Eastmont
Inspection history, citations, penalties and survey trends for this long-term care facility in Lincoln, Nebraska.
- Location
- 6315 O Street, Lincoln, Nebraska 68510
- CMS Provider Number
- 285036
- Inspections on file
- 18
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Eastmont during CMS and state inspections, most recent first.
The facility failed to administer oxygen as ordered for three residents who experienced low O2 saturations. One resident had an O2 saturation of 89% on RA with an order to apply O2 to keep saturations above 90%; staff notified an RN, who assessed the resident, called 911, and prepared transfer paperwork but did not apply O2 or recheck the saturation before transfer. A second resident, care planned as at risk for respiratory distress with orders to maintain O2 saturations above 90%, became lethargic with an O2 saturation in the low 80s on RA; the RN called the POA and 911 and left the room for paperwork, and later could not recall if O2 was applied, with no documentation that it was. A third resident had documented O2 saturations in the high 80s on RA; the RN contacted the provider and believed they may have applied O2 but had no documentation of doing so before ambulance transfer. The DON confirmed that O2 was readily available, that orders required O2 when saturations remained below 90%, and that these residents had documented low O2 saturations without documented O2 administration, and that one resident’s care plan goal for O2 saturation was not met.
Surveyors found that the facility failed to enter and implement PRN oxygen orders for two residents with significant respiratory conditions. One resident with a history of pulmonary embolism and another with COPD each had admission orders from their PCPs for oxygen PRN to maintain O2 sats at 90%, but these orders were not entered into their Order Summaries. For the resident with COPD, documentation showed O2 saturation dropping to 82% with no record that supplemental oxygen was provided. The facility’s medication administration policy requires documentation in accordance with physician orders, and the DON acknowledged that standing orders are expected for all residents but that charts are not consistently reviewed, resulting in the missing PRN oxygen orders in the EMAR.
The facility failed to maintain clean exhaust hoods in the kitchen, as observed during inspections. The hoods were coated with a dark brown substance, and the Dietary Manager confirmed they were not cleaned regularly. The cleaning schedule did not include the exhaust hoods, and the last cleaning by an external company was in March, indicating a lack of regular maintenance.
A nurse aide failed to perform adequate hand hygiene during peri-care for a resident with a suspected UTI, washing hands for only 8 seconds instead of the required 20 seconds. The aide did not change gloves or wash hands after touching objects, contrary to the facility's hand hygiene policy. The DON confirmed the deficiency in infection control practices.
The facility did not submit their PBJ data for Q2 2024 on time due to issues with a new payroll vendor. The vendor incorrectly categorized various hours, leading to a delay in submission. The Staffing Coordinator confirmed the report was one week late.
Failure to Administer Ordered Oxygen for Residents With Low O2 Saturations
Penalty
Summary
The deficiency involves the facility’s failure to provide oxygen therapy in accordance with physician orders and documented care plans for three residents with low oxygen (O2) saturations. For Resident 2, vital signs on 03/28/2026 at 7:02 AM showed an O2 saturation of 89% on room air, while the medication administration record contained an order to apply oxygen as needed to keep O2 saturations greater than 90%. A medication aide reported the low saturation to the RN by phone and remained with the resident until the RN arrived. The RN confirmed that upon arrival they assessed the resident, then left the bedside to call 911 and prepare transfer paperwork, brought the crash cart to the room area, but did not administer oxygen per the physician’s order and did not recheck the O2 saturation before the resident left the facility. For Resident 6, the admission order dated 11/03/2025 directed staff to apply oxygen as needed to keep O2 saturations above 90%, and the care plan identified the resident as at risk for respiratory distress with a goal to maintain O2 saturations above 88% daily. On 02/18/2026, progress notes documented that at 7:00 AM the resident vomited, appeared tired, and had an O2 saturation of 90% on room air. By 9:30 AM, the resident was lethargic with an O2 saturation of 83% on room air. The RN documented calling the power of attorney and 911, and the resident was transferred out shortly thereafter. In interview, the RN could not recall whether oxygen had been administered, acknowledged leaving the room for an unknown period to obtain transfer paperwork, and there was no documentation that oxygen was applied despite the low saturation and existing orders and care plan goals. For Resident 8, progress notes on 02/18/2026 at 12:30 PM recorded an O2 saturation of 88% on room air, and a call was placed to the provider at that time. Later that day, the Weights and Vitals Summary showed an O2 saturation of 89% on room air, and progress notes indicated the resident was transferred via ambulance to the emergency department that evening. The RN reported calling the primary care provider to report the resident’s condition and stated they asked for an oxygen order, and believed they may have applied oxygen but could not remember. There was no documentation that oxygen was administered prior to transfer. The DON confirmed that oxygen supplies were available on the fourth and fifth floors, that it was their expectation that orders be followed and oxygen applied if O2 saturation remained below 90% after deep breathing and rest, and that record review showed these three residents had O2 saturations below 90% without documented oxygen application before hospital transfer, and that Resident 6’s care plan goal for O2 saturation was not met.
Failure to Enter and Implement PRN Oxygen Orders for Two Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that prescribed PRN oxygen orders were entered into the residents’ Order Summaries and available for use. One resident admitted with a pulmonary embolism had an admission order dated 12/18/2025 from the PCP for oxygen as needed to keep oxygen saturation at 90%, but review of the resident’s Order Summary dated 12/30/2025 showed no corresponding PRN oxygen order. Another resident admitted with COPD had an admission order dated 11/04/2025 for oxygen as needed to keep oxygen saturation at 90%, and the resident’s Comprehensive Care Plan documented risk for respiratory distress with a goal to maintain oxygen saturation above 88%. However, the resident’s Order Summary dated 11/25/2025 did not contain the ordered PRN oxygen. For the resident with COPD, the Weight and Vitals Summary showed an oxygen saturation of 82% on 02/18/2026. Progress notes for that date documented an oxygen saturation of 90% at 7:00 AM and 82% at 9:30 AM, with no documentation that supplemental oxygen was provided. The facility’s policy on Medication Administration, reviewed 11/10/2025, states that all medications are to be documented in accordance with the physician’s order. In interviews, the DON stated that all residents should have standing orders obtained on admission and that these should transfer with residents between levels of care, but acknowledged that charts are not consistently reviewed to ensure all orders are placed and available in the EMAR, and confirmed that the PRN oxygen admission orders for both residents were not entered into their Order Summaries as they should have been.
Failure to Maintain Clean Exhaust Hoods in Kitchen
Penalty
Summary
The facility failed to maintain the exhaust hood over the cooking area in a clean and sanitary condition, which could potentially lead to food-borne illnesses affecting all residents who consumed food from the kitchen. During an observation on July 29, 2024, the exhaust hoods were found to be coated with a dark brown substance. The Dietary Manager confirmed that the hoods were not clean and stated that an external company cleans them twice a year. However, the cleaning schedule did not include the exhaust hoods as an assigned task. Further observations on July 31, 2024, revealed that the exhaust hoods remained unclean. The Dietary Manager confirmed that the cleaning task for the exhaust hoods was not listed on the cleaning schedules provided. A review of the cleaning records showed that the last cleaning by an external company was performed on March 27, 2024, indicating a lack of regular maintenance and oversight in keeping the exhaust hoods clean as per the Nebraska Food Code requirements.
Inadequate Hand Hygiene During Peri-Care
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed during peri-care for a resident, leading to a potential risk of cross-contamination. The incident involved a resident with a history of heart attack, heart failure, Alzheimer's disease, rhabdomyolysis, high blood pressure, and anxiety, who was being treated for a suspected urinary tract infection. During the observation, a nurse aide sanitized their hands, entered the resident's room, and performed various tasks before washing their hands with soap and water for only 8 seconds, which is below the recommended duration. The nurse aide then assisted the resident with peri-care without changing gloves or performing hand hygiene after touching other objects. After completing the care, the aide removed their gloves but did not wash their hands before continuing to assist the resident. The facility's hand hygiene policy requires washing hands for at least 20 seconds, which was not adhered to in this instance. Interviews with the nurse aide and the Director of Nursing confirmed that the handwashing duration was insufficient, highlighting a deficiency in following proper infection control protocols.
Failure to Submit PBJ Data on Time
Penalty
Summary
The facility failed to submit their Payroll Based Journal (PBJ) data for the second quarter of 2024, which is a requirement for all long-term care facilities to ensure accountability and consistency in staffing information. The PBJ report, covering the period from January 1 to March 31, 2024, was not submitted on time to the Centers for Medicare and Medicaid Services (CMS). This failure was confirmed during an interview with the Staffing Coordinator, who stated that the report was submitted one week late. The delay was attributed to a recent switch to a new payroll vendor, which incorrectly categorized all facility hours, including paid time off, sick leave, and education hours, as worked hours on the floor. This discrepancy prevented the facility from correcting and submitting the report within the required timeframe.
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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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