Hemingford Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hemingford, Nebraska.
- Location
- 605 Donald Avenue, Hemingford, Nebraska 69348
- CMS Provider Number
- 285306
- Inspections on file
- 17
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Hemingford Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility’s lobby survey-results binder was not updated with the most recent survey findings or the related plan of correction, containing only older survey results and no complaint citations from the latest cycle. Record review confirmed the absence of the most recent survey, and the administrator acknowledged that the required documents were missing from the survey book.
The facility failed to report an allegation of neglect to the State Agency within the required 2-hour timeframe after a family member alleged that the facility caused a resident’s death through medical neglect. An LPN assessed the resident and found no heartbeat, while the resident’s advance directive and current orders still indicated CPR, and a hospice consult had been ordered but not yet completed. The administrator was informed of the situation, spoke with local law enforcement about the family member’s accusations, but did not notify the State Agency until the following day, which was confirmed by the administrator as not meeting the required reporting timeframe.
A resident with a history of TBI, hemiplegia, and bipolar disorder repeatedly complained that a specific CNA was slow to respond, rude, and problematic during cares. Grievance forms documented that the resident requested the CNA not provide care, agreed to 2-hour rounding in pairs, and that cares in pairs would be implemented for night cares, with the form indicating the care plan was updated. However, review of the Comprehensive Care Plan showed no revisions since the prior year and no interventions reflecting paired staffing or altered care approaches related to these grievances. The ADM acknowledged the CCP was not revised, treated the issue as a personnel matter rather than a care-planning issue, and progress notes contained no documentation of the staffing changes, while the resident reported that the CNA continued to enter the room and that grievances did not result in effective changes.
A resident with significant neurological and musculoskeletal conditions, including hemiplegia, epilepsy, spina bifida occulta, muscle spasms, and contractures, had an order for Percocet 5-325 mg every four hours for pain, with care plan goals to maintain acceptable pain control. Over multiple days, staff documented numerous missed doses on the MAR, frequently using a code indicating "other/see progress notes," while progress notes repeatedly stated that the Percocet was not available, not in stock, or pending pharmacy delivery, and one dose was not given because the resident was sleeping. The resident reported concerns about not receiving pain medication as ordered, particularly at night, and stated that nothing else was done to address their pain, and facility leadership confirmed that the ordered Percocet doses were not administered on the identified occasions.
The facility did not employ a full-time Registered Dietitian or a certified Food Service Director, affecting 27 residents. The facility's assessment highlighted the need for a qualified nutrition professional. The Kitchen Supervisor lacked necessary certifications, and the dietitian had resigned.
The facility failed to store, label, and manage food items properly, risking foodborne illness for all residents. Observations included inadequately labeled garlic, unlabeled ground meat, improperly stored diced meat, outdated cooking wine, uncovered coffee carafes near a sink, and outdated sandwiches. The Kitchen Supervisor was unaware of these requirements.
The facility failed to prevent potential cross-contamination by not ensuring hand hygiene during laundry distribution and not using gowns as required by policy when sorting soiled linens. A staff member distributed laundry to residents without performing hand hygiene, and only gloves were used during sorting, contrary to the policy that required gowns.
The facility did not ensure a nurse aide completed initial orientation with abuse training, potentially affecting all 27 residents. The aide, employed since October, could not identify types of abuse or reporting procedures. The Administrator confirmed no evidence of completed training.
The facility did not develop and implement baseline care plans within 48 hours of admission for five residents, as required by policy. The DON confirmed the oversight, stating that the facility had never provided copies of the care plans to residents or their representatives. The residents had various medical conditions, including dementia and chronic pain, requiring timely care planning.
A resident with severe cognitive impairment and aggressive behaviors was involved in multiple altercations with other residents, resulting in injuries. The facility's interventions were inadequate and often duplicated, failing to prevent further incidents, as confirmed by the DON.
A resident alleged a theft of 4 million dollars, but the facility failed to report the incident to the state agency within the required 24 hours and did not submit an investigation report within 5 working days. The delay was confirmed through interviews with the DON and NHA, highlighting non-compliance with the facility's policy and state law.
The facility inaccurately coded the MDS for two residents, leading to errors in documenting active diagnoses and medication use. One resident was incorrectly noted as taking an anticoagulant instead of an antiplatelet, and a contraindicated GDR was not documented. Another resident was wrongly listed as having septicemia, despite no ongoing condition. An MDS-RN confirmed these discrepancies.
A facility failed to provide a complete discharge summary for a resident, omitting the recapitulation of stay. The facility's policy requires this summary to include a recap of the resident's stay and a final status summary at discharge. However, the discharge planning document was incomplete, as confirmed by the DON.
A facility failed to ensure a resident's drug regimen was free from unnecessary drugs, as two prophylactic antibiotics lacked stop dates and valid indications for use. The facility's policy required complete antibiotic orders, but a review revealed deficiencies in the orders for Macrobid and bacitracin-polymyxin ophthalmic ointment. The DON confirmed these issues.
The facility failed to maintain the nutritive value of pureed food for two residents. Cook-A prepared meals by blending chicken and dumplings, peas, and cornbread with unmeasured hot water, affecting the food's nutritive value. The facility lacked recipes for diet modifications and a policy for preparing mechanically altered foods. The Kitchen Supervisor was unaware of the impact of adding water, and the Administrator confirmed the absence of relevant policies.
The facility failed to serve food in the texture ordered by medical providers for two residents. Despite orders for mechanical soft diets, the cook prepared and served pureed food. The facility lacked a policy for preparing modified texture foods, and the administrator was unaware of the inconsistency.
The facility did not perform required nurse aide registry checks for adverse findings on four employees, including a cook, an LPN, and two nurse aides, hired between August and October 2024. This oversight was confirmed by the Administrator and could potentially affect all 27 residents.
A resident's elopement was inaccurately reported by the DON, with inconsistencies in the dates and times of the incident and notifications to APS and the facility administrator. The report misstated the elopement date, notification times, and the resident's return time, as confirmed by the DON.
A resident with severe cognitive impairment and a history of wandering was moved from a locked Memory Care Unit to a non-locked unit, despite ongoing risk behaviors. The facility's interventions, including exit alarms and behavior logs, were insufficient, leading to the resident eloping and being found outside the facility. Safety checks were implemented post-incident but were later discontinued, highlighting inadequate supervision and intervention planning.
A resident experienced a 7.4% weight loss over one month, but the facility failed to notify the resident's POA or PCP as required by policy. The weight changes were documented, but staff did not report the significant change, leading to a deficiency in regulatory compliance.
The facility failed to assist a dependent resident with toileting, as evidenced by multiple observations and interviews. Despite the resident's need for total assistance and the facility's policy requiring timely response to call lights, staff did not provide the necessary help, leaving the resident without assistance for an extended period.
A resident experienced a 7.4% weight loss over one month, which was not properly documented or addressed by the facility staff. The facility failed to follow its policy for significant weight changes, leading to a deficiency in providing adequate food and fluids to maintain the resident's health. The resident frequently refused meals, and there was no consistent documentation of their nutritional intake or the provision of high-calorie supplements.
The facility failed to prepare and administer the correct dosage of medication for two residents, resulting in a medication error rate of 7.69%. An LPN did not measure Diclofenac Gel 1% correctly for one resident and administered an incorrect amount of Miralax to another. The facility's policy on verifying medication details was not followed.
Failure to Provide Access to Most Recent Survey Results and Plan of Correction
Penalty
Summary
The facility failed to provide residents, family members, legal representatives, visitors, and the public with access to the most recent survey results and plan of correction as required. During an observation in the lobby, surveyors noted a 3-ring binder labeled “Hemingford Care Center Survey Results,” which, upon review, contained survey results only up to a survey ending in December 2024. The binder did not include the results of the most recent survey that ended on 2/2/26, nor did it contain the corresponding plan of correction for that survey. Record review further showed that there were no citations related to complaints following the previous survey included in the book. In an interview, the administrator confirmed that the required documents were not included in the survey results book. No specific residents or their medical conditions were mentioned in relation to this deficiency, and the issue centered on the facility’s failure to maintain and make available up-to-date survey documentation for review by stakeholders.
Failure to Timely Report Allegation of Neglect Related to Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of neglect to the State Agency within the required 2-hour timeframe. A family member of Resident 7 alleged that the facility caused the resident’s death through medical neglect. Nursing notes document that the resident died in the facility, with an LPN-C assessing the resident and finding no heartbeat at 2:39 PM. At the time of death, the resident had an advance directive indicating a desire for CPR if the heart stopped, and the physician orders and care plan in Point Click Care still indicated CPR. A hospice consult had been ordered but had not yet occurred. The administrator was updated about the situation at 3:03 PM, and the family member, while in the facility, loudly accused the facility of having murdered the resident, causing distress to other residents. Subsequently, the administrator spoke with local law enforcement and provided the sheriff with requested information regarding the family member’s allegations. Despite receiving the allegation of neglect from the family member on the date of the resident’s death, the facility did not notify the State Agency of the allegation until 1:51 PM the following day. In an interview, the administrator confirmed that the State Agency was not notified within the required 2-hour timeframe. This delay in reporting the allegation of neglect to the State Agency constitutes the cited deficiency.
Failure to Update Care Plan After Resident Grievances About CNA Care
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s Comprehensive Care Plan (CCP) to reflect care changes made in response to the resident’s grievances. The resident, admitted in 2023, had multiple significant diagnoses including sequela of unspecified intracranial injury, personal history of traumatic brain injury, hemiplegia of the left nondominant side, and bipolar disorder. On one grievance dated late March 2026, the resident reported that a specific nursing assistant (NA-A) did not respond when called and was rude and slow to help; the grievance documentation showed the resident requested that NA-A no longer provide care and agreed to 2-hour rounding in pairs, but the form indicated the plan of care was not updated. A second grievance in early April 2026 documented the resident’s concern that CNAs were waking the resident at night, taking too long for cleanup, and being rude or dismissive. The facility’s follow-up section for this second grievance stated that the care plan was updated, that NA-A was educated on tone and approach, and that cares in pairs were implemented for all night cares, with the form marked that the plan of care was updated. Despite these documented changes, record review on April 21, 2026 showed that the behavior section of the resident’s CCP had not been revised since October 2025 and still only described a pattern of accusatory statements and unrealistic demands, with no interventions reflecting paired staffing or altered care approaches related to the grievances. The Administrator confirmed that the CCP interventions for this resident had not been revised since 2025, acknowledged that instead of updating the care plan they wrote progress notes, and further confirmed that the notes from early April 2026 did not address the staffing changes during cares. The Administrator stated they viewed the issue as a personnel matter affecting staff rather than the resident’s plan of care and therefore did not document changes in the CCP, and also confirmed that the care concern from the April grievance was not documented as indicated on the grievance report. The Regional Nurse Consultant confirmed the CCP should have been updated for staffing during cares. The resident reported filing several grievances against NA-A, stated that none of them worked, and that NA-A still entered the room. The DON confirmed that only NA-A and young female staff were required to enter the resident’s room in pairs, and the resident later confirmed that NA-A continued to go into the room, indicating that the documented care changes were not reflected in the CCP.
Failure to Provide Ordered Narcotic Pain Medication Due to Lack of Availability
Penalty
Summary
Surveyors identified a deficiency in medication administration when a narcotic pain medication (Percocet 5-325 mg) was not provided as ordered to one resident with significant neurological and musculoskeletal conditions. The facility’s medication policy required medications to be administered according to prescriber orders and time frames, and the resident’s care plan included goals to be free from pain or at an acceptable level of discomfort, with an intervention to administer Percocet as ordered for pain and muscle spasms. The resident, who had a history of intracranial injury with loss of consciousness, hemiplegia, epilepsy, spina bifida occulta, muscle spasms, restless leg syndrome, traumatic brain injury, and contractures of both ankles, right toes, and both hands, had a standing order for Percocet 5-325 mg, one tablet every four hours for pain starting in August 2025. Record review showed multiple missed doses documented on the March and April 2026 MARs, with chart code "9" (other/see progress notes) used repeatedly instead of administering the medication. Progress notes on several dates documented that Percocet was not available, not in stock, or that staff were awaiting pharmacy delivery, including 10 consecutive missed administration times over two days and additional missed doses on later dates. On one occasion, a dose was marked as not given because the resident was sleeping. Interviews with the resident confirmed concerns about not receiving pain medication as ordered, especially at night, and the resident reported that the facility had not done anything else to help with their pain. The DON, interim DON, and Administrator each confirmed that the resident did not receive Percocet as ordered on the identified dates and times.
Failure to Employ Qualified Dietitian or Certified Food Service Director
Penalty
Summary
The facility failed to employ a full-time Registered Dietitian or have a certified Food Service Director, which had the potential to affect all 27 residents who consumed meals prepared in the kitchen. The facility's assessment identified the need for a qualified dietitian or clinically qualified nutrition professional to oversee the food and nutrition services. An interview with the Kitchen Supervisor revealed that they had been in the role for several months without completing any special certifications and were not a certified Food Service Director. Additionally, an interview with the Administrator confirmed that the dietitian had resigned and was no longer employed at the facility as of November 29, 2024.
Improper Food Storage and Labeling
Penalty
Summary
The facility failed to properly store, label, cover, and manage food and drink items, which could potentially lead to foodborne illness affecting all 27 residents. During an initial kitchen tour, several issues were observed: a half-full container of garlic in water was covered with foil and inadequately labeled; an unlabeled package of ground meat-like substance was found; a ziplock bag of loose raw meat-like substance was improperly labeled; and a tray with bags of diced meat sitting in liquid was incorrectly stored. Additionally, an opened container of cooking wine was past its best-if-used-by date, and a commercial coffee maker had uncovered carafes located next to a sink used for washing dirty dishes. A snack cart contained half-sandwiches in baggies with outdated labels. The Kitchen Supervisor was unaware of the requirement for coffee carafes to be covered and confirmed that the listed items should have been properly sealed, labeled, used, or discarded, and that bagged meats should not have been stored together in liquid.
Inadequate Infection Control in Laundry Handling
Penalty
Summary
The facility failed to handle contaminated linens in a manner that prevented potential cross-contamination and did not complete hand hygiene between distributing laundry for several residents. During an observation, a housekeeping/laundry staff member was seen distributing personal laundry to residents without performing hand hygiene between rooms. The staff member confirmed in an interview that they were unaware of the requirement to perform hand hygiene during the distribution of resident laundry. Additionally, the facility's policy on sorting soiled linen required employees to wear a gown and gloves. However, the housekeeping/laundry staff member stated that only gloves were worn during the sorting process, and no gowns were used. An observation of the laundry area revealed the presence of disposable exam gloves but no gowns, which was confirmed by the Administrator during an interview.
Failure to Provide Abuse Training During Orientation
Penalty
Summary
The facility failed to ensure that a nurse aide (NA-F) completed initial orientation with training on abuse, which had the potential to affect all 27 residents in the facility. A review of the facility's policy on Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revised in April 2021, indicated that staff orientation should include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. However, during an interview, NA-F was unable to verbalize any types of abuse or identify when and whom to report to, despite being employed since October 2024. The Administrator confirmed there was no evidence that NA-F had completed the required abuse training during initial orientation.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for five residents, as required by their policy. The policy mandates that a baseline care plan be developed for each resident within 48 hours of admission and that a copy of the summary be provided to the resident or their representative. However, record reviews revealed that no baseline care plans were developed for Residents 13, 16, and 22. For Residents 15 and 20, the baseline care plans were completed more than 48 hours after admission, and there was no evidence that copies were provided to the residents or their representatives. Interviews with the Director of Nursing (DON) confirmed the deficiencies, as the DON was unaware of the requirement to develop and implement baseline care plans within 48 hours and stated that the facility had never provided copies of the baseline care plans to residents or their representatives. The residents involved had various medical conditions, including dementia, Alzheimer's disease, chronic pain, and kidney disease, which necessitated timely and appropriate care planning to address their immediate needs upon admission.
Inadequate Supervision and Intervention for Resident with Aggressive Behaviors
Penalty
Summary
The facility failed to protect four residents from the adverse behaviors of another resident, identified as Resident 15, who was admitted with severe cognitive impairment and a history of wandering and aggression. Despite being aware of Resident 15's tendency to enter other residents' rooms and engage in altercations, the facility's interventions were inadequate and often duplicated, failing to prevent further incidents. Resident 15 was involved in multiple altercations with other residents, resulting in physical aggression and injuries, such as bruises and skin tears. The facility's care plan for Resident 15 included interventions like increased monitoring and redirection, but these measures were insufficient and inconsistently applied. The Director of Nursing confirmed that no new interventions were implemented after certain altercations, and some interventions were merely duplicates of previous ones. This lack of effective intervention and supervision led to repeated incidents of resident-to-resident altercations, highlighting a deficiency in the facility's ability to provide a safe environment for its residents.
Failure to Timely Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an alleged misappropriation of resident property to the state agency within the required 24-hour timeframe and did not submit an investigation report within 5 working days. The incident involved a resident who alleged that someone had stolen 4 million dollars from them. The facility's policy, last revised in September 2022, mandates that any suspicion of misappropriation must be reported immediately, defined as within 24 hours, to the administrator and other officials according to state law. The deficiency was identified through interviews and record reviews. On August 7, 2024, the dialysis center informed the facility about the resident's allegation. However, the facility did not notify Adult Protective Services (APS) until August 13, 2024, and the investigation report was submitted to the state agency on August 19, 2024. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed the delay in reporting and submission of the investigation, which did not comply with the facility's policy and state requirements.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Sets (MDS) for two residents, leading to discrepancies in the documentation of active diagnoses, medication use, and Gradual Dose Reduction (GDR) information. For Resident 9, the annual MDS inaccurately indicated the use of an anticoagulant, while the resident was actually taking an antiplatelet medication, clopidogrel. Additionally, the MDS did not document that a GDR for Zyprexa, an antipsychotic medication, was clinically contraindicated, despite this being noted in the resident's Medication Risk Benefit Evaluation. For Resident 17, the quarterly MDS incorrectly listed septicemia as an active diagnosis, although there were no indications of ongoing septicemia since before the resident's admission. An interview with the MDS-Registered Nurse confirmed these inaccuracies, acknowledging that Resident 9's MDS should have reflected the use of an antiplatelet and the contraindicated GDR, and that Resident 17's MDS should not have included septicemia as an active diagnosis.
Failure to Provide Complete Discharge Summary
Penalty
Summary
The facility failed to develop and provide a discharge summary that included a recapitulation of stay for a resident who was discharged. The facility's policy, revised in October 2022, mandates that the discharge summary should include a recapitulation of the resident's stay and a final summary of the resident's status at the time of discharge. Additionally, a copy of the evaluation of the resident's discharge needs, the post-discharge plan, and the discharge summary should be provided to the resident and filed in their medical record. However, upon reviewing the discharge planning document dated 10/7/2024, it was found that the section for the recap of the resident's stay was left blank. This was confirmed in an interview with the Director of Nursing, who acknowledged that the recapitulation of stay was not completed or provided to the resident.
Deficiency in Antibiotic Stewardship for a Resident
Penalty
Summary
The facility failed to ensure that the drug regimen for a resident was free from unnecessary drugs, specifically regarding the use of prophylactic antibiotics. A review of the facility's policy on Antibiotic Stewardship indicated that complete antibiotic orders should include the drug name, dose, frequency, duration of treatment, route, and indication. However, a review of Resident 2's Order Summary revealed that the orders for Macrobid and bacitracin-polymyxin ophthalmic ointment lacked stop dates or durations. Additionally, the antibiotic eye drops did not have a valid indication for use. An interview with the Director of Nursing confirmed these deficiencies in the antibiotic orders for Resident 2.
Failure to Maintain Nutritive Value of Pureed Food
Penalty
Summary
The facility failed to maintain the nutritive value of pureed food, affecting two residents. During a meal service observation, Cook-A was seen preparing pureed meals by blending chicken and dumplings, seasoned peas, and cornbread with an electric blender. Unmeasured hot water from a coffee carafe was added to each food item to achieve the desired consistency, which was then served to the residents along with cooked canned sweet potatoes. A review of the facility's recipe for Chicken and Dumplings showed no guidance for mechanical soft or pureed diet modifications, and no recipes were available for the peas or cornbread. Interviews revealed that Cook-A prepared and served the pureed food to the two residents, and the Kitchen Supervisor was unaware that adding water could decrease the nutritive value of the food. The Administrator confirmed the absence of a facility policy for preparing mechanically altered texture foods for residents.
Failure to Serve Food in Ordered Texture
Penalty
Summary
The facility failed to provide food in the texture ordered by the medical provider for two residents, identified as Residents 5 and 15. Resident 5 had an active physician's order for a regular diet with mechanical soft texture and thin consistency liquids, while Resident 15 had an order for a liberalized diet with mechanical soft texture and regular consistency liquids. During an observation of meal service, it was noted that Cook-A prepared and served pureed food to both residents, despite their orders for mechanical soft diets. The cook blended chicken and dumplings, peas, and cornbread into a pureed consistency, which was not in accordance with the dietary orders. The facility lacked a policy for preparing modified texture foods, and the Nursing Home Administrator was unaware that the foods were being served at a different consistency than what was ordered. The facility's documents indicated that chicken and dumplings should be served as a ground texture, peas as pureed, and cornbread as a slurry for residents on a mechanical soft diet. However, the preparation observed did not align with these guidelines, leading to the deficiency in serving food in the correct texture as ordered by the medical provider.
Failure to Conduct Nurse Aide Registry Checks
Penalty
Summary
The facility failed to conduct required nurse aide registry checks for adverse findings for four out of five sampled employees, which could potentially affect all 27 residents within the facility. The facility's policy, revised in April 2021, mandates conducting employee background checks, including state nurse aide registry checks for any adverse findings. However, a review of personnel files revealed that no nurse aide registry checks were completed for a cook, an LPN, and two nurse aides hired between August and October 2024. This was confirmed in an interview with the Administrator, who acknowledged the oversight in conducting these checks.
Inaccurate Reporting of Resident Elopement Incident
Penalty
Summary
The facility failed to submit an accurate investigation report to the state agency following the elopement of a resident. The Director of Nursing (DON) submitted a report that contained several inconsistencies regarding the dates and times of the incident and notifications. The report inaccurately stated that the elopement occurred on a different date than it actually did, and it also provided incorrect times for when the Adult Protective Services (APS) and the facility administrator were notified. Additionally, the report misstated the time the resident returned to the facility with the DON. These discrepancies were confirmed during an interview with the DON, highlighting a failure in accurately documenting and reporting the incident.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to implement adequate interventions to prevent elopements for a resident identified as at risk for wandering and elopement. The resident, who had severe cognitive impairment and a history of wandering, was initially residing in the Memory Care Unit (MCU) but was moved to a non-locked unit after the facility determined they were not at risk for elopement. Despite this, the resident continued to exhibit behaviors indicating a risk for elopement, such as making statements about leaving the facility and asking staff for help to leave. The resident's care plan included interventions like exit alarms, behavior logs, and personalization of their room, but these were not sufficient to prevent an elopement incident. On one occasion, the resident was found outside the facility in a park, indicating a failure in the supervision and interventions in place. Following this incident, the facility implemented 15-minute safety checks, which were later reduced to hourly checks and eventually discontinued, despite the resident's continued risk behaviors. Interviews with facility staff, including the Director of Nursing, revealed that the facility did not have a comprehensive plan to prevent further elopements after the initial incident. The care plan was updated to include a focus on elopement only after the resident had already eloped, and the interventions in place were not sufficient to prevent the resident from leaving the facility again. This lack of proactive measures and adequate supervision contributed to the deficiency identified in the report.
Failure to Notify Resident's Representative of Significant Weight Loss
Penalty
Summary
The facility failed to notify the resident's representative of a significant change in condition for one of the sampled residents. The resident, who was admitted with a principal diagnosis of acute and chronic respiratory failure with hypoxia, experienced a 7.4% weight loss over one month. Despite the facility's policy requiring notification of significant changes in a resident's condition, there was no documentation that the resident's Power of Attorney (POA) had been informed of this weight loss. The resident's care plan included monitoring for signs of dehydration and malnutrition, which listed significant weight loss as a key indicator. However, the weight changes were documented in the electronic health record system without any corresponding notification to the POA or primary care provider (PCP). Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), revealed that the weight loss was not noticed or reported as required. The LPN did not recall noticing the weight change, and the DON confirmed that such a significant weight loss should have been reported to the resident's POA and PCP. The DON also stated that they had not been made aware of the weight loss and, therefore, had not taken the necessary steps to monitor the resident or notify the appropriate parties. This failure to communicate a significant change in the resident's condition constitutes a deficiency in the facility's compliance with regulatory requirements.
Failure to Assist Dependent Resident with Toileting
Penalty
Summary
The facility failed to assist a dependent resident with toileting, as evidenced by multiple observations and interviews. Resident 2, who was admitted with diagnoses including left side hemiplegia, paraplegia, epilepsy, Spina Bifida, and muscle weakness, required total assistance for all Activities of Daily Living (ADLs) according to their Care Plan. On 3/26/2024, Resident 2 reported to an LPN that Nurse Aides had entered the room, shut off the call light, and left without providing assistance for toileting. Despite the LPN's acknowledgment, no staff provided the necessary assistance from 11:57 AM to 12:25 PM. Resident 2 later confirmed that it was common for staff to shut off the call light without offering help. Interviews with staff, including a Nurse Aide and the Director of Nursing (DON), confirmed that Resident 2 was dependent for all care and that the facility's policy required timely response to call lights and adherence to care plans for toileting assistance. The facility's policy on Activities of Daily Living (ADLs), last revised in March 2018, mandates that appropriate care and services be provided to dependent residents in accordance with their care plans, including toileting. The policy also states that staff should not assume residents are refusing care if they resist. Despite these guidelines, the facility failed to meet the care needs of Resident 2, as evidenced by the lack of timely assistance and the common practice of shutting off call lights without providing the required help. This deficiency was identified through record reviews, observations, and interviews with the resident and staff.
Failure to Identify and Address Significant Weight Loss
Penalty
Summary
The facility failed to identify a significant weight loss for one resident, leading to a deficiency in providing adequate food and fluids to maintain the resident's health. The resident experienced a 7.4% weight loss over one month, which was not properly documented or addressed by the facility staff. The facility's policy required that any weight change of 5% or more be retaken the next day for confirmation and that the dietitian be notified immediately. However, this procedure was not followed, and the resident's significant weight loss went unreported to the dietitian, primary care provider (PCP), and the resident's power of attorney (POA). Additionally, there was no documentation of the resident's fluid or meal intake for the prior 30 days in the electronic health record (EHR), despite the resident frequently refusing meals and showing signs of decreased appetite and malnutrition. The resident's care plan included monitoring for signs of dehydration and malnutrition, such as significant weight loss, but these signs were not adequately documented or reported by the staff. Interviews with nursing aides and licensed practical nurses (LPNs) revealed that the resident's weights were obtained and given to the nurse on duty, but there was no clear process for reviewing and acting on significant weight changes. The Director of Nursing (DON) confirmed that a significant weight loss should be considered a change in condition and reported to the PCP and POA, but this did not occur for the resident in question. The DON also stated that the facility's electronic health record system should flag significant weight changes, but this warning was not observed for the resident. The resident had a history of declining meals and requesting only desserts in the evenings, which was known to the staff. Despite this, there was no consistent documentation of the resident's meal refusals, alternative food offerings, or the provision of high-calorie supplements. The resident was eventually sent to the emergency room for evaluation, where they were diagnosed with diverticulitis and dehydration. The lack of proper documentation and communication regarding the resident's weight loss and nutritional intake contributed to the deficiency in maintaining the resident's health through adequate food and fluids.
Medication Dosage Errors
Penalty
Summary
The facility failed to prepare and administer the correct dosage of medication for two residents, resulting in a medication error rate of 7.69%. An observation revealed that an LPN prepared an unmeasured amount of Diclofenac Gel 1% for Resident 8, despite the order specifying 2 grams to be applied to both knees. The LPN admitted to not knowing how to measure the gel. Additionally, the same LPN administered 17 grams of Miralax to Resident 12 instead of the ordered 2 tablespoons. The facility's policy on administering medications, which includes verifying the right medication, dosage, time, and method, was not followed. The facility had a census of 27 residents at the time of the survey.
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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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