Emerald Nursing & Rehabilitation Mercy
Inspection history, citations, penalties and survey trends for this long-term care facility in Omaha, Nebraska.
- Location
- 7410 Mercy Road, Omaha, Nebraska 68124
- CMS Provider Number
- 285058
- Inspections on file
- 42
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Emerald Nursing & Rehabilitation Mercy during CMS and state inspections, most recent first.
Two residents at risk for falls and injury did not receive clearly defined or updated safety interventions. One resident with dementia, severe visual impairment, poor balance, and dependence on staff for transfers had documentation indicating the need for two-person assistance, but the Baseline Care Plan and bedside Kardex did not specify the required level of assist. Staff interviews revealed inconsistent practices, including a report of a single staff member performing transfers, and the resident was later found with a dislocated hip. Another resident with severe cognitive impairment, diabetes, impaired mobility, and poor safety insight had two falls in one morning, yet no fall investigation or new interventions were documented in the EHR or Comprehensive Care Plan after these events, despite existing fall-risk care plan entries and facility policy requiring investigation and follow-up.
A resident with type 2 DM, severe cognitive impairment, and extensive ADL needs experienced two falls resulting in transfer to the hospital and later sustained a 28% weight loss over 30 days. Facility policy required immediate notification of the resident representative and physician for accidents with potential need for physician intervention and for significant changes in condition, but documentation showed no notification to the representative regarding the falls, hospital transfer, or significant weight loss. The ADON confirmed that the representative had not been notified and that notification should have occurred.
A resident with a history of gastric bypass and decreased appetite experienced a large, unintended weight loss while the facility failed to implement effective nutritional interventions, accurately document meal intake, or carry out practitioner orders. Despite documented weight loss and an order for oral nutritional supplements, no new interventions were added to the care plan, and an order to resume bariatric vitamins was never entered or administered. During one observed breakfast, staff left a meal tray at the bedside while the resident slept, did not return to encourage or assist with eating, and later removed the tray after the resident accepted only a banana, without offering a substitute. The meal was then inaccurately charted as 75–100% consumed, which leadership acknowledged was incorrect and would impair the RD’s ability to assess nutritional status.
A resident with severe cognitive impairment, diabetic neuropathy, and near-constant pain had a care plan and multiple physician orders for pain control, including topical lidocaine products, diclofenac gel, pregabalin, and PRN acetaminophen. The ordered Aspercreme with 4% lidocaine for neuropathic foot pain was repeatedly documented as "on order" and remained unavailable, so it was not administered. During a medication pass, an LPN documented the resident’s pain as 10/10 and applied diclofenac to the knees but did not ensure the ordered lidocaine patches were on, did not provide non-pharmacological interventions, did not administer PRN acetaminophen, did not reassess the pain, and did not notify the practitioner. The lidocaine patches were applied several hours late and still scheduled to be removed at the usual time, and staff confirmed the resident had not received the ordered lidocaine cream to the feet that week because it was unavailable.
A resident with ESRD, diabetes, and glaucoma who received thrice-weekly off-site dialysis did not have dialysis details (location, days, times) incorporated into the care plan, and the facility repeatedly failed to administer multiple scheduled morning medications and treatments on dialysis days, including antihypertensives, anticoagulants, insulin, venlafaxine, gabapentin, glaucoma eye drops, a nutritional supplement, blood sugar checks, and wound care, documenting them as not given because the resident was out for dialysis. Following a hospital stay, a physician-ordered 1500 ml/day fluid restriction was not entered on the MAR, fluid intake was not monitored or documented, and the resident was unaware of the restriction, while the ADON acknowledged that medications and treatments should have been coordinated around dialysis and that the fluid limit had not been implemented.
A resident with bipolar disorder, anxiety disorder, severe cognitive impairment (BIMS score 6), and extensive ADL needs had a care plan identifying a positive Level II PASRR and an intervention to arrange mental health services, but no such services were actually arranged. The resident reported previously seeing a counselor before admission and not seeing any mental health practitioner since admission, and the SSD confirmed that no referral for mental health services had been made despite the care plan requirement.
A resident with ESRD, diabetes, glaucoma, and legal blindness, who was cognitively intact and received thrice-weekly off-site dialysis, did not receive multiple ordered medications on dialysis days, including anticoagulants, gabapentin, insulin glargine, and several glaucoma eye drops. MAR review showed these doses were omitted on several occasions because the resident was out of the facility for dialysis. The resident reported not receiving glaucoma drops on dialysis days, previously bringing brimonidine to dialysis for administration before treatment due to eye swelling and pain, and experiencing mild eye pain during a recent dialysis session. The ADON confirmed the resident had not received these medications on dialysis days and identified these as medication errors of omission that should have been scheduled around dialysis.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
A resident who was cognitively intact, required extensive assistance with ADLs, and was at risk for pressure ulcers was readmitted from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle. Despite the facility's policy requiring immediate notification of the physician for significant changes in condition, there were no treatment orders or documented treatments for these pressure ulcers in the transition orders, order summary, or treatment administration record. The WIN confirmed that the physician was not contacted to obtain necessary wound care orders, resulting in a failure to notify the provider of new pressure ulcers.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
A resident with a PICC line and orders for daily weights did not receive care consistent with facility policy and practitioner directives. The facility’s infusion therapy policy required arm circumference and weekly external catheter length measurements for PICC lines, but the resident’s orders lacked PICC cap change and external length measurement directives, which the WIN acknowledged should have been present. Additionally, despite an order to obtain daily weights and notify the provider of weekly gains over 3–5 lbs, staff recorded a large weight increase within one day and did not report it to the provider, as confirmed by the ADON.
Surveyors found that medications were not stored securely as required by facility policy and regulations. A container of Gavilyte-G solution labeled for a resident was left on a bathroom sink, and a clear plastic bag containing multiple medications, including furosemide, pantoprazole, carvedilol, Entresto, aspirin, and a Lantus insulin pen, was found on a dresser in another resident’s room. The second resident was cognitively intact per BIMS, required extensive assistance with ADLs, was at risk for pressure ulcers, and had two venous ulcers. An LPN and the Wound and Infection Nurse confirmed these medications should not have been stored in these unsecured locations and should have been kept locked.
A resident with multiple open wounds, a PICC line, and an active MRSA infection was not managed under the facility’s Enhanced Barrier Precautions (EBP) policy, which requires gown and glove use and door signage for residents with wounds, indwelling devices, or MDROs during high-contact care. Observations showed no EBP signage or gowns available at the room, and an LPN performed wound care using only gloves without a gown, later confirming that EBP should have been used but was not.
Staff did not use the prescribed wound dressing for a resident with stasis ulcers, substituting a different product without a physician order, and failed to complete required weekly skin assessments for another resident. The DON confirmed that wound care orders were not followed and that scheduled skin checks were missed or delayed, contrary to facility policy.
Two residents did not receive prescribed medications as ordered, including missed doses of insulin and antibiotics. One resident with diabetes and pneumonia did not receive evening doses of Cefdinir and Lantus insulin, resulting in elevated blood sugar and subsequent hospital admission for diabetic ketoacidosis. Another resident with diabetes and on dialysis missed multiple scheduled doses of sliding scale insulin, with documentation either indicating absence or left blank. The DON confirmed these were significant medication errors.
A resident with diabetes and on dialysis did not receive ordered sliding scale insulin on multiple occasions, with documentation showing missed or blank entries for the 5 PM dose. There was no evidence that the provider was notified of these missed doses, despite facility policy requiring such notification for medication errors. The DON confirmed the lack of documentation and acknowledged the missed insulin as a significant medication error.
Insulin was administered to three residents by LPNs using insulin pens that were not primed prior to injection, contrary to facility policy and standard practice. Interviews confirmed that staff did not prime the pens, and one LPN was unaware of the requirement. The facility's competency procedure requires priming insulin pens before use.
Staff failed to notify the physician when two residents developed or experienced worsening of pressure ulcers, despite facility policy requiring immediate communication of significant changes in condition. In both cases, the wound nurse confirmed that the physician was not informed as expected.
A resident with impaired mobility and a history of pressure ulcers did not receive appropriate evaluation, monitoring, or interventions for pressure ulcer prevention and wound care. The care plan lacked specific measures for pressure redistribution, and as the resident's wound worsened, no treatment orders or modifications to interventions were documented, resulting in an open, foul-smelling wound.
Two residents did not have dialysis care orders or required pre- and post-dialysis assessments documented, and their dialysis access sites were not assessed each shift as required. Additionally, a resident who missed a scheduled dialysis treatment did not have their physician notified, contrary to facility policy. Staff interviews confirmed the lack of orders, assessments, and notification, and also revealed a lack of dialysis-specific education for nursing staff.
Two residents who were cognitively intact and required varying levels of assistance with daily activities submitted grievances that were not investigated or resolved according to facility policy. Despite the facility's established grievance process, neither resident received a written response or resolution, and the DON confirmed that the required steps were not completed.
A resident who was readmitted after a small bowel obstruction did not have bowel movements monitored as required. The care plan noted bowel incontinence, but no toileting plan was attempted, and documentation of bowel movements was missing for several days. Staff interviews revealed there was no consistent process for tracking bowel movements, and the expected reporting between shifts did not occur.
Two cognitively intact residents with bladder incontinence were not evaluated for toileting programs, despite being able to feel the urge to void. Care plans included interventions for incontinence, but no trial toileting programs were attempted, and required documentation was incomplete or inaccurate. The DON confirmed the lack of evaluation and absence of a facility policy for toileting programs.
Staff did not consistently label or date food items in resident refrigerators and failed to discard expired or improperly stored foods as required by facility policy. Additionally, a dietary aide was observed working multiple times without a beard guard, contrary to hygiene protocols. One resident was noted as not eating facility-prepared food.
Surveyors found that staff failed to follow infection control protocols, including not performing hand hygiene between glove changes during toileting and wound care, and not using required gowns and signage for enhanced barrier precautions in multiple rooms. These lapses involved residents with significant care needs, including those with wounds, indwelling devices, and multidrug-resistant organism (MDRO) infections. Nursing and direct care staff were observed not adhering to facility policies and posted instructions, and leadership confirmed these practices did not meet expectations.
A resident developed a new trauma wound on the right great toe and received new treatment orders, but there was no documentation that the family was notified of these changes, despite facility policy and expectations confirmed by the DON.
The facility did not ensure that two residents received bathing assistance according to their preferences and needs, resulting in missed or undocumented baths, and failed to provide necessary eating assistance to a resident with severe cognitive impairment and physical limitations, as observed during a meal. The DON confirmed these lapses and documentation gaps, and facility policy required support for residents unable to perform ADLs.
A resident with severe cognitive impairment and multiple medical conditions was given a Covid-19 vaccine without a physician order or standing order, contrary to facility policy. Although informed consent was obtained from the healthcare POA, review of medical records confirmed the absence of the required order prior to vaccine administration, as verified by the DON.
A resident with multiple pressure ulcers did not receive wound care as ordered, as an LPN failed to apply the prescribed Adaptic dressing, set the wound vac at the correct pressure, or measure the wound during a dressing change, contrary to physician orders and facility policy.
A resident with lower extremity impairment and non-weight bearing status was left alone in the shower, leading to a fall when the shower chair slipped. The care plan required supervision and locking the chair brakes, but these interventions were not followed. Staff and therapy documentation confirmed the resident should not have been left unattended, and no safety measures were in place at the time.
The facility did not consistently review or act on pharmacy recommendations for medication regimen reviews for two residents with severe cognitive impairment, including repeated requests to discontinue or adjust medications and implement gradual dose reductions for antidepressants. Documentation and interviews confirmed that pharmacy recommendations were not followed up or addressed as required by facility policy.
The facility failed to perform neurological assessments after unwitnessed falls and head injuries for three residents. A resident with severe cognitive impairment fell and sustained a hematoma, but no neurological assessments were recorded. Another resident experienced multiple unwitnessed falls with incomplete assessments, and a third resident with dementia also had falls without proper assessments. The facility's policy required such assessments, but they were not completed.
The facility did not conduct competency evaluations for four nursing assistants hired between 2022 and 2024. This was confirmed by the IDON and could potentially affect all 101 residents.
A resident's medications were improperly managed when the facility failed to follow a medical provider's order to change the administration route from G-tube to oral. The medications were discontinued for two days instead of being continued as ordered, and one medication was delayed for five days. The DON confirmed the error, highlighting a deficiency in adhering to professional standards.
A resident with multiple health conditions was transferred to the hospital without notifying the physician, violating facility policy. The resident required significant assistance and had moderate cognitive impairment. Staff interviews revealed a lack of communication and awareness about the transfer, and the Director of Nursing confirmed the physician was not informed.
A resident with multiple health conditions was transferred to the hospital without proper documentation or communication. The facility did not document the transfer basis or provide a report to the receiving hospital, as required by policy. Interviews revealed the transfer was directed by the DON without a physician's order, and only a medication list was sent with the resident.
A resident with multiple health conditions was discharged to the hospital without the facility providing the required 30-day discharge notice. The facility's policy requires such notice to be given to the resident, their representative, and the Ombudsman, but this was not done, as confirmed by the facility administrator.
A resident with multiple health conditions and a history of falls did not have prescribed fall interventions implemented, such as nonskid strips, signage, and Dycem on the wheelchair. This oversight was confirmed by the ADON, despite the facility's policy requiring such measures to reduce fall risks.
A resident with multiple health conditions, including heart failure and diabetes, received an incorrect dosage of Lasix due to a medication error. Despite a physician's order to reduce the dosage to 40 mg daily, the resident was administered 120 mg daily. This error was confirmed by the DON and an LPN, highlighting a failure to adhere to the facility's medication error policy.
Failure to Implement and Communicate Fall-Prevention and Transfer Interventions
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision and appropriate interventions to prevent accidents. The facility’s own Accidents and Incidents policy states that when an accident occurs, a thorough investigation and follow-up will be completed within five working days to prevent recurrence. Despite this, surveyors found instances where interventions were not implemented or clearly communicated, and where falls were not investigated or followed by new interventions. For one resident with dementia, severe visual impairment, poor muscle control and balance, limited range of motion in all extremities, and dependence on two assistants for transfers, the facility did not clearly specify transfer assistance needs in the Baseline Care Plan or the visual/bedside Kardex. The After Visit summary indicated the resident required assistance with a gait belt, walker, and two people assisting, and the Nursing Admission Data Collection documented dependence on two assistants for transfers. However, the Baseline Care Plan only generally referenced assistance with ambulation, bed mobility, wheelchair mobility, and transfers without indicating the level of assistance, and the Kardex contained no instructions on how much assistance was required. Staff interviews showed inconsistent understanding of the resident’s transfer needs: one nursing assistant reported transferring the resident alone, while another stated they always used two staff and sometimes needed two to three staff. The DON later confirmed the resident was a maximum assist of two to three people for transfers and that the Kardex had not been completed to reflect this prior to the resident being found with a dislocated left hip. For another resident with severe cognitive impairment, diabetes mellitus type 2, weakness, impaired mobility, and dependence on staff for most ADLs and transfers, the Comprehensive Care Plan identified a risk for falls related to these conditions and psychotropic medications, with goals and interventions including PT/OT evaluation and routine visual rounding due to poor safety insight. However, progress notes documented that this resident experienced two falls in the same morning and was sent to the hospital for evaluation. Record review showed no fall evaluation dated for that day and no new interventions added to the Comprehensive Care Plan or elsewhere in the electronic health record following these falls. The ADON confirmed that the falls were not investigated and that new interventions were not implemented, contrary to the facility’s stated policy and expectations.
Failure to Notify Resident Representative of Falls, Hospital Transfer, and Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of significant changes in condition, contrary to its own "Notification of Changes" policy and state licensure requirements. The facility policy dated 01-2024 requires immediate notification of the resident and/or resident representative and the attending physician when there is a change in condition, an accident with potential need for physician intervention, a significant change in physical, mental, or psychosocial status, or a need to significantly alter treatment. The policy states that notification is required after accidents resulting in injury with potential for physician intervention, significant status changes, and significant treatment changes, in order to keep representatives informed of the resident’s current health status and support informed choices about care. Record review for one resident showed that the facility did not follow this policy. The resident, admitted with a diagnosis of type 2 diabetes mellitus, had a BIMS score of 6 indicating severe cognitive impairment and required substantial to total assistance with most ADLs. Progress notes dated 12-13-2025 documented that the resident experienced two falls at 6:15 AM and 7:20 AM and was sent to the hospital for evaluation, but there was no documentation that the resident’s representative was notified of either the falls or the hospital transfer. Dietary progress notes dated 03-11-2026 documented a 68-pound weight loss, representing a 28% loss in 30 days and identified as a significant weight loss, with no indication that the resident’s representative was notified of this change. In an interview, the ADON confirmed that the representative had not been notified of the falls, hospital transfer, or significant weight loss and acknowledged that notification should have occurred.
Failure to Ensure Adequate Nutrition and Accurate Monitoring After Bariatric Surgery
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutrition and accurate monitoring for a resident with a history of gastric bypass surgery and significant weight loss. The facility’s own Weight Monitoring policy required maintaining acceptable nutritional status, monitoring for significant weight changes, and using the interdisciplinary team and care plan to guide interventions. For this resident, the comprehensive care plan identified a nutritional problem related to prior gastric bypass and decreased appetite, with goals to maintain adequate nutrition and hydration through a regular diet, supplements per practitioner orders, and monitoring of weights and meal intakes. Record review showed that the resident’s weight dropped from 240 lbs to 188 lbs between early and late February, a loss of 52 lbs (21.6%), and a dietary note in early March documented a 58-lb weight loss. Despite this, the RD’s note stated the resident ate 50–100% of meals and had an order for an oral nutritional supplement three times daily but did not always take it, and no new interventions were initiated to address the ongoing significant weight loss. The care plan did not reflect additional nutritional interventions beyond the original measures. Later, the practitioner ordered bariatric vitamins to be resumed, but these orders were not entered on the order summary and were not administered, as confirmed by review of the MARs and by the ADON. Observations of a breakfast meal showed further failures in implementation and documentation. Staff delivered a full breakfast tray while the resident was in bed with eyes closed and left the tray at the bedside. Over the next period, staff did not return to encourage or assist with eating. When an LPN later entered for a treatment, the resident stated only wanting the banana; the LPN removed the tray without encouraging intake or offering a substitute. The LPN later confirmed the resident did not eat anything for breakfast and that no substitute was offered. However, the electronic health record documented that 75–100% of the breakfast was consumed, which the DON confirmed was inaccurate. The ADON confirmed that inaccurate meal intake documentation would prevent the RD from accurately assessing the resident’s nutritional status.
Failure to Ensure Availability and Timely Administration of Ordered Pain Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management for a resident with severe, ongoing pain, as required by its pain management policy and licensure regulations. The facility’s policy required systematic recognition, assessment, treatment, and monitoring of pain, including evaluation upon admission, at scheduled intervals, and with changes in condition, and directed staff to notify the practitioner if pain was not controlled. The resident involved had diabetes mellitus type 2, severe cognitive impairment (BIMS score of 6), required extensive to total assistance with most ADLs, and was assessed on the MDS as having pain almost constantly, with pain frequently affecting sleep and almost constantly interfering with therapy. The comprehensive care plan identified potential pain related to diabetic neuropathy in both feet and lower back pain, with goals for adequate pain relief and interventions including the resident’s ability to request help and medication, a preference for medication-based pain control, and use of non-pharmacological measures such as redirection, distraction, and repositioning. The resident’s physician orders included multiple pain interventions: topical Aspercreme with 4% lidocaine to the feet twice daily for neuropathic pain, diclofenac gel to each knee three times daily, a 4% lidocaine patch to the right thigh and back daily for 12 hours on and 12 hours off, pregabalin 150 mg twice daily, and acetaminophen 500 mg every 6 hours as needed for pain. Review of the Treatment Administration Record for April showed that the Aspercreme with lidocaine was not available and was not administered, and that the PRN acetaminophen had not been given at all that month. Progress notes documented repeated entries over several days that the Aspercreme with lidocaine was on order or awaiting delivery from the pharmacy, confirming it remained unavailable for use. Thus, a prescribed topical pain medication specifically ordered for neuropathic foot pain was not accessible or provided to the resident over multiple days. Surveyor observations and interviews further showed failures in timely administration and monitoring of other pain interventions. During a medication pass, an LPN asked the resident to rate their pain; the resident reported a pain level of 10 with throbbing pain. The LPN applied diclofenac cream to the knees, but there was no lidocaine patch on the right leg, and the resident reported that the lidocaine patches due that morning to the right thigh and back had not been applied. Later confirmation from staff showed the lidocaine patches were not applied until midday, and staff acknowledged that, despite the late application, the patch would still be removed at the originally scheduled time, resulting in the resident not receiving the full ordered 12-hour dose. The LPN also confirmed that, despite the resident’s pain level of 10, no non-pharmacological interventions were offered, no PRN acetaminophen was administered, no re-evaluation of the resident’s pain was performed, and the practitioner was not contacted. On a subsequent observation, the resident reported that while knee pain had improved to a 3 with diclofenac, foot pain remained at 10, and the resident stated they had not received the Aspercreme with lidocaine to the feet, which staff confirmed had not been given that week due to unavailability.
Failure to Coordinate Dialysis-Day Medications and Implement Fluid Restriction
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, coordinated dialysis-related care for a resident with end stage renal disease (ESRD). The facility had a written Special Needs–Dialysis Policy requiring assessment of dialysis needs on admission and quarterly, inclusion of dialysis details in the care plan, and coordination of medications and meals with dialysis. For this resident, the comprehensive care plan noted ESRD and dialysis but did not include the location of dialysis services, the days of the week, or the time of treatments, despite an order summary showing dialysis three times weekly at an outside dialysis center early in the morning. The resident’s MDS showed they were cognitively intact, legally blind, required varying levels of assistance with ADLs, and had diagnoses including ESRD, diabetes, and glaucoma. Review of the MARs revealed that on multiple dialysis days, numerous scheduled morning medications and treatments were not administered because the resident was out of the facility for dialysis. These omitted items included several antihypertensives, anticoagulants (Xarelto/Eliquis), insulin glargine, venlafaxine, gabapentin, ferrous sulfate, glaucoma eye drops, a nutritional supplement (Nepro), blood sugar checks, and ordered wound treatments to the abdominal fold and buttocks. The ADON confirmed that medications and treatments should have been scheduled around dialysis and not omitted. Additionally, after a hospitalization, the resident was discharged back to the facility with an order to limit fluids to 1500 ml per day. This fluid restriction order was not entered on the April MAR, and there was no documentation in the progress notes of fluid monitoring or of the fluid restriction being implemented. The resident reported not knowing about the 1500 ml fluid limit. The ADON confirmed that the 1500 ml per day fluid limit was not implemented, despite the hospital discharge order, and acknowledged it should have been in place.
Failure to Arrange Behavioral Health Services for Resident With Bipolar and Anxiety Disorders
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health care and medically-related social services as outlined in its own Mood and Behavior Policy and Procedure dated 01-2024. That policy requires that each resident receive behavioral health care and services and medically-related social services needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and care plan. Surveyors reviewed the record of one resident who had a positive Level II PASRR screen related to anxiety and bipolar disorder, with a care plan goal that the resident’s psychological needs would be met through the review date. The care plan intervention specified that mental health services were to be arranged. Record review showed that the resident had diagnoses of bipolar disorder and anxiety disorder, a BIMS score of 6 indicating severe cognitive impairment, and required substantial to total assistance with multiple ADLs, including dressing, bed mobility, toileting, bathing, and transfers. During interview, the resident reported previously seeing a counselor at another facility due to bipolar disorder and stated that no mental health practitioner had been seen since admission. In a separate interview, the Social Services Director confirmed that the resident had not been referred for mental health services and acknowledged that such a referral should have been made, demonstrating that the planned intervention to arrange mental health services was not implemented.
Medication Omissions on Dialysis Days for Resident With ESRD and Glaucoma
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from significant medication errors, specifically errors of omission on dialysis days. Record review showed that a cognitively intact resident with end stage renal disease, diabetes, glaucoma, and legal blindness, admitted earlier in the year, had standing orders for dialysis three times weekly at an off-site dialysis center. The resident’s Medication Administration Records for March and April 2026 documented that on multiple dialysis days, the resident did not receive ordered medications, including anticoagulants (Xarelto and later Eliquis), gabapentin, insulin glargine, and several glaucoma-related ophthalmic drops (atropine sulfate, brimonidine, dorzolamide/timolol, and prednisolone), with the reason noted as the resident being out of the facility for dialysis. During interview, the resident reported not receiving the ordered glaucoma eye drops on dialysis days and stated that in the past they had taken brimonidine eye drops to dialysis to be administered immediately before treatment because dialysis caused eye swelling and pain. The resident further reported experiencing mild eye pain during dialysis in the week of the survey. In a separate interview, the Assistant Director of Nursing confirmed that the resident had not received the ordered medications and eye drops on dialysis days and acknowledged that the medications should have been scheduled around dialysis, characterizing these as medication errors of omission.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
Failure to Notify Physician and Obtain Orders for New Pressure Ulcers
Penalty
Summary
The facility failed to follow its "Notification of Changes" policy and licensure requirements by not notifying the attending physician of new pressure ulcers for one resident. The policy, dated 01-2024, requires that changes in a resident's condition, including significant changes and conditions that may require physician intervention, be immediately reported to the resident, resident representative, and the attending physician or delegate. This includes new or altered skin conditions such as pressure ulcers. Surveyors reviewed the policy and determined that it obligated staff to promptly communicate such changes to ensure appropriate care decisions. Record review for one resident showed that the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had existing venous ulcers. After a hospital stay, the resident was readmitted with documented unmeasured pressure ulcers to the right outer ankle, right lateral foot, and right 5th toe, and the hospital transition documentation further identified unstageable pressure ulcers to the right lateral ankle, right lateral foot, right lateral 5th toe, and right heel, along with other wounds. However, there were no corresponding treatment orders for these right foot and ankle pressure ulcers in the transition orders, the order summary, or the treatment administration record for March. In an interview, the Wound and Infection Nurse confirmed that the resident did not have treatment orders for these pressure ulcers and acknowledged that the facility should have called the physician to obtain orders, demonstrating that the provider was not notified of the new pressure ulcers as required.
Failure to Revise Care Plan After Amputation, MRSA Infection, and New Pressure Ulcers
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect significant changes in condition, including a new left below-the-knee amputation (BKA), MRSA infection, IV antibiotic therapy, and multiple pressure ulcers. Facility policy required that high-risk areas such as skin/wounds be care-planned immediately upon identifying risk, and that the interdisciplinary team review the plan of care quarterly, annually, with significant change, and when desired outcomes were not met. The resident’s MDS dated 01-04-2026 showed the resident was cognitively intact with a BIMS score of 13, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had two venous ulcers. Record review showed the resident was hospitalized and, upon return, transition orders dated 03-04-2026 documented a left BKA, a PICC line for IV antibiotics to treat a MRSA infection, two open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. However, the comprehensive care plan dated 03-17-2026 did not include the left BKA, the MRSA infection, or the use of IV antibiotics. During interview, the MDS Coordinator confirmed that the care plan had not been revised to include care and services for the resistant infection, IV medications, the new BKA site, and the pressure ulcers on the right foot and ankle, and acknowledged that it should have been updated.
Failure to Monitor PICC Line Care and Significant Weight Gain per Practitioner Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow its infusion therapy policy and practitioner orders for a resident with a PICC line and daily weight monitoring. The facility’s policy for infusion therapy required that for a PICC line, the patient’s upper arm circumference be measured on insertion, on admission, and when clinically indicated, and that the external catheter length be measured on admission and weekly to monitor for outward migration. Record review for one resident showed an order for a PICC line dressing change every seven days while on IV antibiotics, but there were no corresponding orders to change the PICC line caps or to measure the external catheter length. The Wound and Infection Nurse confirmed that the resident did not have orders for PICC line cap changes or weekly external length measurements and that such orders should have been in place. The deficiency also includes the facility’s failure to monitor and evaluate significant weight changes according to practitioner orders. The resident’s MDS indicated the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had two venous ulcers. The practitioner’s order required daily weights and notification of the provider if the resident gained more than 3 to 5 pounds in a week. The EHR showed the resident’s weight increased from 133.9 lbs on one day to 152 lbs the next day, an 18.1 lb gain. The ADON confirmed that staff did not monitor this weight change and did not notify the provider of the significant weight gain, despite the existing order to do so.
Medications Left Unsecured in Resident Rooms
Penalty
Summary
The facility failed to ensure medications were stored safely and securely in accordance with its policy and regulatory requirements. The facility’s policy on centralized medication storage, revised 8/2024, stated that medications are to be stored safely, securely, and properly, accessible only to authorized personnel. During an observation on 3/17/26 at 8:14 AM, surveyors found a container of Gavilyte-G solution, labeled by the pharmacy for Resident 3, sitting on the bathroom sink in Resident 3’s bathroom with approximately one inch of solution remaining. In an interview on 3/16/26 at 10:47 AM, the Wound and Infection Nurse confirmed that the Gavilyte-G container should not have been stored on the resident’s bathroom sink. The facility also failed to secure multiple medications in the room of Resident 2. Resident 2’s MDS dated 01-04-2026 showed the resident was admitted on a prior date, had a BIMS score of 13 indicating cognitive intactness, required extensive assistance with toileting, bathing, dressing, hygiene, bed mobility, and transfers, was at risk of developing a pressure ulcer, and had two venous ulcers. On 03-16-2026, an observation revealed a clear plastic bag containing medications, including furosemide, pantoprazole, carvedilol, Entresto, aspirin, and a Lantus insulin pen, sitting on the dresser in Resident 2’s room. In an interview on the same date, LPN D confirmed that these medications were on the dresser and acknowledged that medications are supposed to be kept locked up.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its own Enhanced Barrier Precautions (EBP) policy during care of a resident with multiple wounds, an indwelling device, and an active MDRO infection. The facility’s EBP policy dated 01-2024 states that residents with wounds or indwelling medical devices, regardless of MDRO status, and residents known to be infected or colonized with an MDRO, are to be placed on EBP with signage on the door and targeted gown and glove use during high-contact activities, including wound care. EBP is required for activities such as dressing, bathing, hygiene, changing linens and briefs, toileting assistance, device care, and any wound care requiring a dressing. Record review showed that the resident was cognitively intact, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had multiple wounds including venous ulcers, open wounds on both buttocks, a left BKA incision, several unstageable pressure ulcers on the right lower extremity, a PICC line in the right upper arm, and an active MRSA infection. Observations on separate days revealed there was no EBP signage on the resident’s door and no gowns available inside or outside the room. During observed wound care, an LPN used gloves but did not wear a gown, and later confirmed that EBP had not been utilized and should have been during the wound care encounter.
Failure to Follow Wound Care Orders and Complete Weekly Skin Assessments
Penalty
Summary
Facility staff failed to follow prescribed wound care orders for one resident with right lower extremity stasis ulcers. The treatment administration record specified cleansing the wound with Vashe-moistened gauze, applying a dime-thick layer of triad paste, and covering with Exufiber AG dressing, ABD pads, and kerlix, with no tape on the skin. However, during an observation, a registered nurse used a calcium alginate AG dressing instead of the ordered Exufiber AG. The nurse stated that the two dressings were the same, but the facility did not have an order for an equivalent dressing until after the discrepancy was identified. The Director of Nursing confirmed that Exufiber AG was not being used as ordered and that an alternative was not ordered until after the issue was discovered. Additionally, the facility failed to conduct weekly skin evaluations as required for another resident. Review of records showed that weekly skin and wound observations were missed or conducted late, with one scheduled assessment not completed and another performed several days late. The Director of Nursing confirmed that weekly skin and wound observations are to be completed for all residents, regardless of the presence of pressure ulcers, and acknowledged the missed assessments. Facility policy requires comprehensive skin assessments on admission, with each risk assessment, as indicated, and prior to discharge.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered in accordance with physician orders for two residents. One resident, admitted with pneumonia and type 1 diabetes mellitus with diabetic polyneuropathy, did not receive scheduled doses of Cefdinir (an antibiotic) and Lantus insulin on the evening of 7/18/25. The resident's blood sugar was subsequently found to be significantly elevated, and the resident was later admitted to the hospital with diabetic ketoacidosis. The DON confirmed that both medications were available and that not administering them constituted a significant medication error. Another resident, admitted with diabetes mellitus and dependence on renal dialysis, had physician orders for sliding scale insulin to be administered three times daily. Review of the medication administration record revealed multiple instances where the 5 PM dose of sliding scale insulin was not provided, either marked as the resident being out of the facility for dialysis or left blank with no documentation. The DON confirmed that the expectation was for blood sugar to be checked and insulin administered after the resident returned from dialysis, and that failure to do so was a significant medication error.
Failure to Notify Physician of Missed Sliding Scale Insulin Administration
Penalty
Summary
The facility failed to ensure that a resident's physician was notified when sliding scale insulin was not administered as ordered. The resident, who had a diagnosis of diabetes mellitus and was dependent on renal dialysis, had physician orders for sliding scale insulin to be given three times daily based on specific blood glucose ranges. Review of the Medication Administration Record (MAR) for the month showed multiple instances where the 5 PM dose of sliding scale insulin was not provided, either due to the resident being out of the facility or with no documentation explaining the omission. On several dates, the MAR was left blank, and there was no evidence that the physician was informed of these missed doses. Further review of the resident's progress notes for the same period did not reveal any documentation that the provider had been notified about the missed insulin administrations. Interviews with the Director of Nursing (DON) confirmed that the expectation was for the resident's blood sugar to be checked and insulin administered after returning from dialysis, and that not administering the insulin constituted a significant medication error. The DON also confirmed that documentation of provider notification could not be located. Facility policy required that the attending physician and responsible party be notified of medication errors, but this was not followed in this case.
Failure to Prime Insulin Pens Prior to Administration
Penalty
Summary
The facility failed to ensure that insulin was administered in accordance with professional standards of practice for three residents. For each of these residents, licensed nursing staff administered insulin using insulin pens without priming the pens prior to injection. Specifically, one resident had an order for Lispro insulin to be given three times daily with meals, and the LPN administered the insulin without priming the pen. Another resident, with an order for Novolog insulin per sliding scale, also received insulin from an unprimed pen. A third resident, ordered Admelog insulin per sliding scale, was similarly administered insulin without the pen being primed. Interviews with the LPNs involved confirmed that the insulin pens were not primed before administration, and one LPN incorrectly believed that only insulin syringes required priming. The facility's own competency procedure for insulin administration specifies that insulin pens must be primed with 2 units and the dose wasted to verify proper functioning. The RN Nurse Consultant confirmed that priming insulin pens is a standard of practice. These actions resulted in the facility not meeting professional standards of quality for medication administration.
Failure to Notify Physician of Resident Condition Changes
Penalty
Summary
Facility staff failed to notify the attending physician of significant changes in condition for two residents. For one resident, who was cognitively intact and required extensive assistance with activities of daily living, staff identified a deep tissue injury on the right heel that progressed to an open wound with green/yellow discharge and foul odor. There was no documentation in the electronic health record that the physician was informed of this change in the wound's condition. The wound nurse confirmed that the physician should have been notified when the wound worsened. For another resident with moderate cognitive impairment and total dependence for care, staff identified a new stage 1 pressure ulcer on the coccyx. The electronic health record did not show that the physician was notified of this new wound. The wound nurse confirmed that the physician was not updated and acknowledged that the expectation is to contact the physician for new wounds. Facility policy requires immediate notification of the physician for significant changes in a resident's condition or the need to alter treatment.
Failure to Implement and Monitor Pressure Ulcer Prevention and Care
Penalty
Summary
Facility staff failed to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and wound care for a resident who was at risk and had a history of pressure ulcers. The resident, who was cognitively intact and required extensive assistance with bathing and dressing, was admitted with a stage 2 pressure ulcer on the right heel. The care plan identified risk factors such as impaired mobility, edema, fragile skin, diabetes, and lymphedema, but did not include specific interventions for pressure redistribution or pressure ulcer prevention. Despite the resident's ongoing risk and the presence of an unhealed pressure ulcer, the care plan lacked measures to prevent further skin breakdown. Subsequent documentation showed the development of a new pressure ulcer and a deep tissue injury on the right heel, with the wound worsening over time and becoming open, weeping, and foul-smelling. There were no physician orders or documented treatments for the pressure ulcer, and the wound nurse confirmed that interventions were not reviewed or modified as the wound deteriorated. Observations confirmed the presence of a significant wound with a foul odor, and facility policy requiring ongoing evaluation and intervention for pressure injury risk was not followed.
Failure to Provide Required Dialysis Assessments and Physician Notification
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for residents requiring such treatment. Specifically, two residents who required dialysis did not have any dialysis care orders in their medical charts, and there was no documentation or evidence that pre- and post-dialysis assessments were performed for these residents. Additionally, the dialysis access sites for these residents were not assessed on each shift as required by facility policy. Interviews with nursing staff and the Director of Nursing confirmed the absence of these orders and assessments, and staff reported that they were only aware of residents' dialysis schedules through a daily sheet, not through formal orders or protocols. Staff also indicated they had not received education specific to dialysis care prior to working at the facility. For another resident, the facility failed to notify the physician when the resident missed a scheduled dialysis treatment. The resident had a diagnosis of dependence on renal dialysis due to end-stage chronic kidney disease and was scheduled for dialysis, but did not attend the appointment. There was no evidence in the medical chart that the provider had been notified of the missed treatment, as required by facility policy. Interviews with staff and the Director of Nursing confirmed that the provider was not notified and that there was no documentation of such notification in the resident's chart. Facility policies reviewed indicated that medical conditions, including those requiring dialysis, should be monitored and managed to prevent complications, with specific requirements for assessment and documentation. However, the lack of dialysis care orders, failure to perform required assessments, and failure to notify the physician of a missed dialysis session demonstrate noncompliance with these policies and regulatory requirements.
Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to investigate and resolve grievances for two of three sampled residents, as required by its grievance policy. Resident 5, who was cognitively intact and required significant assistance with daily activities, submitted a grievance that was logged by the Social Service Director (SSD). Although the SSD communicated that the grievance was being addressed by relevant department heads, no investigation or resolution was completed, and the resident did not receive a written response as outlined in the facility's policy. The Director of Nursing (DON) confirmed that the process was not completed for this grievance. Similarly, Resident 6, also cognitively intact and requiring moderate to limited assistance with daily care, submitted a grievance that was recorded in the facility's grievance log. However, the resident reported not receiving a resolution, and the DON confirmed that no investigation or resolution was completed for this grievance either. The facility's grievance process, as described by the SSD, was not followed, resulting in unresolved grievances for both residents.
Failure to Monitor Bowel Movements After Hospitalization for Bowel Obstruction
Penalty
Summary
Facility staff failed to monitor bowel movements for a resident who had recently been hospitalized for a small bowel obstruction. The resident required total assistance with toileting and was always incontinent of bowel and bladder. Despite this, there was no documentation addressing the small bowel obstruction, abdominal assessments, or bowel movements in the resident's progress notes for an extended period following readmission. The resident's care plan identified bowel incontinence related to immobility, but a trial toileting plan was not attempted, and there were multiple consecutive days without a recorded bowel movement. Interviews with staff, including the DON, RN, and LPNs, revealed that the facility did not have a consistent process for monitoring bowel movements. The night shift was supposed to generate a report of residents who had not had a bowel movement in three days and provide it to the day shift, but this process was not followed. Staff confirmed that such reports were not provided, and the DON acknowledged that bowel movements should have been monitored for the resident after hospitalization for bowel obstruction.
Failure to Implement and Evaluate Toileting Programs for Cognitively Intact Residents
Penalty
Summary
The facility failed to implement and evaluate toileting programs for two residents who were incontinent of bladder, despite both being cognitively intact and able to feel the urge to void. For one resident, records showed new onset bladder incontinence following a femur fracture and impaired mobility. Although the care plan included interventions such as establishing voiding patterns and changing briefs as needed, there was no evidence that a trial toileting program was attempted. The 72-hour toileting log was found to be inaccurate, and the DON confirmed that the resident was not evaluated for a toileting program. For the second resident, who had impaired mobility, prostate enlargement, and end stage renal disease, the care plan also aimed to keep the resident clean and dry with interventions like waking at night to void and regular brief changes. However, no rationale was provided for not attempting a toileting program, and the 72-hour toileting log was incomplete. Interviews revealed that the resident could feel the urge to void and had recently improved mobility, but was still not evaluated for a toileting plan. The DON confirmed the lack of a completed toileting log and the absence of a facility policy for toileting programs.
Failure to Label, Date, and Properly Store Food; Staff Non-Compliance with Hygiene Policy
Penalty
Summary
Facility staff failed to properly label and date food items stored in resident refrigerators and did not dispose of food in accordance with facility policy. Multiple observations revealed unlabeled and undated food items, including bottles of sauces, jars of condiments, and containers of perishable foods, some of which were past their expiration or open dates. The Dietary Director confirmed that these items should have been labeled, dated, and discarded after the appropriate time frame as outlined in facility policy. Additionally, the facility's policy requires regular checks of resident refrigerators for proper food storage and disposal, which was not consistently followed. Further observations showed that a dietary aide was working in the kitchen on several occasions without wearing a required beard guard, in violation of the facility's hygiene and sanitation policy. The Dietary Director acknowledged that beard guards are mandatory for staff with facial hair to prevent contamination. The report also noted that one resident did not consume food prepared by the facility, as indicated in the diet roster.
Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection prevention and control program, specifically related to hand hygiene and the implementation of enhanced barrier precautions (EBP). In one instance, a nursing assistant failed to perform hand hygiene between glove changes while providing toileting care to a resident with severe cognitive impairment and significant physical limitations. The nursing assistant removed soiled gloves, did not perform hand hygiene, donned new gloves, and continued care, which was confirmed by interview as not following proper protocol. Another deficiency was observed during wound care for a resident with cellulitis and a methicillin-resistant Staphylococcus aureus (MRSA) infection. The registered nurse performed wound care without donning a gown, despite the resident being on EBP as indicated by physician orders and signage in the room. The nurse only wore gloves, contrary to the posted instructions requiring both gown and gloves for high-contact care activities. The director of nursing confirmed that the nurse should have worn a gown in addition to gloves. Further observations revealed that 23 resident rooms, housing 25 residents identified as needing EBP due to high-risk care needs, lacked the required personal protective equipment (gowns) and signage indicating EBP status. Staff were observed providing personal hygiene care to residents in these rooms without wearing gowns, and interviews confirmed that gowns were not used as required. Additionally, during wound care for another resident with pressure ulcers, a licensed practical nurse failed to perform hand hygiene between glove changes, despite handling multiple wound sites and changing gloves during the procedure. The assistant director of nursing confirmed that hand hygiene should have been performed between glove changes.
Failure to Notify Family of New Wound and Treatment
Penalty
Summary
The facility failed to notify the family member of a resident regarding the development of a new trauma wound and the initiation of new treatment orders. Record review showed that the resident had an existing wound on the left toes with a wound vac in place, and subsequently developed a new trauma wound on the right great toe, for which treatment with betadine was ordered. Despite facility policy requiring notification of the responsible party or family member for changes in condition, there was no documentation in the resident's medical record or progress notes indicating that the family was informed of the new wound or treatment. The DON confirmed that the expectation is to notify the family of such changes, and the facility was unable to provide additional documentation of notification at the time of survey exit.
Failure to Provide Assistance with ADLs and Bathing per Resident Preferences
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living (ADLs) in accordance with resident preferences and needs for multiple residents. One resident with acute respiratory failure and moderate cognitive impairment was dependent on staff for bathing and preferred two showers per week. Documentation showed that after a bath refusal, there were no further baths or refusals documented for over two weeks, and the resident was not included on the new floor's bath schedule. The Director of Nursing confirmed the resident was omitted from the schedule and that the electronic medical record system was not updated to prompt staff for bathing. Another resident with cellulitis and MRSA infection, who was cognitively intact and required setup or clean-up assistance with bathing, was scheduled for twice-weekly baths. However, documentation revealed that the resident received significantly fewer baths than scheduled over a three-month period, with several missed baths not documented as refusals. Observations noted the resident's hair was oily and unkempt, and the DON was unable to locate additional documentation of bathing during this period. A third resident with severe cognitive impairment and range of motion limitations required supervision and substantial assistance with eating. Observations during a meal showed the resident struggled to eat independently, spilling food and using fingers to eat, without being offered assistance. The resident consumed only about 30% of the meal before being removed from the dining room. The DON confirmed the resident required supervision and assistance with meals, and facility policy stated that residents unable to perform ADLs should receive necessary services to maintain nutrition, grooming, and hygiene.
Covid-19 Vaccine Administered Without Physician Order
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple complex medical diagnoses, including anoxic brain damage, cardiac arrest, and cerebral infarction, was administered a Covid-19 vaccine without a physician's order or standing order in place. Facility policy required that certain vaccines, such as influenza and pneumococcal, could be given under physician-approved standing orders, but all other vaccines, including the Covid-19 vaccine, required a separate written physician order to be documented in the resident's medical record. Review of the resident's records confirmed that no such order or standing order was present for the Covid-19 vaccination. The resident's healthcare power of attorney had provided informed consent for the Covid-19 vaccine, and documentation showed the vaccine was administered. However, subsequent review of the resident's physician order summary and order recap report revealed no documentation of an order for the Covid-19 vaccine. The Director of Nursing confirmed that an order or standing order should have been obtained prior to administration, as per facility policy and regulatory requirements.
Failure to Follow Pressure Ulcer Treatment Orders and Assessment Protocols
Penalty
Summary
A deficiency occurred when a resident with multiple pressure ulcers, including a stage 1 and two unstageable ulcers present upon admission, did not receive wound care as ordered. The resident was dependent on staff for mobility and hygiene and was cognitively intact. The care plan specified the use of a wound vac to the right buttock, with dressing changes every three days, application of Adaptic to the wound base, black foam covering, and a wound vac setting of 125 mmHg. During an observed dressing change, the LPN placed only the black foam into the wound bed, omitting the Adaptic dressing as ordered. The wound vac was set at 120 mmHg instead of the prescribed 125 mmHg, and no wound measurements were taken. The LPN confirmed these deviations from the physician's orders and the facility's wound management policy, which requires full assessment and documentation of pressure sores, including measurements.
Resident Left Unsupervised in Shower Resulting in Fall
Penalty
Summary
A deficiency occurred when a resident with a history of lower extremity impairment, non-weight bearing status, and multiple psychiatric diagnoses was left unsupervised in the shower room, resulting in a fall. The resident, who was cognitively intact and required supervision or assistance when standing, attempted to sit back down on a shower chair after completing personal hygiene. The chair slipped out from underneath, causing the resident to fall. The resident reported being alone at the time, and staff later indicated that the brakes on the shower chair were either not locked or broken. Documentation confirmed that no safety measures were in use at the time of the fall, and the resident was not wearing footwear. Further review revealed that the resident's care plan identified a risk for falls and included interventions such as locking the brakes on the shower chair and staff conducting routine visual rounding. However, these interventions were not implemented during the incident. Observations of the shower chair showed warning labels indicating that the product should always be used with assistance and that it is not safe to leave a person unattended. Interviews with facility staff, including the Director of Rehabilitation and the Director of Nursing, confirmed that the resident should not have been left alone in the shower, and that the fall occurred while the resident was unsupervised.
Failure to Address Pharmacy Recommendations for Medication Regimen Review
Penalty
Summary
The facility failed to ensure that pharmacy recommendations regarding medication regimen reviews (MRR) were consistently reviewed and acted upon for two residents with severe cognitive impairment. For one resident with diagnoses including major depressive disorder, generalized anxiety disorder, and Parkinson's disease, multiple pharmacy recommendations to discontinue mirtazapine, add stop dates for lorazepam, and address discrepancies with tramadol orders were either not responded to or not implemented over several months. The facility's own policy required timely responses to such recommendations, but documentation showed repeated lack of follow-up or rationale for declining recommendations. Additionally, for another resident with major depressive disorder and anxiety disorder, who was dependent on staff for most activities of daily living, pharmacy requests for gradual dose reduction (GDR) of antidepressant medications such as duloxetine and sertraline were not addressed over an extended period. Despite multiple requests and identification of duplicate antidepressant therapy, there was no documented response or action taken by the facility or physician. Interviews with the Director of Nursing confirmed that pharmacy recommendations for GDR were not followed up for this resident. These deficiencies were identified through record reviews and staff interviews, which revealed a pattern of inaction regarding pharmacy recommendations for medication management. The issues affected two of five residents reviewed for unnecessary medications, indicating a failure to comply with established policies and regulatory requirements for medication regimen review and follow-up.
Failure to Conduct Neurological Assessments After Falls
Penalty
Summary
The facility failed to conduct necessary neurological assessments following unwitnessed falls and falls with head injuries for three residents. Resident 2, who had severe cognitive impairment and required total assistance with daily activities, fell out of bed and sustained a hematoma on the forehead. Despite the initiation of neurological assessments, no records of these assessments were found in the resident's electronic health record. Interviews with staff confirmed that neurological assessments were not performed, and the resident later exhibited confusion and was sent to the hospital. Resident 1, who was cognitively intact but required extensive assistance, experienced multiple unwitnessed falls over a period of time. The facility's records showed incomplete or missing neurological assessments for these incidents. Similarly, Resident 4, who had dementia and required extensive assistance, had unwitnessed falls with incomplete or missing neurological assessments. The facility's policy required neurological assessments following unwitnessed falls or head injuries, but these were not completed as confirmed by the Interim Director of Nursing.
Lack of Competency Evaluations for Nursing Assistants
Penalty
Summary
The facility failed to ensure that competency evaluations were conducted for four nursing assistants, identified as NA C, D, E, and F. These nursing assistants were hired on various dates, with NA C hired in 2022 and the others in 2024. A review of the facility's records revealed that there were no competency evaluations available for these staff members. This deficiency was confirmed during an interview with the Interim Director of Nursing (IDON), who acknowledged that the evaluations had not been completed. The lack of competency evaluations for these nursing assistants had the potential to affect all residents in the facility, which had a census of 101 at the time of the survey.
Failure to Follow Medical Provider's Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to the medical provider's orders for a resident, identified as Resident 2, which resulted in a deficiency. Upon admission, Resident 2 was prescribed medications to be administered through a G-tube. However, on a later date, the medical practitioner changed the route of administration from G-tube to oral. Despite this change, the facility discontinued the medications for two days before restarting them, which was not in accordance with the medical provider's instructions. The medications involved included Pantoprazole, Amiodarone, Atorvastatin, Famotidine, Gabapentin, Hydrochlorot, Losartan Potassium, Metoprolol Tartrate, Oxcarbazepine, and Tab-A-Vite. Additionally, the medication Levetiracetam was not restarted until five days after the change in administration route. The Director of Nursing confirmed that the order was to change the route of administration, not to discontinue the medications, indicating a failure in following the medical practitioner's orders.
Failure to Notify Physician Before Resident Transfer
Penalty
Summary
The facility failed to notify the resident's physician prior to transferring a resident to the hospital, which is a violation of the facility's policy on Notification of Changes. The resident, who had a diagnosis of Acute Cystitis, Dementia, Bipolar Disorder, Chronic Obstructive Pulmonary Disease, and a Multi Drug Resistant Organism, was transferred to the hospital without the attending physician being informed. The resident's Minimum Data Set indicated moderate cognitive impairment and required significant assistance with daily activities. The transfer occurred without proper documentation of the hospital destination, the reason for the transfer, or any communication with the receiving hospital's emergency department. Interviews with facility staff revealed a lack of awareness and communication regarding the transfer. LPN B was unaware of the need for the transfer and was instructed to transport the resident without additional information beyond a medication list. The facility van driver confirmed the transport to the hospital emergency department. The Director of Nursing confirmed that the physician had not been updated prior to the transfer, which is contrary to the facility's policy requiring notification of changes in a resident's condition or treatment.
Failure to Document and Communicate Resident Transfer
Penalty
Summary
The facility failed to document the basis for the transfer of a resident to the hospital and did not provide a report to the receiving provider. The resident, who had a diagnosis of acute cystitis, dementia, bipolar disorder, chronic obstructive pulmonary disease, and a multi-drug resistant organism, was transferred to the hospital without proper documentation or communication. The Minimum Data Set indicated the resident had moderate cognitive impairment and required assistance with various activities of daily living. The facility's records showed the resident was admitted from the hospital and discharged back to the hospital within a few days, but the nursing progress notes did not specify the hospital, the reason for the transfer, or whether a report was given to the receiving hospital. Interviews with facility staff revealed that the transfer was directed by the Director of Nursing, but no physician's order was documented, and only a medication list was sent with the resident. The facility's policy required documentation of the transfer basis and communication of specific information to the receiving healthcare institution, including contact information for the resident's practitioner and representative, advance directive information, and comprehensive care plan goals. The Director of Nursing confirmed the absence of necessary documentation and communication in the resident's medical record.
Failure to Provide 30-Day Discharge Notice
Penalty
Summary
The facility failed to provide a 30-day discharge notice for a resident who was discharged to the hospital. The resident, who had a diagnosis of acute cystitis, multi-drug resistant organism, dementia, bipolar disorder, and chronic obstructive pulmonary disease, was admitted to the facility from the hospital and discharged back to the hospital within a span of three days. The Minimum Data Set (MDS) indicated that the resident had moderate cognitive impairment and required varying levels of assistance from the staff for daily activities. The facility's policy mandates that a discharge notice must be issued at least 30 days before a resident is transferred or discharged, and a copy of this notice should be sent to the resident's representative and the Office of the State Long Term Care Ombudsman. However, a review of the resident's nursing progress notes and an interview with the facility administrator confirmed that no such notice was provided. This oversight was identified during a survey, highlighting a deficiency in the facility's adherence to its discharge policy.
Failure to Implement Fall Interventions
Penalty
Summary
The facility failed to implement fall interventions for a resident, leading to a deficiency in ensuring a safe environment free from accident hazards. The resident, who had a history of intervertebral disc degeneration, ataxia, anemia, osteoarthritis, hypertension, and peripheral vascular disease, was assessed to be at risk for falls. Despite this, the facility did not adhere to the care plan interventions designed to mitigate fall risks. These interventions included the application of nonskid strips next to the bed, the placement of a 'call before you fall' sign in the room and bathroom, and the use of Dycem on the wheelchair seat. During an observation, it was noted that these interventions were not in place, as confirmed by the Assistant Director of Nursing. The resident had experienced falls with injury on two occasions prior to the observation. The facility's policy on Falls Management, which emphasizes the implementation of appropriate interventions to reduce fall risks, was not followed, resulting in the deficiency.
Significant Medication Error in Resident's Lasix Dosage
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Resident 6, who had a history of heart failure, peripheral vascular disease, right below the knee amputation, renal insufficiency, and diabetes mellitus, was involved in this incident. The resident had a Brief Interview of Mental Status (BIMS) score of 8, indicating moderate cognitive impairment, and required varying levels of assistance from staff for daily activities. During an interview, the resident expressed uncertainty about receiving the correct medications following a recent medical appointment. The deficiency occurred when the resident was administered an incorrect dosage of Lasix, a medication used to treat fluid retention. Despite a physician's order to reduce the dosage to 40 mg once daily, the resident received 120 mg daily from July 19, 2024, due to an error by the medication aid. This error was confirmed by the Director of Nursing and an LPN during interviews. The facility's policy on medication errors, revised in January 2024, defines a medication error as any preparation or administration of medications not in accordance with the prescriber's order, manufacturer's specifications, or accepted professional standards.
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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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