Adept Nursing & Rehab of Waverly

Inspectors wroteLicensure Reference Number 175 NAC 12-006.19(A) Based on observations, interviews, and record reviews, the facility failed to ensure the bathroom air vents were clean in three resident rooms (rooms [ROOM NUMBER]) out of 12 resident rooms sampled. The facility census was 42 at the time of the survey.

Inspectors wroteLicensure Reference Number 175 NAC Based on record review and interview, the facility failed to have 1 resident (Resident 2) referred for a level 2 PASARR (Preadmission Screening and Resident Review) evaluation based off of Resident 2 current medical diagnosis and failed to include a diagnosis to the level 2 PASARR for 1 resident (Resident 14) of 4 sampled residents. The facility census was 42. A.A record review of the admission Record with a printed date of 2/24/26 revealed that Resident 2 was admitted to the facility on [DATE] with the diagnosis of Diabetes (high blood sugar), cellulitis of left upper limbs (skin infection ), Hypertension (High blood pressure), Atrial Flutter (fast heart rate), and Pain in Shoulder. On 11/25/25 a diagnosis was added of irritability and anger, and disorientation, On 12/23/2025 a diagnosis was added of Visual Hallucinations. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D)Based on observations, record review and interview, the facility failed to maintain a medication error rate of less than 5%, which affected 2 residents (Residents 10 and Resident 12) of 3 sampled residents. The medication error rate was 8%. The facility census was 42. [...]

Inspectors wroteLicensure reference number 175 NAC 12.006.18(D) Based on observations, record reviews, and interviews, the facility failed to perform hand hygiene for 1 resident (Resident 7) of 1 sampled resident. Facility census was 42.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D) Licensure Reference Number 175 NAC 12-006.10(A)(ii) Based on observation, interview, and record review, the facility failed to ensure 2 (Residents 4 and 5) of 2 sampled resident's insulin (a hormone produced in the pancreas which regulates the amount of glucose in the blood) was administered as ordered and to ensure staff followed the 5 rights for medication administration. The facility census was 44.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.19(A) Based on observation, interview, and record review, the facility failed to ensure that the ceiling ventilation (vent) covers in the facility were cleaned and sanitized to prevent cross contamination. This had the potential to affect all residents in the facility. Total census was 46 residents.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09(h)(vi)(3)(g) Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 1) of 1 sampled resident's oxygen concentrator (a machine that purifies oxygen) was functioning properly and that the settings were per the provider's orders. Total facility census was 46 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure posting of the daily nursing staffing was current and contained all the required information. This had the potential to affect all the facility residents. The facility identified a census of 47.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.18(D) Licensure Reference Number 175 NAC 12.006.18(B) Licensure Reference Number 175 NAC 12.006.19(A) Based on observation, interview, and record review, the facility failed to ensure the dietary staff performed handwashing for greater than 20 seconds to prevent foodborne illness, that the kitchen ceiling ventilation covers (vents) and light fixtures were clean to prevent cross contamination, and that all walls and the ceiling were in safe condition. The had the ability to affect 45 residents that consumed food from the kitchen.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.19A Based on observations, interviews, and record review, the facility failed to maintain the walls, floors, door frames, light fixtures, exhaust fans, urine smells and baseboards in 14 rooms (rooms: 104,107,109, 112, 114, 116, 118, 119, 121, 122, 123, 124, 125, 126). The facility identified a census of 47.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.10(D) Based on observation, interviews, and record review, the facility staff failed to ensure a medication error rate of less than 5%. Observation of 40 medications revealed 14 errors resulting in an error rate of 35%. The medication errors affected 3 (Resident 10, 21, and 199) of 5 sampled residents. The facility staff identified a census of 47.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.10(D) Licensure Reference Number 175 NAC 12.006.10(A)(ii) Based on observation, interview, and record review, the facility failed to ensure 2 (Residents 10 and 21) of 5 sampled resident's Insulin was administered as ordered and ensure staff followed the 5 rights for medication administration for 1 (Resident 199) of 5 sampled residents. The facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.02(H) Based on interview and record review, the facility failed to ensure 1 (Resident 10) of 1 sampled resident's abuse investigation was sent to the State Agency within 5 working days. The facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09C(i) Based on the record review and interviews, the facility failed to complete an admission MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) for Resident 196 (1 of 4 sampled residents) in the required time frames. The facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09(I) Based on observation, interview, and record review, the facility failed to ensure interventions were added to prevent falls for 1 (Resident 10) of 1 sampled resident. The facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.18(B) Based on observation, record review, and interview, the facility failed to ensure Personal Protective Equipment (PPE) was followed in an Enhanced Barrier Precautions (EBP) room for 1 (Resident 1) of 1 sampled residents. This had the potential to affect all residents EBP. The facility failed to ensure the staff performed hand hygiene for 2 (Resident's 4 and 21) of 2 sampled residents during cares this had the potential to affect all the residents in the facility. The facility failed to ensure Resident 21's BiPAP filter was cleaned or replaced to prevent cross contamination. This had the potential to affect 1 (Resident 21) of 1 sampled resident. The facility identified a census of 47.

Inspectors wroteLicensure Reference Number 175 NAC 4-006.09(H) Based on interview and record review, the facility failed to ensure daily weights were completed physician's order on 4 (Residents 1,3,5 and 6) of 4 sampled residents. The total facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 4-006.04(G) Based on observation, interview, and record review, the facility failed to ensuring nursing staff level were maintained to provided bathing for 4 (Resident 3,4,5 and 6) of 4 sampled residents. The total facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H) Based on observation, record review and interview; the facility failed to monitor wounds for 2 (Residents 5 and 8) of 2 sampled residents. The facility census was 46.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iii)(2) Based on observations, record review and interview; the facility staff failed to monitor a pressure ulcer condition for 1 (Resident 10) of 1 sampled residents. The facility staff identified a census 46.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on record review and interview; facility staff failed to follow protocol related to incomplete assessments when determining the death of 2 of 3 sampled residents; Resident 1 was pronounced dead and later discovered breathing while at the funeral home and Resident 2 had no evidence vital signs were assessed and verified at the time of death. The facility was notified on [DATE] at 4:20 PM of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. The facility census was 48.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on record review and interview; the facility staff failed to evaluate, implement practitioner's orders, and initiate notification of emergency medical personnel for a change in condition for 1 (Resident 1) of 4 sampled residents. This caused the resident to not receive emergency care services resulting in the death of the resident. The facility census was 50.

Inspectors wroteLicensure Reference Number 175 NAC 12-06.18E Based on record review and interview; the facility failed to safely transport a resident after sliding out of a wheelchair during transport. This affected 1 (Resident 1) of 1 sampled resident. The facility census was 50.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11E Based on observation, interview and record review, the facility failed to ensure foods were dated upon opening and failed to ensure the facility staff food/drinks were not stored in the refrigerator used to store resident foods to prevent the potential for cross contamination. This had the potential to affect all 48 residents receiving food from the kitchen. The facility had a census of 48.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09D6(7) Based on observation, interview, and record review, the facility failed to ensure a complete, valid prescription was completed for 3 (Residents 33, 35, and 153) of 5 sampled resident's non-invasive ventilators (NIV)(a machine used to assist with breathing with a mask), ensure 1 (Resident 35) of 5 sampled residents had an order for oxygen, and ensure 2 (Residents 26 and 33) of 5 sampled resident's oxygen order was followed. The total facility census was 48.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09D6(7) Licensure Reference Number 175 NAC 12.006.09D3(1) Based on observation, interview, and record review, the facility failed to ensure 3 (Residents 33, 35, and 153) of 5 sampled resident's Non-Invasive Ventilator (NIV)(a machine used to assist with breathing with a mask) masks were cleaned daily and failed to ensure 1 (Resident 153) of 2 sampled resident's urinary catheter bag was off the floor to prevent the potential for cross contamination. The total facility census was 48.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04C3a(6) Based on interview and record review, the facility failed to notify the provider of blood sugar results outside of ordered parameters for 1 (Resident 6) of 1 sampled resident. The facility census was 48. Findings Are: A. A record review of the Demographic Information (undated) revealed, that the facility readmitted Resident 6 on 12/29/23 with diagnoses of: Sepsis (the body's extreme response to an infection) and secondary Diabetes Mellitus type 2 (DMII -- a long-term medical condition in which your body doesn't use insulin properly, resulting in unusual blood sugar levels) and Chronic Congestive Heart Failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs). [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05 Based on interviews and record review, the facility failed to notify a resident or their representative of the facility's bed hold policy upon transfer to the hospital for 1 (Resident 42) of 1 sampled resident. The census was 48.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to follow provider orders for daily weights for 1 (Resident 6) of 1 sampled resident. The facility identified a census of 48. Findings Are: The record review of the Order Summary ran on 1/4/24 revealed, Resident 6 had an order to obtain their daily weight in the morning related to Chronic Congestive Heart Failure. A record review of the daily weights for Resident 6 dated 11/27/23 thru 1/4/24 revealed: [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D4 Based on observation, interview and record review, the facility failed to ensure interventions were followed to manage contractures for 1 (Resident 31) of 1 sampled residents. The facility census was 48.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 (Residents 4 and 35) of 3 sampled resident's Advanced Beneficiary Notice (ABN) had room and board listed and an estimated cost for the potential billed for services. The total facility census was 48.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17 Based on observation, interview, and record review, the facility failed to ensure staff donned (put on) and doffed (took off) the required PPE (personal protective equipement) when in a resident's room marked for transmission based precautions (TBP)(a resident that had or was exposed to COVID-19) to prevent the spread of COVID-19, ensure that the COVID-19 testing surface was sanitized (cleaned) to prevent the spread of COVID-19 and prevent cross contamination (spread of bacteria from one surface to another), ensure COVID-19 tests sat for 15 minutes before the result was read, ensure hand hygiene (cleaning) was completed between glove changes, and failed to ensure gloves, towels, and gauzes were changed between wound sites to prevent cross contamination. This had the potential to affect all 49 residents in the facility. [...]