Colonial Acres Of Humboldt
Inspection history, citations, penalties and survey trends for this long-term care facility in Humboldt, Nebraska.
- Location
- 1043 10th Street, Humboldt, Nebraska 68376
- CMS Provider Number
- 285248
- Inspections on file
- 14
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Colonial Acres Of Humboldt during CMS and state inspections, most recent first.
Expired and improperly dated food items were found in the storage room, including condensed milk, Splenda, poppy seeds, graham cracker pie crusts, cake sprinkles, vanilla pudding, cheesecake mix, and ranch dressing mix. Several opened dry goods were marked only with a month and date and no year, and the Dietary Mgr confirmed the expired items and undated packages should be discarded.
Uncovered clean linen carts were observed being pushed down two hallways with clean linens exposed. The facility policy required clean items to be in a covered cart or truck designed for clean laundry only, and the DON confirmed the cart was not covered during linen delivery.
Missing COVID-19 Vaccine Documentation for Staff: The facility failed to document that the COVID-19 vaccine was offered to staff, that education on the vaccine was provided, and that current vaccine status was maintained for 5 of 5 sampled employees. Employee files for multiple MAs and a NA contained no record of vaccine offering, education, or status, and the Infection Preventionist confirmed there was no documentation of these actions despite staff education being provided during orientation and information being posted annually.
Missing Documentation for Annual Nurse Aide Training: The facility failed to document the required 12 hours of annual ongoing training for several nurse aides and MAs. Record reviews showed monthly education calendars with initials in some months, but the records did not include training length, and one employee file had no 2025 calendar at all. HR confirmed there was no documentation that the annual training requirement was completed for these staff members.
The facility failed to provide written transfer notices and bed hold policy information to residents and their representatives for multiple hospital transfers, and an LPN/social services designee confirmed the notices had not been given and the Ombudsman had not been notified. Residents involved had diagnoses including pneumonia, COPD, and rhabdomyolysis, and one resident was transferred for shortness of breath. The facility also lacked a proper discharge summary with a recapitulation of stay for a resident who died and was discharged to a mortuary.
Bathroom vents in rooms 200, 201, 203, 205, 207, 209, 211, and 213 were not functioning and were found with whitish, brown debris. Observations showed the vents did not draw up a 1 ply sheet of toilet paper, and the ADM and Maintenance Director confirmed the vents were not working and had not been checked in a few months.
Failure to document informed consent for psychotropic medications for two residents. One resident with dementia, agitation, anxiety, and depression received Risperidone and Escitalopram without consent documentation, and the DON confirmed no consent was on file. Another resident had orders for Pregabalin, Hydroxyzine, Donepezil, and Fluoxetine, but the record contained no informed consent for psychotropic meds, and the Regional Corporate Nurse confirmed the lack of documentation.
A resident admitted with traumatic subdural hemorrhage, dementia, and depression had physician orders for multiple psychotropic medications, including Bupropion, Divalproex sodium, Quetiapine, and Venlafaxine. The baseline care plan did not include these medications or related interventions, and the DON confirmed the omission. The resident’s BIMS score was 7, indicating severe cognitive impairment.
Staffing information was not posted as required. Surveyors observed no staffing sheet in the hallways, nurses' station, lobby, entrance, or front office areas, and a whiteboard near the nurses' station only listed staff names without hours or census information. An LPN and the ADM confirmed there was no written staffing sheet posted and that the facility used the whiteboard to list scheduled staff.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling devices and wounds, as observed in several cases. Residents with catheters, wounds, urostomies, colostomies, and tube feedings lacked EBP supplies and signage in their rooms. The Director of Nursing was observed assisting residents without the necessary protective equipment, and interviews confirmed the facility's non-compliance with EBP protocols.
A facility failed to document a resident's catheter status on the MDS, despite the resident being admitted with a urinary catheter and having physician's orders for its maintenance. The resident was observed with a catheter bag, but the MDS inaccurately stated no catheter was present. The DON confirmed the documentation error.
A facility failed to include catheter care in a resident's Comprehensive Care Plan, despite the resident having a urinary catheter and physician's orders for its maintenance. The care plan focused on incontinence management but omitted necessary catheter care instructions, which was confirmed as an oversight by the DON.
Expired and Improperly Dated Food Items in Storage
Penalty
Summary
The facility failed to ensure that expired foods were discarded and that open packages of dry food were dated with the month, date, and year. During an observation of the storage room, surveyors found 4 cans of condensed milk with a best used by date of 2/17/26, a bag of opened Splenda with a best used by date of 3/8/26, and 2 plastic containers of poppy seeds with a best used by date of 2/28/26. Surveyors also observed a bag of 4 regular graham cracker pie crusts marked only with 3/27 and no year, a plastic container of cake sprinkles with the cap dated 6/24 or 6/04 and no year, 2 bags of vanilla pudding opened and marked 10/16 with no year, a 4 lb bag of cheesecake mix opened and marked 11/4 with no year, and a 3.2 oz bag of ranch dressing mix dated Nov. 25 with no year. A review of the facility policy titled Food Receiving and Storage stated that dry foods stored in bins are removed from original packaging, labeled, and dated with a used by date. A review of the Food Code 2022 stated that the day or date marked by the food establishment may not exceed a manufacturer's used by date. During interview, the Dietary Manager confirmed being unaware of the year the vanilla pudding, cheesecake mix, and ranch dressing packages had been opened and believed they had been opened this year. The Dietary Manager also confirmed that the graham cracker pie crust had expired and should be thrown away, and that the condensed milk and poppy seeds should be tossed out. The Dietary Manager further confirmed that all opened packages with only a month and date marked should be thrown out.
Uncovered Clean Linen Cart During Delivery
Penalty
Summary
The facility failed to ensure clean linens were delivered in a covered cart to prevent potential cross contamination. On 3/9/26 at 3:00 PM, laundry staff were observed passing clean linens on a cart down the 200 hallway with no cover over the clean linens. On 3/10/26 at 1:30 PM, laundry staff were again observed passing clean linens on a cart down the 300 hallway with no cover over the clean linens. Review of the Environmental Services Standard Operating Policy dated January 13, 2026 stated that clean items must be in a covered cart or truck specifically designed for clean laundry only. The DON confirmed during interview on 3/10/26 at 1:30 PM that the clean linen cart did not have a cover over the clean linens and that the cart should be covered when delivering clean linens down the hallways.
Missing COVID-19 Vaccine Documentation for Staff
Penalty
Summary
The facility failed to maintain staff documentation showing that the COVID-19 vaccine was offered, that education on the COVID-19 vaccine was provided, and that current vaccine status was documented for 5 of 5 sampled employees. Record review of the employee files for Medication Aide D, Medication Aide C, Medication Aide F, Medication Aide B, and Nursing Aide E showed no record of the facility offering the COVID-19 vaccine, no record of education on the COVID-19 vaccine, and no record of each employee’s current vaccine status. Record review of the facility’s Infection Prevention and Control Program, revised in 2018, showed sections on Immunization and Monitoring Employee Health and Safety that encouraged the COVID-19 vaccine, but there was no policy addressing COVID-19 education, offering the COVID-19 vaccine, or documentation of staff vaccine status. The Infection Preventionist stated that staff receive education during orientation and that information is posted annually by the time clock, but also confirmed there was no documentation that the facility had offered the COVID-19 vaccine, provided education on the vaccine, or maintained current vaccine status for employees.
Missing Documentation for Annual Nurse Aide Training
Penalty
Summary
The facility failed to ensure the required 12 hours of annual ongoing training was provided for nurse aides. Record reviews showed that Medication Aide B, Medication Aide C, Medication Aide D, Nurse Aide E, and Medication Aide F did not have documentation demonstrating completion of the required annual training for 2025. The report noted that the deficiency had the potential to affect all residents, and the facility census was 30. Employee file reviews found Monthly Education Calendar 2025 records for Medication Aide B, Medication Aide C, Medication Aide D, and Nurse Aide E, with initials entered in various monthly boxes, but the records did not include the length of the training. Medication Aide F's employee file did not contain a Monthly Education Calendar 2025. An interview with HR confirmed the facility did not have documentation that the required 12 hours of annual ongoing training was completed in 2025 for these staff members.
Failure to Provide Transfer, Bed Hold, Ombudsman, and Death Discharge Documentation
Penalty
Summary
The facility failed to provide written notice of transfer to the hospital and the bed hold policy to the resident and the resident's representative for 3 of 3 sampled residents. Resident 3 was admitted with pneumonia and later transferred to the hospital for a respiratory infection; the census list showed a hospital paid leave, but the medical record contained no notification of transfer or bed hold notice to the resident or representative. Resident 5 was admitted with COPD and had multiple hospital paid leave dates listed on the census, yet the record showed no transfer notice or bed hold notification for those events. Resident 30 was admitted with rhabdomyolysis and had a therapeutic paid leave after being transferred to the hospital for shortness of breath, but again there was no documentation that transfer or bed hold notices were provided to the resident or representative. The facility also failed to notify the Ombudsman of the transfers for Residents 3, 5, and 30. An interview with the Social Services designee confirmed that since November 2025 no written notice of transfer or bed holds had been provided to residents or their representatives, and that the Ombudsman had not been notified of any facility transfers as required. In addition, Resident 31 died and was discharged to a mortuary, but the discharge summary provided was the admission record with handwritten notes about the time of death and items sent with the family and mortician. The document did not include a recapitulation of stay, and the facility's transfer/discharge and post mortem care policies did not address the procedure to follow for a resident death.
Bathroom Ventilation Systems Not Functioning and Contaminated
Penalty
Summary
The facility failed to ensure bathroom ventilation systems were functioning and clean in rooms 200, 201, 203, 205, 207, 209, 211, and 213. Observations on 3/9/2026 and 3/10/2026 showed that the bathroom vents in these rooms did not draw up a 1 ply sheet of toilet paper, indicating the vents were not working. The vents also contained a whitish, brown substance and debris. Interviews with the Administrator and Maintenance Director confirmed that the bathroom vents in these rooms were not working, that debris was present in the vents, and that the ventilation system had not been checked in a few months with no record of the vents being checked.
Failure to Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents or their representatives were informed of the risks, benefits, and alternative treatments for psychotropic medications for 2 of 2 sampled residents, Resident 1 and Resident 8. Resident 8 was admitted with diagnoses including unspecified dementia with agitation, anxiety disorder, and depression, and had a BIMS score of 2 indicating extreme impairment. Resident 8’s orders included Risperidone 0.5 mg at bedtime and Escitalopram 10 mg daily, both of which were administered as ordered in January 2026. The care plan identified psychotropic medication use for flat affect and delusions, with interventions including monitoring for side effects, non-pharmacological interventions, offering snacks and fluids, calling the daughter, and behavior monitoring. The medication records contained no evidence of consent for Risperidone or Escitalopram, and the DON confirmed there was no consent for these medications. Resident 1’s medication orders included Pregabalin, Hydroxyzine, Donepezil, and Fluoxetine. The annual MDS showed a BIMS score of 15, no adverse behaviors or rejection of care, and the care plan included goals and interventions for anxiety, depression, and bipolar disorder. The MAR for March 2026 showed no indication of target behaviors for antidepressant or antianxiety medications, and the admission record and MAR did not show diagnoses supporting Donepezil or Pregabalin. The electronic record did not contain informed consent documentation for psychotropic medications, and when the informed consent document was requested from the Administrator, none was provided. The Regional Corporate Nurse stated there was no documentation of informed consent for Resident 1’s medications.
Baseline Care Plan Missing Psychotropic Medication Information
Penalty
Summary
The facility failed to develop a baseline care plan within the required timeframe for one resident, Resident 33, who was admitted with traumatic subdural hemorrhage with loss of consciousness, dementia, and depression. Physician admission orders dated 3/3/26 included Bupropion, Divalproex sodium, Donepezil, Quetiapine, and Venlafaxine. The admission MDS completed on 3/11/26 showed a BIMS score of 7, indicating severe cognitive impairment. A review of the baseline care plan dated 3/5/2026 showed that it did not include any of Resident 33’s psychotropic medications or interventions related to psychotropic medication use. The facility’s policy stated that a baseline plan of care to meet the resident’s immediate needs shall be developed within 24 hours of admission and include orders and services to be administered by the facility. The DON confirmed in interview on 3/11/26 at 2:00 PM that the baseline care plan did not contain information and interventions for the resident’s psychotropic medications.
Staffing Information Not Posted
Penalty
Summary
The facility failed to ensure staffing information was posted as required. Observations on 03/09/2026 at 1:30 PM, 03/10/2026 at 7:49 AM, and 03/10/2026 at 9:46 AM found no staffing information posted in either hallway, around the nurses' station, in the lobby or entrance areas, or around the front offices. At the 03/10/2026 9:46 AM observation, a whiteboard near the nurses' station had staff names written on it, but there were no hours or census information posted. An interview with an LPN at 9:50 AM confirmed there was no written staffing sheet posted and that the facility wrote the staff scheduled to work on the whiteboard daily. An interview with the Administrator at 9:56 AM confirmed the facility did not have a staffing sheet including census and total hours posted, and that the staff scheduled to work were written on the whiteboard.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) to prevent the transmission of infections among residents with indwelling devices and wounds. Observations revealed that several residents, including those with urinary catheters, wounds, urostomies, colostomies, and tube feedings, did not have EBP supplies or signage in their rooms. This lack of EBP was noted during various observations, such as when Resident 18 was seen without EBP supplies or signage, despite having open wounds on the buttocks. Similarly, Resident 27, who had a catheter, was observed without EBP measures in place. The Director of Nursing (DON) was observed assisting residents without utilizing the necessary EBP measures. For instance, the DON was seen assisting Resident 18 with personal care without the required protective equipment, and there was no signage indicating the need for EBP. Additionally, Resident 22, who had a urostomy, colostomy, and wound vac, was found without EBP supplies or signage in their room. These observations indicate a systemic failure to adhere to infection control protocols for residents with indwelling devices and wounds. Interviews with the DON confirmed that the facility was not following EBP for residents with indwelling catheters, devices, or wound care. The DON acknowledged the absence of EBP signage and supplies for residents who required them, including Residents 27, 22, 131, 18, and 129. This deficiency highlights a significant lapse in infection prevention and control practices, as the facility did not provide the necessary personal protective equipment or signage to minimize the risk of infection transmission.
Failure to Document Catheter Status on MDS
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the status of a resident's catheter at the time of admission. Resident 27 was admitted with several diagnoses, including malignant neoplasm of the bladder, kidney stones, hematuria, urinary retention, and obstructive and reflux uropathy. The resident was observed on two separate occasions with a catheter bag hanging from their wheelchair, indicating the presence of an indwelling catheter. However, a review of the resident's MDS documentation revealed that the section regarding bladder and bowel status incorrectly stated that the resident did not have an indwelling catheter. Further record reviews showed that the resident had physician's orders for catheter maintenance, including daily flushing and monthly changes. Despite these orders and the resident's medical history, the MDS failed to document the presence of the catheter. An interview with the Director of Nursing confirmed that the catheter should have been marked on the MDS, acknowledging the oversight in documentation.
Failure to Include Catheter Care in Resident's Care Plan
Penalty
Summary
The facility failed to develop a Comprehensive Care Plan (CCP) for a resident's catheter care, which is necessary to provide effective and person-centered care that meets professional standards of quality. The deficiency was identified for one resident, who was observed on multiple occasions with a catheter bag hanging from their wheelchair. Despite having a physician's order to flush the Foley catheter daily and change it every 30 days, the care plan did not include any instructions or interventions related to catheter care. The resident, who was admitted with a urinary catheter, had a history of bladder cancer, kidney stones, hematuria, urine retention, and obstructive and reflux uropathy. The existing care plan focused on managing the resident's incontinence with interventions such as brief use and checking for wet clothing, but it did not address the specific catheter care needs. The Director of Nursing confirmed that catheter care should have been included in the care plan, indicating a lapse in the facility's care planning process.
Latest citations in Nebraska
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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