Emerald Nursing & Rehab Lancaster Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lincoln, Nebraska.
- Location
- 1001 South Street, Lincoln, Nebraska 68502
- CMS Provider Number
- 285275
- Inspections on file
- 46
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Emerald Nursing & Rehab Lancaster Llc during CMS and state inspections, most recent first.
Surveyors found that ice machines on two nursing stations were visibly soiled, with stained and discolored plastic components and, in one case, a brown fuzzy buildup on the evaporator grid and surrounding surfaces. Staff, including a NA and an LPN, confirmed the machines were used to obtain ice for residents and acknowledged the parts were not clean, while also indicating they did not know cleaning frequencies or responsibilities. A maintenance worker reported cleaning one of six ice machines per month, and the ADM confirmed the unclean conditions and the absence of a defined process to keep the ice machines clean and sanitary.
A resident with multiple serious cardiac and neurologic conditions experienced a notable change in condition, including lethargy, labored breathing, low oxygen saturation, and hypotension in one arm, requiring initiation of 3L O2 with improvement in SpO2. Nursing documentation reflected these findings but did not include any notification to the physician or the family representative. Subsequent record review and interviews with the APRN, the family representative, and the DON confirmed that the provider and family were not informed of the change in condition and that the family was only contacted after the resident died.
A resident with multiple serious cardiac and neurologic conditions became lethargic and was reported by an aide as not looking right. The charge nurse assessed the resident, who was responsive and denied pain, but had hypotension (BP 78/64), tachycardia (pulse 105), and low O2 saturation (83% on room air), and placed the resident on 3L O2, improving saturation to 93%. No further assessments or monitoring by the nurse were documented between that time and about 1:00 AM, when the aide again requested the nurse to check the resident, who was then found unresponsive, pulseless, and without respirations, and was later pronounced deceased. The DON confirmed the nurse should have reassessed and checked on the resident more frequently after the change in condition but did not do so.
A resident with multiple chronic conditions, including Parkinson's disease and dementia, had a UA and C&S ordered after family reported concerns about UTI symptoms. The UA showed a culture was indicated and the C&S was completed, and nursing staff noted the lab results, but they were not sent to or communicated to the physician. Later, when the family again reported UTI symptoms and confusion, the physician indicated the C&S had not previously been provided for review and only then ordered Bactrim DS. The DON confirmed that the lab results were not communicated in a timely manner and that antibiotic therapy should have been initiated earlier.
Surveyors found that all four dining room steam tables contained brown water with floating particles, corrosion, and dried food, and that a toaster in one serving station was heavily soiled with crumbs, black stains, and dried food on its surfaces and surrounding counter. Facility policies required daily draining, cleaning, and sanitizing of steam tables and adherence to Food Code standards for clean food-contact and non-food-contact surfaces. A cook and the Food Service Manager acknowledged that the steam tables were not being cleaned and the water was not being changed daily, and could not identify when this was last done. The Administrator confirmed that dietary sanitation was deficient and that no process improvement plan was in place, affecting meal service for about 170 residents using the dining area.
A resident with a history of substance use and cognitive impairment was found to have an unsecured bottle of alcohol in their room, despite provider orders limiting alcohol consumption to special occasions. Multiple staff members were aware of the alcohol but did not secure it, and there was no documentation of a self-administration assessment or notification to the POA or provider. The resident became intoxicated, and the POA was only informed after the incident.
The facility did not maintain adequate nursing staff on all shifts, with staffing records showing nurse and NA coverage below required ratios. Residents reported long waits for call light responses, and staff described frequent call-ins and being left to care for large numbers of residents, especially at night and on weekends. Grievances about delayed care further confirmed the staffing deficiencies.
A facility failed to change soiled bed linens for a resident with bladder incontinence, despite the resident's care plan requiring routine checks and changes. During an observation, NAs A and B were seen providing care to the resident, and it was noted that the draw sheet and fitted sheet had yellow stains. Although a new draw sheet was obtained, the fitted sheet was not changed because the resident was scheduled for a bath later. The DON confirmed that the soiled linens should have been changed immediately.
A nursing assistant failed to follow proper infection control practices by not performing hand hygiene at required intervals and improperly using gloves while providing care to multiple residents. The assistant did not change gloves or wash hands between resident interactions, leading to potential cross-contamination. The Director of Nursing confirmed the breach of protocol despite previous staff education on hand hygiene.
The facility failed to have an RN on duty for at least 8 consecutive hours on a weekend, as required. Staffing schedules showed no RN was scheduled, and interviews confirmed the absence. The staffing coordinator was unaware of RN identities due to missing titles on schedules, and the DON admitted that procedures to cover RN absences were not followed.
The facility failed to provide the required 12 hours of ongoing training for five direct care staff members, including four NAs and one UD. Record reviews and interviews revealed that none of the sampled staff completed the mandated continuing education hours, with attendance ranging from 5 to 10 hours during 2024. The absence of documentation for ongoing education was confirmed by the COO and Administrator, highlighting a potential impact on all 174 residents.
The facility failed to maintain proper food safety and hygiene standards, with undated and outdated food items found in storage, a dirty ice machine, and inadequate hand hygiene practices by staff. Observations revealed that kitchen staff did not consistently wear hair restraints or wash hands for the required duration, as confirmed by interviews with the Director of Food Service.
The facility failed to prevent cross-contamination in laundry handling and did not adhere to infection control practices for CPAP/BiPAP cleaning and oxygen tubing replacement. A resident's BiPAP machine was observed with layers of dust, and two residents had outdated oxygen tubing. Staff interviews confirmed the lapses in following the facility's infection control policies.
The facility failed to ensure a clean environment, with observations revealing lint and debris on fans, a pivot stand, and a vent cover. The facility's cleaning policies did not include these items, and the last deep cleaning dates were outdated. The Administrator confirmed the need for cleaning.
The facility lacked a qualified Activity Professional, affecting all residents involved in activities. The AD had no activity training, and the MOO, who oversaw activities, lacked experience in recreational programs. The RA confirmed no staff had formal training in activities, and 20-25 residents routinely refused activities.
The facility failed to provide written notices of transfer to residents or their representatives prior to hospitalization, as required by policy. Four residents were transferred without receiving notices that included the reason for transfer, location, and appeal rights. Interviews confirmed the facility's non-compliance with providing the necessary information for emergency transfers.
A facility failed to accurately document a resident's unstageable pressure ulcer in the MDS. The resident had an unstageable pressure ulcer on the right hand, covered with eschar, but the MDS incorrectly recorded zero unhealed pressure ulcers. The DON confirmed the error and acknowledged that the MDS should have indicated one unhealed pressure ulcer, as per the RAI manual guidelines.
The facility failed to provide scheduled activities for residents in the Alzheimer's Unit, affecting three residents with cognitive impairments. Observations showed no activities on Station 5, despite scheduled events on the activity calendar. Interviews confirmed the absence of an activities person for two months, and no activities were documented for the affected residents in the last 30 days. The facility's policy required staff education on resident rights, but no activities were scheduled due to a norovirus outbreak.
A facility failed to obtain a complete, valid prescription for a CPAP machine for a resident. The resident confirmed using the CPAP nightly, and the Order Summary Report included instructions for its use with oxygen. However, the DON confirmed the absence of a valid prescription with current settings.
The facility did not have a qualified Infection Preventionist (IP) since mid-October, affecting infection control duties for all 178 residents. The Infection Prevention and Control Program Policy outlined the IP's responsibilities, but no documentation was available for November. Interviews with the DON and Administrator confirmed the absence of an IP and the lack of infection control activities.
A resident with a UTI experienced delays in urine sample collection and antibiotic administration due to communication breakdowns among staff. Despite the resident's guardian expressing concerns, the facility did not collect a urine sample until several days after it was ordered, and there were delays in starting a new antibiotic after receiving culture results.
A facility failed to follow its infection control policies during wound care for a resident. An RN did not wear an isolation gown as required by the Enhanced Barrier Precautions policy and washed hands for less than the mandated 20 seconds at various stages of the procedure. Interviews confirmed the facility's expectations for PPE use and hand hygiene.
A resident with a Stage 2 pressure ulcer on the coccyx did not receive appropriate wound care as per medical orders, leading to the ulcer worsening to Stage 3. Despite a care plan indicating risk for skin breakdown, no wound care treatments were documented or administered. Interviews with staff confirmed the absence of treatment orders and care, resulting in a deficiency.
The facility failed to honor the religious preferences of a Muslim resident, who was unable to pray and fast as desired, and did not include these preferences in their care plan. Additionally, several residents experienced significant gaps between scheduled baths, contrary to their stated preferences. Staff interviews revealed a lack of awareness and action regarding these preferences, with systemic issues in documentation and implementation of resident rights and self-determination policies.
Two residents left the facility unsupervised due to staff's failure to follow procedures for monitoring residents with wanderguards and Community Access Passes. One resident, who was cognitively impaired and at risk for elopement, wore a wanderguard that did not trigger the alarm. The other resident, who was cognitively aware, had a pass to sit out front only but was able to leave with the first resident. Staff were unaware of the residents' departure, and the receptionist mistakenly allowed them to leave, thinking one was a visitor.
Two residents left the facility unaccompanied, despite one wearing a wandering device. The receptionist cleared the alarm, mistaking one resident for a visitor. The facility did not conduct a formal investigation or report the incident to the State Agency, as management deemed it not an elopement.
A resident with multiple health issues, including dementia and a history of UTIs, showed increased confusion and hallucinations. Despite a family member's request for a urinalysis, the facility failed to notify the physician of the change in condition. This delay led to the resident being hospitalized for a UTI.
A resident with severe cognitive impairment and communication challenges was sent to a CT scan appointment without an escort, contrary to the facility's practice for residents with low BIMS scores. The DON confirmed that staff should have accompanied the resident to provide necessary support.
A resident with a history of falls and cognitive impairment experienced multiple falls from a recliner due to impulsiveness and confusion. Despite previous incidents, the LTC facility did not assess the resident's ability to use the recliner safely, resulting in a severe fall causing a subdural hematoma. The facility lacked a policy for assessing the use of mechanical lift chairs.
A resident with multiple diagnoses, including ataxia and chronic heart failure, exited the facility undetected due to a malfunctioning Wander Guard system. The resident, who required assistance with all activities of daily living and had moderate cognitive impairment, was not initially identified as an elopement risk. Increased confusion and agitation led to the placement of a Wander Guard bracelet, but no subsequent elopement assessment was documented. The Wander Guard system failed to alarm, and the resident was found outside after tipping over in a wheelchair. Staff awareness of elopement risks and Wander Guard functionality varied, and the facility lacked specific policies and procedures for managing wandering and elopement risks. Quarterly nursing assessments, including elopement risk, were not conducted as required.
A facility failed to ensure that a bed alarm was properly connected for a resident with severe cognitive impairment and a history of falls. Despite staff education, the bed alarm cord was found unplugged, rendering it ineffective and increasing the resident's risk of falls.
A resident's preference for two baths per week was not honored, as documented in their care plan and confirmed by the resident and the Director of Nursing. The resident received baths on only a few occasions over several months, despite being present in the facility and having no documented refusals.
Unsanitary Ice Machines on Two Nursing Units
Penalty
Summary
Surveyors identified a deficiency related to unsanitary ice machines on Stations 1 and 3, which were used to obtain ice for residents on those units. On Station 1, observation showed the white plastic piece over the ice had red stains and a black and brown substance on it. A nurse aide confirmed the machine was used for residents on Station 1, acknowledged the plastic piece was not clean, and stated they did not know how often the ice machines were cleaned, only that maintenance was responsible. The facility census was 191, with 55 residents on Station 1 and 33 residents on Station 3 potentially affected. On Station 3, an initial observation revealed the white plastic piece over the ice had a grey film, and an LPN confirmed the machine was used for residents on that station and that the piece was not clean. The LPN did not know when the machine was last cleaned or who was responsible for cleaning it. A later observation of the Station 3 ice machine, partially disassembled by a maintenance worker for cleaning, showed the evaporator grid and surrounding area coated with a brown fuzzy substance. The maintenance worker stated there were six ice machines in the building and that they cleaned one per month. A subsequent observation showed the Station 1 ice machine still operating with visible red stains and black and brown substance on the plastic piece, and the administrator confirmed both the unclean condition and that there was no process being followed to maintain the ice machines in a clean and sanitary condition.
Failure to Notify Physician and Family of Resident’s Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and family representative of a significant change in condition. The resident was admitted with multiple serious diagnoses, including subarachnoid hemorrhage, hypoglycemia, anxiety disorder, hypotension, shortness of breath, chronic CHF, NSTEMI, TIA, and edema. A nursing assessment documented that the resident was lethargic, denied pain, and was alert and oriented x3 but responded incorrectly to the day of the week. The resident’s CGM blood sugar was 234, and vital signs showed a left arm blood pressure of 78/64, pulse 105, and oxygen saturation of 83% on room air, with a right arm blood pressure of 128/76. The resident reported feeling hot, denied shortness of breath, but had labored breathing, and oxygen was initiated at 3L via concentrator, improving oxygen saturation to 93%. Record review showed no progress notes on the following day documenting that the physician or family representative had been notified of this change in condition. Interviews confirmed that the physician’s office had not been informed of the resident’s status change, and the family representative reported not being updated about the change in condition, only being notified after the resident’s death. The DON confirmed that the charge nurse should have notified both the physician and the family representative of the change in condition and that this did not occur.
Failure to Reassess Resident After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to maintain professional standards of practice in assessing a resident after a documented change in condition. The resident had multiple serious diagnoses, including subarachnoid hemorrhage, hypoglycemia, anxiety disorder, hypotension, shortness of breath, chronic congestive heart failure, non-ST elevation myocardial infarction, transient ischemic attack, and edema. On the evening in question, a nurse aide alerted the charge nurse at 8:30 PM that the resident “did not look right.” The charge nurse found the resident lethargic but responsive and denying pain. Vital signs at that time showed a blood pressure of 78/64, pulse 105, and oxygen saturation of 83% on room air. The charge nurse initiated oxygen at 3 liters via concentrator, after which the resident’s oxygen saturation increased to 93%. Following this initial assessment and intervention, there is no documentation of any further assessment or monitoring of the resident by the charge nurse between approximately 8:30 PM and 1:00 AM, despite the significant change in condition and abnormal vital signs. At around 1:00 AM, the aide again requested that the charge nurse check on the resident. Upon entering the room, the charge nurse found the resident lying on the bed with feet on the floor, with color “gone,” unresponsive, and without pulse or respirations. The resident’s code status was Do Not Resuscitate, and emergency medical services were called and pronounced the resident deceased. The Director of Nursing confirmed in interview that the charge nurse should have performed another assessment and checked on the resident more frequently after the change in condition, and that this did not occur.
Failure to Communicate UA and C&S Results to Physician
Penalty
Summary
The facility failed to notify the physician of urinalysis and culture and sensitivity (C&S) results for one resident when these laboratory tests were completed. The resident had multiple diagnoses, including Parkinson's disease, major depressive disorder, edema, dysphagia, dementia, and ADHD. A fax to the physician documented that the family was concerned about a possible UTI and dysuria, and the physician responded with an order to obtain a UA with C&S as indicated. The UA completed on 3/12/26 showed that a culture was indicated, and the C&S was completed on 3/14/26. The laboratory results were noted by facility nursing staff on 3/16/26, but they were not sent to or communicated to the physician at that time. Subsequently, another fax to the physician documented that the family reported the resident had another urinary infection with confusion and questioned why there was another infection despite believing an antibiotic had been given a week earlier, although no antibiotic had been started because the facility was waiting on the culture. The physician’s response on that later fax indicated that the C&S had not been provided for review and was only then being reviewed, at which time an antibiotic (Bactrim DS) was ordered. Progress notes documented that the DON acknowledged the UA results had not been communicated or followed up on in a timely manner. In an interview, the DON confirmed that the labs had not been sent to the physician, that they should have been, and that the antibiotic should have been started earlier but was not.
Failure to Maintain Sanitary Steam Tables and Toaster in Dining Areas
Penalty
Summary
Surveyors identified a deficiency related to food service sanitation and equipment maintenance when observing all four dining room steam tables and a toaster in one dining area. Policy review showed the facility’s Resident Rights policy guarantees residents a safe, clean, comfortable environment, and the facility’s steam table cleaning policy requires daily draining of water, cleaning, and sanitizing of the units. The 2022 Food Code requires food-contact surfaces to be free of encrusted grease and soil, and non-food-contact surfaces to be free of dust, dirt, food residue, and other debris. During the tour, steam tables at stations one, two, and three were observed with brown liquid containing floating particles in the compartments, brown corrosion on the sides, and dried food present. The steam table at station four contained dark brown liquid with floating particles in all compartments, and the toaster at station four was covered with food crumbs, stained black, and had dried food on the top, sides, and counter below. Further observation with the Food Service Manager confirmed that the water in all steam table compartments at all four stations was brown with floating particles. In interviews, the cook stated the steam tables were supposed to be cleaned daily, including changing the water, but acknowledged this was not occurring and could not state when the water was last changed. The Food Service Manager confirmed that all unit steam tables had brown water with floating particles, that they should be cleaned and sanitized daily, and that they were unaware of when the water was last changed. The Food Service Manager also confirmed the toaster at station four was soiled and needed replacement. The Administrator acknowledged that dietary sanitation needed improvement and that there was no process improvement plan in place. These actions and inactions affected the sanitation of food service equipment used by approximately 170 residents who utilized the dining area for meals.
Failure to Prevent Accident Hazard Due to Unsecured Alcohol
Penalty
Summary
A deficiency occurred when the facility failed to implement appropriate interventions to prevent potential accidents for a resident with a history of substance use and multiple medical conditions. The resident, who was moderately cognitively impaired and used a manual wheelchair, had an invoked Power of Attorney (POA) for healthcare decisions. The resident's care plan and provider orders allowed for alcohol consumption only on holidays or special events, yet the resident was found to have an unsecured bottle of alcohol in their room for an extended period, accessible at any time. Staff interviews and record reviews revealed that several staff members, including nursing assistants and social services, were aware of the bottle of alcohol in the resident's room but did not take action to secure or remove it, believing the resident had an order for alcohol. However, the order was limited to specific occasions, not for unsupervised possession. There was no documentation of a self-administration assessment to determine if the resident could safely manage alcohol, nor was there evidence of provider or POA notification regarding the unsecured alcohol. Additionally, after the resident was found intoxicated, there was no record of an alcohol toxicology test being completed as part of the emergency room visit, despite a provider order for a toxicology screen. The resident's POA was not informed about the presence of alcohol in the room until after the intoxication incident. The facility's social services staff had previously consulted with the Ombudsman regarding confiscation of alcohol, who advised that alcohol could not be taken from a resident without their consent. Despite this, the facility did not ensure that the resident's access to alcohol was consistent with the provider's order or that appropriate safety measures were in place, resulting in a failure to prevent a potential accident hazard.
Failure to Maintain Sufficient Nursing Staff on All Shifts
Penalty
Summary
The facility failed to provide a sufficient number of nursing staff on all shifts, as required by its own policies and state regulations. Record reviews showed that the facility's staffing levels frequently did not meet the ratios outlined in its Facility Assessment, with nurse and nursing assistant (NA) coverage falling short on multiple days and shifts. For example, there were instances where the nurse-to-resident ratio was as high as 1 nurse for every 91 residents, and NA-to-resident ratios were also higher than the facility's stated standards. The facility's own Director of Nursing confirmed that staffing was insufficient on certain shifts during the reviewed period. Residents and staff interviews corroborated the staffing shortages. Multiple residents reported having to wait long periods for their call lights to be answered, sometimes over an hour, and attributed these delays to short staffing and high staff turnover. Staff members also described frequent call-ins and being left to care for large numbers of residents, particularly during the night shift and on weekends. Nursing assistants reported being responsible for entire wings by themselves and having to wait for assistance with residents requiring more complex care, such as Hoyer lift transfers. A review of grievances filed in 2025 revealed 18 complaints related to long call light response times, further supporting the finding of inadequate staffing. The combination of documented staffing levels, resident and staff interviews, and grievance records demonstrated that the facility did not consistently provide enough nursing staff to meet the needs of all residents, as required by policy and regulation.
Failure to Change Soiled Linens for Resident
Penalty
Summary
The facility failed to ensure that soiled bed linens were changed for a resident, identified as Resident 2, who was part of a sample size of five residents in a facility with a census of 183. Resident 2 was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15/15. The resident's care plan highlighted bladder incontinence related to impaired mobility, with a goal to keep the resident clean and dry through routine checks and changes at standard intervals. However, during an observation, Nursing Assistants (NAs) A and B were seen providing peri care to Resident 2, and it was noted that the draw sheet and fitted sheet had yellow stains. Although NA-B acknowledged the need for a new draw sheet and obtained one, the fitted sheet was not changed because NA-A mentioned that Resident 2 was scheduled for a bath later that morning. The Director of Nursing (DON) confirmed that the expectation for nursing assistants is to change any soiled linens immediately, regardless of whether it is a bath day. Both NA-A and NA-B admitted that the stained fitted sheet should have been changed. This oversight in changing the soiled fitted sheet was acknowledged by the DON, who confirmed that the actions of the nursing assistants did not meet the facility's standards for maintaining cleanliness and hygiene for residents, particularly those with incontinence issues.
Infection Control Breach Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by the actions of Nursing Assistant (NA)-A. During observations, NA-A was seen walking down the hallway with gloves on and entering Resident 2's room without removing the gloves or performing hand hygiene. NA-A then performed peri care on Resident 2, gathered dirty linens and trash, and proceeded to the trash room without changing gloves or performing hand hygiene. This pattern continued as NA-A entered Resident 1's room, again failing to perform hand hygiene before and after care, and similarly with Resident 3. NA-A did not perform hand hygiene after removing gloves or handling trash, which is a violation of the facility's infection control standards. The Director of Nursing (DON) confirmed that the facility had conducted audits and provided education on proper handwashing practices, yet the observed actions of NA-A did not align with these standards. The DON acknowledged that gloves should not have been worn down the hallway and that hand hygiene should have been performed before and after resident care. The failure to follow these protocols raises concerns about the potential for cross-contamination between residents, as NA-A did not adhere to the infection control practices outlined in the facility's guidelines.
RN Staffing Deficiency on Weekend
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present for at least 8 consecutive hours on the weekend of January 4th and 5th, 2025. This deficiency was identified through a review of nursing staffing schedules, which revealed no RN was scheduled to work on these dates. Interviews with the Nursing Assistant working as the staffing coordinator and the Director of Nursing (DON) confirmed the absence of an RN on these days. The staffing coordinator was unaware of which staff members were RNs due to the lack of staff titles on the schedules. The DON acknowledged that if an RN calls in sick, other RNs should be contacted to cover the shift, and incentives should be offered, but this procedure was not followed, resulting in no RN being present in the facility on the specified dates.
Deficiency in Ongoing Training for Direct Care Staff
Penalty
Summary
The facility failed to provide the required 12 hours of ongoing training for five direct care staff members, including four Nursing Assistants (NAs) and one Unit Director (UD). This deficiency was identified through a record review and interviews, revealing that none of the sampled staff completed the mandated continuing education hours. Specifically, NA-N, NA-O, NA-P, UD-Q, and NA-R did not meet the 12-hour requirement, with their attendance ranging from 5 to 10 hours of in-service training during 2024. The facility's policy mandates that the Staff Development Coordinator maintain a training schedule and documentation system, and failure to complete the required training should result in termination. Interviews with the Chief Operating Officer and the Administrator confirmed the absence of documentation for the ongoing education of the NAs over the past 12 months. The Administrator also noted that the review of continuing education hours is conducted annually based on the calendar year rather than the hire date. This lack of compliance with training requirements had the potential to affect all 174 residents in the facility, as the ongoing education is crucial for maintaining employment status and ensuring quality care.
Food Safety and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to proper food safety and hygiene standards, as observed during a survey. In the kitchen, various food items were found to be improperly stored, with some being undated, opened, or outdated. This included chicken breaded powder, macaroni, cakes, turkey patties, grilled chicken breast fillets, and precooked pork breaded patties. Additionally, lemonade and coleslaw were found to be out of date. Interviews with the cook and the Director of Food Service confirmed these lapses in food safety practices. Furthermore, an ice machine was found to be dirty, with gray-blackish debris on the ice chute, and the last recorded cleaning was several months prior. The facility's ice policy was not followed, as evidenced by a nurse assistant placing an ice scoop back into a cooler without performing hand hygiene. The facility also failed to ensure that kitchen staff adhered to hygiene protocols, such as wearing hair restraints and performing adequate hand hygiene. Observations revealed that a dietary aide scooped ice without a hairnet and performed hand hygiene for only 15 seconds, contrary to the facility's policy of 20 seconds. Similarly, a cook was observed washing hands for less than the required time during food preparation. These actions were confirmed by interviews with the Director of Food Service, who acknowledged the need for staff to follow proper hygiene procedures to prevent foodborne illness.
Infection Control Deficiencies in Laundry Handling and Equipment Cleaning
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices in several areas. During an observation, a laundry aide was seen handling clean linens improperly by holding them against their uniform and placing a towel that had fallen on the floor back into a clean linen cart. Interviews with the laundry aide and the Director of Environmental Services confirmed that linens should not be held against the body and any linens that fall to the floor should be placed in the dirty laundry bin. The facility's laundry policy emphasizes that soiled laundry should be handled and transported according to best practices for infection prevention and control. Resident 101, who was diagnosed with obstructive sleep apnea and used a BiPAP machine, had their equipment observed to be unclean over several days. The BiPAP machine was noted to have layers of white and gray fuzzy substances on its surface, indicating a lack of cleaning. The facility's infection control policy required that CPAP and BiPAP machines have their external surfaces wiped twice a week, but there was no order for cleaning the machine itself in Resident 101's records. The Director of Nursing confirmed the machine's unclean state during an observation. Additionally, the facility failed to ensure the timely replacement of oxygen tubing for Residents 60 and 66. Observations revealed that there was no indication of when Resident 60's oxygen tubing was last changed, and Resident 66's tubing had a date of 11/9, which was not within the weekly replacement guideline. Interviews with a registered nurse and the unit coordinator confirmed that oxygen tubing should be changed weekly and dated accordingly. The facility's policy on cleaning respiratory equipment required masks and cannulas to be replaced within seven days or as needed when contaminated.
Facility Fails to Maintain Clean Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by the presence of lint and debris on wall-mounted oscillating fans, a pivot stand, and a vent cover. Observations revealed that the shrouds and blades of fans in several resident rooms contained a moderate amount of gray fuzzy substance. Additionally, a pivot stand located in the hallway outside a resident room was found to have a large amount of brown fuzzy and grainy substance on its base, along with gray scum on the handles and bars. The vent cover above the whirlpool tub in the Station 2 bathhouse also contained a large amount of brown and gray fuzzy substance. The facility's Cleaning and Disinfection - Environmental Infection Control policy indicated that environmental surfaces should be disinfected regularly and when visibly soiled. However, the facility's Survey Readiness Environmental Checklist and Environmental Service Associate checklist did not include cleaning of the bathhouses, pivot stand, or room fans. The Deep Cleaning Calendar showed that the rooms had not been deep cleaned recently, with the last deep cleaning dates ranging from October 2024 to January 2025. Interviews with the facility's Administrator confirmed the observations and acknowledged that the items should have been cleaned.
Lack of Qualified Activity Professional
Penalty
Summary
The facility failed to have a qualified Activity Professional, which had the potential to affect all residents participating in activities. The Activity Director (AD) confirmed during an interview that they had not received any activity training, and a review of their credentials supported this lack of training. The Facility Assessment, which should document the facility's needs to care for residents, was undated, and the facility policy emphasized the need for staff education on resident rights and responsibilities. The Manager of Operations (MOO), who was the activities supervisor, did not engage with the activities program and lacked experience in recreational or therapeutic activity programs. The Regional Administrator confirmed that no staff, including the MOO, had formal training or full-time experience in an activity program. Additionally, the AD noted that 20-25 residents routinely refused activities.
Failure to Provide Required Transfer Notices
Penalty
Summary
The facility failed to provide written notice of transfer to residents or their representatives prior to hospitalization for four sampled residents. The facility's policy on Transfer and Discharge from the Facility, dated January 2024, requires that notices include the reason and effective date of the discharge/transfer, the location where the resident was transferred, a statement of the resident's appeal rights, and contact information for the agency that receives discharge appeal requests and the State Long Term Care Ombudsman's office. However, the facility did not adhere to this policy. Resident 16, who had diagnoses including toxic encephalopathy and dementia, was transferred to the hospital on November 21, 2024, without receiving a notice containing the required information. Similarly, Resident 85, with Alzheimer's disease and a history of cerebrovascular infarction, was transferred on October 5, 2024, without the necessary notice. Both residents' Bed Hold/Therapeutic Leave Policy forms lacked the location or reason for transfer and appeals information. Resident 99, with conditions such as deep vein thrombosis and high blood pressure, was transferred twice, on December 7, 2024, and January 1, 2025, without proper notice. Resident 115, diagnosed with deep vein thrombosis, type 2 diabetes mellitus, and COPD, was also transferred twice, on December 5, 2024, and January 16, 2025, without the required notice. Interviews with the Clinical Consultant and Regional Administrator confirmed that the facility had not been providing written notices of transfer that included the required information for emergency transfers.
Inaccurate MDS Documentation of Pressure Ulcers
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the current number of unhealed pressure ulcers for a resident. A review of the resident's tissue analytics revealed an unstageable pressure ulcer on the right hand, fully covered with eschar. However, the MDS inaccurately recorded the number of unhealed pressure ulcers as zero for all stages, including unstageable-slough and/or eschar. During an interview, the Director of Nursing confirmed the presence of the unstageable pressure ulcer and acknowledged the error in the MDS documentation, which should have indicated one unhealed pressure ulcer. The facility follows the Resident Assessment Instrument (RAI) manual to complete the MDS, which requires accurate coding of pressure ulcers within a 7-day look-back period.
Failure to Provide Scheduled Activities in Alzheimer's Unit
Penalty
Summary
The facility failed to provide activities to meet the needs of residents in the Alzheimer's Unit, specifically affecting three residents. Observations on multiple occasions revealed that no activities were taking place on Station 5, despite the activity calendar indicating scheduled events such as cafe cart, Catholic Mass, Pampered Nails, Baby Sitting, Crafts, and Active Games. Interviews with staff, including a Nursing Assistant and the Activity Director, confirmed the absence of an activities person on Station 5 for about two months, and no evening or weekend activities were offered during this period. Resident 109, diagnosed with Non-Alzheimer's Dementia and having a BIMS score of 0, was observed sitting alone without participating in any activities. The resident's Comprehensive Care Plan indicated a goal of attending 3-5 activities weekly, with preferred activities including arts and crafts, bingo, and musical movement. However, no activities were documented for this resident in the last 30 days. Similarly, Resident 133, also with a BIMS score of 0, was observed alone, with no activities available. The resident's care plan required participation in activities 3-5 times weekly, but no activities were documented in the last 30 days. Resident 168, with a diagnosis of Alzheimer's Disease and a BIMS score of 15, was also affected by the lack of activities. The resident's care plan included participation in activities 1-2 times weekly, with preferences for bingo and live music, yet no activities were documented in the last 30 days. The facility's policy required staff education on resident rights and responsibilities, but interviews revealed that no activities were scheduled due to a norovirus outbreak, which led to the closure of all units from mid-December 2024 to mid-January 2025. The Clinical Coordinator confirmed the absence of a facility Activity Policy.
Incomplete CPAP Prescription for Resident
Penalty
Summary
The facility failed to ensure a complete, valid prescription was obtained for a CPAP machine for Resident 60. An observation revealed a CPAP machine on Resident 60's bedside stand, and an interview with the resident confirmed that they use the CPAP every night. A review of the resident's Order Summary Report indicated instructions for using the CPAP with oxygen, including connecting O2 tubing to the mask and filling the chamber with distilled water. However, the Director of Nursing confirmed that there was no complete, valid prescription with the current settings for the CPAP machine.
Failure to Employ Infection Preventionist
Penalty
Summary
The facility failed to employ a qualified Infection Preventionist (IP) to oversee the infection prevention and control program, which had the potential to affect all 178 residents. A review of the facility's Infection Prevention and Control Program Policy, dated May 20, 2017, indicated that the designated IP is responsible for consulting staff on infectious diseases, resident room placement, implementing isolation precautions, and conducting surveillance and epidemiological investigations. However, the Antibiotic Stewardship and Infection Control Surveillance Record showed no documentation for November 2024. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility had been without an IP since mid-October 2024. The DON confirmed that infection control duties had not been performed since that time. The Administrator acknowledged the absence of an IP and mentioned that a new hire for the position would start the following week.
Failure to Timely Address UTI Symptoms
Penalty
Summary
The facility failed to adequately assess and monitor a resident for potential signs and symptoms of a urinary tract infection (UTI). The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, was prescribed antibiotics for a UTI on multiple occasions. However, there was a delay in collecting a urine sample for urinalysis and culture, which was ordered on 11/15/24 but not collected until 11/20/24. This delay occurred despite the resident's guardian expressing concerns about the resident's symptoms and behaviors indicative of a UTI. Interviews revealed communication breakdowns among staff members. The Social Services (SS) staff reported the guardian's concerns to an LPN, but the symptoms were not communicated on the physician's board. The LPN assumed that SS had informed the floor nurse, which did not happen, leading to a delay in addressing the resident's condition. The facility received UA results on 10/31/24 and started an antibiotic, but there was further delay in starting a new antibiotic after receiving culture and sensitivity results, which were faxed to the doctor multiple times before an order was received.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control program during the wound care of a resident. Specifically, a registered nurse (RN) did not follow the Enhanced Barrier Precautions policy by neglecting to wear an isolation gown while performing wound care on a resident's left heel. The resident was admitted to the facility with a wound vac on the left heel, requiring dressing changes every night shift on specified days. During the observation, the RN brought supplies into the room, performed hand hygiene with sanitizing gel, and donned gloves but did not wear the required isolation gown. Additionally, the RN did not comply with the facility's hand hygiene policy, which mandates washing hands for at least 20 seconds. The RN washed hands for only 11 to 12 seconds at various stages of the wound care process, including after removing edema wear and old dressing, cleaning the wound, opening dressings, and applying skin prep. Interviews with the RN and the Director of Nursing confirmed the expectation to wear PPE during wound care and to wash hands for the required duration.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to follow the medical practitioner's orders regarding wound care for a resident, leading to a deficiency in pressure ulcer management. The resident, who was admitted with Chronic Obstructive Pulmonary Disease and Type 2 Diabetes, had a Stage 2 pressure ulcer on the coccyx that was documented to have worsened over time. Despite the presence of a comprehensive care plan indicating the resident was at risk for skin breakdown, there were no documented orders for wound care treatments on the Treatment Administration Record (TAR) from August through early October. The resident's condition deteriorated to a Stage 3 pressure ulcer, with no evidence of wound care being administered as per the practitioner's orders. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed the absence of documented treatment orders and the lack of wound care provided to the resident. The LPN acknowledged the presence of a wound but could not confirm the treatment details or completion. The Director of Nursing also confirmed the absence of wound treatment orders on the TAR and acknowledged the wound's progression. This lack of adherence to the facility's Skin and Wound Management Policy and the practitioner's orders resulted in the deficiency noted by the surveyors.
Failure to Honor Resident Preferences in Religious Practices and Bathing
Penalty
Summary
The facility failed to honor the religious preferences of Resident 2, who is Muslim and expressed a desire to pray and fast according to their religious practices. Despite having an intact cognitive status, as indicated by a BIMS score of 14, Resident 2's care plan did not include their religious preferences or requirements. The resident expressed distress over their inability to pray and fast, and although the facility contacted the Islamic Foundation for support, there was no follow-up documentation of visits or services provided. Interviews with staff revealed a lack of awareness and action regarding Resident 2's religious needs. Additionally, the facility did not respect the bathing preferences of several residents, including Residents 1, 4, 5, 6, and 7. These residents experienced significant gaps between scheduled baths, contrary to their stated preferences and the facility's policy. For instance, Resident 1 preferred two baths per week but went up to 13 days without a bath. Similarly, Resident 4, who was dependent on staff for bathing, experienced intervals of up to 10 days without a bath. The facility's documentation did not reflect refusals or alternative arrangements, indicating a systemic issue in honoring resident preferences. Interviews with staff, including the DON and nurse aides, confirmed that residents' bathing preferences were not consistently asked about or documented during care plan meetings. Staff shortages and reassignments further contributed to the failure to provide baths as scheduled. The facility's policies on resident rights and self-determination were not effectively implemented, leading to unmet needs and dissatisfaction among residents.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to implement interventions to prevent elopement for two residents, leading to an immediate jeopardy situation. Resident 1, who was moderately cognitively impaired and assessed as an elopement risk, was wearing a wanderguard safety device. Despite this, Resident 1 was able to leave the facility without staff or family, as the wanderguard did not trigger the alarm system. The resident was observed to have increased confusion and was exit-seeking, yet the staff did not effectively monitor or prevent the resident from leaving the premises. Resident 2, who was cognitively aware and had a Community Access Pass allowing them to sit out front only, was able to leave the facility with Resident 1. The staff did not realize the residents were gone, and the receptionist mistakenly allowed them to leave, thinking Resident 1 was a visitor. The facility's procedures for monitoring residents with wanderguards and Community Access Passes were not followed, and staff were not adequately informed about which residents were at risk for elopement. Interviews with staff revealed a lack of awareness and communication regarding residents' permissions and restrictions. The wanderguard system was not effectively managed, and staff did not consistently check or refer to the lists of residents with wanderguards or Community Access Passes. This oversight allowed the residents to leave the facility unsupervised, leading to the immediate jeopardy situation.
Removal Plan
- Resident resides on a locked unit.
- Resident is hospitalized. Community Pass has been revoked.
- Staff member who shut the Wanderguard system off has been suspended pending investigation related to supporting documentation that had been educated on facility procedures.
- Immediate Education to Receptionist with Competency.
- Community Pass Policy revised as a Best Practice of the facility and not a physician's order.
- Current Community Pass residents will be evaluated for prior restrictions to ensure following revised policy.
- Receptionist staff will be re-educated with Competency by the Administrator or designee on resident safety with community passes and wanderguards prior to next immediate shift.
- All staff will be re-educated by the Administrator or designee on resident safety with community passes and wanderguards immediately.
- Competency will be placed in Orientation for all new hires and agency staff.
- Audits to be completed to ensure receptionist are knowledgeable about resident safety with community passes and wanderguards.
- The Plan of correction will be reviewed by QAPI committee.
Failure to Investigate and Report Resident Elopement
Penalty
Summary
The facility failed to ensure a formal investigation was completed and the State Agency was notified regarding the elopement of two residents. The facility's Missing Resident/Elopement Procedure required all nursing staff to be aware of residents' whereabouts and to activate the elopement procedure if a resident could not be located. However, the facility did not document any elopement incidents for the two residents involved, nor did they notify the State Agency as required. Resident 1, who had impaired cognitive function and was at risk for elopement, was wearing a wandering device. Despite this, Resident 1 was able to leave the facility unaccompanied, pushing Resident 2 in a wheelchair. The facility's security video showed that the receptionist cleared the wanderguard alarm, allowing the residents to exit the building. The receptionist mistook Resident 1 for a visitor and did not realize the resident was wearing a wanderguard. The residents were later found at a nearby location and returned to the facility. The facility's management group determined that the incident was not an elopement, and thus, no formal investigation was conducted, and no report was submitted to the State Agency. The Director of Nursing confirmed that the only action taken was viewing the security video, and the Clinical Consultant acknowledged that the receptionist should not have turned off the alarm. This lack of action and failure to follow protocol led to the deficiency noted in the report.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident, which is a violation of the regulatory requirement to immediately inform the resident's doctor of any significant changes. The resident, who was admitted with multiple diagnoses including urinary tract infections, Type 2 diabetes, and unspecified dementia, exhibited increased confusion and hallucinations. A family member visiting the resident reported these symptoms and suspected a urinary tract infection, requesting a urinalysis. Despite this request being communicated to the facility staff, there was no documentation of the physician being informed of the resident's change in condition from May 2 to May 8. The situation escalated when the resident was found yelling in the hall and displaying confusion, prompting a delayed order for a urinalysis. The family member was not updated on the physician's order until May 10, and the resident was eventually sent to the hospital on May 12 due to altered mental status and other symptoms. Interviews with the family member, a registered nurse, and the Director of Nursing confirmed the failure to update the physician and the delay in addressing the family's concerns, which ultimately led to the resident's hospitalization for a urinary tract infection.
Failure to Provide Escort for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide an escort for a resident with significant cognitive and communication impairments during a scheduled CT scan appointment. The resident, who was admitted with diagnoses including aphasias following cerebral infarction, epilepsy, and major depressive disorder, was dependent on staff for assistance with daily activities and had severe cognitive impairment as indicated by prior BIMS assessments. The care plan noted the resident's communication challenges and dependency on staff for mobility and other activities. On the day of the CT scan, the resident was sent to the hospital without an escort, despite the facility's typical practice of sending staff or family members with residents who have a BIMS score under 10. This oversight was confirmed by the Director of Nursing (DON) during an interview, acknowledging that staff should have accompanied the resident to the appointment to provide necessary support.
Failure to Assess Resident's Ability to Use Recliner Leads to Injury
Penalty
Summary
The facility failed to ensure that a resident was assessed for the ability to safely use a recliner/lift chair, leading to a fall with major injury. The resident, who had a history of falls and was moderately cognitively impaired, was found on multiple occasions to have fallen or slid out of the recliner due to impulsiveness and confusion. Despite these incidents, the facility did not have a policy in place to assess the resident's ability to use the recliner safely. The resident had a complex medical history, including dementia, anxiety, depression, and cerebrovascular disease, which contributed to their impulsiveness and confusion. The facility's records showed multiple falls from the recliner, with interventions such as encouraging the resident to call for help and placing signage in the room. However, these measures were insufficient, as the resident continued to experience falls, culminating in a severe incident where the resident fell and sustained a subdural hematoma and other injuries. Interviews with staff and the resident's power of attorney revealed that the facility did not assess the resident's ability to use the recliner safely and did not have a policy for mechanical lift chairs. The facility's failure to assess the resident's ability to use the recliner and to implement effective interventions to prevent falls resulted in a significant injury to the resident.
Elopement Risk Management and Wander Guard System Failure
Penalty
Summary
The facility failed to ensure elopement door alarms were functioning, leading to a resident (Resident 3) leaving the facility without staff knowledge. Resident 3, who had diagnoses including ataxia, cerebral infarction, attention deficit, and chronic heart failure, was moderately cognitively impaired and required assistance with all activities of daily living. Despite not being identified as an elopement risk initially, Resident 3 exhibited increased confusion and agitation on 3/22/2024, prompting the placement of a Wander Guard bracelet. However, there was no documentation of an elopement assessment after the bracelet was placed. The Wander Guard system on the front door failed to alarm when Resident 3 exited the facility on 3/27/2024, resulting in Resident 3 being returned after tipping over in a wheelchair outside. The maintenance log indicated that the Wander Guard system was tested on 2/29/2024, with the next scheduled check on 3/31/2024. Interviews with staff revealed varying levels of awareness regarding residents at risk for elopement and the functioning of Wander Guard bracelets. The facility lacked a policy and procedure for wandering/behavior or elopement for at-risk residents, and nursing assessments, including elopement risk, were not being done quarterly as required. The deficiency was further highlighted by the lack of an elopement assessment for Resident 3 on 3/22/2024, as confirmed by the Director of Nursing and Clinical Consultant.
Failure to Ensure Bed Alarm Functionality for Resident at Risk of Falls
Penalty
Summary
The facility failed to ensure that interventions were in place as care planned for a resident with severe cognitive impairment and a history of falls. The resident, who was admitted with diagnoses including late-onset dementia and restlessness, was dependent on staff for all activities of daily living and transfers. The comprehensive care plan included the use of bed and chair alarms to prevent falls. However, during an incident, the bed alarm was found to be non-functional because it was not connected to the alarm box, despite staff education on the importance of ensuring alarms were properly set up. Observation revealed that the bed alarm cord was not plugged into the alarm box, rendering it ineffective. Interviews with staff confirmed that the bed alarm was an essential intervention for the resident and should have been connected. The Assistant Director of Nursing also confirmed that the bed alarm was a necessary intervention that was not properly implemented at the time of the observation. This failure to ensure the bed alarm was functional directly contributed to the resident's risk of falls and injury.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor Resident 4's bathing preferences, as documented in their undated Admission Record and confirmed by the resident's Minimum Data Set (MDS) and Brief Interview for Mental Status (BIMS) score of 15, indicating cognitive intactness. Despite Resident 4's stated preference for two baths per week, the facility's records show that the resident received baths on only a few occasions over a span of several months. Specifically, baths were documented on 12/5/23 and 12/29/23 in December, 1/3/23, 1/8/23, and 1/27/24 in January, and 2/5/24 in February, with significant gaps in between. The resident was hospitalized for short periods in December but was otherwise present in the facility without documented refusals or reasons for missed baths. The undated Preference Sheet printed on 2/1/24 confirmed the resident's preference for two baths a week, which was not met according to the records reviewed. The Comprehensive Care Plan (CCP) for Resident 4, revised on 10/27/23, included an intervention for showers/baths per schedule, which was not adhered to. The Director of Nursing (DON) confirmed in an interview that Resident 4 went 18 days in January and 9 days in February without a bath. The facility's policy dated December 2016, titled Care Plans, mandates that the Comprehensive Person-Centered Care Plan should include the resident's stated preferences, which was not followed in this case. This failure to provide the resident's preferred bathing schedule constitutes a deficiency in honoring resident self-determination and choice.
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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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