Wauneta Care and Therapy Center

Licensure Reference Number 175 NAC 12-006.04(B)(ii)(1) Based on record review and interview the facility failed to ensure that nurse aides received a minimum of 12 hours of continuing education per year as required for 1 of 5 sampled nurse aides. This had the potential to prevent residents from receiving competent care. The facility census was 30. Findings are: Record review of the facility policy titled Required Training, Certification and Continuing Education of Nurse Aides dated 3/12/24 revealed that it is the facility policy to comply with State and Federal regulations and requirements as they pertain to continuing education of nurse aides. The facility will provide at least 12 hours of in-service training annually, based on employment date and not on calendar year. Record review of the undated facility Employee List revealed that Nurse Aide (NA)-E had a hire date of 2/1/22. Record review of the facility Training Hours report dated 5/8/25 for NA-E for the date range of 2/1/24 through 2/1/25 (the annual period based on NA-E's employment date) revealed that NA-E completed a total…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure that residents were seen by a physician during the initial 30-day visit and at a minimum of every other visit. This affected 6 (Residents 10, 18, 25, 28, 31, and 32) of 12 sample residents reviewed. The facility census was 30. Findings are: Interview with the Director of Nursing (DON) on 05/08/2025 at 1:35 PM revealed that the DON believed that a physician assistant or nurse practitioner could perform all the 60-day certifications for nursing home residents after admission. At that time when asked about specific residents, the DON showed examples on the computer of the primary care physician for 2 residents was a Physician Assistant listed on the resident profile status. Another resident example revealed one resident's primary care physician was an Advanced Practice Registered Nurse. DON confirmed that the words primary care physician and primary care practitioner were used interchangeably but that they are not the same. DON confirmed a nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.08(A) Based on record reviews and interviews, the facility failed to ensure that all residents who were admitted to the facility had a written recommendation or had written orders from a physician. This affected 1 (Resident 32) of 12 residents sampled. The facility census was 30. Findings are: Record review of the admission orders for Resident 32 who was admitted to the facility on [DATE], revealed the orders had been written and signed on 12/18/2024 at 8:27 AM by Physician Assistant (PA)-H (a licensed healthcare professional who works with physicians to provide medical care - a non physician care provider). There was no co-signature of a physician (An MD or Medical Doctor) on these orders. According to the admission orders the resident had diagnoses for status post left hip replacement with complications, chronic right hip hardware infection, long term use of suppressive antibiotic use, hypertension, allergic rhinitis, history of deep vein thrombosis (blood lots),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interviews, the facility failed to ensure gradual dose reductions were completed for residents taking psychotropic medications. This affected 1 (Resident 23) of 5 sampled residents. The facility census was 30. Findings are: Record review of the 02/11/2025 quarterly Minimum Data Set (MDS - a standardized, comprehensive assessment tool used to evaluate and document the health status of residents in Medicare and Medicaid certified nursing homes) revealed Resident 25 was unable to answer questions to perform a Brief Interview for Mental Status exam (BIMS), got annoyed eaily and was short tempered, had poor appetite, difficulty concentrating, had delusions, would verbally and physically act out towards others, rejected cares one to three days a week, wandered 4 to 6 days a week, was able to ambulate with their walker throughout the facility, and had urinary incontinence. Resident 25 was diagnosed with renal insufficiency, Alzheimer's dementia, anxiety disorder, adjustment disorder with mixed disturbances of emotions and conduct, and had orders for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.10(D) Based on observations, record reviews, and interviews, the facility failed to ensure that medication error rates were less than 5%. This was based on 31 medication administration opportunities and 2 medication errors resulting in an error rate of 6.5%. This affected 2 (Residents 27 and 18) of 4 sampled residents. The facility census was 30. Findings are: Record review of the undated facility policy The Five Rights of Medication Administration stated the safe provision of medication also includes observing a rule called the Five Rights. The Five Rights consist of several safety checks which help to prevent mistakes. While providing medications, give the right drug to the right resident, at the right amount at the right time, and by the right route. The five rights of medication administration are: -right drug -right resident -right amount -right time -right route Record review of the March 2010 policy Medication Errors - Defined revealed in paragraph 4 that medication errors can be made by not following accepted practice standards of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview; the facility failed to submit their Payroll Based Journal (PBJ) data for Quarter 1 of 2024 as required. This had the potential to affect all residents residing within the facility. The facility census was 32. The Findings Are: A record review of the PBJ report from CMS revealed no direct care nursing staff (Registered Nurses, License Practical Nurses, Medication Aides, and Nurse Aides) data was submitted for the first quarter of fiscal year 2024, from 10/1/2023 through 12/31/2023. An interview on 5/15/24 at 1:46 PM with the Administrative Assistant (AA) confirmed the AA was responsible for submitting the facility's PBJ Data and that they did not submit the data for 2024 Quarter 1. The AA stated they attempted to log onto the site the evening of the due date and entered an incorrect password too many times, causing themselves to get locked out of the system and therefore unable to submit the required data.

Licensure Reference 175 NAC 12-006.04B2a Based on record review and interview; the facility failed to ensure Nurse Aide (NA)-H completed 12 hours of ongoing training per year as required. This had the potential to affect all residents who resided within the facility. The facility census was 32. The Findings Are: A record review of a Relias (an online training program utilized by long term care facilities) Transcript for NA-H dated 5/14/24, revealed NA-H had completed two 0.5-hour training courses for a total of 1.0 hour of training in the prior 12 months. A record review of a Relias Transcript for NA-H dated 5/15/24, revealed NA-H had completed five training courses on 5/14/24 for a total of 1.85 hours of training. An interview on 5/15/24 at 9:19 AM with the Administrative Assistant (AA) confirmed that NA-H had completed only 2.85 hours of training on Relias and had not attended any of the in-person facility in-services over the last twelve months.

Licensure Reference 175 NAC 12-006.09C Based on record review and interviews; the facility failed to develop and implement comprehensive care plans for 4 (Residents 19, 23, 26, and 32) of 12 sampled residents. The facility census was 32. The Findings Are: A record review of the facility policy Comprehensive Care Plans with a last revised date 5/15/2024 revealed the facility will develop a comprehensive person-centered care plan for each resident to meet the resident's medical, nursing, mental, and psychosocial needs based off the resident's needs as identified in the resident's comprehensive assessment. A. A record review of facility policy Pain Management with reviewed/revised date of 5/15/24 revealed the facility would observe for nonverbal indicators which may indicate the presence of pain and that the facility would use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain. The policy also revealed that the interventions for pain management would be incorporated into the components of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference 175 NAC 12-006.17B Licensure Reference 175 NAC 12-006.17D Based on record reviews, observations, and interviews; the facility failed to don (put on) the required personal protective equipment (PPE) of a gown for enhanced barrier precautions during catheters cares for 1 (Resident 4) of 1 sampled resident and failed to ensure hand hygiene was completed as required and medications were not contaminated during medication pass for 3 (Residents 16, 19, and 31) of 4 sampled residents. The facility census was 32. Findings are: A. A record review of the facility's policy Enhanced Barrier Precautions with a date implemented of 3/26/2024 revealed PPE of gowns and gloves is necessary when performing high-contact care activities, including urinary catheter care. A record review of a Face Sheet indicated the facility admitted Resident 4 on 4/18/2023 with diagnoses of left hip fracture and hydronephrosis (a condition that occurs when a kidney swells and can't get rid of urine like it should.) A record review of Resident 4's Minimum Data Set (MDS, a standardized assessment tool…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

LISCENSURE Reference Number 175 NAC 12-006.09D Based on record reviews and interviews; the facility failed to ensure that all psychotropic medications (medications that are given for a variety of mental health disorders including psychosis, depression, anxiety, and sleep) given only when needed (PRN) are reviewed and reordered every 14 days for 1 (Resident 32) of 1 sampled resident. The facility census was 32. Findings are: In an interview with Resident 32 on 5/13/24 at 1:35 PM in Resident 32's room. Resident 32 revealed admission to this facility last year after being discharged from the hospital. Resident 32 confirms [gender] has meetings with some people by video (Telemedicine, the ability to visit a physician from home by using a television, computer, or other audio visual equipment) about every other week about how [gender] feels and about anxiety and depression. In an interview with Social Services Director (SSD) on 5/14/24 at 9:30 AM revealed Resident 32 is usually seen every one or two weeks with telemedicine for psychiatric care. In an interview with Minimum Data Set Nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference 175 NAC 12-006.10D Based on record reciews, observations, and interviews; the facility failed to ensure medications that could not be crushed were not crushed for 1 (Resident 16) of 4 sampled residents and failed to ensure the medication error rate was less than 5%. The medication error rate was 16.67%. The facility census was 32. Findings are: A record review of a facility policy Medication Administration with a last revised date of 9/13/2023 revealed the following: - Crush medications as ordered. Do not crush medications with do not crush instructions. - Do not crush slow release or enteric coated medications. A record review of a facility Face Sheet revealed the facility admitted Resident 16 on 5/7/2019 with diagnoses of atrial fibrillation, heart failure, hypertension, Gastro-esophageal reflux disease, iron deficiency, and overactive bladder. A record review of Resident 16's Physician Orders dated May 2024 revealed the following: - ferrous sulfate 325 milligrams (mg) - take 1 tablet daily - without instruction of do not crush. - pantoprazole 40 mg - take 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175NAC 12-006.02(8) Based on record review and interview the facility failed to report potential abuse and neglect to the state agency in the required timeframe. This affected 1 resident (Resident 3) of 3 residents reviewed. The facility census was 31. Findings are: Record review of the facility policy titled Abuse, Neglect, and Exploitation dated 3/6/2 revealed that the resident has the right to be free from mistreatment, neglect and misappropriation of property. When abuse, neglect or exploitation is suspected, the Licensed Nurse should notify the Director of Nursing and Administrator and document the notification. Initiate an in investigation immediately. Contact the State Agency and the local Ombudsman office to report the alleged abuse. The administrator should follow up with government agencies and report the results of the investigation when final, as required by state agencies. Interview on 8/14/23 at 1:54 PM with Resident 3 revealed that Resident 3 had missing cash (misappropriation- a type of abuse and neglect) and that Resident 3 reported it to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number: 175 NAC 12-006.04D2 Based on record review and interview, the facility failed to ensure there was a qualified dietary manager (DM). This had the potential to affect all residents in the building. The facility census was 26. Findings are: Record review of the Dietary Manager's employee records verified there were no educational or certification records identifying the DM successfully completing a course in food management. On 03/13/23 at 1:02 PM an interview with the DM confirmed that the educational requirements for the dietary manager was not completed. An interview on 03/15/2023 at 02:07 PM with the Administrator revealed the facility does not have a full time RD or a qualified DM.