Wauneta Care and Therapy Center

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(D)Based on observation, record reviews and interviews, the facility failed to serve foods to the residents based on the serving sizes in the recipes to ensure all residents received the correct amounts of protein and other nutrients. This had the potential to affect all residents. The facility showed a census of 27.

Inspectors wroteLicensure reference number 12-006.11(E)Based on observations, record reviews, and interviews, the facility to ensure that dietary personnel used hand hygiene as required in the kitchen, and the facility failed to ensure that foods in the kitchen were dated, labeled, and discarded to prevent food borne illnesses.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(B)(ii)1 Based on record review and interview, the facility failed to ensure that Nurse Aides (NAs) are provided 12 hours of yearly education, and fails to follow their Facility Assessment that includes dementia management training for NAs. This affected 1 of 1 NAs sampled. The facility census was 27.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(F)(iii) Based on record review and interview, the facility failed to ensure that the Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) was updated with a change in orders for oxygen to reflect the current order for Resident 1; and failed to ensure Residents' 5 and 7's CCPs reflected their ability and desire to self administer medications. The sample size was 12 and the facility identified a census of 27. Findings Are: A. A record review of Resident 1's admission Record dated 7/21/2026 revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of malignant neoplasm of unspecified part of left bronchus or lung (a cancerous tumor). [...]

Inspectors wroteLicensure reference number 175 NAC 12-006.10(A)(i)Based on observations, record reviews, and interviews, the facility failed to ensure residents who self-administer medications were competent to do so for one resident (Resident 5). The Facility showed a census of 27.

Inspectors wroteLicensure reference number 175 NAC 12-006.10(D)Based on record review, interview and observations, the facility failed to ensure that residents are free of significant medication errors for one resident (Resident 9). The facility showed a census of 27.

Inspectors wroteLicensure 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.

Inspectors wroteBased 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.

Inspectors wroteLicensure 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.

Inspectors wroteBased 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure Reference 175 NAC 12-006.09 Based on record review, observations, and interviews; the facility failed to identify and treat 1 (Resident 19) of 2 sampled resident's pain. The facility census was 32.

Inspectors wroteBased 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. [...]

Inspectors wroteLicensure 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. [...]

Inspectors wroteLicensure 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. [...]

Inspectors wroteLicensure 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.

Inspectors wroteLISCENSURE 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.

Inspectors wroteLicensure 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.