Christian Homes Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Holdrege, Nebraska.
- Location
- 1923 West 4th Avenue, Holdrege, Nebraska 68949
- CMS Provider Number
- 285246
- Inspections on file
- 18
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Christian Homes Health Care Center during CMS and state inspections, most recent first.
Surveyors found unlabeled and undated foods in the kitchen and walk-in refrigerator, along with soiled storage containers, drawers, and a food scale with residue. A cook was observed preparing multiple menu items without hand hygiene, using bare hands on frozen foods, handling foods and sauces without temperature checks, and retrieving rice from the dirty pan area. During meal service, staff served residents with the same gloved hands after touching doors, resident items, and other potentially contaminated surfaces, and the DM confirmed gloves do not replace HH.
Meals were not served consecutively to residents seated at the same table, affecting multiple residents observed during the noon meal. A dietary staff member served some residents at one table while leaving tablemates waiting, and one plated meal was even carried out of the dining room to a resident room before all dining room residents were served. The DM and a dietary cook confirmed the expectation is to serve all residents at one table before moving to the next table.
Failure to Inform Residents and Representatives About Psychotropic Medication Risks and Alternatives: Surveyors found that the DON confirmed residents receiving psychotropic meds were not given signed forms or advance discussion of risks, benefits, and alternatives before administration. Records for several residents with diagnoses such as dementia, depression, schizoaffective disorder, bipolar disorder, Alzheimer’s disease, and Down syndrome showed orders for antipsychotics and antidepressants, but no evidence that the resident and/or representative was informed in advance of care.
Failure to complete baseline care plans and provide written summaries to residents or their representatives. The facility did not complete baseline care plans within the required timeframe for multiple residents, and EMR review showed missing or blank baseline care plan documentation for several admissions. The SSD and DON confirmed that written summaries were not provided or reviewed with the resident or representative as required.
The facility failed to ensure the Ombudsman was informed of all resident discharges and transfers. Record review showed that two residents had an emergency hospital transfer or discharge, but neither resident was included on the monthly transfer forms sent to the Ombudsman. The SSD confirmed the events were not reported as required.
MDS coding was inaccurate for two residents. One resident with Type 2 DM was incorrectly coded as having an ostomy and as receiving an insulin injection during the lookback period, even though the EMHR showed no ostomy and no insulin orders. A second resident with Type 2 DM was also incorrectly coded as receiving an insulin injection during the lookback period, despite no EMHR evidence of insulin orders; the MDSC confirmed the errors.
A CCP failed to include a resident’s stated discharge goal to return home after a stage 3 pressure ulcer healed, even though the resident and spouse both identified that plan. Another resident’s CCP did not match the current pureed diet order and also omitted the resident’s antipsychotic medication use and monitoring needs, despite MDS, physician orders, EMAR, and staff interviews confirming the diet change and ongoing Risperidone administration.
Failure to Administer PRN Midodrine as Ordered: A resident with orthostatic hypotension and a care plan for fall risk had a provider order for PRN Midodrine when BP was below 100, but repeated BP checks showed readings below that threshold without evidence the medication was given. The MAR and BP summary documented multiple low readings over two months, and an LPN, the CCC, and the DON confirmed the PRN medication was not being administered as ordered.
A facility failed to identify a resident’s preference for dental services during admission. The resident was edentulous, had not worn dentures for a long time because they no longer fit, and was on a modified texture diet due to coughing and choking at meals. The resident said they were not offered dental services on admission and wanted new dentures. An LPN was unaware of any dental appt, and the SSD stated the resident should have been asked about dental services.
An LPN failed to perform hand hygiene between glove changes while providing catheter care and wound care for a resident with a stage 3 pressure ulcer. During the observation, wound care supplies were placed directly on the resident’s bed, gloves were removed and replaced multiple times without hand hygiene, and a Q-tip and measuring device that had been on the bedding were used during wound care. The LPN and CCC confirmed hand hygiene should have been done after glove removal and before donning new gloves.
An unqualified individual who was not an employee assisted with food preparation in the kitchen due to a staffing shortage. The Dietary Manager confirmed the individual was not qualified to work in the kitchen, and the Administrator was unaware of this occurrence. This had the potential to affect all residents in the facility.
The facility did not notify the State Agency of a change in the DON position within the required timeframe, as confirmed by record review and administrator interview. This delay had the potential to impact all residents in the facility.
A resident reported being hit and restrained by an unidentified individual during the night. The DON investigated the allegation and deemed it unfounded but failed to report it to the State Agency as required by the facility's policy.
The facility failed to identify specific target behaviors for psychotropic medications in several residents, as required by policy. This deficiency was observed in residents prescribed antidepressants, antianxiety, and antipsychotic drugs, with no documentation of targeted behaviors in their care plans. Additionally, PRN orders for psychotropic medications lacked necessary stop dates. Staff interviews confirmed a lack of awareness and documentation, indicating non-compliance with the facility's medication management policy.
The facility did not provide the required SNF ABN and NOMNC to two residents in a timely manner. These notices, which inform residents about costs and appeal rights related to Medicare Part A coverage, were signed after the Last Covered Day for both residents. Interviews confirmed the delay in providing these notices.
A facility failed to report a suspected abuse allegation involving a cognitively intact resident with multiple medical conditions. The resident reported feeling uncomfortable due to a nursing assistant's actions, which was communicated to the ADON by a family member. Despite awareness of the allegation, the facility did not report the incident to the state agency within the required timeframe, as confirmed by a review of reportable incidents.
A resident reported feeling uncomfortable due to a nursing assistant's actions, but the facility failed to investigate or report the alleged abuse. Despite the resident being cognitively intact and the incident being reported to staff and a family member, no investigation was conducted, violating the facility's abuse policy.
The facility failed to accurately code the MDS for a resident with a Level II PASARR evaluation for SMI and ID, marking 'No' instead of 'Yes'. Additionally, another resident's MDS did not reflect the use of an antibiotic, despite it being administered as per the eMAR. These discrepancies were confirmed by the MDS Consultant.
The facility failed to develop comprehensive care plans for two residents. One resident's care plan lacked details on managing antidepressant, antianxiety, and anticoagulant medications, while another resident's care plan did not address an actual fall incident despite being at risk for falls. These deficiencies were confirmed by facility staff.
The facility failed to update the Comprehensive Care Plans for three residents, leading to deficiencies in addressing their current medical needs. A resident with obstructive sleep apnea had a BiPAP order not reflected in their care plan, while another resident's CPAP use was similarly omitted. Additionally, a resident who experienced a fall did not have their care plan updated to address the incident. These oversights were confirmed by the ADON.
The facility failed to implement Enhanced Barrier Precautions for a resident with an MDRO and an indwelling catheter, as staff did not wear gowns or perform proper hand hygiene during care. Additionally, the facility did not ensure daily cleaning of a CPAP device for another resident, as required by physician orders. These deficiencies highlight lapses in infection control practices.
The facility did not designate a licensed RN to work full-time as the Director of Nursing (DON) while the previous DON was on maternity leave. During this period, the ADON, an LPN, and the ADM, who was not a nurse, performed some of the DON's responsibilities. The facility census was 61, and the deficiency had the potential to affect all residents.
Food Labeling, Sanitation, and Hand Hygiene Failures During Meal Preparation and Service
Penalty
Summary
The facility failed to label and date multiple foods stored in the kitchen and walk-in refrigerator. During the initial kitchen inspection, surveyors observed trays and pans of desserts, fruit cups, and a sealed bag of cornbread that were not labeled or dated. The inspection also found soiled food storage containers, drawers with dried food residue, and a food scale covered with grease-like film and food particles. The dietary manager confirmed that foods were supposed to be labeled before being placed in refrigerators and that the drawers and dry food containers needed cleaning. Surveyors also observed multiple food preparation practices that did not follow the facility’s own procedures or basic food handling expectations. A dietary cook prepared chicken with teriyaki sauce using a paint brush, kept the sauce covered on an unheated stove without cooling or hot holding it, and repeatedly handled foods and equipment without performing hand hygiene. The cook handled frozen hamburger patties and hot dogs with bare hands, mixed rice, vegetables, eggs, and sauces without obtaining temperatures at several points, and used rice retrieved from the dirty pan area after it had already been discarded there. The cook also used a food scale and other equipment that had not been cleaned or sanitized after use. During meal service, surveyors observed dietary staff serving residents while wearing gloves but not changing gloves or performing hand hygiene after touching potentially contaminated items. One aide handled a door, resident cups, and plates with the same gloved hands, including placing gloved thumbs on the food-contact surface of a plate. The dietary manager also handled jelly packets, touched a resident’s shoulder, and then continued serving meals without removing gloves or performing hand hygiene. Another aide handled a resident’s personal cell phone with gloved hands and then served desserts and meals to residents without removing the gloves or performing hand hygiene. The dietary manager confirmed that gloves did not replace hand hygiene during meal service.
Meals Not Served Consecutively at Shared Tables
Penalty
Summary
The facility failed to consecutively serve meals to all residents seated at the same table to maintain resident dignity for 10 of 12 residents observed. During the noon meal observation in the Peony dining room, 12 residents were seated at 5 different tables, and the first plated meal was taken from the kitchenette and carried to a resident room before meals were served in the dining room. In the dining room, residents seated together were not consistently served one table at a time; for example, Resident 62 was served first at 12:50 PM while tablemates Residents 47 and 70 had not yet been served, and Resident 41 was served at 12:50 PM while tablemate Resident 27 was not served until 12:55 PM. Additional observations showed similar delays within tables. Resident 35 was served at 12:57 PM while tablemates Residents 31 and 12 were not served until 1:03 PM and 1:04 PM, respectively. Resident 72 was served at 12:58 PM while tablemate Resident 36 was not served until 1:00 PM. Resident 47 was served at 12:59 PM, 9 minutes after tablemate Resident 62, and Resident 70 was served at 1:01 PM, 11 minutes after tablemate Resident 62. The Dietary Manager and a Dietary Cook both confirmed that the expectation is to serve all residents seated at one table before moving to the next table.
Failure to Inform Residents and Representatives About Psychotropic Medication Risks and Alternatives
Penalty
Summary
The facility failed to inform residents and/or their representatives in advance of care about the risks, benefits, and possible alternatives of psychotropic medications for 5 of 6 sampled residents: Residents 1, 4, 10, 53, and 60. The cited regulation was 175 NAC 12-006.05(D)&(E), and the facility census was 71. Surveyors reviewed records, observed documentation, and interviewed the DON, who confirmed that residents receiving psychotropics were not given a form to sign showing the risks and benefits of these medications and that alternatives were not discussed with the resident or family representatives before the medications were administered. Resident 4 had diagnoses of depression and dementia with agitation and orders for quetiapine 50 mg at 7:00 PM, quetiapine 200 mg twice daily, and sertraline 50 mg daily. The electronic medical record showed no evidence that the resident and/or representative were informed in advance of the risks, benefits, and possible alternative treatments for the antidepressant and antipsychotic medications. Resident 60 had diagnoses of dementia and depression and orders for sertraline 100 mg daily and quetiapine 12.5 mg at 7:00 PM, and the record also lacked evidence of advance notification regarding risks, benefits, and alternatives. Resident 1 was admitted with depression and schizoaffective disorder and received Celexa daily and olanzapine every evening, with no evidence in the EMHR that the resident and/or representative were informed in advance of care. Resident 53 was admitted with bipolar disorder and received buspirone daily and risperidone every evening, with no documentation of advance notification. Resident 10 had diagnoses including Alzheimer’s disease, Down syndrome, depression, and unspecified mood disorder, and received multiple Seroquel and Zoloft orders over time; the DON stated education for medication changes was done at care planning meetings with the POA, but advance notification of the risks, benefits, and possible alternatives of psychotropic medications was not completed prior to dispensing.
Failure to Complete and Share Baseline Care Plans
Penalty
Summary
The facility failed to ensure that a baseline care plan was completed within 24 hours of admission for 7 of 10 sampled residents, including Residents 18, 60, 11, 53, 70, 2, and 9. The report states that the baseline care plan is intended to provide initial effective and person-centered care and to meet a resident’s immediate needs, but record review showed no evidence that a baseline care plan had been completed for several of the residents reviewed. The facility policy titled Care Plans, dated January 2026, stated that a baseline plan of care should be developed within 48 hours of admission, while Nebraska requires it within 24 hours. The facility also failed to provide a written summary of the baseline care plan to the resident or their representative for 9 of 10 sampled residents, including Residents 18, 74, 60, 11, 53, 3, 70, 2, and 9. Interviews with the SSD and DON confirmed that written summaries were not provided as required. Record review showed blank or missing baseline care plan summary and signature sections for some residents, and EMR review for others showed no evidence that a summary had been completed or reviewed with the resident or representative.
Failure to Report Resident Transfers and Discharges to the Ombudsman
Penalty
Summary
The facility failed to ensure the Ombudsman was informed of all resident discharges and transfers. Record review and interview showed that the Social Services Director stated the facility sent a monthly list of emergency transfers to the Ombudsman. However, Resident 74 had an emergency transfer to the hospital on 1/2/2026 at 7:45 AM, and although the January 2026 Emergency Transfers from Facility form was provided to the Ombudsman, Resident 74 was not included. Resident 76 was transferred from the facility on 2/9/2026, but the February 2026 Emergency Transfers from Facility form provided to the Ombudsman did not include Resident 76. In follow-up interview, the Social Services Director confirmed that the discharge for Resident 76 and the transfer of Resident 74 were not reported to the Ombudsman as required.
MDS Coding Errors for Ostomy and Insulin Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for 2 of 18 sampled residents. Facility policy assigned the MDS Coordinator responsibility for completing Section H: Bladder and Bowel, Section N: Medications, and submitting the MDS. The RAI Manual instructions cited in the report state that Section H0100C should be coded if an appliance was used at any time in the 7 days prior to the ARD, and Section N0350A should reflect the number of days insulin injections were received during the 7 days prior to the ARD. For one resident with a diagnosis of Type 2 Diabetes Mellitus, the comprehensive MDS coded Section H0100C as if the resident had an ostomy and coded Section N0350A as 1 for an insulin injection during the 7-day lookback period. Review of the EMHR showed no evidence of an ostomy and no orders for insulin injections during that period, and the MDSC confirmed both codes were incorrect. For a second resident with Type 2 Diabetes Mellitus, the quarterly MDS coded Section N0350A as 1 for an insulin injection during the 7-day lookback period, but the EMHR showed no orders for insulin injections during that period; the MDSC confirmed this code was also incorrect.
CCP Did Not Reflect Discharge Plan, Diet, or Antipsychotic Use
Penalty
Summary
The facility failed to ensure the Comprehensive Care Plan (CCP) reflected the discharge plan and goals for a resident admitted with a stage 3 pressure ulcer. The resident’s MDS documented that the resident and/or significant other provided information and that the overall goal was to discharge to the community. During interviews, the resident stated the plan was to return home after the wound healed, and the spouse stated the goal was for the resident’s wound to heal and then return home. However, the CCP contained no focus, goal, or interventions addressing the resident’s desired discharge plan to return home after healing. The facility also failed to ensure another resident’s CCP accurately reflected the current therapeutic diet. That resident was admitted with epilepsy and had a quarterly MDS indicating no signs or symptoms of swallowing disorders while receiving a mechanically altered diet. The CCP documented a no added salt diet with mechanical soft texture and thin liquids, along with use of a scoop plate and handled cups, and listed a goal to maintain adequate nutritional status. The resident stated they had no teeth or dentures, had been receiving a baby food diet, did not like it, and wanted to eat regular food again. The physician order summary showed a no salt added, pureed texture diet, and an LPN confirmed the diet had been changed to puree due to coughing during meals. The CCC confirmed the CCP did not accurately reflect the current pureed diet order. The same resident’s CCP also failed to reflect antipsychotic medication use. The quarterly MDS showed routine antidepressant and antipsychotic medication use, and the physician order summary listed Buspirone daily and Risperidone every evening. The EMAR showed the resident had been receiving the antipsychotic as ordered since admission. The CCP included a psychosocial wellbeing focus related to bipolar disorder and an intervention to administer an antidepressant medication, but it did not include the antipsychotic medication or the need to monitor for possible side effects. The CCC confirmed that the antipsychotic use and possible side effects were not listed on the care plan and should have been.
Failure to Administer PRN Midodrine as Ordered
Penalty
Summary
The facility failed to follow a provider’s order for PRN Midodrine for a resident admitted with orthostatic hypotension and a care plan focus for fall risk related to hypotension. The physician order directed that 1 tablet of Midodrine be given by mouth every 8 hours as needed for hypotension when blood pressure was below 100. Record review showed the resident had repeated blood pressure readings below 100 during February and March 2026, including readings as low as 70/46, 73/44, 75/48, and 76/50, yet there was no evidence that the PRN Midodrine was administered on those occasions. The MAR and blood pressure summary documented multiple instances in which the resident’s blood pressure was below the ordered threshold without a corresponding medication administration entry. In February, low readings were recorded on several dates, including 75/48, 92/57, 98/62, 86/57, 96/64, 94/58, 82/54, 73/44, 80/50, 91/57, 95/63, 86/54, 99/76, and 88/63, with only one documented administration on 02/20/2026 despite a continued low blood pressure reading afterward. In March, additional low readings were documented, including 76/50, 95/60, 92/66, 86/62, 75/49, 88/52, 95/63, 99/60, 96/62, 84/56, 94/62, 88/56, and 70/46, again without evidence of the PRN medication being given as ordered. During interview, the LPN stated staff obtained the resident’s blood pressure daily and, when low, advised the resident to be careful when sitting, standing, or walking and to use the call light to prevent falls. The LPN denied knowledge of the PRN Midodrine order until reviewing the physician orders and confirming it had not been administered as ordered. The CCC and DON also confirmed that the resident had an order for PRN Midodrine for blood pressures less than 100 and that the medication was not being administered according to the provider’s order.
Failure to Identify Resident’s Dental Service Preference on Admission
Penalty
Summary
The facility failed to identify Resident 53’s preference to have or not have dental services during admission, as required for routine and 24-hour emergency dental care. Record review showed the facility policy stated residents and/or their representatives are to be notified during the admission process about available dental services under the State Plan and any potential charges for outside dental care. The deficiency was identified based on the facility not documenting whether Resident 53 wanted dental services on admission. Resident 53 told the surveyor they were eating a modified texture diet because they had no teeth and were not sure how long it had been since they last used dentures. The resident stated their dentures had stopped fitting a while ago and they stopped wearing them, and they were not offered dental services on admission. The resident also stated they would like to get new dentures so they could eat regular food again. An LPN stated Resident 53 was edentulous, did not have dentures on admission, was on a modified texture diet due to coughing and choking at meals, and did not have a dental appointment that the nurse was aware of. The SSD stated staff ask residents about dental services during admission, but they did not ask Resident 53 and should have.
Hand Hygiene Not Performed Between Glove Changes During Wound and Catheter Care
Penalty
Summary
The facility failed to perform hand hygiene between glove changes during catheter care and wound care for one resident with a stage 3 pressure ulcer. The resident was admitted with a diagnosis of a stage 3 pressure ulcer on the right buttock, and provider orders directed dressing changes that included removing the old dressing and packing strip, cleansing the wound with wound cleanser, placing gauze packing strip in Vashe wound solution, packing the wound bed, and covering it with a 4x4 gauze secured with a Mepilex dressing. During an observation of wound care, an LPN placed wound care supplies directly on the resident’s bed without a barrier, provided suprapubic catheter care with gloved hands, removed gloves, and then put on new gloves without first performing hand hygiene. The LPN later removed soiled wound dressing material, removed gloves again, and put on another pair of gloves without hand hygiene. After cleansing the wound, the LPN again removed gloves and donned new gloves without hand hygiene. The LPN also used a Q-tip and a clear plastic measuring device that had been placed directly on the resident’s bedding and used the measuring device on the wound and surrounding skin. The LPN and the facility Clinical Care Coordinator both confirmed that hand hygiene should have been completed after removing gloves and before putting on new gloves.
Unqualified Individual Assisted in Kitchen Due to Staffing Shortage
Penalty
Summary
The facility failed to ensure that only qualified dietary staff worked in the kitchen, as required by licensure regulations. Record reviews showed that an individual, SR-A, who was not an employee of the facility and did not meet the qualifications outlined in the Dietary Aide job description, was present in the kitchen assisting with food preparation by peeling potatoes. This occurred due to a shortage of staff in the kitchen. The Dietary Manager confirmed that SR-A was not qualified and should not have been working in the kitchen, and the Administrator was unaware of SR-A's involvement until after the fact. This deficiency had the potential to affect all 75 residents residing in the facility.
Failure to Timely Notify State Agency of DON Change
Penalty
Summary
The facility failed to notify the State Agency of a change in the Director of Nursing (DON) position within the required five-day timeframe. Record review showed that the DON was changed on 11/8/24, but the notification to the State Agency was not received until 1/15/25. During an interview, the Administrator confirmed that the notification was not sent within the required period. This lapse had the potential to affect all 75 residents residing in the facility.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, as required by their Abuse Policy and Procedures. The incident involved a resident who was reported by a Nursing Assistant to have been difficult to arouse during the night. The resident later complained that an unidentified individual was hitting and pounding on their chest, instructing them not to get up until the day shift staff arrived. Despite the resident's inability to provide further details, the incident was documented in the resident's progress notes. The Director of Nursing (DON) was informed of the allegation on the same day it was made. An investigation was conducted by the DON, who concluded that the allegation was unfounded. However, the DON did not report the allegation to the required State Agency, as mandated by the facility's policy. A review of the facility's records confirmed that no reports of staff-to-resident abuse investigations were submitted to the state agency for the month in question.
Failure to Identify Target Behaviors for Psychotropic Medications
Penalty
Summary
The facility failed to identify specific target behaviors for the use of psychotropic medications in several residents, which is a requirement for monitoring the effectiveness of these medications. This deficiency was observed in five residents who were prescribed various psychotropic medications, including antidepressants, antianxiety, and antipsychotic drugs. The facility's policy requires that target behaviors be documented and monitored, yet this was not done for the residents in question. Interviews with staff, including a Medication Aide and a Registered Nurse, revealed a lack of awareness regarding the behaviors to be monitored, and the Assistant Director of Nursing confirmed the absence of documentation for targeted behaviors in the residents' electronic health records. Resident 35 was prescribed multiple antidepressants and an antianxiety medication, but their Comprehensive Care Plan (CCP) did not include any care plan related to the psychotropic medication uses or identification of targeted behaviors. Similarly, Resident 37 was prescribed an antidepressant without any identification of targeted behaviors in their CCP. Resident 44, who was prescribed both an antidepressant and an antipsychotic, also lacked documentation of targeted behaviors in their care plan. Interviews with staff confirmed the absence of this critical information, which is necessary for assessing the effectiveness of the medications. Additionally, the facility failed to include stop dates for PRN orders of psychotropic medications, as required by their policy. Resident 53 had a PRN order for Ativan without a stop date, and Resident 55 had a PRN order for Buspirone, which should not have been a PRN order and also lacked a stop date. The Assistant Director of Nursing confirmed these oversights, indicating a failure to adhere to the facility's policy on psychotropic medication management.
Failure to Provide Timely SNF ABN and NOMNC Notices
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and the Notice of Medicare Non-Coverage (NOMNC) to two residents, Resident 3 and Resident 44, or their representatives, in a timely manner. These notices are essential for informing residents about the costs of continuing skilled services and their right to appeal the decision to end Medicare Part A coverage. For Resident 3, the Last Covered Day (LCD) for Medicare Part A services was on 10/05/2024, but the SNF ABN was signed on 10/07/2024. Similarly, for Resident 44, the LCD was on 11/03/2024, but the SNF ABN was signed on 11/07/2024. Interviews with the Social Services Director confirmed that the notices were not signed within the required timeframe prior to the LCD for both residents.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report a suspected allegation of abuse involving a resident to the state agency within the required time frame and did not report the follow-up investigation within the mandated five working days. The incident involved a resident who was cognitively intact, as indicated by a BIMS score of 13, and had multiple medical conditions including atrial fibrillation, unspecified psychosis, depression, hypothyroidism, Meniere's disease, unspecified convulsions, chronic kidney disease, and hearing loss. The resident reported to a family member that a nursing assistant had made them feel uncomfortable by rubbing up against them in the bathhouse. The family member communicated this allegation to the facility's Assistant Director of Nursing (ADON). Despite being aware of the allegation, the facility staff, including the ADON, did not report the incident to the state agency as required. A review of the facility's reportable incidents confirmed that no report of the alleged abuse had been made in the last six months. The facility's policy and procedures, revised in January 2024, clearly state that allegations of abuse should be investigated and reported to the Department of Health and Human Services, a responsibility designated to the Administrator or the Director of Nursing.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility staff failed to investigate an alleged incident of abuse involving a resident, identified as Resident #53, who was part of a sample of 16 residents in a facility with a census of 61. The facility's abuse policy and procedures, revised in January 2024, require that allegations of abuse be investigated and reported to the state. However, a review of the facility's reportable incidents revealed no report of the alleged abuse involving Resident #53 and a nursing assistant, NA-H, in the last six months. Interviews with facility staff, including a medication aide and a licensed practical nurse, confirmed that the resident had reported feeling uncomfortable due to NA-H's actions, and the matter was brought up in risk management. Despite this, the Assistant Director of Nursing confirmed that no investigation had been conducted. Resident #53, who was admitted with multiple medical conditions including atrial fibrillation, unspecified psychosis, depression, hypothyroidism, Meniere's disease, unspecified convulsions, chronic kidney disease, and hearing loss, was cognitively intact with a BIMS score of 13. The resident reported to a family member and a medication aide that NA-H had made them feel uncomfortable by rubbing up against them in the bathhouse. The family member contacted the facility to report the allegation, but the facility failed to follow through with an investigation or report the incident as required by their policy.
Inaccurate MDS Coding for PASARR and Antibiotic Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the Level II PASARR status for a resident with serious mental illness (SMI) and intellectual disability (ID). The resident had a PASARR Level 2 evaluation indicating these conditions, but the MDS was incorrectly marked as 'No' for the presence of SMI and/or ID. This discrepancy was confirmed during an interview with the MDS Consultant, who acknowledged that the MDS should have been marked 'Yes' to reflect the resident's PASARR Level 2 status. Additionally, the facility did not accurately code the use of an antibiotic for another resident. The resident's electronic Medication Administration Record (eMAR) showed a new order for Rifaximin, an antibiotic, which was administered as prescribed. However, the MDS did not indicate that the resident was taking an antibiotic during the 7-day look-back period. This oversight was also confirmed by the MDS Consultant, who stated that the antibiotic should have been checked as taken on the MDS.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, which accurately reflected their care needs. For Resident 35, the admission Minimum Data Set (MDS) indicated the use of antidepressant, antianxiety, and anticoagulant medications. However, the comprehensive care plan did not include any resident-centered plan related to these medications. This omission was confirmed by the MDS Consultant during an interview, highlighting a gap in medication management and mood and behavior considerations as per the facility's policy. For Resident 3, the facility did not address an actual fall in the resident's care plan. Despite being identified as at risk for falls on a Fall Risk Evaluation, the care plan for falls was not initiated until after the resident experienced an unwitnessed fall. The resident, who had a BIMS score indicating cognitive intactness, reported a fall while reaching for food, which resulted in a visit to the emergency room. The Assistant Director of Nursing confirmed that the care plan for falls was delayed, failing to address the resident's actual fall incident.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to revise the Comprehensive Care Plans (CCPs) for three residents, which led to deficiencies in addressing their current medical needs. Resident 14, who was diagnosed with dementia, leukemia, type 2 diabetes, high blood pressure, irregular heartbeat, and obstructive sleep apnea, had an order to use a BiPAP device at night. However, the CCP did not include the use of this device, as confirmed by the Assistant Director of Nursing (ADON). Similarly, Resident 62, diagnosed with obstructive sleep apnea among other conditions, had an order for a CPAP device, but this was not reflected in their CCP. Observations confirmed the presence of CPAP equipment, yet the care plan remained unupdated. Additionally, Resident 2, who had diagnoses including Major Depressive Disorder and Generalized Anxiety Disorder, experienced a fall resulting in abrasions to the left temple. Despite this incident, the CCP for Resident 2 was not updated to address the fall. The ADON confirmed the fall occurred, yet the care plan did not reflect this event. These oversights in updating the CCPs for the residents indicate a failure in maintaining accurate and current care plans, which are essential for providing effective and person-centered care.
Inadequate Infection Control Practices for Residents with MDRO and CPAP Devices
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for Resident 3, who had a history of infection with a multi-drug resistant organism (MDRO) and an indwelling catheter. Despite having an order for staff to wear gowns and gloves during catheter care, observations revealed that staff did not wear gowns during these procedures. Additionally, hand hygiene was not performed appropriately, as staff did not wash their hands before donning gloves, between glove changes, or when moving from contaminated to clean body sites. The facility's policy on EBP did not address all high-contact resident care activities, and personal protective equipment (PPE) was not readily available in the resident's room. Resident 3, who was cognitively intact with a BIMS score of 15, reported that staff only wore gloves during catheter and peri care, not gowns. Observations confirmed the absence of EBP signage and gowns in the resident's room. During peri and catheter care, staff failed to perform hand hygiene at critical points, such as before care, between glove changes, and after handling contaminated objects. The Assistant Director of Nursing (ADON) confirmed that the facility's EBP policy was incomplete and that PPE was not easily accessible. The facility also failed to ensure proper cleaning of a CPAP device for Resident 62, who had a diagnosis of obstructive sleep apnea and other medical conditions. Observations showed that the CPAP humidity reservoir was not emptied and cleaned daily as required by the physician's order. The ADON confirmed that the CPAP equipment had not been cleaned according to the facility's policy, which mandates daily cleaning to prevent infection. This oversight in infection control practices highlights deficiencies in the facility's adherence to established protocols.
Failure to Designate RN as Director of Nursing During Leave
Penalty
Summary
The facility failed to designate a licensed Registered Nurse (RN) to work full-time as the Director of Nursing (DON) during a period when the previous DON, RN E, was on maternity leave. The record review of the Archived Time Card Report forms for RN E showed that RN E clocked out in early May and did not return until August, with a Leave of Absence noted during this period. During RN E's absence, the Assistant Director of Nursing (ADON), who was a Licensed Practical Nurse (LPN), and the Administrator (ADM), who was not a nurse, performed some of the DON's responsibilities. The facility census was 61, indicating that this deficiency had the potential to affect all residents. Interviews with the DON, ADM, and ADON confirmed that while RN E was on leave, the ADON, an LPN, was performing the responsibilities of the DON, such as attending meetings and managing staff. The ADM confirmed that the ADON was the designee during this period, and RN E was available by phone if needed. However, the facility did not have an RN designated to perform the duties of the DON while RN E was on leave, which was a requirement according to the licensure reference number 175 NAC 12-006.04(D)(i).
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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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