Community Memorial Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Burwell, Nebraska.
- Location
- 1015 F Street, Burwell, Nebraska 68823
- CMS Provider Number
- 285257
- Inspections on file
- 17
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Community Memorial Health Center during CMS and state inspections, most recent first.
Surveyors found that dietary staff failed to follow facility policy and Federal Food Code requirements for checking and maintaining safe temperatures of food and beverages. Microwaved items such as a grilled cheese sandwich, macaroni and cheese, and hot dogs were heated and served to residents without any temperature checks, despite policy requiring all prepared items and reheated ready-to-eat foods to be verified for proper temperatures. Additionally, a dietary aide routinely refilled partially used juice and milk pitchers without discarding leftovers or checking temperatures, and these beverages were found above the required 41°F standard. Staff interviews confirmed that these temperature checks were not performed and that beverage pitchers were only fully cleaned every 72 hours.
Surveyors found that dietary staff did not follow facility policies for personal hygiene and handwashing. A dietary aide with a full beard worked in the kitchen and handled dishes without a beard cover, and another aide wore a hair cap that left loose hair exposed while working around exposed food and serving drinks. The facility’s policy required full hair and beard restraints. Additionally, a cook repeatedly washed hands for only 4–10 seconds with soap and water instead of the policy-required 20 seconds while engaged in meal preparation and related tasks, potentially affecting all residents receiving food.
Surveyors found that the facility did not ensure residents and their POAs were informed of the risks, benefits, side effects, and alternative/non-pharmacological options before initiating or continuing antipsychotic and other psychotropic medications, and did not notify a POA of new skin conditions. Several residents with diagnoses including delusional disorder, anxiety, bipolar disorder, dementia, and major depressive disorder were receiving medications such as Risperidone, Depakote, Risperdal, Xanax, Mirtazapine, Olanzapine, and a compounded topical Ativan/Benadryl/Haldol preparation. Facility policy required education on psychotropic drug use, but medical records and care plan notes lacked specific documentation of risk/benefit and alternative treatment education, and the DON acknowledged that POAs were not informed prior to prescriptions being written and dispensed. In addition, one resident developed multiple new foot and heel wounds, yet the POA reported being unaware of any skin issues, and an LPN confirmed there was no communication to the POA about these wounds or related interventions.
Surveyors found that staff failed to follow infection control policies for hand hygiene and linen handling. A laundry aide delivered clothing to several residents, including one on Enhanced Barrier Precautions, without performing hand sanitization between rooms and placed used hangers back into a shared cart before retrieving more clothing. The same aide was later observed carrying clothing protectors pressed against their uniform instead of away from the body. In a separate observation, an LPN administered medications and applied topical treatments to a resident with multiple chronic conditions, including DM and recurrent infections, without performing hand hygiene between glove changes and after touching potentially contaminated surfaces, despite facility policies requiring hand hygiene before and after glove use and after handling contaminated objects.
The facility did not implement or communicate a method for residents and families to file grievances anonymously, despite a written policy stating grievances may be filed anonymously. Admission materials directed a resident to bring concerns to the administrator, DON, social services, or resident council but did not explain any anonymous option. The SSD, identified as the grievance officer, reported that residents typically notify staff to file grievances and acknowledged not knowing how an anonymous grievance would be submitted beyond possibly sliding a note under the office door. The FA described an open-door grievance approach but did not identify any formal anonymous grievance mechanism, affecting all residents in the facility.
A resident with dementia, Parkinson’s disease, depression, and a history of myocardial infarction had a PRN order for Zyprexa 5 mg every 6 hours for agitation related to dementia that lacked a 14-day limit or specified duration, as required by facility policy. Record review showed no practitioner documentation of review or renewal of this PRN antipsychotic order, and the DON and interim DON confirmed the absence of an end date and physician notes addressing continuation of the medication.
Surveyors found that the facility did not develop baseline care plans within required timeframes and did not provide written summaries of these plans to two residents or their representatives. One resident admitted after a stroke and circulatory surgery had an interim care plan with no documentation of resident or representative participation, and the first care plan meeting occurred after the comprehensive care plan was already completed. Another resident with Parkinson’s disease, visual hallucinations, and a UTI had a baseline care plan initiated more than 48 hours after admission, also without documented participation. For both residents, the first care plan meetings occurred only after comprehensive care plans were developed, and the DON confirmed that the facility discusses baseline care plans verbally but does not complete or offer written summaries for residents or their representatives.
A resident with cervicalgia and osteoarthritis had an order for Diclofenac Sodium 1% gel that lacked a specified dose, despite manufacturer instructions requiring use of dosing cards and defined gram amounts per application. During a medication pass, an LPN applied an unmeasured amount of the gel to the resident’s neck. The IDON confirmed that medication orders must include a dose and that the prescription label for this resident’s Diclofenac gel was missing dose information, even though dosing instructions and a dosing card were present in the medication packaging.
Surveyors observed that two residents with dementia and/or wandering tendencies had multiple prescribed topical medications, including diclofenac gel, Eucerin cream, miconazole powder, and triamcinolone cream, left unsecured in their shared bathroom. Record review showed no Self Administration of Medication (SAM) authorizations for either resident. The DON and IDON confirmed that all practitioner-prescribed medications, including creams and powders, must be locked and never left out, indicating a failure to keep the area free from accident hazards and to provide adequate supervision to prevent accidents.
A resident with obstructive sleep apnea had a provider order for nightly BiPAP use and relied on staff for equipment care, but the facility failed to replace the BiPAP mask and tubing according to its own policy and provider recommendations. Over several observations, the mask and tubing were seen lying on the bed, sometimes lodged between the mattress and side rail, and the mask appeared cloudy with dried white spots. An LPN reported that central supply was responsible for respiratory equipment changes, while central supply staff stated they were unaware the resident used a BiPAP and had not ordered or changed any supplies. The DON confirmed the resident’s respiratory equipment had not been replaced as required.
A resident with chronic kidney disease and actinic keratosis developed a discolored area on the right cheek. Facility staff failed to document weekly skin assessments as required by policy, with a gap of more than one week between entries and missing measurements in later documentation. The DON confirmed these omissions, resulting in noncompliance with facility protocols.
A resident with multiple medical conditions experienced significant weight loss over several months due to the facility's failure to monitor and address the issue. Despite an initial intervention of a daily milkshake, the RD did not evaluate or implement additional interventions until the resident had lost over 12% of their weight in 90 days.
The facility failed to update and implement care plans for several residents, leading to deficiencies in care. A resident with heel wounds and infection control measures lacked documentation in their care plan. Another resident's care plan was missing documentation for daily living activities and pressure ulcer care, and staff did not follow proper infection control procedures. Additionally, two other residents had outdated care plans that did not reflect their current needs or diagnoses. Interviews confirmed these deficiencies.
The facility failed to ensure meals in the SCU were served at the proper temperature, affecting 16 residents. Observations showed inconsistent temperature checks, with some food items below the required 135°F. The DON had to reheat food multiple times, and logs revealed missing temperature documentation on several days. The DM confirmed the issue, emphasizing the need for food to be served at the correct temperature.
Staff at an LTC facility failed to follow infection control protocols, including improper use of gloves and hand hygiene during resident care. Enhanced Barrier Precautions were not consistently implemented for residents with MDROs, leading to inadequate use of PPE during high-contact activities. Documentation and communication issues contributed to staff confusion about PPE requirements.
The facility failed to notify the PCP and RD of significant weight loss in two residents, as required by policy. One resident experienced a 5% and 6% weight loss over consecutive months, while another lost 11% in one month. The lack of communication with healthcare professionals constitutes a deficiency.
The facility failed to accurately complete Level 1 PASARR screenings for two residents prior to admission. One resident's PASARR did not include diagnoses of delusional disorder, anxiety disorder, depression, and PTSD, despite receiving related medications. Another resident's PASARR omitted bipolar disorder and anxiety disorder, even though they were prescribed medications for these conditions. The DON confirmed the facility did not verify the accuracy of these screenings, which should have identified the need for Level 2 evaluations.
A resident under hospice care experienced inadequate bowel management due to the facility's failure to coordinate with the hospice provider. Despite a history of constipation, the resident's care plan did not address this issue, and prescribed laxatives were not consistently administered. Interviews revealed a lack of communication between facility staff and hospice personnel, contributing to the deficiency.
Two residents at high risk for falls experienced multiple incidents without adequate review and update of their care plans. Despite being identified as high risk, interventions were not consistently implemented or documented, and staff were not fully aware of specific fall prevention measures. This led to ongoing fall risks due to insufficient causal factor analysis and care plan revisions.
A facility failed to follow its Antibiotic Stewardship Program for a resident receiving Bactrim DS since June without a clinical rationale or stop date. Despite a recommendation from the Consultant Pharmacist for clarification, the physician continued the medication without proper documentation, and the DON confirmed the ongoing use without adherence to the ASP protocols.
The facility failed to document specific clinical rationales for not attempting Gradual Dose Reductions (GDR) of psychotropic medications for three residents, despite policy requirements. Residents with cognitive impairments and various diagnoses were receiving multiple psychotropic drugs, and the attending physician marked dose reductions as contraindicated without providing patient-specific reasons. The Director of Nursing confirmed the lack of required documentation.
Failure to Monitor and Maintain Safe Food and Beverage Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies and the Federal Food Code regarding monitoring and maintaining safe temperatures for food items prepared and served by the dietary department. Surveyors reviewed the 2022 Federal Food Code, which requires microwave-cooked items to be heated to at least 165°F, and a facility policy stating that all items prepared in the dietary department must have temperatures checked, and that ready-to-eat foods requiring heating before consumption should be heated to at least 135°F. During meal service observations, a dietary aide removed a cellophane-covered grilled cheese sandwich from a mobile hot cart, uncovered it, and had it served to a resident without checking its temperature. In separate observations, the dietary manager microwaved a single-serving macaroni and cheese, and a dietary aide microwaved hot dogs covered in cellophane; both items were plated and served to residents without any temperature checks. In interviews, the cook and the dietary manager confirmed that temperatures were not checked on these items, despite the facility policy requiring such checks. The deficiency also includes improper handling and temperature control of beverages served to residents. A dietary aide was observed serving drinks from a wheeled cart in the dining area and later returning the cart with partially used pitchers of various juices and milk to the meal service area. The aide placed a pitcher containing remaining apple juice under a juice dispenser and added more juice to it without discarding the leftover contents, and stated that pitchers are only cleansed and changed every 72 hours, with fluids simply refilled between meals. The aide also stated that temperatures of the drinks are not checked prior to refilling. When the aide did check temperatures during the observation, apple juice, grape juice, orange juice, milk, and tomato juice were all measured above the stated standard of 41°F for cold items. The aide and the dietary manager both confirmed that the fluids were not maintained at the recommended temperature or lower, as required.
Improper Hair Restraints and Inadequate Hand Hygiene in Dietary Services
Penalty
Summary
Surveyors identified deficiencies in dietary staff hygiene practices related to hair restraints and handwashing. Facility policy on Dietary Employee Personal Hygiene required all dietary staff to wear hair restraints, including hair nets, hats, and beard restraints, to prevent hair from contacting food. During multiple observations, one dietary aide was seen rinsing dishes and placing them in the automatic dish machine, and later putting away clean dish items in the main kitchen, while wearing a hair cap but no beard covering despite having a full beard. Another dietary aide was observed in the main kitchen and later serving drinks in the main dining area with a blue hair cap that covered only the top quarter of their head, leaving loose hair exposed while moving around areas where exposed food items were present. In an interview, the Dietary Manager confirmed that the beard covering and proper hair covering should have been used in these situations. The facility’s Hand Hygiene policy, dated 12/15/2025, required staff to rub their hands together vigorously with soap and water for approximately 20 seconds. During a series of observations, the cook repeatedly performed hand hygiene using soap and water but rubbed their hands for significantly less than the required 20 seconds, with durations ranging from 4 to 10 seconds before rinsing. In a subsequent interview, the cook acknowledged not rubbing their hands with soap for the required 20 seconds, and the Dietary Manager confirmed that the cook did not follow the approved hand hygiene method. These observed practices occurred during meal preparation and food service activities and had the potential to affect all residents receiving food from the kitchen, with a facility census of 59.
Failure to Inform POAs of Psychotropic Medication Risks and New Skin Conditions
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents and/or their POAs were informed of the risks, benefits, side effects, and alternative treatment options before initiating or continuing antipsychotic and other psychotropic medications, and failure to notify a POA of new skin conditions. For one resident admitted with delusional disorder, restlessness, agitation, and anxiety disorder, the record showed existing orders for Risperidone and Depakote. The facility’s policy on psychotropic medication use required that residents and/or representatives be educated on risks, benefits, and non-pharmacological alternatives. Care plan meeting notes for this resident over multiple dates only indicated that psychoactive medications were prescribed and that family/resident were educated, but contained no details of risks, benefits, side effects, or alternative options. Progress notes over several months also lacked documentation of such education, and the resident’s POA confirmed that no education on these topics had been provided. Another resident admitted with anxiety disorder and bipolar disorder had orders for Risperdal and Xanax. Review of this resident’s medical record revealed no documentation that the resident or responsible party had been educated on the risks, benefits, or alternative/non-pharmacological interventions for these medications. A third resident admitted with major depressive disorder had an order for Mirtazapine, but the medical record similarly contained no documentation that the resident or responsible party received education on the risks, benefits, or alternative treatments for this antidepressant. In interviews, the DON stated that medications are reviewed with residents or responsible parties during care plan meetings, but acknowledged there was no documentation of risk/benefit or alternative treatment education for these medications. For another resident with multiple dementia-related diagnoses, major depressive disorder in remission, and bipolar disorder, the admission record showed a POA for healthcare and orders for Olanzapine at two different dosages. Nursing notes for the period surrounding the initiation of a new Olanzapine order did not document that the POA was informed of the new antipsychotic prescription, its side effects or risks, or any alternative treatment options. The DON confirmed that the POA was not notified of the new treatment’s risks, benefits, side effects, or alternatives prior to prescription and dispensing, and that notification occurred only later during care plan meetings. A further resident with a history of mental and behavioral disorders, dementia, and major depressive disorder in remission had a POA for healthcare and orders for a compounded topical preparation containing Ativan, Benadryl, and Haldol applied to the neck and wrists on a scheduled basis. The DON stated that the POA was not notified of the side effects, risks, benefits, or alternative options for this treatment prior to it being prescribed and dispensed, and that notification occurred during care plan meetings. Care plan notes indicated the POA attended and participated in plan development and was notified of psychoactive medications and educated at those meetings. Separately, this same resident developed multiple new skin issues on both feet and the right heel, documented in progress notes and wound history beginning on a specific date. The resident’s POA reported being unaware of any current skin issues, and an LPN confirmed there was no communication with the POA regarding the foot wounds or related interventions, demonstrating a failure to notify the POA of a change in skin condition.
Infection Control Failures in Hand Hygiene and Linen Handling
Penalty
Summary
Surveyors identified deficiencies in the facility’s infection prevention and control program related to hand hygiene and linen handling. The facility’s hand hygiene policy, dated 12/15/25, required staff to perform hand hygiene between resident contacts, after handling contaminated objects, and before and after handling clean or soiled linens. During observation on the 100 hall, Laundry Aide-G (LA-G) delivered clothing to multiple residents’ rooms, including a resident on Enhanced Barrier Precautions (EBP), without performing hand sanitization between rooms. After exiting each room, LA-G placed used hangers back into the laundry cart and then retrieved additional clothing from the same cart for the next resident without using the alcohol-based hand rub that was available on the cart, contrary to facility policy and LA-G’s own acknowledgment of the requirement. Additional observations showed that the facility did not ensure laundry was transported in a sanitary manner. The infection prevention and control policy for linens required that laundry staff handle, store, process, and transport linens to prevent the spread of infection. However, LA-G was observed carrying a stack of clothing protectors cradled against their shirt while moving from the laundry area through the dining room and into another hallway. In an interview, the DON confirmed that clothing and linens were expected to be carried away from the uniform to prevent potential cross-contamination, indicating that this method of transport did not comply with facility policy. Surveyors also found failures in hand hygiene practices during medication administration and topical treatment for a resident. Resident 17’s record showed multiple diagnoses, including hypothyroidism, diabetes mellitus, basal cell carcinoma of the skin, candidiasis, urinary tract infections, and excoriation (skin-picking) disorder. During a medication pass, LPN-E did not perform hand hygiene between glove changes and applied topical medications to Resident 17 without changing gloves or performing hand hygiene after touching the wheelchair, medication cart, and tablet used for charting. Facility hand hygiene policy stated that glove use does not replace hand hygiene and required hand hygiene before donning gloves, immediately after removing gloves, after handling contaminated objects, and when moving from a contaminated body site to a clean body site. The Infection Preventionist confirmed that staff were expected to perform hand hygiene after removing dirty gloves and before donning clean gloves, which did not occur in this instance.
Failure to Provide and Communicate Anonymous Grievance Process
Penalty
Summary
The facility failed to ensure residents and family members had a method to file grievances anonymously and were provided information on how to do so, as required by its own policy and licensure regulations. Record review of the undated facility policy titled "Resident and Family Grievances" showed that information on how to file a grievance or complaint would be available and that a grievance may be filed anonymously. However, review of the undated Admission Agreement showed that while residents were encouraged to voice grievances and suggestions to the administrator, DON, social service director, or resident council, it did not include any information on how to file a grievance anonymously. During interviews, the SSD, who serves as the facility’s grievance officer, stated that residents or families wishing to file a grievance would notify a staff member, who would assist them with the process, and acknowledged uncertainty about how a resident could file a grievance anonymously other than sliding it under the SSD’s office door. The SSD confirmed that although the policy states a grievance may be filed anonymously, residents and families are only educated on the grievance process during admission paperwork and are not given education or instruction on how to file grievances anonymously. The FA reported that the facility has an open-door policy for grievances and that residents and families are encouraged to notify staff with grievances, but did not identify any established anonymous grievance mechanism. This deficiency had the potential to affect all 59 residents in the facility.
Failure to Limit and Review PRN Antipsychotic Medication Order
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to limit a PRN antipsychotic medication order to 14 days and to ensure practitioner evaluation for renewal. The facility’s policy on psychotropic medication, dated 10/12/2025, stated that PRN psychotropic orders must be used only for a diagnosed specific condition documented in the clinical record and for a limited duration of 14 days, and that if the practitioner believed it appropriate to extend the PRN order beyond 14 days, the duration must be specified. Record review showed that this policy applied to psychotropic medications, including antipsychotics. Record review for one resident revealed an admission date of 1/29/26 and diagnoses including dementia in other diseases classified elsewhere with behavioral disturbance, non-ST-elevation myocardial infarction, Parkinson’s disease with dyskinesia and fluctuations, and unspecified depression. The resident had a PRN order for Zyprexa 5 mg by mouth every 6 hours as needed for agitation/outbursts related to dementia, with an order date of 2/6/26. The order did not include an end date. During an interview, the DON and Interim DON confirmed that there was no end date on this PRN antipsychotic order and that there were no physician notes documenting a review of the PRN antipsychotic medication, contrary to the facility’s policy and regulatory requirements.
Failure to Develop Timely Baseline Care Plans and Provide Written Summaries to Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure baseline care plans were developed within required timeframes and that written summaries of these plans were reviewed with and provided to residents or their representatives. Facility policy required an interim/baseline care plan to be developed and implemented within 24 hours of admission, using information from the admission assessment, hospital transfer documents, physician orders, and discussions with the resident and/or representative, with initial goals reflecting the resident’s stated goals and objectives. The policy also required that a comprehensive care plan be developed within 7 days after completion of the comprehensive MDS assessment, with participation from the resident and/or representative to the extent practicable. Despite these policies, records showed that baseline care plans were either not timely or did not document resident/representative participation or receipt of a written summary. For one resident admitted from the hospital with diagnoses including stroke, difficulty swallowing after stroke, and circulatory system surgery, the interim (baseline) care plan contained no documentation that the resident or resident representative participated in or reviewed the baseline care plan. The comprehensive admission MDS assessment was completed, and the comprehensive care plan was developed with a focus on the resident’s need for long-term care due to decreased mobility and weakness requiring assistance with transfers, toileting, and ADLs. However, the first care plan meeting with the resident/representative occurred two days after completion of the comprehensive care plan, which did not allow participation in the development of either the baseline or comprehensive care plan. The medical record contained no documentation that a written summary of the baseline care plan was provided to the resident or representative. For another resident admitted with Parkinson’s disease, visual hallucinations, and a urinary tract infection, progress notes documented that the resident arrived able to walk with a walker, with a bent neck posture and shakiness due to Parkinson’s. The interim (baseline) care plan for this resident was not developed until more than 48 hours after admission, exceeding the 24-hour requirement. This baseline care plan also lacked documentation of resident or representative participation or review. The comprehensive admission MDS assessment and comprehensive care plan were completed, but the first care plan meeting occurred after the comprehensive care plan was already developed, again preventing participation in the development of the baseline and comprehensive care plans. The medical record contained no documentation that a written summary of the baseline care plan was provided. In an interview, the DON confirmed that baseline care plans are discussed verbally on admission, that the facility does not complete written summaries, and that no written summaries were offered or signed for these residents.
Failure to Include and Use Measured Dose for Topical Diclofenac Gel
Penalty
Summary
The facility failed to ensure that a prescribed topical medication included dosing information and was administered in a measured amount for one resident. The resident was admitted with diagnoses of cervicalgia and unspecified osteoarthritis. An order dated 2/25/2026 for Diclofenac Sodium 1% external gel directed staff to apply the gel to the resident’s neck and back every day and on the night shift for primary osteoarthritis, but the order did not specify the dose. Review of the manufacturer’s instructions for Diclofenac sodium topical gel showed that the medication is to be measured using dosing cards, with application within the oblong area of the card up to the 2‑gram or 4‑gram line, and a total daily dose not to exceed 32 grams. During observation of a medication pass, an LPN applied an unmeasured amount of Diclofenac gel to the resident’s neck rather than using a measured dose. The Interim DON confirmed that medication orders are required to include the resident’s name, medication dose, time of administration, route of administration, and prescriber name, and that orders missing information should be corrected after notifying nursing and pharmacy. Review of the prescription label for the resident’s Diclofenac sodium topical gel with the Interim DON confirmed that the label lacked dose information, even though the manufacturer’s instructions and dosing card were available in the medication box.
Unsecured Topical Medications Left in Bathroom of Residents With Dementia
Penalty
Summary
Surveyors found that two roommates with dementia and/or wandering tendencies, residing on a secure unit, had multiple prescribed topical medications left unsecured in their shared bathroom. During an environmental observation, diclofenac sodium 1% gel, Eucerin cream, miconazole nitrate powder, and triamcinolone cream were observed in the bathroom designated for these two residents’ use. These medications had active prescriber orders with various start dates and were not stored in a locked medication cart or locked nurse office as required. Record review showed that neither resident had a Self Administration of Medication (SAM) authorization on file for any of the observed medications. In interviews, the DON and IDON confirmed that all medications, including creams, powders, and other topicals prescribed by a practitioner, are required to be locked and are not to be left out under any circumstance. The presence of these unsecured medications in the residents’ bathroom, combined with the absence of SAM documentation, constituted a failure to maintain an environment free from accident hazards and to provide adequate supervision to prevent accidents.
Failure to Replace and Maintain BiPAP Equipment per Policy
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to replace and maintain respiratory equipment for a resident using a BiPAP machine. Facility policy dated 02/25/2026 required routine replacement of BiPAP components to prevent infection, specifying that the face mask and tubing be replaced every three months and the headgear, non-disposable filters, and humidifier every six months. A diagnostics and consultants document for the resident also specified replacement intervals for the water chamber, tubing, and face mask. The resident, admitted with obstructive sleep apnea and with a provider order for nightly BiPAP use, reported using the BiPAP every night and relying on staff for care and maintenance of the equipment. The resident stated that the mask in use was the same one received at the initial equipment appointment and, to their knowledge, had never been changed. During multiple observations over three days, surveyors saw the resident’s BiPAP mask and tubing lying on the bed, with the mask lodged between the mattress and a quarter side rail on two occasions, and noted the mask appeared cloudy with dried white spots. In interviews, an LPN stated that central supply was responsible for managing and changing residents’ respiratory equipment and determining replacement frequency. The central supply staff member reported being unaware that the resident used a BiPAP and confirmed they had not ordered or changed any respiratory supplies for this resident. The DON confirmed that the resident’s respiratory equipment had not been changed according to facility policy or the provider’s recommendations documented on the diagnostics and consultants form.
Failure to Complete and Document Weekly Skin Assessments per Policy
Penalty
Summary
The facility failed to complete skin assessments per its own policy and standards of practice for one resident with a notable wound and high risk for skin breakdown. The facility policy required weekly skin assessments for residents with wounds or high Braden scores, and documentation of any alterations in skin integrity using a standardized method. For the resident in question, who had chronic kidney disease and actinic keratosis and was cognitively intact, a discolored area was observed on the right cheek. The area was initially documented with measurements, but subsequent documentation was missing for a period exceeding one week, and later entries lacked required measurements. Interviews with staff confirmed that the resident had been self-administering a steroid cream and staff were applying urea cream, both of which were discontinued after the discoloration developed. The Director of Nursing acknowledged that there was a gap in documentation from the initial assessment to the next entry, which was longer than the weekly interval required by policy, and that some later assessments did not include measurements. These actions and omissions resulted in the facility not following its own protocols for skin assessment and documentation.
Failure to Monitor and Address Resident's Weight Loss
Penalty
Summary
The facility failed to adequately monitor and address ongoing weight loss for a resident, identified as Resident 19, who was admitted with a history of weight loss and several medical conditions, including major depressive disorder, Parkinson's disease, non-Alzheimer's dementia, and chronic obstructive pulmonary disease. The resident's Minimum Data Set indicated moderate cognitive impairment and a need for assistance with eating and drinking. Despite an initial order for a daily milkshake to provide additional calories, the resident experienced significant weight loss over several months, with a 5% loss in one month and a 6% loss in another. The facility's Weight Monitoring policy required the Registered Dietician (RD) and physician to be notified of weight loss and to assist with interventions. However, the RD did not evaluate the resident's weight loss or develop additional interventions after the initial assessment. It was not until several months later, after the resident had lost a total of 12.2% of their weight over 90 days, that a new intervention was implemented. This delay in response and lack of ongoing monitoring and intervention contributed to the deficiency identified by the surveyors.
Deficiencies in Care Plan Implementation and Revision
Penalty
Summary
The facility failed to implement and revise care plans for several residents, leading to deficiencies in their care. Resident 29, who was cognitively intact and had multiple diagnoses including dementia and Parkinson's Disease, was at risk for pressure ulcers and had ongoing heel wounds. However, the care plan did not document these pressure sores or the Enhanced Barrier Precautions (EBP) in place for infection control. Observations confirmed the presence of heel sores with black eschar, and interviews with staff verified that these issues were not reflected in the care plan. Resident 59, who was dependent on staff for various activities of daily living and had a stage 3 pressure ulcer, also had an incomplete care plan. The care plan lacked documentation for activities of daily living, indwelling catheter care, falls, pressure ulcer care, hospice care, pain management, and constipation. During care observations, staff failed to follow proper infection control procedures, such as changing gloves after providing peri and catheter care, which was not addressed in the care plan. Resident 54's care plan had not been reviewed or revised since June, despite the resident's dependence on staff for several activities of daily living and the use of antipsychotic and antianxiety medications. Similarly, Resident 1's care plan was outdated and did not include interventions for impaired cognition or activities, nor did it address the resident's MRSA diagnosis. The care plan had not been updated since August, even though a quarterly MDS assessment was completed in October. Interviews with the MDS Nurse confirmed these deficiencies in care plan updates and implementations.
Failure to Maintain Proper Food Temperatures in SCU
Penalty
Summary
The facility failed to ensure that meals served in the Special Care Unit (SCU) were palatable and served at the proper temperature, potentially affecting all 16 residents in the unit. The facility's policy required food temperatures to be recorded daily to ensure they were served at the proper temperature, with hot food items maintained at 135 degrees Fahrenheit or higher. However, observations revealed that food temperatures were not consistently checked or documented. For instance, during a breakfast meal, the Director of Nursing (DON) had to reheat ground sausage multiple times to reach the required temperature of 165 degrees Fahrenheit, and no further temperature checks were conducted for the rest of the meal. Additionally, a test tray after a noon meal service showed several food items, including cheesy potatoes, ham slice, and diced carrots, were below the required temperature of 135 degrees Fahrenheit. A review of food temperature logs from the SCU indicated that temperature checks were not documented on multiple days for breakfast, noon, and evening meals. An interview with the Dietary Manager (DM) confirmed that SCU staff were not consistently completing temperature checks, and food should not be served below 135 degrees Fahrenheit to ensure palatability.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility staff failed to adhere to proper infection prevention and control protocols, specifically in the use of gloves and hand hygiene during the provision of care to several residents. Observations revealed that staff did not wash hands or use hand sanitizer at appropriate intervals, such as before and after resident contact, and when handling potentially contaminated items. For instance, a Medication Aide assisted a resident with toileting without washing hands or wearing gloves, and continued to provide care without changing gloves or performing hand hygiene. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) as required for residents known to be colonized or infected with multidrug-resistant organisms (MDROs). Staff failed to wear gowns and gloves during high-contact care activities for residents on EBP, such as those with indwelling medical devices or chronic wounds. In one case, a Licensed Practical Nurse did not change gloves after removing a soiled dressing from a resident's suprapubic catheter, and in another instance, staff did not wear the required PPE while repositioning a resident with a foley catheter. The facility's documentation and communication regarding EBP were inconsistent, leading to confusion among staff about when PPE was necessary. For example, a resident with heel wounds was on EBP, but staff were incorrectly informed that PPE was only needed when the wounds were uncovered. This lack of clarity resulted in staff not wearing gowns during high-contact care activities, contrary to the facility's policy. Interviews with staff, including the Director of Nursing, confirmed these deficiencies in following EBP protocols.
Failure to Notify Healthcare Professionals of Significant Weight Loss
Penalty
Summary
The facility staff failed to notify the primary care practitioner (PCP) and the Registered Dietician (RD) of significant weight loss in two residents, which is a requirement according to the facility's policy on Notification of Changes. The policy mandates prompt notification to the resident's physician and representative when there is a change requiring notification, such as significant changes in the resident's physical condition. For Resident 27, the Weights and Vitals Summary Sheet showed a progressive weight loss over several months, with a 5% loss in one month and a 6% loss in another. Despite this ongoing significant weight loss, there was no evidence in the resident's electronic medical record that the RD or PCP were notified. Similarly, for Resident 12, the Weights and Vitals Summary Sheet indicated a substantial weight loss of 17 pounds, or an 11% loss, in one month. An interview with the Dietary Manager confirmed that neither the PCP nor the RD were informed of this significant weight change. This lack of communication and failure to adhere to the facility's policy on notifying relevant healthcare professionals of significant changes in residents' conditions constitutes a deficiency in the care provided by the facility.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of Level 1 Preadmission Screening and Resident Review (PASARR) for two residents prior to their admission. Resident 48's PASARR did not include diagnoses of a delusional disorder, anxiety disorder, depression, and PTSD, despite the resident receiving antipsychotic, antianxiety, and antidepressant medications. The Director of Nursing (DON) confirmed that the facility did not verify the accuracy of Resident 48's Level 1 PASARR screen at the time of admission, which should have included these diagnoses to determine if a Level 2 evaluation was necessary. Similarly, Resident 44's PASARR Level 1 screen failed to include diagnoses of bipolar disorder and anxiety disorder, even though the resident was prescribed medications for these conditions. The DON acknowledged that the facility did not check the accuracy of Resident 44's Level 1 PASARR screen at the time of admission, which should have identified the need for a Level 2 screen. Both residents were at risk for adverse reactions to medications, and their care plans reflected the need for monitoring due to their mental health conditions.
Failure to Coordinate Bowel Management with Hospice Care
Penalty
Summary
The facility failed to ensure that a resident's bowel and bladder management plan was coordinated with the hospice care provider. The resident, who was under hospice care, had a history of constipation, as noted in the Minimum Data Set. Despite having a care plan in place, the facility did not address constipation in the resident's care plan. The facility's policy required specific interventions if a resident had no bowel movement for a certain number of days, but these interventions were not consistently followed. The resident experienced extended periods without bowel movements, and the facility's documentation showed gaps in the administration of prescribed laxatives. Interviews with facility staff and hospice personnel revealed a lack of communication and coordination regarding the resident's constipation management. The Director of Nursing confirmed that the resident's bowel medications were administered on an as-needed basis rather than routinely, and the resident's limited activity and poor intake were noted. The hospice nurse was not informed of any constipation concerns, and a registered nurse confirmed the absence of a constipation care plan for the resident. This lack of coordination and adherence to the facility's bowel management policy contributed to the deficiency identified by the surveyors.
Inadequate Fall Prevention and Care Plan Updates
Penalty
Summary
The facility failed to ensure that falls experienced by Residents 14 and 16 were adequately reviewed for causal factors, and that fall prevention interventions were based on these factors and revised as necessary. Resident 16, who had cancer and required partial assistance with daily activities, was identified as being at high risk for falls. Despite multiple incidents of falls, the facility did not consistently update the resident's care plan with new interventions based on the causal factors of each fall. For instance, after several falls, interventions such as using a gait belt during transfers and ensuring proper footwear were not consistently implemented or documented as new interventions. Resident 14, who was severely cognitively impaired and required assistance with various activities, also experienced multiple falls. The facility's response to these incidents was inadequate, as the care plan was not updated with new interventions based on the causal factors of the falls. For example, after a fall where the resident was found without gripper socks, the intervention to use gripper socks was not clearly documented as a new measure. Additionally, the use of a TABS monitor was not consistently included in the care plan following incidents where the resident removed the alarm and attempted to walk unassisted. Interviews with staff, including the Director of Nursing, confirmed that while falls were reviewed, the facility did not always identify causal factors or implement prevention measures related to those causes. Furthermore, staff were not consistently aware of specific fall prevention interventions for the residents, indicating a lack of communication and training regarding fall prevention strategies. This oversight contributed to the ongoing risk of falls for Residents 14 and 16, as their care plans were not adequately updated to reflect necessary interventions.
Failure to Adhere to Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure antibiotics were administered in accordance with its Antibiotic Stewardship Program (ASP) for a resident. The ASP is designed to optimize infection treatment and reduce adverse events from antibiotic use. The program involves the Infection Preventionist, Director of Nursing, Medical Director, Consultant Pharmacist, and Attending Physicians in developing and implementing protocols for antibiotic use, including assessment, laboratory testing, and criteria for treatment. However, the facility did not adhere to these protocols for a resident who had been receiving the antibiotic Bactrim DS since June 2023 without a documented clinical rationale or supporting evidence for its continued use. The resident's Minimum Data Set (MDS) indicated antibiotic use in the preceding week, and a recommendation letter from the Consultant Pharmacist to the physician requested clarification of the Bactrim DS order. Despite this, the physician continued the medication without providing a clinical rationale or a stop date, contrary to the facility's ASP. The Director of Nursing confirmed the ongoing use of the antibiotic without a stop date or predetermined course duration, highlighting a failure to comply with the facility's ASP requirements.
Failure to Document Clinical Rationale for Psychotropic Medication Use
Penalty
Summary
The facility failed to attempt a Gradual Dose Reduction (GDR) of psychotropic medications for three residents or to have a documented clinical rationale for continued use. The facility's policy on the use of psychotropic medications, implemented on October 6, 2023, requires that residents who use these drugs receive gradual dose reductions unless clinically contraindicated. However, the facility did not adhere to this policy, as evidenced by the lack of specific clinical reasons documented for not reducing the doses of psychotropic medications for Residents 24, 26, and 29. Resident 24, who had severe cognitive impairment and diagnoses of depressive disorder and anxiety, was receiving multiple psychotropic medications, including antipsychotics and antidepressants. Despite the requirement for a GDR, the attending physician marked the dose reduction as contraindicated without providing a patient-specific reason. Similarly, Resident 29, who was cognitively intact but dependent on assistance for daily activities and had diagnoses of dementia, Parkinson's Disease, anxiety, and depression, also did not have specific reasons documented for the contraindication of GDR for their medications. Resident 26, who had moderate cognitive impairment and a range of diagnoses including Parkinson's disease, cancer, and bipolar disorder, was also due for a GDR of several psychotropic medications. The physician denied the GDR due to the resident's behaviors but failed to document a specific clinical rationale. Interviews with the Director of Nursing confirmed that the required documentation for contraindications was missing for these residents, indicating a failure to comply with the facility's policy and regulatory requirements.
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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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