway of the secured care unit, multiple pieces of white material were secured to the ceiling, with one piece being wavy and warped. Further issues included a wooden rocking chair in the Activities Room without a cushion, exposing frayed brown cloth material. An interview with the Facility Administrator confirmed these observations, including the peeling paint, improperly sealed ceiling areas, absence of a cushion on the rocking chair, and the presence of cobwebs. The Facility Administrator also confirmed that there was no current written action plan to address these issues of disrepair and cleanliness, affecting 11 of the 69 residents in the facility.
Deficiency in Meal Portion Sizes
Penalty
Summary
The facility failed to ensure that the menus were followed as written, specifically regarding the portion sizes of meals served to residents. During an observation, it was noted that the chicken pot pie, which was supposed to be served in an 8-ounce portion, was instead served using a 6-ounce scoop. This discrepancy in portion size resulted in residents receiving less than the required caloric intake. The issue affected 13 out of 15 residents who were served meals, with the facility census being 69. Interviews with facility staff revealed that the cook had reviewed the menu for the week and discussed the serving spoons used in the facility. The serving spoons were color-coded and stored according to size, with the 8-ounce spoons being orange and green. However, during the meal service, a white 6-ounce scoop was used, as confirmed by the dietary aide and the facility representative. This improper use of serving utensils led to the deficiency in meeting the nutritional needs of the residents as outlined in the menu.
Infection Control Deficiency in Laundry Delivery
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during the delivery of laundry to residents, as observed by surveyors. The report highlights that laundry aides did not perform hand sanitization between resident room visits, which is a critical step in preventing cross-contamination. This deficiency was observed with two laundry aides, identified as LA-D and LA-E, who repeatedly handled clothing and hangers without sanitizing their hands after exiting each resident's room. The facility's infection prevention and control program mandates hand hygiene between resident contacts, but this protocol was not followed. During the observations, LA-D was seen delivering clothing to multiple residents' rooms without performing hand sanitization after each visit. The clothing was often carried against the aide's uniform, which further increased the risk of cross-contamination. Despite being aware of the hand hygiene protocol, LA-D continued to neglect hand sanitization, even after being questioned by the surveyor. Similarly, LA-E was observed on a different hall, also failing to sanitize hands between room visits, despite acknowledging the requirement to do so. Interviews with the facility's Director of Nursing (DON) and Infection Preventionist (IP) confirmed that the expectation is for all staff to perform hand sanitization after exiting a resident's room. The IP also emphasized that clothing should not be carried against uniforms to prevent cross-contamination. The facility's failure to adhere to these infection control protocols resulted in a deficiency, as it compromised the safety and sanitary conditions necessary to prevent the spread of infections among residents.
Failure to Assess Resident's Respiratory Condition
Penalty
Summary
The facility failed to provide an assessment by a licensed professional nurse for a resident with symptoms of a potential respiratory infection. The resident, who had diagnoses of Allergic Rhinitis and Chronic Sinusitis, had an order for Mucinex to be administered as needed for a cough. The Medication Administration Record indicated that the resident received Mucinex 22 out of 30 days in November, with follow-ups on its effectiveness conducted by a Medication Aide. However, there was no documentation of respiratory assessments or nursing attention directed towards the resident's cough in the progress notes. Observations revealed the resident had a deep, productive cough, which had worsened over the past two weeks. The resident reported informing nursing staff about the worsening condition but could not recall specific staff members. An LPN, who was the full-time day shift nurse for the resident, was unaware of the resident's concerns and confirmed that no respiratory assessment had been completed. The Director of Nursing acknowledged the absence of a policy on follow-up for as-needed medications and procedures for focused assessments related to acute conditions, confirming that it is best practice to perform such assessments.
Failure to Document and Monitor Pressure Ulcer Care
Penalty
Summary
The facility failed to routinely assess and monitor the effectiveness of treatment for a pressure ulcer in a resident who was fully dependent on nursing staff for all activities of daily living. The resident had multiple diagnoses, including spastic quadriplegic cerebral palsy, contractures, severe intellectual disabilities, and a pressure ulcer of unspecified stage. Despite having specific wound care orders for the right knee and left foot, the facility did not document wound descriptions or measurements in the Weekly Skin Assessment for November 2024. This lack of documentation was confirmed by the Director of Nursing, who stated that wound measurements and descriptions were not being recorded on skin assessment days or at any other time, except monthly with the wound care nurse. A wound consultation on November 1, 2024, revealed concerns about the right medial knee ulceration, which was slightly larger and had seropurulent drainage, indicating possible infection or inflammation. The provider started the resident on oral antibiotics for cellulitis of the wound. The facility's policy on Skin and Wound Management required nursing staff to assess and document significant risk factors for pressure ulcers, including a full assessment of the sore's location, stage, dimensions, and presence of exudates or necrotic tissue. However, these assessments were not being conducted as per the policy, leading to the deficiency.
Failure to Implement Interventions for Contractures
Penalty
Summary
The facility failed to implement necessary interventions to prevent the worsening of contractures in a resident's left hand. The resident, who was admitted with a diagnosis of contractures, experienced pain and discomfort due to the condition, which also interfered with activities of daily living. Despite the presence of contractures prior to admission, the care plan lacked documentation and interventions for managing the condition. Observations revealed that the resident's fingers were bent inward, and the facility staff did not assist with cleaning under the fingers or placing a towel roll between the fingers and palm, as recommended. The resident had previously received occupational therapy services, which were discontinued after reaching maximum potential. The occupational therapy discharge note indicated that the resident could not tolerate range of motion exercises or a splint but could use a small towel roll as a barrier in the left hand. Training was provided to the resident and caregivers on exercises, compensatory strategies, and self-care. However, after unsuccessful Botox injections in early 2024, no further interventions were implemented by the facility, despite the resident's ongoing needs.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with an observed error rate of 7.41%. This deficiency affected two residents out of a sample of ten. The first incident involved Resident 17, where a medication aide administered Ultra Eye Preservative Free Drops routinely instead of on an as-needed basis, as indicated on the pharmacy label. The physician's order, however, directed the drops to be administered four times a day. This discrepancy between the label and the physician's order was confirmed by the Director of Nursing. The second incident involved Resident 14, where Diclofenac Gel was applied to the resident's back instead of the knees, as per the physician's order. The medication aide offered the resident a choice of application site, which was not in accordance with the physician's directive. The Director of Nursing confirmed that the order specified application to the knees only, and there was no order for application to the back.
Failure to Provide Physician-Ordered Therapeutic Diet
Penalty
Summary
The facility failed to provide a physician-ordered therapeutic diet with increased protein for a resident, identified as Resident 22, who was part of a sample in a facility with a census of 69. The resident had a cognitive score indicating intact mental status and was diagnosed with severe protein-calorie malnutrition, among other conditions. The care plan specified the need for double portions of protein with meals, as well as snacks and supplements, based on the registered dietician's recommendations. However, during an observation, it was noted that the dietary aide served only one scoop of meat and one sandwich to the resident, contrary to the dietary orders. Interviews conducted with the dietary aide and the resident confirmed that the resident did not receive the prescribed double protein servings. The dietary aide initially claimed that two sandwiches were served but later admitted that the resident had not been given the double servings of protein. The resident, who only speaks Spanish, confirmed through an activity aide that only one sandwich was received. The facility administrator also confirmed the order for double protein servings, highlighting the failure to adhere to the prescribed dietary plan.
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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 Grand Island
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eventide Prairie Commons Care Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Chi Health St. Francis | 2.6 mi | ★★★★★ | 0 | 0 |
| Adept Nursing & Rehab Of Grand Island | 2.8 mi | ★★★★★ | 0 | 0 |
| Tiffany Square | 2.8 mi | ★★★★★ | 7 | 0 |
| Good Samaritan Society - Grand Island Village | 3 mi | ★★★★★ | 16 | 0 |
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