F725 · Sufficient nursing staff

Licensure Reference Number 175 NAC 12-006.04Based on observation, record review, and interview the facility failed to have sufficient staff to complete resident assessments and resident observations as required to identify and monitor residents at risk for skin injury. This had the potential to affect all facility residents. The facility census was 33. The facility Administrator was notified on 8/5/26 at 6:25PM of an Immediate Jeopardy (IJ) which began on 3/29/26. The IJ was removed on 8/6/26, as confirmed by surveyor onsite verification.Findings are:Record review of the policy titled, Skin Assessment Pressure Ulcer Prevention and Documentation Requirements dated 3/30/26 revealed that all residents will be identified for their risk of developing pressure ulcers on admission/readmission by… …

Good Samaritan Society - Colonial Villa · Nebraska

This citation pertains to intake #3073875Based on observation, interview and record review, the facility failed to provide sufficient nursing staff for 5 (Resident #6, #45, #57, #30, and #110) of 99 residents who reside in the facility, resulting in a delay in wound assessment and treatment for Resident #6 who developed osteomyelitis and required a toe amputation, unmet care needs (#30), lack of supervision for a resident who wanders (Resident #6), missed or late medication administration (Resident #45 & #57), long call light wait times and unmanaged pain (Resident #110) and a potential for decreased overall well-being of all 99 residents within the facility. …

Optalis Health and Rehabilitation of Grand Rapids · Michigan

Based on observation, interview and record review it was determined the facility failed to ensure sufficient nursing staff were available to meet resident needs for 3 of 3 resident halls reviewed for staffing. This placed residents at risk for lack of timely assistance and unmet care needs. Findings include: On 9/3/26 the facility provided lists of residents who:-Required assistance with transfers: 10-Required a mechanical lift with transfers: 10- Required one or two-person assistance with bathing: 21-Required one or two-person assistance with toileting: 20-Required assistance with personal hygiene and dressing: 21These residents resided on all three facility halls. a. …

Nehalem Valley Care Center · Oregon

Based on observations and interviews with residents and staff, the facility failed to ensure proper levels of staff were maintained to provide for the residents' needs. This was discovered during the normal Long Term Survey Process, while meeting with the resident council and has the ability to affect more than a limited number of residents. Census 59. Findings included:a) On 07/14/26 at approximately 10:30 AM during a meeting with the resident council, twelve (12) out of thirteen (13) members in attendance brought up that call light response times are very long. When the group was asked how long they thought the average wait time for a call light to be answered, the response was longer than 45 minutes most days. This was the answer given. …

Canterbury Center · West Virginia