Accura Healthcare Of Kenesaw
Inspection history, citations, penalties and survey trends for this long-term care facility in Kenesaw, Nebraska.
- Location
- 100 West Elm Avenue, Kenesaw, Nebraska 68956
- CMS Provider Number
- 285166
- Inspections on file
- 26
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Accura Healthcare Of Kenesaw during CMS and state inspections, most recent first.
Surveyors found that the facility failed to protect several residents from falls and injuries by not implementing and not developing effective fall-prevention interventions. One resident with dementia and a history of falls had a care plan requiring close supervision and a reclined Broda chair, yet staff left the resident unattended and previously failed to keep the chair tilted, resulting in a serious head injury and subdural hematoma. Another resident with hemiplegia and a below-knee amputation, care planned and posted as requiring a full Hoyer lift with two staff, was instead pivot-transferred by two aides without the lift and fell, sustaining chest pain that required ER evaluation; required post-fall assessments were not completed. A third resident with stroke-related weakness and a seizure disorder experienced multiple falls linked in documentation to call-light use limitations, lack of non-skid footwear, lighting, and toileting needs, but the care plan did not consistently incorporate interventions addressing these specific root causes. The MDSC and DON acknowledged there was no fall policy and that interventions were not reliably based on identified root causes of falls.
Staff failed to maintain resident dignity and privacy when one cognitively intact resident who required assistance with upper body dressing was left in the dining area and then wheeled down the hall with their abdomen exposed, despite staff presence and the resident's inability to adjust clothing independently. In a separate incident, a medication aide and a laundry staff member entered a cognitively intact resident's room without knocking or announcing while the roommate was receiving personal care and had their lower body exposed. Both direct-care staff and the DON acknowledged that residents' body parts should not be exposed in public view and that staff are expected to knock and announce before entering rooms.
A resident with a history of wandering and intrusive behaviors repeatedly entered other residents’ rooms, leading to multiple resident‑to‑resident altercations, including being pushed to the floor with a resulting hematoma, and later incidents where the resident hit and choked another resident in a wheelchair and struck two additional residents in an activity area. Facility policy required identification of residents at risk of abusing others and implementation of protective measures, but only short‑term checks and temporary interventions such as redirection, music, snacks, toileting, 1:1 time, and PRN psychotropic medication were used. Interviews indicated that 1:1 supervision was inconsistent and that no long‑term interventions, such as continuous 1:1 supervision, were implemented despite ongoing aggressive behaviors, resulting in a failure to protect residents from physical abuse.
A medication aide administered a resident’s entire set of morning medications after the ordered time window, with all doses showing as late on the eMAR, and documented them as given before the resident actually consumed them. During the same pass, the aide gave an incorrect dose of Azelastine nasal spray by administering two sprays per nostril instead of the ordered one spray per nostril, and improperly discarded a prepared dose of Polyethylene Glycol powder into the trash rather than using the facility’s medication destruction method. The resident, an LPN, and the DON all confirmed the late administration and dosing/documentation errors, which resulted in a medication error rate far exceeding the required threshold.
The facility did not complete required nurse aide registry checks before three staff members began working with residents, and failed to report an adverse event involving a resident who fell during a transfer due to malfunctioning equipment. The incident resulted in soreness and bruising for the resident, and the event was not reported to the appropriate agencies as required by facility policy.
The facility did not ensure that employee health screens were reviewed by appropriate staff before employment began for several employees, and staff did not consistently follow proper hand hygiene procedures, including washing hands for the required duration and using clean paper towels to turn off faucets, as confirmed by both observation and staff interviews.
A resident with dementia and risk for skin integrity issues was prescribed an oral antibiotic for cellulitis without completion of required infection criteria assessments or a timely review of antibiotic appropriateness. The antibiotic was also prescribed outside recommended dosing guidelines, and the provider was not notified of this deviation, resulting in a failure to follow established antibiotic stewardship protocols.
A resident with schizophrenia and bipolar disorder, identified as high risk for elopement, repeatedly exited the facility without staff knowledge. Despite a physician order for a wander guard and documented incidents of the resident leaving the building, there were no incident reports or changes to interventions to prevent further unauthorized exits. The DON confirmed that no new measures were implemented during this period.
A resident with moderate cognitive impairment was moved to a new room without receiving written notification or explanation, and the resident's POA was not notified due to being unreachable. The move was made to prevent falls, but the required notification form, which allows for appeal, was not provided to the resident or their representative.
Two residents were incorrectly coded on the MDS as having received insulin during the assessment period, when in fact their MARs showed they received non-insulin injectable diabetes medications. The MDS Coordinator confirmed the error after review and interview.
Two residents did not receive required 30-day physician visits after admission, as confirmed by review of medical records and staff interviews. One resident with multiple diagnoses, including Alzheimer's and dyskinesia of the esophagus, missed the initial 30-day visit and was not seen by a physician until 60 days post-admission, despite significant weight loss. Another resident did not receive a follow-up physician visit 30 days after the initial assessment, with the next visit occurring 60 days later. These deficiencies were acknowledged by the DON and RNC.
A medication aide failed to follow proper procedures by not instructing a resident to rinse their mouth after inhaler use, not using a dosing card for topical medication, and administering a PRN pain medication without prior nurse approval, resulting in a medication error rate of 12%.
The facility did not consistently identify causes of falls or implement timely interventions after each fall incident for several residents with high fall risk, including those with cognitive impairment, mobility issues, and recent infections. Care plans were not promptly updated with new interventions, and staff often relied on verbal communication rather than documented updates, leading to repeated falls and delayed responses.
The facility did not ensure that residents with complex medical conditions were seen by a physician or physician delegate at the required intervals, as documented records showed gaps in mandated face-to-face visits. The DON and ADM confirmed that the available visit records did not meet regulatory requirements for several residents.
The facility failed to properly label and date food items, risking food-borne illnesses for 62 residents. Surveyors found unlabeled cereal, sandwiches, and nutritional shakes, as well as expired and dented items in storage. The Dietary Supervisor confirmed these deficiencies.
The facility failed to ensure accurate MDS assessments for two residents, resulting in deficiencies. One resident's MDS did not reflect a Stage 2 pressure injury, despite evidence and confirmation from staff. Another resident's hospice care status was inaccurately documented as 'No' in the MDS, despite being on hospice services. These errors were attributed to staffing changes and oversight.
A resident with muscle wasting, generalized muscle weakness, hemiplegia, and hemiparesis did not receive necessary restorative therapy or an assistance device for contractures. Despite the care plan indicating the need for a right hand splint, the resident reported never receiving a brace. Facility staff were unaware of the resident's contractures, and no restorative program was in place, leading to the deficiency.
A resident with moderate cognitive impairment and a history of falls was placed in a Broda chair without a safety evaluation. Observations showed the resident frequently attempted to climb out of the reclined chair and called for help without staff intervention. Interviews revealed the facility used the chair to prevent falls but failed to assess its appropriateness, as confirmed by the DON and a hospice RN.
A facility failed to provide non-pharmacological interventions before administering PRN Xanax to a resident with a high cognitive function and diagnoses of Sepsis and Pulmonary Embolism. The resident received Xanax 54 times in a month without documented non-pharmacological interventions, contrary to the facility's policy. The Administrator confirmed the expectation to attempt such interventions first, which was not met.
A malfunctioning emergency entrance/exit door at the south end of the 100-hallway hindered access during an emergency. The Kenesaw Fire Department was unable to enter through this door due to a keypad issue, confirmed by a resident and facility staff. Observations showed the door required pressure to release, and it was the closest entry to the 100-hallway, crucial for emergency access.
Failure to Implement and Develop Effective Fall-Prevention Interventions for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure a safe environment and adequate supervision to prevent accidents, including falls, for multiple residents. For one resident with dementia, confusion, lack of safety awareness, and a history of falls with injury, the care plan identified the resident as high risk for falls and included specific interventions such as keeping the resident in visual range, not leaving the resident unattended in a wheelchair, and keeping the specialized Broda chair reclined unless staff were sitting with the resident. Despite these interventions, the resident was observed seated in a tilted Broda wheelchair in the dining room without staff nearby. Earlier in the month, this resident had a witnessed fall from the wheelchair in the dining room when the chair was not tilted back as required, resulting in the resident leaning forward, tumbling out of the chair, and sustaining a head laceration and subdural hematoma that required hospital admission. For a second resident with hemiplegia, a below-knee amputation, and dependence on staff for transfers, the MDS and care plan specified that the resident required a full mechanical Hoyer lift with two staff for all transfers. A sign above the bed also indicated the resident was a full Hoyer lift with two-person assist. Despite these documented requirements, two nurse aides performed a pivot transfer without using the Hoyer lift, during which the resident reported feeling weak and fell, becoming stuck between a shower chair and the wall and sustaining right chest pain that required emergency room evaluation. The facility’s own records showed that this fall was not followed by completion of a fall risk assessment or post-fall data collection, even though the facility’s risk management policy required all accidents and incidents, including falls, to be reported, investigated, and accompanied by triggered assessments. For a third resident admitted with a stroke affecting the left side and a seizure disorder, the MDS showed the resident used a wheelchair or walker, had unilateral range-of-motion limitations, required assistance with mobility and toileting, and had experienced falls without injury since admission. The care plan identified the resident as high risk for falls and included a general intervention to review information on past falls and determine root causes. Facility incident and post-fall documentation showed this resident had multiple falls over several days, with identified potential root causes including inability to use the standard call light due to hand function, lack of non-skid footwear, lighting issues, and attempts to self-transfer to the bathroom related to toileting needs. Although some interventions were added, such as a pressure call light, side rails, a bed alarm, nonskid strips, and anti-rollbacks on the wheelchair, the care plan did not consistently incorporate interventions directly tied to the documented root causes, such as addressing toileting needs, adjusting toileting schedules, or ensuring non-skid socks and improved lighting. The MDS Coordinator and DON confirmed that the facility did not have a fall policy and that interventions for this resident were not consistently based on the identified root causes of the falls. Additionally, interviews with facility staff confirmed systemic gaps in fall prevention processes. The MDS Coordinator stated that the facility did not have policies and procedures for falls or for resident lifts and transfers, and acknowledged that while incident reports and certain assessments were expected after falls, they were not always completed or used to drive care plan changes based on root cause analysis. For the resident with multiple falls, the MDS Coordinator confirmed that the resident’s toileting schedule and habits had not been evaluated despite toileting being identified as a root cause in several post-fall assessments. The DON confirmed that root causes should guide interventions and acknowledged that the interventions placed for this resident were not based on the documented root causes. These findings collectively demonstrate failures to implement existing care plan interventions, to use required equipment and assistance levels during transfers, and to develop and revise fall-prevention interventions in response to identified causal factors.
Failure to Maintain Resident Dignity and Privacy During Care and Room Entry
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and privacy by allowing exposure of body parts in public areas and by entering a resident room without knocking or announcing. One cognitively intact resident with Type 2 diabetes and spinal stenosis, who required substantial to maximal assistance with upper body dressing and used a wheelchair for mobility, was observed in the main dining area with their gray sweatshirt pulled up, exposing their abdomen to public view during a meal. Other residents were seated nearby and staff were present serving meals and drinks. When the resident requested to return to their room, a staff member pushed the wheelchair down the hallway without attempting to pull down the resident's shirt or otherwise cover the exposed abdomen. The resident later confirmed that their abdomen had been exposed both in the dining room and while being assisted down the hall, and stated they were unable to pull their shirt down independently and needed staff assistance to ensure their abdomen was covered. A nurse aide interviewed acknowledged that residents' body parts should not be exposed to public view and agreed this was a dignity issue. The DON also confirmed that residents' body parts should not be exposed for public view and that this constituted a dignity concern. A separate dignity and privacy concern was identified involving another cognitively intact resident with schizoaffective disorder and morbid obesity, who required assistance with bed mobility, transfers, and toileting. A medication aide entered this resident's room to administer medications by pushing open a partially open door without knocking or announcing, while other staff were providing personal care to the roommate, whose legs and lower body were exposed when the door was opened. During the medication pass, a laundry staff member also opened the door and entered the room without knocking while the roommate's lower body remained exposed. The resident later reported not being sure that staff always knock before entering and described waking up at times to find staff already in the room. The medication aide and the DON both confirmed that staff are expected to knock and announce themselves before entering a resident's room.
Failure to Prevent Resident-to-Resident Physical Abuse by a Behaviorally Challenging Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable adult from physical abuse by other residents despite ongoing behavioral concerns. Facility policy defined all adults in the facility as vulnerable adults and required systems to identify residents at risk of abusing others, continual assessment and care planning, and implementation of measures to protect residents from abuse. Resident 3 had a documented history of wandering into other residents’ rooms and intrusive behaviors. On one occasion, Resident 3 entered another resident’s room and would not leave, resulting in the other resident pushing Resident 3 out of the room, causing Resident 3 to fall face down and sustain a hematoma above the left eye. The care plan included short-term 15‑minute checks and later temporary interventions such as redirection, music, snacks, toileting, 1:1 time, and PRN psychotropic medication, but no long‑term interventions were initiated to address the ongoing risk of resident‑to‑resident altercations. Progress notes over the following weeks documented repeated episodes of Resident 3 wandering into other residents’ rooms, being invasive, touching other residents on the chest and head, and becoming physically aggressive toward staff. On a later date, staff responded to residents screaming for help and found Resident 3 in another resident’s room; the resident in the room reported that Resident 3 had hit and choked them while they were sitting in their wheelchair. On another occasion, Resident 3, while in an activity room, walked over and hit one resident on the top of the head and then pursued and hit another resident in the face. Interviews with the Facility Administrator and the MDS Coordinator revealed that 1:1 supervision for Resident 3 occurred only at times and that long‑term interventions such as continuous 1:1 supervision were not implemented, despite recognition that Resident 3’s behaviors placed other vulnerable adults at risk of abuse. These actions and inactions resulted in the facility’s failure to ensure that Resident 3 and other residents were free from physical abuse as required by policy and regulation.
Multiple Medication Administration Errors During Morning Medication Pass
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less when a medication aide (MA) was observed administering multiple morning medications to one resident outside the ordered administration time window of 0630 to 1100. During the observation period, all of the resident’s scheduled morning medications appeared in red on the electronic medication administration record (eMAR), indicating they were late. The MA acknowledged that administering medications late constituted a medication error, and the resident and an LPN both confirmed that all of the resident’s morning medications were given late. During the same medication pass, the MA did not follow facility policy or professional standards regarding the rights of medication administration and documentation. The MA removed medications from bubble packs, placed them into a medication cup, and documented them as given in the eMAR by clicking the “Y” button before the resident actually consumed them. The MA and the DON both confirmed that medications should not be signed out as administered until after the resident has taken them, and that this practice did not comply with the five rights of medication administration. The MA also administered an incorrect dose of a nasal spray and improperly handled a powdered laxative medication. For the nasal spray Azelastine 0.1%, which was ordered as one spray in each nostril, the MA administered two sprays in each nostril; both the MA and the resident confirmed the ordered dose and the error, and the DON confirmed this was a medication error. In addition, when preparing Polyethylene Glycol 3350, the MA poured the white granular powder into a 30 ml cup, realized grams could not be measured with that cup, and then discarded the medication-filled cup into a trash can instead of using the facility’s medication destroyer as required. The DON confirmed that this disposal method was not in accordance with facility policy.
Failure to Complete Registry Checks and Report Adverse Event
Penalty
Summary
The facility failed to complete nurse aide registry checks prior to staff having possible or probable contact with residents for three of six sampled staff members. Specifically, a nurse aide and a business office manager both began working before their registry checks were completed, with the checks occurring 10 and 12 days after their respective start dates. Additionally, a housekeeper worked multiple days without any evidence of a completed registry check. The facility administrator confirmed that these staff members worked prior to the completion of the required registry checks. The facility also failed to report an adverse event involving a resident who was admitted with spinal stenosis. The resident experienced a fall during a transfer from a wheelchair to a bed using a full body lift, when the sling strap broke, causing the resident to fall partially onto the bed and partially onto the floor. The incident resulted in soreness and bruising, and was attributed to malfunctioning equipment. The director of nursing confirmed that this event was an unusual, unanticipated event with the potential to cause serious injury, and acknowledged that it was not reported to the appropriate agencies as required by facility policy.
Failure to Review Employee Health Screens and Inadequate Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure that employee health screens were reviewed by appropriate staff prior to the start of employment for four out of five sampled employees. Specifically, the Employee Health History Screens for the Business Office Manager, two Nurses Aides, and a Housekeeper were completed and signed by the employees themselves, but there was no evidence that a facility staff member or nurse had reviewed these documents before the employees began working. Interviews with the MDS Coordinator, who serves as the infection preventionist, and the Director of Nursing confirmed that the required review process was not followed for these individuals. Additionally, the facility did not ensure that staff consistently performed hand hygiene according to professional standards. Observations of a Medication Aide and two LPNs revealed that hand washing was performed for less than the required 20 seconds, and in some cases, used paper towels were employed to turn off the water instead of a clean paper towel, contrary to facility policy. Staff interviews confirmed awareness of the correct procedures, but acknowledged that proper hand hygiene was not consistently practiced during the observed instances.
Failure to Follow Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Program standards for monitoring and surveillance of antibiotic use for one resident. According to the facility's policy, nurses are required to utilize infection criteria protocols to determine the necessity of antibiotics, document the rationale for antibiotic prescriptions, and monitor for effectiveness, side effects, and adverse consequences. In the case reviewed, a resident with dementia and at risk for skin integrity issues was prescribed an oral antibiotic for cellulitis of the left second toe. The antibiotic prescribed was noted to be outside the recommended dose and frequency, yet there was no assessment indicating that infection criteria protocols were completed or reviewed by the provider before or after the prescription. Additionally, the required 'antibiotic time out'—a review of the appropriateness of the antibiotic 24-48 hours after initiation—was not performed. The provider was not notified that the prescribed antibiotic was outside the recommended dosing guidelines, nor was there documentation that the provider was made aware of whether infection criteria were met. The facility's Infection Preventionist confirmed that these antibiotic stewardship processes were not followed for this resident.
Failure to Prevent Elopement and Inadequate Supervision for High-Risk Resident
Penalty
Summary
The facility failed to prevent accidents and incidents for a resident with a high risk of elopement. The resident, who had diagnoses of schizophrenia and bipolar disorder with psychotic features, was assessed as cognitively intact but had a history of wandering, episodes of disorientation, and confusion. Despite being identified as high risk for elopement on a risk assessment, documentation inconsistently described the resident as only a moderate risk, and a wander guard was removed. The resident had a physician order for a wander guard to be in place and functioning, with staff directed to check its placement and function every shift. Multiple incidents occurred where the resident exited the building without staff knowledge, including being found outside by therapy staff and being brought back inside on two separate occasions after exhibiting aggressive behaviors. On another occasion, the resident exited the building by following another resident who had entered the security code to the front door, and was only noticed and assisted back inside by an LPN after about a minute. There was no documentation of incident reports or changes to interventions following these events, and the DON confirmed that no new interventions were implemented to prevent further unauthorized exits during this period.
Failure to Provide Written Notification Before Resident Room Change
Penalty
Summary
The facility failed to provide written notification to a resident or their Power of Attorney (POA) prior to a room change. Record review showed that the resident was moved to a new room to prevent falls, as decided by the Interdisciplinary Team (IDT) and the Director of Nursing (DON). The resident, who had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment, reported having no knowledge of the move or the reason for it. The resident's belongings were packed and moved without their prior awareness. Interviews with facility staff revealed that the Social Services Director (SSD) was typically involved in room changes but was not familiar with this particular move. The DON stated that the resident was spoken to about the move and had agreed, but also described the resident as not alert and oriented, with hallucinations and delusions, and unable to make such decisions. The DON confirmed that the POA could not be reached and that no written notification was provided to either the resident or the POA. The SSD confirmed that a notification form, which includes information about the right to appeal, should have been provided but was not.
Incorrect MDS Coding for Insulin Administration
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two of seventeen sampled residents, as required by federal and state regulations. Specifically, the MDS for both residents was coded to indicate that they had received insulin injections during the 7-day look back period. However, a review of the Medication Administration Records (MAR) for both residents showed no documented administrations of insulin during that time frame. Instead, the records indicated that the residents had received other injectable medications for Type 2 Diabetes—Trulicity and Ozempic—which are not classified as insulin. The Minimum Data Set Coordinator (MDSC) confirmed during an interview that the residents did not receive insulin during the assessment period and acknowledged that the MDS coding was incorrect. The coding error was attributed to the misclassification of non-insulin injectable diabetes medications as insulin in the MDS documentation. This discrepancy was identified through record review and staff interview, confirming that the facility did not follow the correct coding instructions as outlined in the Resident Assessment Instrument (RAI) Manual.
Failure to Provide Required 30-Day Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that residents received their required 30-day physician visits, as mandated by facility policy and federal regulations. For one resident with Alzheimer's dementia, anxiety, dyskinesia of the esophagus, and high blood pressure, there was no documentation of a physician visit within 30 days of admission. The first documented physician visit occurred 60 days after admission, during which the resident had already experienced a 7.14% weight loss and required new nutritional orders. Both the Director of Nursing (DON) and the Regional Nurse Consultant (RNC) confirmed the absence of the required 30-day physician visit for this resident. Another resident, admitted with a documented initial physician visit, did not receive the subsequent required 30-day follow-up visit. The medical record showed a gap between the initial visit and the next documented physician encounter, which did not occur until 60 days after the previous visit. Interviews with the DON and RNC confirmed that the required 30-day physician visit was not completed for this resident as well. These lapses prevented timely physician assessments necessary for developing and updating comprehensive care plans, verifying orders, and prescribing appropriate treatments.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
A medication aide (MA) failed to follow proper medication administration procedures for a resident, resulting in a medication error rate of 12%, which exceeds the acceptable threshold of 5%. During observed medication administration, the MA did not instruct the resident to rinse their mouth after using the Trelegy Ellipta inhaler, as required by both manufacturer instructions and facility competency guidelines. Additionally, the MA did not use the provided dosing card to measure the correct amount of Diclofenac Sodium gel before applying it to the resident's ankles, instead using a finger to scoop the medication from a cup. These actions were confirmed by the MA during an interview. Further, the MA administered an as-needed (PRN) dose of acetaminophen to the resident for a reported headache without first obtaining permission from the nurse, as required by facility protocol. The MA only informed the nurse of the administration after the fact. The nurse confirmed that the MA should have sought approval prior to giving the PRN medication. These failures in medication administration practices were observed and documented during the survey, affecting one of five sampled residents.
Failure to Identify Fall Causes and Update Care Plans After Incidents
Penalty
Summary
The facility failed to identify causal factors for falls and did not implement timely or appropriate interventions to prevent new falls after each incident, as required by their own policies and regulatory standards. This deficiency was observed in three residents, all of whom were at high risk for falls due to various medical conditions such as cognitive impairment, use of anticoagulants, gait and balance problems, incontinence, and recent infections. Despite multiple falls, the care plans for these residents were not consistently updated with new interventions after each incident, and some interventions identified in fall reports were not incorporated into the care plans at all. For one resident, multiple unwitnessed and witnessed falls occurred over a short period, with post-fall reports indicating issues such as improper footwear, incontinence, and changes in mental and physical status. However, interventions such as ensuring the call light was within reach or obtaining therapy referrals were not always added to the care plan, and updates were sometimes delayed until after additional falls had occurred. Another resident experienced falls associated with urinary symptoms and was later diagnosed with a urinary tract infection and sepsis, yet care plan updates did not occur with each incident, and communication of changes to staff was inconsistent. Staff interviews revealed that updates to care plans were often communicated verbally or through informal means such as whiteboards or binders, rather than being systematically documented and accessible to all staff. Charge nurses and nurse aides reported relying on word of mouth for care updates, and not all staff reviewed care plans directly. The Director of Nursing and MDS Coordinator confirmed that not all interventions from fall reports were added to care plans, and that root causes for falls were not always identified. This lack of timely and comprehensive care plan updates and failure to address causal factors for falls placed residents at risk and resulted in an Immediate Jeopardy situation.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that all residents were seen by a physician or physician delegate at the required intervals, as outlined in their own policy and federal regulations. Specifically, the policy requires that residents be seen by a physician within 30 days of admission, at least every 30 days for the first 90 days, and at least every 60 days thereafter. Record reviews and interviews revealed that five sampled residents did not have documentation of face-to-face physician visits that met these mandated timeframes. The Director of Nursing (DON) and Administrator (ADM) confirmed that the available records did not cover all required physician visits for these residents. The sampled residents had various medical conditions, including osteoporosis, atrial fibrillation, dementia, diabetes, chronic kidney disease, hypertension, depression, stroke, COPD, history of falls, use of anticoagulants, anxiety, bipolar disorder, schizophrenia, hemiplegia, and end stage renal disease. Despite the complexity of their medical needs, the documentation provided for each resident showed significant gaps in the frequency of physician visits, as required by policy. The deficiency was identified through review of medical records and staff interviews, which confirmed the lack of compliance with mandated physician visit schedules.
Deficiencies in Food Labeling and Storage Practices
Penalty
Summary
The facility failed to ensure that food items were properly labeled and dated, which could potentially lead to food-borne illnesses for all 62 residents served from the kitchen. During an initial kitchen tour, surveyors observed several deficiencies in food storage and labeling practices. Five bags of opened cereal were found on a metal cart without any labels or dates. In the upright refrigerator, 12 half chicken salad sandwiches and an open Med Pass nutritional shake were found without dates, despite the manufacturer's label instructing use within four days of opening. Further inspection revealed a can of dented mandarin oranges in the dry storage room, a large bag of taco seasoning open without a date, a container of chicken bouillon cubes past their best-by date, and a bag of semi-sweet chocolate chips open without a date. In the walk-in refrigerator, a plastic container of pears was found with a use-by date that had passed, and a container of sliced jalapenos was labeled with an open date but no use-by date. The Dietary Supervisor confirmed these findings, acknowledging the lack of proper labeling and the presence of expired items.
Inaccurate MDS Assessments for Pressure Injury and Hospice Care
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the documentation of their care needs. For one resident, identified as Resident 33, the MDS did not accurately reflect the presence of a Stage 2 pressure injury. Despite the resident reporting a sore on their bottom and observations confirming a red, open area on the left buttock, the MDS inaccurately indicated that the resident did not have any unhealed pressure ulcers. This discrepancy was confirmed by the facility's administrator, who acknowledged that the pressure ulcer should have been coded on the MDS. Another resident, identified as Resident 16, was inaccurately documented in the MDS regarding their hospice care status. Although the resident had been admitted to hospice services, as confirmed by both the hospice RN and the Director of Nursing, the MDS incorrectly marked the hospice section as 'No'. This error was attributed to changes in MDS staffing at the time, leading to a failure in accurately updating the resident's care status in the MDS.
Failure to Provide Restorative Therapy and Assistance Device for Resident with Contractures
Penalty
Summary
The facility failed to provide necessary restorative therapy and an assistance device for a resident with contractures. Resident 58, who was admitted with diagnoses including muscle wasting, generalized muscle weakness, hemiplegia, and hemiparesis, was not receiving restorative therapy for their condition. The resident's care plan indicated the need for a right hand splint to be applied daily by staff, but the resident reported never having received a brace for their contracted hand. Observations confirmed the resident's inability to open contracted fingers on the right hand, move the right wrist, and limited elbow extension. Interviews with facility staff, including a Certified Occupational Therapy Assistant (COTA) and the Director of Nursing (DON), revealed that the therapy department was unaware of the resident's contractures and that no restorative program was in place for the resident. The facility's policy on contracture prevention and management outlined procedures for providing range of motion exercises and splint/brace application, but these were not implemented for Resident 58. The lack of a restorative program and failure to provide an orthotic device contributed to the deficiency identified by the surveyors.
Failure to Evaluate Broda Chair Safety for Resident
Penalty
Summary
The facility failed to evaluate the safety of a Broda chair before its use for a resident, identified as Resident 16, who was admitted to the facility with a diagnosis of senile degeneration and was placed on hospice care. The resident's cognitive skills for daily decision-making were moderately impaired, and they required substantial assistance for transfers. The care plan noted the resident's potential for falls due to confusion, gait/balance problems, and unawareness of safety needs. Despite these risks, the facility did not assess the Broda chair's suitability for the resident, who had a history of falls when using a regular wheelchair. Observations revealed that Resident 16 was frequently left unsupervised in the Broda chair, which was often reclined, making it difficult for the resident to sit up or move independently. On multiple occasions, the resident was observed attempting to climb out of the chair, calling for help, and trying to get the attention of staff, who did not respond. The resident's family member also reported seeing the resident in a precarious position in the chair, indicating a lack of proper supervision and intervention by the facility staff. Interviews with facility staff, including a hospice RN and the DON, confirmed that the Broda chair was used to prevent falls and support the resident's weak core. However, the facility had not conducted an evaluation to determine the appropriateness of the Broda chair for Resident 16. The DON acknowledged the lack of assessment, and a corporate RN suggested that an occupational therapy assessment might be necessary, highlighting the oversight in ensuring the resident's safety and proper use of the Broda chair.
Failure to Implement Non-Pharmacological Interventions Before PRN Xanax Administration
Penalty
Summary
The facility failed to ensure non-pharmacological interventions were provided prior to administering PRN Xanax for a resident, leading to a deficiency. The resident, who had a BIMS score of 15 indicating high cognitive function, was admitted with a primary diagnosis of Sepsis and Pulmonary Embolism with Acute Cor Pulmonale. The resident had orders for Alprazolam 0.5mg to be administered as needed for anxiety or sleep, with a maximum of three tablets in a 24-hour period. However, the facility did not document any non-pharmacological interventions before administering the medication. The facility's Comprehensive Care Plan for the resident included goals and interventions related to anxiety, such as administering medications as ordered and monitoring for side effects and effectiveness. Despite this, the Medication Administration Record showed that the resident was given PRN Xanax 54 times in July without any documented non-pharmacological interventions. The facility's policy on Behavior Management emphasized that non-pharmacological interventions should be the first choice in managing behavioral symptoms. An interview with the facility Administrator confirmed the expectation to attempt non-pharmacological interventions prior to administering PRN Xanax, which was not met in this case.
Emergency Door Malfunction
Penalty
Summary
The facility failed to ensure the proper functioning of the emergency entrance/exit door at the south end of the 100-hallway, which compromised the safety and accessibility of the building during an emergency. On June 21, 2024, the Kenesaw Fire Department (KFD) was called to the facility to investigate a shorted electrical receptacle in a resident's room. However, they were unable to access the building through the emergency door at the south end of the 100-hallway and had to use the main entrance instead. This issue was confirmed by a resident during an interview on June 25, 2024. Further observations on June 25, 2024, revealed that the keypad code on the emergency door allowed exit but did not permit re-entry from the street, despite sounding as if it had released the door. The egress mechanism required pressure for five seconds to release the door, which was not functioning as intended. The door was the closest entry point to the 100-hallway from the street, making it critical for emergency access. Interviews with the Senior Administrator and Maintenance Supervisor confirmed that the door was not functioning properly before repairs were made on June 25, 2024.
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Surveyors found that the facility did not maintain a medication error rate below 5%, identifying multiple late and improperly timed medication administrations and a missing medication. A medication aide gave a cholesterol medication and wound-healing supplements significantly later than their scheduled times, and another aide administered acetaminophen well outside the ordered time window and could not obtain a prescribed dose of Ingrezza because it had not arrived from the pharmacy. An LPN administered fast-acting Humalog insulin before a meal when no food was available and was unaware of the required timing of insulin in relation to meals, while the facility’s insulin policy lacked guidance on meal-related timing despite manufacturer instructions specifying administration within 15 minutes before or immediately after eating.
A resident with severe cognitive impairment, a history of CVA, and total dependence for ADLs developed a new right ankle wound and a new DTI to the left heel. Facility policy and licensure rules require immediate notification of the resident representative and physician for significant changes in condition, but review of progress notes showed no documentation that the representative was informed. An LPN confirmed the representative was not updated about the new wounds, despite the requirement to do so.
A family member filed a written grievance about a staff member’s attitude toward a resident and the family member, but the facility did not complete the grievance documentation or ensure timely communication of the specific resolution. The grievance form lacked documented resolution and administrator review, the ADM was initially unaware of the grievance, and the SW delayed completing the form while awaiting permanent interventions from nursing leadership. Although staff reported discussing a general resolution with the resident and family, the family member later stated they had not been informed of the actual grievance resolution, and the grievance form was not fully completed until well beyond the facility’s stated 10–14 day timeframe for resolving grievances.
The facility failed to report an allegation of physical abuse to law enforcement as required by its abuse reporting policy. A cognitively intact resident with dementia, anxiety, bipolar disorder, and major depressive disorder reported refusing a shower when a NA placed a lift sling under them, after which the situation escalated and both the resident and the NA exchanged punches. Skin assessments documented multiple new bruises on both of the resident’s arms and hands that were not present the prior day. Although facility policy required timely notification of law enforcement for such allegations, documentation in the abuse report form and EHR showed no law enforcement notification, and facility leadership confirmed that the incident and bruising were not reported to police.
A resident receiving hospice services with a condition expected to limit life expectancy had a DNR order requested by their representative and entered into the medical orders, but the comprehensive care plan (CCP) was not updated to reflect this change in code status. Facility policy required the CCP to be reviewed and revised by the interdisciplinary team following MDS assessments, yet the CCP continued to show an earlier full code status instead of the current DNR. The SSS acknowledged that the code status should have been updated when the change was made.
A resident with ESRD on dialysis, Type 2 DM, A-fib, COPD, and CHF, and requiring total assistance with ADLs, had physician orders for sacral and coccyx skin care, including cleansing, application of preventative ointment up to four times daily and PRN, and use of a sacral mepilex dressing. The order appeared on the Order Listing Report but was absent from the Nurse Administration Record, so staff were not cued to provide the treatment. During observed incontinence care, the resident’s sacral area was pink and no mepilex dressing was in place. An LPN confirmed the treatment was ordered but not provided and attributed the omission to a possible electronic medical record glitch.
Two residents at risk for or with existing pressure ulcers did not receive appropriate, individualized pressure ulcer prevention and treatment. One resident with hemiplegia, severe cognitive impairment, total ADL dependence, and incontinence developed multiple heel and ankle wounds after initial blanchable redness was noted; ordered Prevalon boots were repeatedly unavailable, the order to use them at all times was not promptly updated in the NAR, a turning schedule was not entered into the EHR, tissue analytics were missed on a scheduled date, and a nutrition consult and initiation of ordered supplements for wound healing were significantly delayed. Another resident with a stage 2 pressure ulcer was repeatedly observed on a DermaFloat LAL mattress left on the firmest setting, and the DON confirmed staff had not followed the manufacturer’s instructions to adjust and verify the mattress setting to prevent bottoming out.
A resident with ESRD on dialysis, along with multiple comorbidities including CHF, COPD, A-fib, and Type 2 DM, had physician orders and a care plan for a therapeutic renal diet, a 1200 ml/day fluid restriction divided across meals and med passes, and no water pitcher in the room, consistent with facility policy for dialysis residents. Observations showed a full water pitcher at the bedside and meal trays providing more than the ordered 240 ml of fluid per meal, while documentation also reflected conflicting fluid restriction amounts. Staff confirmed the resident had been offered more fluid than ordered and that a water pitcher had been present. In addition, on a dialysis day, multiple scheduled 9 a.m. medications were not administered because the resident was away at dialysis and the facility had not coordinated medication timing around dialysis services, contrary to its own policy.
The facility failed to respond to resident call lights within its stated goal of 7 minutes, with documented response times exceeding 30 minutes for multiple residents. A cognitively intact resident reported being left on the toilet for extended periods, and call system data showed call lights active for well over an hour on several occasions. Another resident with moderately impaired cognition had call lights unanswered for more than an hour, including after returning from dialysis. A third cognitively intact resident reported waiting up to two hours, with records confirming multiple call light activations lasting over an hour. The DON acknowledged that call light times over 30 minutes were not timely.
A resident with ESRD on thrice-weekly dialysis, along with DM2, A-fib, COPD, and CHF and moderate cognitive impairment, did not receive scheduled morning medications, including metoprolol and linagliptin, while away at dialysis. The MAR documented that the 9 AM metoprolol dose was not given because the resident was away from the facility without medications, and a progress note confirmed that morning medications were not administered due to the dialysis appointment. The DON later confirmed these omissions and identified them as medication errors.
Failure to Maintain Acceptable Medication Error Rate and Proper Medication Timing
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 5 errors out of 39 opportunities, resulting in a 12.82% error rate. The facility’s policy allowed medications to be given within one hour before or after the scheduled time, but staff did not adhere to this window. One medication aide administered pravastatin 10 mg to a resident at 8:52 PM when it was scheduled for 7:00 PM, and confirmed it was given late. The same aide also administered LiquaCel 30 cc and Juven 1 packet to another resident at 9:20 PM, despite orders for these supplements to be given twice daily with morning and evening medications at 8:00 AM and 7:00 PM, and confirmed these were also late. Additional errors involved improper timing and availability of medications. An LPN administered 4 units of Humalog, a fast-acting mealtime insulin ordered to be given before meals, to a resident at 7:37 AM when the resident had no food present and did not receive a meal tray until 8:18 AM; the LPN stated they did not know how quickly food should be provided after fast-acting insulin. The facility’s insulin policy lacked guidance on timing relative to meals, while the manufacturer’s prescribing information specified administration within 15 minutes before or immediately after a meal. Another medication aide administered acetaminophen 500 mg (two tablets) at 7:30 AM instead of the scheduled 6:00 AM dose and was unable to locate the resident’s ordered Ingrezza 80 mg capsule, confirming the medication had not arrived from the pharmacy and required reordering. The DON confirmed that the acetaminophen should have been given at 6:00 AM.
Failure to Notify Resident Representative of New Wounds
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition, specifically the development of new wounds. The facility’s policy titled "Change in Condition" dated 05-21-2023 states that changes in a resident’s condition or treatment are to be immediately shared with the resident and/or resident representative and reported to the attending physician or delegate. The policy requires notification of the resident, resident representative, and physician for events such as accidents resulting in injury with potential need for physician intervention, significant changes in physical, mental, or psychosocial status, and the need to significantly alter treatment. Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) also requires immediate notification of the resident, the resident’s doctor, and a family member of situations that affect the resident. Record review showed that one resident, admitted on a specified date, had a history of cerebrovascular accident (stroke) affecting the right side, severe cognitive impairment with a BIMS score of 5, total dependence for toileting, hygiene, dressing, bed mobility, transfers, and bathing, frequent urinary incontinence, and constant bowel incontinence, and did not have a pressure ulcer at the time of the MDS dated 01-26-2026. A Tissue Analytics Document dated 03-03-2026 revealed the resident had developed a new wound on the right ankle and a new deep tissue injury to the left heel. Progress notes contained no indication that the resident’s representative was informed of these new wounds. In an interview, an LPN confirmed that the resident’s representative was not updated about the new wounds and acknowledged that they should have been.
Failure to Timely Complete and Communicate Grievance Resolution
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to resolve and communicate the resolution of a grievance submitted on behalf of a resident. The facility’s written policy required Social Services and department managers to investigate written grievances, submit a written report of findings to the administrator, and ensure the resident or complainant was informed of the investigation findings and corrective actions in a timely manner, with documentation on the grievance form. A family member filed a written grievance concerning a staff member’s attitude toward the resident and the family member. The initial grievance form obtained from the social worker showed the grievance was received, but the sections for resolution and administrator review were incomplete, and the administrator reported being unaware of the grievance until it was brought to attention by surveyors. Interviews revealed that the social worker left the grievance form incomplete because they were waiting for permanent interventions from nursing leadership and did not document the final, grievance-specific resolution until much later. The social services supervisor stated the grievance was being processed, and the assistant DON reported speaking with the staff member involved, who denied the allegation, and removing that staff member from the resident’s care. Although facility staff reported that grievance resolution had been provided to the resident and family through a one-to-one discussion, the resident’s family member later stated they had not been notified of the grievance resolution. The administrator indicated that a reasonable timeframe for grievance resolution, including completion and review of the form, was 10–14 days, but the grievance form was not fully completed until nearly two months after the grievance was filed, and the permanent, grievance-specific resolution was not communicated to the family at the time the grievance was initially addressed.
Failure to Report Alleged Physical Abuse and Resulting Bruising to Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of physical abuse to law enforcement within the required timeframe. Facility policy, revised 08/08/2024, required the administrator or designee to notify multiple entities, including law enforcement, no later than two hours after an allegation involving serious bodily injury or within 24 hours if there was no serious bodily injury. The policy also specified notification of the state licensing authority, Ombudsman, resident representative, APS, the resident’s attending physician, and the facility medical director. Despite this written requirement, documentation showed that law enforcement was not notified following an allegation of physical abuse involving a resident. The resident involved had been admitted in 2019 and had diagnoses including moderate vascular dementia with agitation, generalized anxiety disorder, bipolar disorder, and major depressive disorder. A recent MDS showed a BIMS score of 15, indicating the resident was cognitively intact, and noted episodes of care rejection but no documented physical behavioral symptoms toward others. On the date of the incident, a NA entered the resident’s room, placed a lift sling under the resident, and informed the resident they would be taking a shower; the resident reported refusing the bath and stated that the situation escalated into both the resident and the NA exchanging punches. Subsequent skin assessments documented multiple bruises on both upper extremities that were not present the day before. A Potential Resident Abuse Report Form and the EHR contained no evidence that law enforcement was notified, and both the Administrator and Social Services Supervisor confirmed in interviews that the allegation of physical abuse and associated bruising were not reported to law enforcement, contrary to facility policy and reporting requirements.
Failure to Update Comprehensive Care Plan to Reflect Current DNR Status
Penalty
Summary
The facility failed to update a resident’s comprehensive care plan (CCP) to reflect the current resuscitation status after a change in code status was ordered. Facility policy on Comprehensive Care Plans, last reviewed/revised on 09/02/2025, required the CCP to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Record review showed that the resident was admitted on 09/23/2024, had a condition or chronic disease that may result in a life expectancy of less than six months, and was receiving hospice services. A Do-Not-Resuscitate (DNR) order dated 04/03/2026 documented that the resident’s representative requested DNR status, and an order listing report showed a DNR order dated 04/22/2026. However, the resident’s CCP printed on 04/28/2026 at 9:18 AM still reflected a “full code, do not resuscitate” status dated 10/02/2024, indicating the CCP had not been updated to match the current DNR order. In an interview, the Social Services Supervisor confirmed that the code status should have been updated at the time of the code status change.
Failure to Implement Physician-Ordered Sacral Skin Treatment
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered skin integrity interventions for a resident with multiple comorbidities. The resident’s MDS dated 03-24-2026 documented End Stage Renal Disease with dialysis dependence, Type 2 Diabetes Mellitus, A-Fib, COPD, and Chronic Heart Failure, as well as moderate cognitive impairment with a BIMS score of 12. The resident required setup and cleanup assistance with eating and total assistance with hygiene, toileting, bathing, dressing, bed mobility, and transfers, and was receiving dialysis services. The physician’s order, as shown on the Order Listing Report printed 04-28-2026, directed staff to cleanse the buttocks and coccyx with foam soap and water, pat dry, apply preventative ointment up to four times daily and as needed for soiling, and secure the area with a sacral mepilex dressing. Despite this order, the Nurse Administration Record for April 2026 contained no entry for the ordered wound care to the buttocks and coccyx, meaning the treatment was not listed to cue staff for administration. During an observation of incontinence care on 04-30-2026 at 10:40 AM, the resident’s sacral area showed pink skin discoloration and there was no mepilex dressing present on the sacral or coccyx area, indicating the ordered treatment had not been provided. In an interview later that day at 2:30 PM, an LPN confirmed that the resident was supposed to receive wound care to the sacral and coccyx area, acknowledged that the treatment had not been provided, and stated there must have been a glitch in the electronic medical record program because the order did not appear on the NAR.
Failure to Implement and Adjust Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
The deficiency involves the facility’s failure to develop, implement, and reevaluate effective interventions to prevent pressure ulcer development and to promote wound healing for two residents at risk or with existing pressure injuries. Facility policy required Braden Scale risk assessments on admission, weekly for four weeks, then quarterly or with significant change, and mandated a systematic approach including prompt assessment and treatment, monitoring, and modification of interventions as needed. The policy also required that interventions be adjusted when risk changed, when new or recurrent pressure injuries developed, when there was lack of healing progression, or when residents were non-compliant. The Braden Scale reference used by the facility defined scores of 10–12 as high risk and 13–14 as moderate risk for pressure ulcer development. One resident with a history of stroke, right-sided hemiplegia, severe cognitive impairment, total dependence for ADLs, and bowel and bladder incontinence was identified as at moderate to high risk for pressure ulcer development on admission, with a baseline care plan including a pressure-relieving wheelchair cushion and a comprehensive care plan identifying high risk for skin breakdown. The care plan listed general interventions such as Braden evaluations, observation and documentation of skin condition, use of a special mattress, skin hygiene, and nutritional and lab monitoring. A skin check initially showed no pressure ulcers, but a subsequent skin check documented blanchable redness to the right heel. An order was in place for Prevalon boots to be worn in bed, but progress notes over several consecutive days documented that the boots were not available, and heels were instead floated on a pillow. A pressure ulcer on the right heel was then identified, and later tissue analytics showed the wound had significantly enlarged, with additional findings of a new dark area consistent with a deep tissue injury on the right heel, a new wound on the right ankle possibly related to pressure or boot straps, and a deep tissue injury on the left heel. Practitioner instructions were to protect the heels at all times, including when out of bed and to avoid resting the feet on foot pedals, but the medication/nurse administration record was not updated to reflect the “at all times” order until many days after it was given. For this same resident, the facility did not promptly obtain a nutritional evaluation for wound healing, as the dietician’s assessment and recommendation for a nutritional supplement occurred several weeks after the first pressure ulcer was identified, and the ordered supplement was not started until several days after the recommendation. Tissue analytics documentation was also not completed on one of the scheduled dates, and interviews with nursing staff confirmed that a turning/repositioning schedule was not entered into the electronic health record to cue staff, despite the resident’s high risk and existing wounds. Staff interviews further confirmed that the resident was non-compliant with Prevalon boots and that the interdisciplinary team had not re-evaluated pressure-relief interventions for the feet during this period. Another resident, cognitively intact but totally dependent for bed mobility, transfers, and personal care, and always incontinent of bowel and bladder, was assessed as at risk for pressure ulcers and already had a stage 2 pressure ulcer. This resident was observed on multiple occasions lying in bed on a Joerns DermaFloat low air loss mattress that was consistently set at the firmest setting. The manufacturer’s instructions for this mattress required individualized adjustment of the comfort setting using a hand-check method to prevent bottoming out and directed that the proper setting be documented and re-evaluated as the resident’s condition warranted. The DON confirmed that the facility had not followed the mattress manual for setup for this resident and could not confirm that the mattress was at the correct setting to prevent bottoming out as described in the manual.
Failure to Adhere to Dialysis Resident Fluid Restriction and Medication Scheduling
Penalty
Summary
Surveyors identified that the facility failed to follow its own policy for dialysis residents and to adhere to physician-ordered fluid restrictions and medication timing for one dialysis-dependent resident. The facility’s policy required that dialysis residents receive fluids only as ordered by the physician, that nursing and dietary staff organize the division and distribution of fluids, that no water pitcher be present when restricted, and that medications be administered before departure and after return from dialysis so as not to interfere with treatment. The resident had end stage renal disease on dialysis, Type 2 diabetes mellitus, atrial fibrillation, COPD, and chronic heart failure, with a care plan and orders specifying a therapeutic diet, low potassium, no added salt, double protein, and a 1200 ml/day fluid restriction divided as 240 ml at each meal and 120 ml with each med pass, and no water pitcher in the room. Despite these orders and care plan interventions, observations showed a 600 ml water pitcher in the room filled to the 500 ml mark, and lunch trays that included a 240 ml milk carton plus additional juice and ice, exceeding the ordered 240 ml fluid allotment at meals. Record review further showed conflicting fluid restriction documentation, with an After Visit Summary listing a 1500 ml fluid restriction while the facility’s orders and care plan reflected a 1200 ml restriction, and staff interviews confirmed that the resident had been offered more than the ordered 240 ml of fluid with meals and that a water pitcher had been present contrary to the care plan. Additionally, the facility failed to coordinate medication administration around dialysis treatments. The Medication Administration Record documented that multiple scheduled 9 a.m. medications, including atorvastatin, fluticasone nasal spray, linagliptin, sennosides-docusate, metoprolol tartrate, mucinex ER, carboxymethylcellulose eye drops, and ipratropium-albuterol inhalation solution, were not given on a dialysis day because the resident was away from the facility without medications. The DON confirmed that these medications were omitted due to the resident being at dialysis and acknowledged not knowing that medication administration should be scheduled around dialysis services, contrary to the facility’s dialysis care policy.
Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely response to resident call lights, with multiple documented instances of response times far exceeding 30 minutes. One cognitively intact resident (BIMS score 13) reported being left on the toilet for a very long time in mid-January and again on a later date in April, though for a somewhat shorter period. Alarm Average Response Time Reports (AARTR) showed that this resident’s call light remained on for 167 minutes and 51 seconds on one January date, and for 46 minutes and 32 seconds and 73 minutes and 34 seconds during two separate call light activations in April. Another resident with moderately impaired cognition (BIMS score 12) had a family member report that the resident had to wait an hour to be laid down after dialysis. AARTR data for this resident showed call light durations of 61 minutes and 38 seconds and 76 minutes and 33 seconds on separate occasions in April. A third cognitively intact resident (BIMS score 15) reported having waited as long as two hours for a call light to be answered, and AARTR records documented call light durations of 65 minutes and 18 seconds and 63 minutes on two separate occasions. The DON stated that the facility’s goal for call light response was 7 minutes and confirmed that call light times over 30 minutes were not timely.
Failure to Administer Ordered Medications During Dialysis Absence
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when required medications were not administered as ordered while the resident was away from the facility for dialysis. The resident had multiple serious diagnoses, including end stage renal disease requiring dialysis, type 2 diabetes mellitus, atrial fibrillation, COPD, and chronic heart failure, and was assessed with moderate cognitive impairment. The resident required extensive assistance with most activities of daily living and was receiving dialysis services three times weekly. The comprehensive care plan documented scheduled dialysis on Monday, Wednesday, and Friday. On a documented dialysis day, the resident did not receive the scheduled 9 AM dose of metoprolol tartrate 25 mg because the resident was away from the facility without medications. The medication administration record showed a code indicating the medication was not given due to the resident being away, and a progress note stated that morning medications were not administered because the resident was at dialysis that morning. Later, the physician ordered metoprolol to be given after the resident’s heart rate was found to be 116. In an interview, the DON confirmed that the resident did not receive metoprolol and linagliptin on that date and acknowledged that the omission constituted a medication error.
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