Douglas County Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Omaha, Nebraska.
- Location
- 4102 Woolworth Avenue, Omaha, Nebraska 68105
- CMS Provider Number
- 285019
- Inspections on file
- 21
- Latest survey
- October 30, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Douglas County Health Center during CMS and state inspections, most recent first.
Three residents experienced significant medication errors, including administration of an anticoagulant against physician orders, inappropriate holding of a nerve pain medication, and multiple errors involving sedative, opioid, and cardiac medications. These incidents resulted from miscommunication, incorrect pharmacy labeling, and failures in medication administration and verification processes.
Two residents did not receive pain medications as ordered: one experienced abrupt discontinuation of both gabapentin and Lyrica due to a pharmacy hold, leading to withdrawal symptoms and increased confusion, while another did not have a buprenorphine patch changed as scheduled, resulting in a missed dose. Both incidents were confirmed by staff and documented in medical records.
Dietary staff with facial hair exceeding policy limits were repeatedly observed preparing and serving food without wearing required beard restraints, in violation of both state food code and facility policy. This noncompliance was confirmed by the Dietary Manager and had the potential to impact nearly all residents receiving meals.
A resident with dementia was prescribed Quetiapine Fumarate, but the facility did not identify or monitor target behaviors as required. Physician orders called for daily behavior monitoring, yet neither the MAR nor TAR included prompts or documentation for this, and the care plan lacked identified target behaviors. This was confirmed by staff interview and was not in accordance with the facility's psychotropic medication policy.
A resident admitted with dementia, anxiety disorder, and PTSD did not have PTSD documented in the MDS admission assessment. The assessment only listed dementia and anxiety, omitting PTSD, even though it was an established diagnosis at admission. Staff interviews confirmed the diagnosis should have been included.
A resident with dementia, anxiety disorder, and PTSD was admitted and exhibited confrontational behavior and war-related hallucinations. The MDS assessment failed to include PTSD as a diagnosis, and the care plan did not address the resident's PTSD, despite facility policy requiring all identified needs to be included. Staff confirmed the omission, resulting in the resident's mental health needs not being fully addressed.
A resident with impaired mobility and incontinence developed multiple open wounds that were not consistently evaluated or measured as required by facility policy. Staff failed to document wound measurements during weekly skin assessments, and some wounds were not evaluated at all. Direct observation confirmed the presence of several open lesions, and staff interviews revealed a lack of knowledge regarding wound treatment.
A resident with an existing pressure ulcer and a physician's order for heel offloading was repeatedly observed lying in bed without their heels offloaded. The care plan did not specify interventions for heel protection, and staff confirmed the omission, despite facility policy requiring such measures for pressure injury prevention.
A resident with severe cognitive impairment and total dependence on staff for ADLs was repeatedly observed in a tilt-in-space wheelchair without proper leg or head support, despite physician orders for leg rests and a headrest. Staff did not consistently attach or adjust the leg rests or headrest, and the wheelchair components provided were not suitable for the resident's body size, resulting in inadequate support. The facility did not contact the hospice agency to reevaluate the wheelchair.
A resident with congestive heart failure and obstructive sleep apnea used a BiPAP machine without facility staff obtaining physician orders for its use or settings, and required cleaning protocols for the device were not implemented until several days after admission, contrary to facility policy.
A resident with frequent, severe pain received scheduled Tramadol without assessment of pain levels prior to administration or monitoring of the medication's effectiveness. Documentation and physician orders did not include requirements for pain assessment, and the care plan intervention to evaluate pain relief was not implemented.
A resident with dementia, anxiety disorder, and PTSD, who showed confrontational behavior and war-related hallucinations, did not receive a trauma-informed care assessment or have PTSD addressed in the care plan. Facility policy required identification of trauma triggers and individualized interventions, but these were not implemented.
Staff failed to secure a catheter drainage bag and oxygen tubing for two residents, leaving both items on the floor in violation of infection control protocols. One resident with an indwelling catheter and another receiving oxygen therapy were observed with their medical equipment improperly placed, and staff confirmed these practices did not meet facility policy for maintaining clean, non-sterile items.
A resident with moderate cognitive impairment was subjected to racial slurs, derogatory language, and threats by another resident, leading to feelings of shock and unsafety. Staff intervened to prevent physical harm, but facility leadership did not report the incident to APS or state authorities as required, citing a belief that the remarks did not constitute reportable abuse. The Administrator later acknowledged the event was reportable, highlighting a lapse in timely reporting procedures.
A resident with cognitive impairment was subjected to racial slurs, derogatory language, and threats by another resident, leading to a physical confrontation that was stopped by staff. Despite facility policy requiring investigation and reporting of such incidents, nursing leadership did not investigate or report the event, only recognizing its reportable nature after administrative review.
Three residents did not receive a required face-to-face visit by a physician within the first 30 days after admission, as only NPs conducted the initial assessments and there was no facility policy ensuring physician visits. Staff interviews confirmed that the Medical Director relied on NPs for initial care and only became involved if concerns were identified.
A resident in an LTC facility experienced a delay in receiving appropriate care for a shoulder fracture due to the facility's failure to ensure timely follow-up with the physician. Despite the resident's repeated complaints of shoulder pain, the facility did not promptly contact the physician or follow up on x-ray recommendations. This resulted in a 30-day delay between the initial x-ray showing a possible fracture and the follow-up x-ray confirming a healing fracture.
A facility failed to maintain a care-planned intervention for a resident with severe cognitive impairment, leading to repeated altercations with another resident. Despite an active care plan intervention to use a magnetic barrier to prevent room entry, the barrier was removed during remodeling and not reinstalled, resulting in incidents where the resident pushed another resident, causing falls and injuries. Staff interviews revealed inconsistent adherence to the care plan, with no documentation supporting the barrier's removal.
The facility failed to store foods for residents in a sanitary manner, with staff not labeling and dating resident foods, clearing spoiled foods, or maintaining temperature logs for nourishment refrigerators. This affected six neighborhoods and potentially 153 residents.
A resident, who was cognitively intact and expressed a desire to participate, was not invited to their care conferences. Despite facility policy and staff expectations, the resident was excluded from the care planning process, with only their family member participating via phone calls.
A resident's hospice and primary care provider were not informed of an abnormal C&S lab result until a week after it was reported to the facility, delaying necessary antibiotic treatment. The resident had multiple diagnoses and was receiving hospice services. Facility staff failed to follow policy requiring immediate notification of the physician for abnormal lab results.
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency in care. Both residents, who had mobility issues and were dependent on staff for assistance, were observed with their call lights on the floor and out of reach. Staff confirmed the call lights should have been accessible, and the facility had ordered clips to secure the call lights, but they had not yet been installed.
The facility failed to update PASRRs for two residents after they were diagnosed with new mental illnesses and prescribed psychotropic medications. Despite the facility's policy requiring new PASRRs for significant changes in status, the Admissions Clinical Liaison and Chief Nursing Officer were unaware of the new diagnoses, resulting in non-compliance with state requirements.
A resident in a locked behavioral unit was found with medications left unattended at their bedside. The resident, who was cognitively intact, indicated that it was common for the nurse to leave medications in their room. Staff interviews confirmed that this practice posed risks, and the facility's policy required nurses to observe residents taking their medications.
A facility failed to ensure staff performed proper hand hygiene and did not touch medications with their bare hands when administering medication to a resident with severe cognitive impairment. The RN involved did not use hand sanitizer or wash their hands between resident contacts and touched medications with bare hands, contrary to the facility's hand hygiene policy.
The facility failed to ensure that the most recent survey results were readily accessible to all residents and that posted notices of the availability of the survey results were in a prominent and accessible area. The survey book was not updated with the latest recertification survey, and no signs were posted to indicate its location.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving three residents. For one resident with a history of traumatic cerebral hemorrhage and severe cognitive impairment, there was a physician order to hold apixaban, an anticoagulant, until cleared by neurosurgery. Despite this, the resident received 21 doses of apixaban due to a miscommunication between the facility, pharmacy, and nursing staff. The medication was dispensed and administered based on an incorrect pharmacy label and a lack of proper verification against the actual physician order, which resulted in the resident receiving the medication prior to neurosurgical clearance. Another resident, who had moderate cognitive impairment and was being treated for nerve pain, experienced a medication error when Lyrica, a prescribed medication, was held for several days without a physician order. This occurred after the pharmacy placed a hold on the medication following a neurology appointment that only called for discontinuation of gabapentin, not Lyrica. Despite attempts by facility staff to clarify the order with the pharmacy, the resident missed nine doses of Lyrica, leading to increased confusion and withdrawal symptoms until the medication was restarted. A third resident, with a diagnosis of congestive heart failure and who was receiving opioid and hypnotic medications, experienced several medication errors. These included administration of a sedative-hypnotic at the wrong time, omission of a scheduled buprenorphine patch change, administration of another resident's medications, and administration of Entresto despite blood pressure readings below the ordered threshold for holding the medication. These errors were confirmed through record review and staff interviews, indicating failures in medication administration, documentation, and adherence to physician orders.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
Facility staff failed to administer pain medication according to practitioner orders for two residents. For one resident with moderate cognitive impairment and significant assistance needs, gabapentin was discontinued per neurology orders, but Lyrica, which was to be continued, was incorrectly placed on hold by the pharmacy. Despite staff contacting the pharmacy multiple times, the Lyrica was not reinstated, resulting in the resident missing nine doses over several days. The resident subsequently became more confused and stopped eating, and it was noted that the abrupt discontinuation of both medications led to withdrawal symptoms. For another resident with congestive heart failure and extensive care needs, there was a failure to change a prescribed buprenorphine patch for chronic pain management as ordered. The patch, which should have been changed weekly, remained in place for twelve days, resulting in a missed dose. This omission was confirmed by facility staff and documented in the resident's medical records.
Failure to Use Beard Restraints During Food Preparation
Penalty
Summary
Dietary staff members were observed on multiple occasions preparing and plating food in the facility kitchen without wearing required beard restraints, despite having facial hair such as goatees and mustaches exceeding the length specified in facility policy. Specifically, one dietary aide was seen at the service line and another at the short-order grill, both with facial hair and not wearing beard nets, during several morning meal preparations. These observations were made over several days and involved staff directly handling and serving food. A review of the Nebraska Food Code and the facility's own Dress Code Policy confirmed that beard restraints are required for food employees with facial hair longer than half an inch. The Dietary Manager acknowledged that the staff members in question had facial hair that necessitated the use of beard restraints. The failure to comply with these standards had the potential to affect the majority of residents receiving food from the kitchen.
Failure to Identify and Monitor Target Behaviors for Antipsychotic Use
Penalty
Summary
The facility failed to identify and monitor target behaviors for the use of an antipsychotic medication for a resident diagnosed with dementia. Record review showed that the resident had physician orders for Quetiapine Fumarate, including instructions to monitor behaviors daily, but the orders did not specify time values. Further review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the relevant month revealed that target behaviors were not identified, and there was no indication or prompt for staff to record behavior monitoring related to the use of Quetiapine Fumarate. Additionally, the resident's care plan did not include any identified target behaviors, and an interview with a registered nurse confirmed that neither target behaviors nor prompts for behavior monitoring were present on the MAR or TAR. The facility's policy on the use of psychotropic medications requires ongoing evaluation of the effects of such medications, including behavior monitoring, but this was not followed in the case of this resident.
Failure to Accurately Document PTSD Diagnosis in MDS Admission Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) comprehensive assessment accurately identified all current diagnoses for a resident upon admission. Specifically, a resident admitted with diagnoses of unspecified dementia, anxiety disorder, and post-traumatic stress disorder (PTSD) did not have PTSD documented in Section I of the MDS admission assessment. The assessment, completed on 03/18/2025, only listed non-Alzheimer's dementia and anxiety as current diagnoses, omitting PTSD despite it being part of the resident's medical history. Interviews with facility staff revealed that the omission occurred because the MDS coordinator did not include PTSD in the assessment, relying instead on the timing of the resident's appointment with a mental health provider, which took place after the MDS was completed. The lead MDS coordinator confirmed that PTSD should have been included in the admission assessment, as the diagnosis was already established at the time of admission.
Failure to Address PTSD in Resident's Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan that addressed the mental and psychological needs of a resident with a diagnosis of post-traumatic stress disorder (PTSD). Record reviews showed that the resident was admitted with diagnoses including unspecified dementia, anxiety disorder, and PTSD, and had a moderately impaired cognitive status as indicated by a BIMS score of 10/15. Despite documentation in progress notes of the resident being confrontational and experiencing war-related hallucinations, the admission assessment on the Minimum Data Set (MDS) did not include PTSD as a diagnosis in Section I. The lead MDS Coordinator confirmed that PTSD should have been included in the assessment. Further review of the resident's care plan revealed no evidence that the PTSD diagnosis was addressed. Interviews with facility staff, including the social worker, confirmed that the comprehensive care plan did not include interventions for PTSD. Facility policies required that all identified problems, including those found in the MDS and other assessments, be addressed in the care plan with specific goals and interventions. The failure to include PTSD in both the MDS and the care plan resulted in the resident's mental health needs not being fully addressed as required by facility policy and regulatory standards.
Failure to Evaluate and Monitor Resident Wounds per Policy
Penalty
Summary
Facility staff failed to properly evaluate and monitor open lesions for one resident with significant risk factors for impaired skin integrity, including impaired mobility, incontinence, and anemia. The resident's care plan included interventions such as weekly skin assessments, use of pressure reduction devices, and prompt notification of providers for skin concerns. However, record reviews showed that open wounds on the resident's buttocks and gluteal area were not consistently evaluated or measured as required. Several weekly skin assessments lacked documentation of wound measurements, and in some instances, the wounds were not evaluated at all. Direct observation confirmed the presence of multiple open wounds on the resident's buttocks and upper thigh, with staff interviews revealing a lack of awareness regarding the treatment for these wounds. The facility's own policy required comprehensive weekly skin assessments with detailed documentation, including wound measurements and descriptions, which was not followed. The unit manager confirmed that the wounds had not been measured weekly as required by policy.
Failure to Offload Heels for Pressure Ulcer Prevention
Penalty
Summary
Facility staff failed to implement ordered interventions to offload the heels of a resident who was at risk for pressure ulcer development and already had a pressure ulcer present. The resident, who was cognitively intact and required extensive to total assistance with mobility and activities of daily living, had a physician's order to offload heels while in bed. However, multiple observations revealed the resident lying in bed with heels resting directly on the mattress, without any offloading devices or supports in place. The resident's care plan addressed pressure ulcer prevention and treatment but did not include specific interventions for heel offloading. The resident reported that while hospitalized, staff offloaded their heels using a pillow, but this was not done at the facility. A registered nurse confirmed during wound care that the heels were not offloaded as required. Facility policy required evidence-based interventions, including heel offloading, for residents at risk or with existing pressure injuries, but these were not implemented for this resident.
Failure to Ensure Proper Wheelchair Positioning and Support
Penalty
Summary
Facility staff failed to ensure proper wheelchair positioning and support for a resident with severe cognitive impairment who was dependent on staff for all activities of daily living and receiving hospice care. Despite physician orders for a tilt-in-space wheelchair with leg rests, repeated observations showed the resident seated without leg rests, resulting in unsupported, dangling legs. The headrest was consistently positioned against the resident's upper shoulders or back, leaving the head unsupported. Even when leg rests were attached, they were too short for the resident's long legs, causing the knees to be elevated and not in contact with the wheelchair seat. The headrest repeatedly failed to stay in position to support the head, and staff did not consistently attempt to reposition it or the resident's legs when they became unsupported. The unit manager confirmed that the facility had not contacted the hospice agency to reevaluate the wheelchair, as it was provided by hospice and selected based on height and weight. Staff interviews and observations indicated a lack of ongoing assessment and adjustment of the wheelchair and its components to ensure proper support and positioning for the resident, despite clear orders and the resident's total dependence on staff for mobility and positioning.
Failure to Obtain Orders and Implement Care for BiPAP Use
Penalty
Summary
Facility staff failed to obtain and implement physician orders for the use of a non-invasive ventilator, specifically a BiPAP machine, for a resident diagnosed with congestive heart failure and obstructive sleep apnea. The resident, who was cognitively intact and required assistance with several activities of daily living, had a BiPAP machine at the bedside, but there were no documented orders specifying its use or settings in the resident's medical record. The care plan included a focus on BiPAP therapy, but interventions were limited to encouraging use, without reference to specific orders or settings. Additionally, the facility did not implement the required daily, weekly, and monthly cleaning protocols for the BiPAP machine until several days after the resident's admission. The Unit Manager confirmed that cleaning procedures were not followed initially because the machine belonged to the resident and not the facility. Facility policy outlined specific cleaning requirements for CPAP/BiPAP equipment, but these were not adhered to until after the deficiency was identified.
Failure to Assess and Monitor Pain Management
Penalty
Summary
The facility failed to assess a resident's pain prior to administering scheduled pain medication and did not monitor the effectiveness of the pain management provided. Record review showed that the resident had a physician's order for scheduled Tramadol HCL 50 mg three times daily for pain, and the resident's Minimum Data Set (MDS) assessment indicated frequent pain rated as 8 out of 10, which limited daily activities. However, the Medication Administration Record for the resident did not include any documentation of pain level assessments at the time of medication administration. Additionally, there was no physician's order in place to assess the resident's pain or to monitor the effectiveness of the scheduled pain medication. The resident's care plan included an intervention to evaluate the effectiveness of pain-relieving interventions, but this was not implemented as required. An interview with a registered nurse confirmed that there was no order or process in place for pain assessments or monitoring the effectiveness of the scheduled pain medication for this resident.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with dementia, anxiety disorder, and post-traumatic stress disorder (PTSD). The resident, who had moderately impaired cognition as indicated by a BIMS score of 10/15, exhibited confrontational behavior and hallucinations related to war, as documented in progress notes by an LPN. Despite these symptoms and the PTSD diagnosis, there was no evidence in the medical record that a trauma-informed care assessment had been completed for the resident. Further review and interviews revealed that the resident's care plan did not address the PTSD diagnosis, and no assessment had been conducted to identify potential triggers that could cause re-traumatization. The facility's own policy required the use of a multi-pronged approach to identify trauma history and triggers, as well as collaboration with the resident and relevant professionals to develop individualized care plan interventions. These steps were not followed for the resident in question.
Failure to Secure Catheter Bag and Oxygen Tubing Compromises Infection Control
Penalty
Summary
Facility staff failed to properly secure and maintain medical equipment for two residents, resulting in potential infection control deficiencies. For one resident with an indwelling urinary catheter, observations on two separate occasions revealed that the catheter drainage bag was lying on the floor without a cover or barrier. The resident required total assistance with bed mobility, toileting, and bathing, and was unable to complete a mental status interview. A nursing assistant confirmed that the catheter bag was on the floor and acknowledged it should not have been. For another resident receiving oxygen therapy, observations showed that the oxygen tubing and cannula were left lying on the floor in the resident's room while the oxygen concentrator was running. This resident had severe cognitive impairment and required extensive to total assistance with activities of daily living. A nursing assistant confirmed that the oxygen tubing and cannula were on the floor and should not have been. The facility's infection prevention and control policy requires all non-sterile items to be stored and maintained as clean, which was not followed in these instances.
Failure to Timely Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to report an alleged verbal altercation between two residents to Adult Protective Services and the Department of Health and Human Services within the required timeframe. The incident involved a resident with moderate cognitive impairment, non-traumatic brain dysfunction, non-Alzheimer's dementia, and a psychotic disorder. During the altercation, another resident used racial slurs, derogatory language, and made threats, prompting the affected resident to attempt to physically respond before staff intervened. No physical harm occurred, but the resident who was verbally abused reported feeling shocked and unsafe as a result of the incident. Despite the facility's policy requiring immediate reporting of suspected abuse or neglect, interviews with the Unit Manager, DON, and ADON revealed that they did not consider the verbal remarks or the situation to be reportable and did not initiate an investigation or report the incident. The Administrator, upon review, agreed that the event was reportable, but this determination was made after the fact, indicating a failure to follow established reporting protocols.
Failure to Investigate and Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to investigate an alleged verbal altercation between two residents, one of whom had a history of non-traumatic brain dysfunction, non-Alzheimer's dementia, and a psychotic disorder. The incident occurred in the dining room, where one resident used racial slurs, derogatory language, and threatened physical harm toward another resident, who then attempted to physically retaliate. Staff intervened and separated the residents, and no physical harm was reported. Despite the severity of the verbal altercation and the facility's policy requiring investigation and reporting of suspected abuse, the incident was not investigated or reported to the appropriate authorities. Interviews with the Unit Manager, DON, and ADON revealed that they did not consider the incident reportable or requiring further investigation, even though the facility's policy mandates reporting and investigation of all alleged abuse, including resident-to-resident incidents. The Administrator, upon review, agreed that the event was reportable, but no investigation or reporting had been initiated at the time of the survey.
Failure to Ensure Timely Physician Face-to-Face Visits After Admission
Penalty
Summary
The facility failed to ensure that three out of seven reviewed residents received a face-to-face visit by a physician within the required first 30 days after admission. Record reviews showed that these residents were only seen by nurse practitioners (NPs) for their initial admission assessments and subsequent care, with no documentation of a physician visit within the mandated timeframe. Specifically, one resident was admitted and seen by an NP for both the initial assessment and recertification, while two other residents were also only seen by NPs for their admission history and physicals. Interviews with facility staff confirmed that there was no policy in place regarding physician visits, and the Medical Director stated that NPs conducted the initial assessments, with the physician only becoming involved if concerns were raised by the NP.
Failure to Ensure Timely Follow-Up for Resident's Shoulder Fracture
Penalty
Summary
The facility failed to ensure timely follow-up with a physician to obtain x-rays for a resident who complained of shoulder pain. The resident, who was cognitively intact and independent in daily activities, reported pain on multiple occasions starting on May 15, 2024. Despite the resident's repeated requests for an x-ray, the facility staff did not attempt to contact the physician between May 15 and May 17, 2024, to expedite the x-ray process. The x-ray was eventually scheduled for May 21, 2024, but the delay in obtaining the x-ray and the lack of immediate follow-up with the physician contributed to the deficiency. The x-ray results from May 21, 2024, indicated a possible non-displaced fracture of the right shoulder, with a recommendation for follow-up radiographs in 10-14 days. However, the facility did not follow up with the physician regarding these recommendations, and no further x-rays were scheduled until June 21, 2024, after the physician inquired about the follow-up. This resulted in a 30-day gap between the initial x-ray and the follow-up, during which time the resident continued to experience pain. Interviews with facility staff, including the Assistant Director of Nursing, a Registered Nurse, and the Director of Nursing, confirmed that there was a lack of timely communication and follow-up with the physician. The facility's policy required immediate notification of the physician for new or severe pain and suspected fractures, but these protocols were not followed. The resident's fracture was not addressed promptly, leading to a delay in appropriate care and treatment.
Failure to Implement Care-Planned Intervention Leads to Resident Altercations
Penalty
Summary
The facility failed to implement a care-planned intervention for a resident with severe cognitive impairment and a history of physical aggression. The resident, who had been admitted with diagnoses of dementia with agitation and major depressive disorder, had an intervention in place since April 2023 to deter other residents from entering their room using a magnetic barrier. Despite this intervention being active in the care plan, the barrier was removed during a remodeling period, and no documentation was found to support the decision to discontinue its use. Subsequent incidents occurred where another resident entered the room, leading to altercations. On two occasions, the resident pushed the intruding resident out of the room, causing them to fall and sustain injuries. These incidents highlighted the failure to maintain the care-planned intervention, as the magnetic barrier was not reinstalled after the remodeling, and the care plan was not updated to reflect any changes or discontinuation of the intervention. Interviews with facility staff revealed a lack of consistent adherence to the care plan. Staff described the interventions as tools that could be used at their discretion, but there was no documentation to support the removal of the barrier due to the resident's stability. The facility's policy required the interdisciplinary team to update and evaluate care plans as needed, but this was not followed, leading to repeated resident altercations.
Failure to Maintain Sanitary Food Storage
Penalty
Summary
The facility failed to ensure that staff stored foods for residents in a sanitary manner. Specifically, staff did not label and date resident foods brought in by visitors, clear the nourishment refrigerators of spoiled foods, and maintain the temperature logs for the nourishment refrigerators. This deficiency was observed across six neighborhoods within the facility, potentially affecting 153 residents. The facility's policy required that all food items brought in by family or visitors be labeled with content and date, and consumed within three days, but this was not adhered to in multiple instances. Observations revealed that nourishment refrigerators in several neighborhoods contained undated and spoiled food items. For example, the Windsong Way neighborhood's refrigerator had undated food containers and an open container of butter spread. Similar issues were found in the Field of Dreams, [NAME] Way, Tranquility Road, Sunshine Gardens, and Safe Harbor neighborhoods, where temperature logs were incomplete, and food items were undated or spoiled. Interviews with staff confirmed that the food items should have been dated and that the dietary department was responsible for maintaining the nourishment refrigerators. The Director of Support Services and the Administrator confirmed that it was the facility's expectation for food items to be labeled and dated, and for refrigerator temperatures to be logged daily. The Assistant Director of Nursing reiterated that the facility's policy required daily checks of the refrigerators to discard any outdated, undated, or spoiled food items. However, these procedures were not consistently followed, leading to the observed deficiencies.
Resident Not Invited to Care Conferences
Penalty
Summary
The facility failed to invite a resident, who was cognitively intact, to attend their care conferences. The resident, diagnosed with chronic atrial fibrillation, unspecified intellectual disabilities, Tourette's disorder, and major depressive disorder, expressed a desire to participate in their care conferences. Despite the facility's policy requiring the involvement of residents in their care planning, there was no documentation indicating that the resident had been invited to any of their care conferences. The resident's family member participated via phone calls, but the resident was not given the opportunity to attend in person. Interviews with facility staff, including the Chief Nursing Officer, Registered Nurse, Social Worker, Assistant Director of Nursing, and the Administrator, revealed a consensus that residents should be invited to their care conferences. However, the Social Worker admitted to not inviting the resident, citing past negative experiences with resident participation. The facility's policy and staff expectations were not followed, resulting in the resident being excluded from their care planning process.
Delayed Notification of Abnormal Lab Results
Penalty
Summary
The facility failed to promptly notify a resident's hospice service provider of a change in condition. Specifically, Resident #231's hospice and primary care provider were not informed of an abnormal culture and sensitivity (C&S) lab result until a week after it was reported to the facility. This delay resulted in the hospice provider not ordering an antibiotic to treat Resident #231 until a week after the abnormal C&S lab result was reported to the facility. Resident #231 was admitted with diagnoses including neurocognitive disorder with Lewy bodies, dementia, adult failure to thrive, benign prostatic hyperplasia with lower urinary tract symptoms, and retention of urine. The resident had an indwelling catheter and was receiving hospice services. The facility's policy required immediate notification of the physician for laboratory tests revealing a urinary pathogen with symptoms and no treatment. However, the abnormal lab results reported on 11/23/2023 were not communicated to the hospice service provider until 11/30/2023. Interviews with facility staff and the hospice service provider confirmed the delay in notification. The facility's Advanced Practice Registered Nurse (APRN) noted the abnormal results on 11/30/2023, and the hospice service provider received the results the same day. The hospice provider then ordered the necessary antibiotic treatment. The facility's Administrator and Assistant Director of Nursing (ADON) acknowledged that the staff should have notified the physician immediately and followed up within 48 to 72 hours if there was no response, or sooner if the situation was urgent.
Failure to Ensure Call Lights Were Within Reach
Penalty
Summary
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency in care. Resident #487, who had a history of falls and difficulty walking, was observed with their call light out of reach, lying on the floor. Despite being dependent on staff for transfers and having a care plan that directed staff to encourage the use of the call light, the resident was unable to access it without assistance. Nursing Assistant D confirmed the call light should have been within reach and acknowledged that all staff were responsible for ensuring this. The resident expressed difficulty reaching the call light when it fell to the floor and requested a clip to secure it, which was missing at the time of the observation. Licensed Practical Nurse E also confirmed the call light should be within reach and noted the absence of the clip. Similarly, Resident #101, who had muscle weakness and a history of falls, was observed with their call light on the floor multiple times. The resident, who needed substantial assistance from staff for mobility, was unable to reach the call light to request help. Nursing Assistant F and LPN E both confirmed that the call light should be within reach and noted the difficulty in keeping it on the bed due to the lack of securing devices. The resident's care plan also directed staff to encourage the use of the call light for assistance, but the absence of a securing mechanism led to repeated instances where the call light was out of reach. Interviews with the Administrator and Chief Nursing Officer revealed that the facility had evaluated the need for clips to secure call lights and remotes, and clips had been ordered but not yet installed. The deficiency was identified through observations and interviews, highlighting a failure to ensure call lights were accessible to residents, as required by the facility's policy and the residents' care plans.
Failure to Update PASRRs for Residents with New Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure new Level I Preadmission and Resident Reviews (PASRRs) were completed after residents were diagnosed with new mental illness diagnoses and prescribed psychotropic medications for two residents. Resident #12 was admitted in 2008 with no initial mental illness diagnoses. However, in 2022, the resident was diagnosed with traumatic brain injury, unspecified psychosis, bipolar disorder, anxiety disorder, and unspecified moderate dementia with agitation. Despite these new diagnoses and the prescription of multiple psychotropic medications, a new PASRR was not completed. The Admissions Clinical Liaison (ACL) and Chief Nursing Officer (CNO) acknowledged that a new PASRR should have been submitted but was not done due to a lack of awareness of the resident's new diagnoses. Similarly, Resident #74 was admitted in 2021 and readmitted in 2022 with no initial mental illness diagnoses. The resident was later diagnosed with alcohol dependence with alcohol-induced persisting dementia, major depressive disorder, anxiety disorder, and delusional disorders. Despite these new diagnoses and the prescription of psychotropic medications, a new PASRR was not completed. The ACL and CNO both stated that a new PASRR should have been submitted but was not done due to a lack of awareness of the resident's new diagnoses. Interviews with the ACL and CNO revealed that the facility's policy required new PASRRs to be completed when residents had significant changes in status or new mental illness diagnoses. Both staff members acknowledged that the PASRRs for Residents #12 and #74 did not reflect their current psychiatric diagnoses or medications, indicating a failure to comply with the facility's policy and state requirements.
Medications Left Unattended at Resident's Bedside
Penalty
Summary
The facility failed to ensure medications were not left at the bedside of a resident in a locked behavioral unit. Resident #102, who was cognitively intact with a BIMS score of 15, was observed with a cup of medication at their bedside. The resident had already taken some medications and had placed others on their over-the-bed table. The resident indicated that it was not unusual for the nurse to leave medications in their room, trusting that the resident would take them. This practice was confirmed by the resident and observed by surveyors on 04/22/2024. Interviews with staff, including a Registered Nurse (RN) and the Chief Nursing Officer (CNO), revealed that leaving medications in a resident's room posed several risks, including the possibility of the resident not taking the medications, spilling them, or other wandering residents taking them. The CNO and the Administrator both stated that nurses were expected to observe residents taking their medications and not leave medications unattended in residents' rooms. The deficiency was identified as a failure to provide adequate supervision to prevent accidents and ensure the safety of all residents in the unit.
Failure to Perform Hand Hygiene and Proper Medication Handling
Penalty
Summary
The facility failed to ensure staff performed proper hand hygiene and did not touch medications with their bare hands when administering medication to a resident. Specifically, a Registered Nurse (RN) was observed preparing medications for a resident without using hand sanitizer or washing their hands after completing a medication pass with another resident. Additionally, the RN touched two medications with their bare hands while placing them into a medication cup. This action was contrary to the facility's hand hygiene policy, which mandates hand hygiene between resident contacts and before handling medications. The resident involved had a medical history that included vascular dementia, type two diabetes mellitus, hypertensive heart disease, unspecified mood disorder, and vitamin D deficiency. The resident's quarterly Minimum Data Set (MDS) indicated severe cognitive impairment. Interviews with other staff members, including another RN, the Chief Nursing Officer (CNO), and the Staff Development Instructor (SDI), confirmed that the facility's policy prohibits touching medications with bare hands due to infection control concerns. The SDI also confirmed that nurses are trained to avoid such practices during their education sessions.
Failure to Ensure Accessibility of Survey Results
Penalty
Summary
The facility failed to ensure that the most recent survey results were readily accessible to all residents and that posted notices of the availability of the survey results were in a prominent and accessible area. The facility's policy required that a readable copy of the most recent federal and/or state survey report and plan of correction be maintained in a 3-ring binder in the main lobby and that signs indicating the availability and location of the survey binder be posted throughout the building. However, during the recertification and complaint survey, no signs were observed indicating where the survey results were located, and the survey book did not contain the latest recertification survey from 05/16/2023. The Compliance Officer (CO) confirmed that the survey book was not updated and was located in the lobby at the security desk, but it was the incorrect notebook. Interviews with the facility staff revealed that the CO was responsible for updating the survey notebook and checking it monthly, but this was not done. The Administrator acknowledged that the facility had not put back the signs indicating the location of the survey book after renovations. The Assistant Director of Nursing (ADON) stated that the survey notebook was available in the lobby and the CO's office, but there were no signs on the units to indicate its location. The ADON also mentioned that a handful of residents would ask about the survey results, but none had asked for the recent survey results. The facility's failure to ensure the survey results were readily accessible and properly indicated had the potential to affect all residents in the facility.
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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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